The main roles of the penis are to carry urine and sperm out of the body. The urethra is the tube that carries urine and sperm through the penis to the outside. The opening to the outside is called the “meatus.” Both tasks are easier when the meatus is at the tip of the head (“glans”) of the penis.
Hypospadias is a congenital condition (birth defect) where the meatus is not at the tip of the penis. Instead, the hole may be any place along the underside of the penis. The meatus (hole) is most often found near the end of the penis (“distal” position). But it may also be found from the middle of the penile shaft to the base of the penis, or even within the scrotum (“proximal” positions).
Symptoms
Signs and symptoms of hypospadias may include:
- Opening of the urethra at a location other than the tip of the penis
- Downward curve of the penis (chordee)
- Hooded appearance of the penis because only the top half of the penis is covered by foreskin
- Abnormal spraying during urination
Causes
Hypospadias is present at birth (congenital). The key steps in forming the penis take place between weeks 9 and 12 of pregnancy. As the penis develops in a male fetus, certain hormones stimulate the formation of the urethra and foreskin. Hypospadias results when a malfunction occurs in the action of these hormones, causing the urethra to develop abnormally.In most cases, the exact cause of hypospadias is unknown. Sometimes, hypospadias is genetic, but environment also may play a role.
Risk factors
Although the cause of hypospadias is usually unknown, these factors may be associated with the condition:
- Family history.This condition is more common in infants with a family history of hypospadias.
- Certain gene variations may play a role in disruption of the hormones that stimulate formation of the male genitals.
- Maternal age over 35.Some research suggests that there may be an increased risk of hypospadias in infant males born to women older than 35 years.
- Exposure to certain substances during pregnancy.There is some speculation about an association between hypospadias and a mother’s exposure to certain hormones or certain compounds such as pesticides or industrial chemicals, but further studies are needed to confirm this.
Complications due to hypospadias
If hypospadias is not treated, it can result in:
- Abnormal appearance of the penis
- Problems learning to use a toilet
- Abnormal curvature of the penis with erection
- Problems with impaired ejaculation
Diagnosis
Hypospadias is most often noticed at birth. Not only is the meatus in the wrong place, but the foreskin is often not completely formed on its underside. This results in a “dorsal hood” that leaves the tip of the penis exposed. It’s often the way the foreskin looks that calls attention to the problem. Still, some newborns have an abnormal foreskin with the meatus in the normal place. And in others a complete foreskin may hide an abnormal meatus. About 8 in 100 of boys with hypospadias also have a testicle that hasn’t fully dropped into the scrotum.
Treatment
Some forms of hypospadias are very minor and do not require surgery. However, treatment usually involves surgery to reposition the urethral opening and, if necessary, straighten the shaft of the penis. Surgery is usually done between the ages of 6 and 12 months.
The goal of any type of hypospadias surgery is to make a normal, straight penis with a urinary channel that ends at or near the tip. The operation mostly involves 4 steps:
- straightening the shaft
- making the urinary channel
- positioning the meatus in the head of the penis
- circumcising or reconstructing the foreskin
Most forms of hypospadias can be corrected in a single surgery that’s done on an outpatient basis. Some forms of hypospadias will require more than one surgery to correct the defect.When the urethral opening is near the base of the penis, the surgeon may need to use tissue grafts from the foreskin or from the inside of the mouth to reconstruct the urinary channel in the proper position, correcting the hypospadias.
In most cases, surgery is highly successful. Most of the time the penis looks normal after surgery, and boys have normal urination and reproduction.
Modern hypospadias surgery results in a penis that works well and looks normal (or nearly normal). Many surgeons leave a small tube (“catheter”) in the penis for a few days after surgery to keep urine from touching the fresh repair. The catheter drains into the diaper. Antibiotics are often given while the catheter is in place.
Younger boys seem to have less discomfort after repair. When the surgery is done at 6 to 12 months of age, as most pediatric urologists recommend, the child doesn’t even remember it. Older boys handle this surgery well, also, especially with the types of drugs we now have to treat pain. In some cases, medication may be needed to treat bladder spasms.
Complications of surgery
The most common problem after surgery is a hole (“fistula”) forming in another place on the penis. This is from a new path forming from the urethra to the skin. Scars can also form in the channel or the urethral opening. These scars can interfere with passing urine. If your child complains of urine leaking from a second hole or a slow urinary stream after hypospadias repair, he should see his pediatric urologist.
Most complications appear within the first few months after surgery. But fistulas or blocks might not be found for many years. Most problems are easily fixed with surgery after the tissues have healed from the first operation (often at least 6 months).