What is Hypospadias?
“Hypospadias” means the urine opening is somewhere below the normal location at the end of the head of the penis. Most often, it is near the head, which is called “distal” hypospadias. Much less often the opening is lower near the scrotum, or even behind it near the anus, called “proximal” hypospadias.
A. A normal urine opening seen after newborn circumcision.
B. Distal hypospadias, arrow shows the opening just under the head
C. Proximal hypospadias, arrow shows the opening within the scrotum.
Hypospadias is found in 1 out of every 200 newborn boys, in all races and ethnicities. Each year approximately 2 million boys are born in the US, meaning there will be 10,000 with this condition. Of those, 9000 will have distal hypospadias and 1000 will have proximal hypospadias. Although only ½% of newborn boys will have hypospadias, it is one of the most common birth conditions, happening more often than cleft lip or Down’s syndrome.
Most boys with hypospadias also have only a partial foreskin, missing the part that covers the under side of the head of the penis. This gives an appearance that is neither natural nor circumcised, and it is this appearance that first calls attention to the problem in the newborn nursery.
A few boys with distal hypospadias have normal foreskin, which covers the hypospadias so that it is not seen unless newborn circumcision is done, or until the foreskin begins to pull back later in childhood. It is important for parents to know that the hypospadias was not caused by an injury during circumcision, and that circumcision did not remove skin needed for hypospadias repair.
A. The penis looks normal.
B. When the foreskin is pulled back a concealed hypospadias is discovered.
Does my son have “chordee”?
About 10% of boys with distal hypospadias also have downward bending of the penis. The extent of this bending is nearly always less than 30 degrees. In contrast, most boys with proximal hypospadias have downward bending, which in the most severe cases is greater than 30 degrees and can be as much as 120 degrees! The distinction between less than versus greater than 30 degrees is important, since adult men, and their sexual partners, begin to experience sexual discomfort when bending is 30 degrees or more.
2 examples of penile curvature:
Bending is often referred to as “chordee”, which can be very confusing. In the past, surgeons believed the bending was caused by bands of scar tissue they called chordee, and they tried to straighten the penis by cutting away various tissues. Today it is clear that the penis tissues are not scarred, but may be shorter in length than similar tissues on the top of the penis.
Specifically, downward curvature can be due to 3 factors. Most common is short ventral skin. The typical boy with hypospadias has relatively less skin on the underside than on the top, which causes the head of the penis to pull down, as show in the picture above. This bending spontaneously corrects during routine hypospadias repair.
Bending that persists after the skin is released is due to a short urethral plate and/or a short underside of the internal cylinders for erections. Although this is occasionally seen in boys with distal hypospadias, the vast majority of the time this bending occurs in proximal hypospadias.
Parents are often told their son has “hypospadias with chordee”. It would be more accurate to say he has hypospadias with ventral curvature, or, in most cases, just hypospadias. Of those 10,000 boys born in the US with hypospadias each year, only approximately 20% will have ventral curvature that requires specific treatment during the hypospadias repair, and most of these have proximal hypospadias.
Why do boys get hypospadias? Did I do something wrong to cause it?
The cause of hypospadias is not known. Most boys with hypospadias are otherwise healthy. In most cases there is no history of hypospadias in other men in the family.
Mothers may worry they did, or failed to do, something in their pregnancy that caused hypospadias to develop. As far as doctors know, this is almost never the case – mothers are not responsible for hypospadias in their sons.
There is an increased possibility of a boy having hypospadias when progesterone was needed early in pregnancy. Yet even in this situation, mothers who required progesterone should know that the vast majority of sons born will not have hypospadias.
As mentioned earlier, hypospadias occurs in similar numbers of boys born around the world, despite differences in the diets of their mothers, prenatal care their mothers had, or medications their mothers may have taken.
If father or a brother has hypospadias, the chance that a baby boy will also have hypospadias is higher. Still, 90% of boys whose father and a brother have hypospadias will not have the condition.
What tests are needed in a boy with hypospadias?
Blood tests or x-rays are rarely needed in newborn boys with hypospadias – even in those with the most severe proximal forms.
Sometimes a boy has hypospadias and an “undescended testicle”, meaning one or both of the testicles are not in their normal place in the scrotum. A blood test (“karyotype”) is recommended for these boys, although it is usually normal.
Occasionally, hypospadias is part of several birth problems in a boy. Evaluation of these conditions may require both blood tests and x-rays. X-ray tests are otherwise not needed for boys who only have hypospadias, regardless of how severe it is.
