Hypospadias: A birth defect of the penis involving the urethra (the transport tube leading from the bladder to discharge urine outside the body). The urethra normally travels in the male through the full length of the penis so that the stream of urine comes from the urethral opening at the tip of the penis. However, in hypospadias the urethra does not go all the way through the penis but, instead, opens on the underside of the shaft of the penis or below the penis.
Hypospadias is relatively common, affecting approximately 1 in every 500 newborn boys. Hypospadias can occur as an isolated birth defect in an otherwise normal child or it can be part of a multiple malformation syndrome. There is no association between the mother's use of loratadine (Claritin) in early pregnancy and the occurrence of hypospadias in her son.
In mild type (first-degree) hypospadias, the urethral opening is below the tip but still nearby (on what is called the glans). In moderate (second-degree) hypospadias, the urethra opens closer to the body on the underside of the shaft of the penis. In severe (third-degree) hypospadias, the urethal opening is below the penis on the skin and this is called a perineal hypospadias.
In a child with hypospadias, the urine comes from an opening that is on the underside of the penis or below the penis. With moderate-to-severe degrees of hypospadias, the boy will therefore usually sit to urinate. Some cases of first-degree hypospadias are so mild as to not require treatment.
If the hypospadias needs to be repaired, this is done by surgery. The aim is to repair and reconstruct the urethra. Depending on the degree of the hypospadias, the surgery can range from relatively simple to very challenging.
The opposite of hypospadias is epispadias, a less common birth defect in which the urethra opens prematurely on the upperside of the penis or above it.
What is Hypospadias?
Hypospadias refers to a urethral meatus ("pee-hole") which is located along the underside, rather than at the tip of the penis. In minor, or distal hypospadias, the meatus may be located on the underside of the penis, in the glans. In more pronounced hypospadias, the urethra may be open from mid-shaft out to the glans, or the urethra may even be entirely absent, with the urine exiting the bladder behind the penis.
Types of Hypospadias
There are different types of hypospadias.
- The opening of the urethra (where the urine comes from) is not at the end of the penis but is somewhere else along the penis (see the diagram below).
- The foreskin may be all at the back of the penis (“dorsal hood”) and may have none on the undersurface.
- The penis may not be straight (has a bend in it and this is called a “chordee”)
There is not a Straight Stream of Urine
What problems can hypospadias cause?
Problems are likely to occur if hypospadias is left untreated. The further back the opening of the urethra is, the more severe the problems are likely to be.
- Passing urine is different to normal. A baby in nappies will have no problem. However, when older the urine stream may not be able to be directed forward into a urinal. When going to the toilet the urine is likely to 'spray' backwards. Sitting on a toilet may be needed to pass urine without mess.
- Chordee which causes bending of the penis. This is more noticeable when the penis is erect. Sexual intercourse may be difficult or impossible in severe cases.
- Psychological problems about being 'different' to normal are common.
How Common is Hypospadias & what Causes it?
About 1 in 400 boys are born with some degree of hypospadias. It seems to be getting more common.
The reason why the penis does not develop properly is not clear. The development of the penis whilst the baby is growing in the womb is partly dependent on the male sex hormones such as testosterone. The effects of testosterone on the growing penis may be blocked in some way. One study found that vegetarian mothers were five times more likely to have a son with hypospadias than meat eaters. The reason for this is not known. One theory is that chemicals such as fertilisers, pesticides, etc, that are more commonly eaten by vegetarians may have something to do with it.
In hypospadias, the opening of the urethra is located on the underside of the penis instead of at the tip. The severity of the condition varies. In most cases, the opening of the urethra is near the head of the penis. Less often, the opening is at midshaft or at the base of the penis. Rarely, the opening is in or beneath the scrotum.
Other signs and symptoms of may include:
- Downward curve in the penis (chordee)
- Hooded appearance of the penis because only the top half of the penis is covered by foreskin
- · Abnormal spraying during urination
Are any Tests Needed?
The diagnosis is usually obvious from examining the penis. No other tests are routine.
A small number of people with severe hypospadias (when the urethral opening is at the base of the scrotum) may have other abnormalities of the genitals. The appearance of severe hypospadias may be part of a rare 'intersex' syndrome. Therefore, tests of the chromosomes and scans of the genitals may be made to determine if it is part of a wider syndrome. Note: these syndromes are rare and most boys with hypospadias are truly 'male' and have no other abnormalities.
How will Hypospadias affect my Child?
Hypospadias is essentially a cosmetic difference. A person with hypospadias may have to urinate sitting, rather than standing. He may also be prone to urinary tract infections.
More important is the emotional impact of having a penis that "looks different." This is why your doctor may advocate surgery for your child's hypospadias. Our discussions with men who have had hypospadias surgery lead us to believe that the physical damage and emotional trauma of genital surgery are frequently far worse than the hypospadias itself.
