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Hypospadias is a condition in which the urethra does not develop completely. This results in an opening that is somewhere on the underside of the penis, scrotum, or perineum.
Hypospadias is almost always associated with other defects, including penile curvature (chordee) and an incomplete or hooded foreskin.
Very mild hypospadias may have a few functional implications, but the condition can affect a child's ability to void standing and eventually to have erections satisfactory for intercourse. It is for these reasons, as well as the obvious cosmetic defect, that most parents elect to have hypospadias repaired.
The different types of hypospadias are based on the location of the opening of the urethra. Types of hypospadias include:
The exact causes of hypospadias are unknown. Although, there are factors that are believed to be involved in its cause.
Causes may include:
Some boys with mild forms of hypospadias have no symptoms at all. Symptoms may include:
Hypospadias is generally diagnosed with a physical exam when a baby is born. Most hypospadias will be easily recognized due to the appearance of the penis and foreskin.
Circumcision is generally not recommended when hypospadias is known as the surgeon may need to use the foreskin tissue as part of hypospadias repair surgery. Occasionally, hypospadias is recognized after circumcision; these are usually the most minor forms. Your pediatrician will determine if a urology referral is necessary. Some boys with mild hypospadias can note more penile curvature after puberty, which warrants evaluation in urology.
Repair of hypospadias can take many forms, depending on the severity of the deformity.
The first step of any repair is straightening the penis. Almost all hypospadiac penises will have some degree of curvature that needs to be corrected. Often this can be accomplished simply by "degloving" the penis. This involves making an incision around the skin of the penis just under the coronal groove.
As the skin is separated from the shaft of the penis, tethering bands of tissue are released, straightening the penis. Sometimes this dissection can be carried under the skin of the scrotum and even into the perineum, referred to as a radical mobilization of the urethra, a technique developed by UPMC pediatric urology specialists.
If degloving the penis does not result in sufficient straightening, further treatment will be needed. These treatment options fall into two general categories:
A penis with severe curvature that requires grafting on the underside will often be repaired in a staged fashion. The first operation involves straightening the penis as described and transposing most of the foreskin to the underside of the penis for later u se in reconstructing the urethra. Approximately six months later, a second operation is performed to create a urethra from the skin on the underside of the penis.
If the urethral plate can be preserved, most often UPMC specialists will try to use it as a primary repair to the hypospadias. This results in a urethra that is composed completely of tissue that was originally intended to be urethra, rather than using skin or other materials. This technique also gives a very normal functional and cosmetic result.
Repair of severe hypospadias or repair after prior failed surgery might require a "free graft" of tissue to rebuild the urethra. This can be skin from the penis, inner arm, or lining of the mouth. Hospitalization is often required after a free graft repair to allow the graft to heal in place with little movement of the area as possible.
After surgery, a tube is left in the reconstructed urethra in all but the simplest cases. This tube is called a "stent", and its purpose is to allow free flow of urine while the tissues are healing. Often there is significant swelling in the penis, and voiding might be difficult for your child.
The tube is most commonly managed simply by allowing it to drain into a diaper. In older children, the tube might be attached to a drainage bag that is emptied periodically.
These tubes are usually attached to the head of the penis with one or two stitches, which need to be cut before the tubes can be removed. The tubes might be in place for as few as two or three days, or as long as two weeks. Any changes in drainage from these tubes, or in their position, should be reported to your doctor immediately.
There often will be a dressing, or bandage, around the penis after hypospadias surgery. Most often, this is clear plastic dressing and is removed at the first postoperative visit in the office. These dressings often will fall off by themselves, and this is not a cause for concern unless the dressing bunches at the base of the penis and acts as a tourniquet. If this occurs, the dressing should be removed, or your physician should be contacted immediately.
Overall, the results of hypospadias repair are excellent. However, it is important to realize that no surgical procedure is perfect and that the results of hypospadias repair cannot be guaranteed.
Nevertheless, in almost every case, these problems can be dealt with to give a very acceptable result. Some complications that may occur with hypospadias repair include:
The goal of hypospadias surgery is to provide a penis that is functionally and cosmetically normal. Whether these goals will be met to your satisfaction depends largely on the original anatomy and the tissue available for reconstruction.
Minor cosmetic defects can be found after hypospadias surgery, but often these will not be noticeable to the casual observer.
Concerns have been raised, especially on the Internet, about long-term sensation and sexual pleasure in men who have undergone hypospadias repair. The best data indicates that difficulties with erection, sensation, or orgasm are very unlikely to result from hypospadias surgery.
The Department of Pediatric Urology at UPMC Children's Hospital of Pittsburgh has pioneered new and simpler techniques for the repair of hypospadias, with excellent results. Contact us to schedule an appointment, 412-692-4100.