A boy with hypospadias and an undescended right testicle.
Does my son have intersex?
By definition, hypospadias and intersex are different. A very small number of boys with hypospadias do have an intersex condition, but these almost never grow up to have questions about being males. Most often, these few boys are tested because one of their testicles is not in the correct location at birth.
Unfortunately, some boys with proximal hypospadias are mis-diagnosed by the doctors who examine them in the newborn nursery as having “ambiguous genitalia”, which is related to intersex. Some parents have even been advised to postpone naming their son until tests are completed! Endocrinologists are consulted, and various blood tests and ultrasounds are ordered. But unless neither testicle can be felt, the genitalia are not ambiguous and the boy simply has severe hypospadias.
Will my son need surgery?
Not every boy with hypospadias needs to have the urine opening fixed. In boys without hypospadias, the head of the penis wraps around the end of the urinary channel and the opening, which acts like a nozzle on a hose to focus the urine stream. The extent of this enclosure by the head has been measured in boys without hypospadias.
One goal of hypospadias repair is to enclose the urine opening within the head of the penis. In some boys with the most distal hypospadias, the opening is already enclosed by the head to a similar extent as boys without hypospadias, so that surgery on the opening is not needed.
A. The normal distance from the lip of the urine opening to the edge of the head of the penis, showing how the head wraps around the opening.
B. The arrow shows the opening in a boy with distal hypospadias. The head of the penis does not enclose the opening at all.
C. Another boy with distal hypospadias, with the opening on the head of the penis. Although the distance from the opening to the edge of the head is less than seen in A, it is still within the normal range and does not need to be fixed.
In such boys with a normal opening, there is still need to consider the partial foreskin. If the foreskin is nearly completely formed, no surgery may be needed. However, the more typical partial foreskin, which looks neither natural nor circumcised, may best be operated to either do a circumcision or to restore it to a natural, whole appearance. The decision for circumcision versus foreskin repair should be made by the parents according to their cultural preferences, because the small risk for complications (about 2%) is the same for both. Not all pediatric urologists are familiar, or willing to do, foreskin repair, and so parents interested in that may need to seek out a specialist who does that procedure regularly.
In addition, if the head of the penis is bent down from short ventral skin on the underside of the penis (“chordee”), surgery on the skin should be considered to release that tethering.
A. Partial foreskin in a boy with distal hypospadias. He does not look natural or circumcised
B. Appearance after a foreskin repair
Most boys with hypospadias have the urine opening just off the head of the penis or lower, meaning none of the head wraps around the opening. Without that “nozzle” these boys are more likely to experience a deflected or spraying urine stream after toilet training, which can make it difficult for them to stand normally to pee. Some will have to sit to pee to avoid getting urine on their clothes or on the floor around the toilet, while others will learn to hold their penis at odd angles, or their hand in front of the stream, to try to deflect it into the toilet. Older boys and adults with uncorrected, or partially corrected, hypospadias may endure ridicule by their friends for using the stalls to sit down, or from getting urine on their clothes and shoes.
Parents watching their newborns sons with hypospadias pee usually report the stream looks normal to them. During toilet-training, the abnormal stream can also be missed, since the penis is nearly inside the toilet when they pee. Boys with uncorrected hypospadias often begin to report problems when they grow taller, often around age 8 years or later.
Older boys, teens, and adults with hypospadias often have body image concerns. Even those who have not been ridiculed by peers about their different appearance frequently express this concern, and have taken steps to avoid being seen undressed, for example, in the gym at school.
Older teens and adults with uncorrected or partially corrected hypospadias also say they are worried about what a new sexual partner will think or say about their penis looking different.
In addition, those with bending, especially greater than 30 degrees, are more likely to experience some difficulties and discomfort during sex. Partners also say that the bent penis can be uncomfortable for them. Even when sex is possible, some positions may cause pain and have to be avoided.
Despite these issues, hypospadias does not prevent a man from having children. It also does not predispose to urine infections.
Here is an adult with uncorrected hypospadias. He had spraying of his urine and was embarrassed for others to see his penis.
Is hypospadias repair a cosmetic operation?
Plastic surgeons define “cosmetic surgery” as operations to “reshape normal structures”. Surgery done to fix problems such as hypospadias are “reconstructive operations” done to improve function and appearance. This is an important distinction, which emphasizes that hypospadias reconstruction is done to give better function and create a normal appearance to the penis, not as a “cosmetic” enhancing surgery.