Hypospadias does not in itself cause infertility. Infertility may be present in the more extreme forms of hypospadias, where the testes are irregular and cannot produce viable sperm. Hypospadias surgery cannot make an infertile male fertile.
A hypospadic penis is entirely capable of pleasurable sexual sensation and orgasm. Plastic surgery on the genitals damages erotic sensation; it cannot improve it. There are some conditions however, which may require surgery to save your child from pain or illness, such as chordee which bends the penis causing painful erections, exposed mucous membrane, or adhesions.
Did I Cause it?
Hypospadias is not caused by any parental negligence. Because genital difference is so stigmatized in our culture, there are no good statistics, but hypospadias is quite common, probably occurring in one of two or three hundred births.
Does my Son Need Surgery?
Although surgeons usually counsel early surgery to repair the hypospadias, we have found that surgery is frequently very harmful, both physically and psychologically. Surgeons, of course, are trained in surgery; they are not experts in child psychological development or human sexuality.
Many complications can occur with hypospadias surgery. Unfortunately, it is usually performed on children before puberty, and few doctors do extensive follow up on their hypospadias patients. A young man who finds that his sexual function was irreversibly damaged by surgery during childhood is often
Natural vs. Surgically Constructed Urethra
The urethra, the tube which carries urine and semen out of the penis, is made of mucosal tissue, like the inside of your nose or mouth. This mucosal tissue is designed to resist both the irritating effect of urine, and the growth of bacteria, which would otherwise flourish in such a warm, wet, protected environment.
When surgeons use a flap of skin to construct or extend the urethra, the skin tube that results is poorly equipped to resist irritation from urine, or infection by bacteria. Further, the surgically created urethra is not as smooth as a real urethra, and may grow hair.
Urinary Tract Infections, Fistulae
Urine may collect in a surgically constructed urethra. Pressure during urination can force urine to escape into the body of the penis. These factors can result in pain and a life-long tendency toward urinary tract infections, which may involve the bladder and kidneys, and become quite serious. The surgical scar can break down, forming fistulae, or holes, in the urethra, resulting in pain and more surgery.
Hair in the Urethra
The penis heals poorly after surgery, because of its midline, distal location. Surgeons often resort to cortisone to promote healing. Unfortunately, cortisone can cause hair to grow in the skin which was used to build the urethra. This hair exacerbates the urinary tract infections that can plague boys and men who have had hypospadias surgery.
Poor healing also leads to extensive scarring. The penis is an unfortunate part of the body on which to have thick, inflexible scars. More important than the appearance is the fact that scar tissue has little sensation, and is very stiff. Instead of a penis capable of exquisitely pleasurable sensation, many men who have had hypospadias surgery report that they have little or no sensation, or even that the stiff scar tissue causes them pain upon erection.
Local Infection, Sloughing
Skin which is transplanted to the penis from another part of the body, or penile or scrotal skin which is wrapped around to form a urethra, is at risk of infection or sloughing away. The result is often more pain, emotional trauma, and repeated invasive genital surgeries for the unfortunate boy.
We have found that genital surgery performed on infants and children who are too young to understand the implications for their sexual future can be emotionally traumatic. The hidden message is that the child's genitals, although not causing him any physical discomfort, made adults so uncomfortable that they had to be surgically "fixed" before he was old enough to have a say in the matter.
Counseling is Essential
We believe that your child will be best helped by minimizing genital surgery. No surgery should be performed unless it is absolutely necessary for his comfort and safety. Whatever you decide, we urge you to obtain help from a professional therapist with training in sexuality. Education and counseling for the whole family, including parents and siblings, will help you to help your son deal with his difference.
After puberty, when your son is sexually mature, and able to make responsible decisions for himself, he may wish to consider hypospadias repair surgery. He will be able to weigh for himself the inevitable trade-off of sexual feeling for a possible improvement in appearance. Furthermore, the surgical prospects are improved when working with a mature, full grown organ, after the dramatic size and shape changes of puberty are complete.
Understanding the Normal Penis & Urethra
The urethra is the tube that urine flows through out of the bladder. It passes through the penis. The opening of the urethra (meatus or 'pee-hole') is normally at the end of the penis, partly covered by the foreskin.
What is the Penis Like in Hypospadias?
The main problem is that the urethra opens on the underside of the penis instead of at the end of the penis. The opening can be anywhere from just below the normal position (mild) to as far back as the base of the scrotum (severe).
Hypospadias may also Include the following.
- A hooded appearance of the foreskin. This is because the foreskin does not develop on the underside of the penis.
- Tightening of the tissues on the underside of the penis (called 'chordee'). This pulls the penis down and it cannot fully straighten. The further back the urethral opening is the more severe the chordee tends to be. Mild hypospadias may not have any chordee.
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