As mentioned earlier, some boys with hypospadias have curvature of the penis, many will have spraying or deviation of the urine stream, and most have a partial foreskin. Reconstruction involves making certain the penis is straight, the urine opening is at the normal location, and the penis looks either natural or like it has only had a circumcision.
Does a circumcision have to be done with hypospadias repair?
Either circumcision or foreskin repair can be done during distal hypospadias surgery, according to the wishes of the caregivers. Nearly all published reports say the likelihood for complications from the hypospadias repair are the same with either circumcision or foreskin reconstruction. Foreskin repair can also be done in boys having proximal hypospadias repair, although when a 2-stage operation is needed it may be preferable to use the foreskin to make the urine channel.
Some parents asking about foreskin repair have been misinformed about that option. Results of the hypospadias repair should be the same with either circumcision or foreskin repair for distal hypospadias, and the foreskin afterwards should look normal. It may not retract in the initial months after surgery, but normal foreskin in infants the same age does not retract either, and there are no health problems from not retracting the foreskin in children. Like hypospadias repair in general, successful reconstruction in childhood should last through puberty and sexual activity in adulthood.
A teenager who had foreskin repair during hypospadias surgery as an infant. The skin pulled back naturally.
Many surgeons are not familiar with foreskin repair. However, circumcision is not optimal in some cultural settings, and a boy who is circumcised may face ridicule worse than might have occurred if the foreskin had been left un-operated. Parents desiring a natural appearance should ask for referral to a specialist who does this surgery.
Is testosterone treatment recommended?
In some boys with hypospadias the penis is smaller than the average size. This is especially true for boys with proximal hypospadias. However, it is important to emphasize that these boys do not have a “micropenis”! Just as normal people can be shorter or taller than the average height, the penis can be smaller or larger than average, but still a normal size.
Unfortunately, some doctors use the word “micropenis” inaccurately. This diagnosis specifically refers to a penis that is more than 2 standard deviations below the average, a statistical term that means it is smaller than 95% of all boys. These small penises are nearly always otherwise normal, and almost never have hypospadias. In boys with hypospadias who do have a smaller than normal penis, the size in nearly all of them is in the range considered to be normal.
Pubic hair and an unnaturally large penis in a 5 year old persisting more than 3 years after testosterone treatment.
Testosterone, and other similar hormones, can enlarge the penis. Some pediatric urologists commonly use testosterone before surgery, while other pediatric urologists say they never use this treatment. When it is given, either shots (in the arm, not the penis!) or creams (applied to the penis) are available, according to the preference of the surgeon.
The doses of testosterone that are commonly used by pediatric urologists and surgeons do not always grow the penis larger, and in some boys much larger doses than usual are needed to achieve that goal. Most surgeons do not actually measure the penis to decide who will get treatment, or when to stop treatment.
Sometimes this growth is permanent, whereas in others the enlargement is temporary. While making the penis larger can be considered a goal of treatment, a more important question is if testosterone improves the results of surgery?
There are very few scientific studies comparing the results of hypospadias surgery in boys who were first treated with testosterone versus similar boys who were not treated. One article said complications were less when dihydrotestosterone cream (not available in the US) was used. Two other articles say that complications are increased if testosterone is given beforehand.
Infant boys experience a brief “surge” of testosterone naturally when they are between 6 and 20 weeks of age. After that, they make very little testosterone until puberty. There are possible side-effects of giving testosterone earlier than normal puberty. For example, the penis may grow to an unnaturally large size for a boy and remain enlarged. Some boys will develop pubic hair that persists through childhood. There is a potential for bone growth to be stunted, making the boy shorter in height, although that seems to be a low risk for the usual treatments used.
What is the best age for surgery?
The American Academy of Pediatrics recommended surgery be done between 6 months and 18 months of age, based on the opinion of experts in 1996. Various studies have suggested results are better when the surgery is done in younger than in older boys, although each found different ages when complications seemed to increase. Other studies report that the age of the patient, whether an infant, child or adult, makes no difference in the results of the hypospadias surgery.
Most boys with hypospadias are otherwise healthy, with no other medical problems. Those with distal hypospadias can have surgery as early as 3 months of age, if they were full-term at birth and a certified pediatric anesthesiologist gives the anesthesia. It may be better to wait until 6 months of age in boys with proximal hypospadias since many boys with proximal hypospadias are born prematurely and/or small for gestational age, to give them more time to grow. Distal hypospadias surgery is also done at 6 months or later if a boy was born prematurely.
However, some families live in countries where it is not possible to have surgery done in the first year, or years, of life. Parents should be re-assured that waiting will not make urinary channel complications more likely.
Another consideration is the awareness and psychological health of the child having penis surgery. The AAP panel suggested surgery be done before 18 months, as that is the time when boys are becoming aware of their penis. After that recommendation was made, one study found there was no difference in psychologic adjustment when hypospadias surgery was done before versus after 18 months of age, however, larger studies to evaluate this would be helpful.
Nevertheless, it is clear that as boys get older they are more aware and possibly fearful of the hospital and surgery. There is no advantage to waiting for the boy to get older before surgery, and so doing the repair before the child has much awareness of the operation seems preferable when it is possible.
Some parents ask if it might be better to wait until later in childhood for surgery so that the penis will be bigger. In fact, most growth of the penis occurs during the natural hormonal “surge” that occurs within a few weeks after birth. After the first 3 months of life, there is minimal change in its size until puberty. It grows an average of only 1 inch in length from 6 months to 10 years, and the width of the head increases by only a few millimeters, before puberty.
Lately there have been questions about the safety of anesthesia in infants. These came from studies in lab animals who were given extremely long anesthesias, much longer than surgery to correct hypospadias. Several recent studies done in children with versus without anesthesia have not found developmental problems or health concerns related to the anesthesia when other health conditions (like congenital heart problems, multiple birth defects, etc) are taken into account.
In addition, all patients having hypospadias surgery can (and should!) have a “nerve block” to reduce the amount of general anesthesia needed to do the operation, and to reduce discomfort when the child wakes up afterwards. This is similar to the nerve numbing that dentists use. These nerve blocks can be done directly near the penis (“penile nerve block”), in the lower back (“caudal block”) similar to an epidural, or in the pudendal nerves (“pudendal nerve block”). All have been shown to help decrease pain during penile surgery.
Should surgery wait until my son is old enough to participate in the decision?
Some parents say they are uncomfortable making a decision about “cosmetic surgery” for their son. It is important to understand that hypospadias repair is not a cosmetic operation. It is reconstructive surgery to correct a birth defect, just like cleft lip repair.
Legally, children cannot make their own decision for surgery until age 18 years. Generally, they may not be able to really understand enough to help make a decision until their teenage years, which is a challenging time already when they are developing their own adult identities. Body image is an important concern to teens, and teenage boys with uncorrected hypospadias are likely to be concerned what their friends in the locker room or at sleep overs, and girlfriends, will think about their different penis.
Parents should also realize that making a decision not to fix hypospadias is also making a decision for their son that he cannot, as an infant or child, participate in. In some cases when surgery has been postponed until teenage years, the patient has expressed anger at his parents for not taking care of the problem earlier. However, in some countries, microscope glasses and the delicate instruments and sutures that are needed for hypospadias repair in infants and children may not be available. In these countries, it may be best to wait until puberty to correct the hypospadias.
It is important to emphasize again that hypospadias is not intersex. Discussions about surgery in patients with intersex may not apply to boys with hypospadias. Hypospadias repair does not involve removing any glands/organs that contribute to hormonal function.
Another reason parents may be reluctant to have their son operated for hypospadias is their concern that there will be complications that require many surgeries. While this does happen, it should be unusual when surgery is done by experts. Parents should research their surgeon and ask for before and after photographs to be certain he/she has good results, which is discussed in the next section.
Operation Hap-penis does not take a position regarding surgery or no surgery, or the timing of surgery if that is selected. It is our mission to provide families and patients with reliable information to use to reach their own decision, based upon the specific factors like anatomy and geography that affect you/your child.
Choosing a Surgeon
If you are considering hypospadias repair, there are some facts to have in mind when talking to potential surgeons. In the United States, pediatric urologists do nearly all the hypospadias surgery. In other countries, pediatric urologists, pediatric surgeons, and plastic surgeons might do these repairs.
Using the United States as an example, there will be approximately 10,000 first-time hypospadias operations done each year. There are approximately 500 US pediatric urologists, who do, on average, about 1 distal repair a month. For proximal repairs it is even less common, with each pediatric urologist doing an average of only 2 operations a year, even in major medical centers.
Many studies show that the best results for complex operations, such as hypospadias repair, are gotten by surgeons with the most experience. Families and patients should also be aware that many surgeons do not know their personal results for hypospadias repair, but instead will quote results from published articles assuming theirs are similar.
For example, parents are very commonly told that distal hypospadias repair has 95% success without complications. However, a recent national study in the Netherlands found that success rates were extremely variable among surgeons. While a few surgeons had success of 90-95%, the average success rate was 84%, and some surgeons had success in only 40%!
It is not enough to rely on the advice of your primary care physician to find a surgeon. Primary care doctors almost never know the actual success of a surgeon.
So when choosing a surgeon, there are several important questions to ask:
- How many hypospadias repairs like your son needs does he/she do each year?
- What is his/her own complication rate for the type of repair your son needs?
- How do they know their results – have they specifically reviewed their own work to know what they are?
- Who will assist with the operation, a nurse or a trainee, and how much of the actual operation will a trainee do?
What to Expect After Surgery
Hypospadias repair in infants and children in the US is done as day surgery, meaning the patient comes to the hospital 1-2 hours before the scheduled operation, has the surgery, and then goes back home afterwards. This has been the standard of care in the US since the mid-1980s. Nevertheless, in some health care systems around the world, boys are still kept in the hospital after surgery, sometimes for over a week. Parents in these regions have the right to ask that their son be discharged home sooner.
After surgery, boys will usually have a catheter to drain their urine, and bandages over the wounds. Generally, the catheter stays in for about 1 week after distal hypospadias surgery, and up to 2 weeks after proximal hypospadias repair. There is no known benefit to using a catheter longer, and if a catheter comes out prematurely, usually the boy will pee fine and not need it replaced.
All patients have some discomfort after surgery, but generally it is less than many families anticipate for an operation on the penis! Infants less than a year of age get good pain relief using ibuprofen and acetaminophen (Tylenol). Older boys are prescribed a narcotic such as hydrocodone to take in addition to ibuprofen.
Catheters irritate the bladder and cause “bladder spasms”. Patients older than 1 year can be given an anti-spasm medicine such as oxybutynin (Ditropan) to prevent or reduce this discomfort. Many pediatric urologists also prescribe an antibiotic to take while the catheter is in.
Teens and adults may be given diazepam (Valium) to take at bedtime to diminish discomfort related to nighttime erections. Studies have shown no medications are capable of completely preventing erections in teens and adults undergoing penile surgery.
Some surgeons use a tube to drain the bladder called a supra-pubic tube in addition to the urethral catheter. There are no studies that show a benefit to additional tubes in otherwise healthy children and adults, but rarely these may be needed when there is concern for a poorly functioning bladder when other urologic or neurologic problems are present.
Some surgeons recommend “double diapering”, with an inner diaper to collect the stool, and an outer diaper where the catheter is placed to collect the urine. There are no studies that show if this is helpful to reduce complications or infections, so either single or double diapering may be recommended by your surgeon.
Surgery for Distal Hypospadias
The most common operation done worldwide for distal hypospadias is the TIP (or “Snodgrass”) repair. This procedure uses the tissues that should have made the urine channel, called the “urethral plate”, to extend the opening to the tip of the head of the penis.
The TIP repair was first published in 1994, and so has been used now for nearly 25 years. Many reports from centers around the world say the repair is successful in over 90% of cases. They also agree that TIP is the most reliable operation to make the urine opening and head of the penis look normal.
Skin incision for distal hypospadias, when the family prefers circumcision.
Incisions have been made to isolate the urethral plate from the head of the penis. Then the urethral plate is cut longitudinally in the middle to make it wider. Next, the plate is sewn into a tube to extend the opening to the tip of the head.
The head of the penis is sewn around the urine opening.
Circumcision is completed.
Before & After Surgery Images
A boy without hypospadias
A boy after TIP repair
Appearance with foreskin repair, rather than circumcision
Man with uncorrected distal hypospadias
Same man after TIP repair
Teenager after childhood TIP surgery with foreskin repair
Since it has now been used for so long there is information on how these patients are doing during puberty. Reports from centers around the world indicate that the urine channel grows with the rest of the penis.
Initially, some surgeons were concerned this operation, like some others, would eventually stricture, meaning scar tissue would gradually restrict the urine channel and make peeing difficult. However, these worries have not proven true, and stricture or other blockage after distal TIP repair develops in less than 3% of patients.
There are other operations still used by some surgeons to repair distal hypospadias, such as the “Mathieu”, “MAGPI”, or “urethral advancement” techniques. These may be less reliable than TIP to achieve the best functional and aesthetic results.
There is no “minor” hypospadias. Many parents of boys with distal hypospadias comment how everyone, from the doctors in the newborn nursery, to their pediatrician, and sometimes even their pediatric urologist, said the condition is mild and only needs a small operation that is usually successful. They are understandably confused and even angry if their son happens to have complications and need more operations! Unfortunately, if the first operation is not successful, the next operation has a higher chance for more complications – which emphasizes the need to find a surgeon with good results to do the repair right the first time.
Surgery for Proximal Hypospadias
These are the most challenging first-time hypospadias operations, and should be done by specialists who do many more than the average of 2 a year mentioned above.
The type of repair recommended depends in large part on the extent of penis curvature the boy has. When bending is less than 30 degrees, a 1-stage operation can be done. Currently popular techniques include TIP and “onlay prepucial flap”. Success, meaning no complication, has been reported in 85% of proximal TIP repairs and 75% of onlay flap operations.
When there is bending more than 30 degrees, the urethral plate is best removed as part of maneuvers to straighten the penis. While 1-stage repair can still be done, for example using the foreskin rolled into a tube and transferred to the underside of the penis, there has been a trend towards 2-stage operations to create the most normal appearance. When a 2-stage operation is done, the first procedure focuses on straightening the bending, and the urine channel is made at the second operation, usually 6 months later.
Severe hypospadias that looks like there is no penis
The penis is seen under the scrotum, and is bent down to near the anus
Appearance after straightening and sewing a foreskin graft to the underside of the penis
6 months later the graft is outlined. It will be made into a tube all the way to the end of the head of the penis
Final appearance of a normal, circumcised penis
2-stage operations most often use the foreskin, as either a “flap”, meaning the skin is left attached to the penis and moved to the underside, or as a “graft”, which takes the skin off the penis and then sews it back onto the underside. Recent studies indicate that graft repairs have better success than do flap operations.
All these operations can also be done as day surgeries, sending the patient home afterwards.
Complications after Hypospadias Repair
There are several potential problems that can develop after hypospadias repair. Most of these will be discovered in the first year after surgery, often in the first weeks following repair, and it is important that patients attend their scheduled follow up visits with the surgeon to check for these, even if everything seems to be ok.
In general, when additional surgery is planned to fix these, it is done no earlier than 6 months after the last operation to give time for tissue reaction to subside.
Click on the tabs to learn more about each condition…
Persistent or Recurrent Curvature
Fistula
Glans Dehiscence
Meatal Stenosis
Stricture
Diverticulum
Short, Scarred Skin
Persistent or Recurrent Curvature
It is very important for bending more than 30 degrees to be successfully straightened at the initial operation. Otherwise, other complications such as fistulas may also develop and be more difficult to fix, and an adult man with this degree of bending is more likely to have problems with sex.
When there is curvature more than 30 degrees, as in this picture, the previously made urinary channel often has to be removed and a 2-stage reoperation done – which emphasizes the need to get it straight the first time.
Fistula
A fistula is a hole below the normal opening that leaks urine when the boy pees. These can sometimes be seen as early as a week or so after surgery. Fistulas are usually diagnosed within a few months of the operation, although in rare cases a fistula may not appear for many years.
Most boys with fistulas do not have other complications from the hypospadias repair, although some will have persistent curvature, or a blockage in the urine channel beyond the hole, or ballooning of the new urine channel when the boy pees. These problems should be evaluated by your surgeon during the fistula closure, and should definitely be checked in the rare instances when a fistula recurs.
A fistula can occur anywhere below the normal opening. Many develop just under the head of the penis. If the head of the penis has otherwise healed normally, these fistulas can be closed without redoing the entire hypospadias repair or even using a catheter, with success in over 90%.
Fistulas with other complications are closed during a redo hypospadias repair, as described below.
Glans Dehiscence
Hypospadias repair includes sewing the head of the penis around the new urine channel. Sometimes it comes partially or completely back open again. A partial separation that maintains the normal enclosure of the opening does not need another operation, but complete dehiscence returns the urine opening to a lower position and increases the likelihood the patient will have a deflected or spraying urine stream after toilet training.
Meatal Stenosis
Stricture
A stricture is a partial blockage from scar tissue inside the urine channel away from the opening. These are usually discovered when patients have urinary infection or are not able to empty their urine.
Diverticulum
Short, Scarred Skin
Shrinking of the skin on the underside of the penis can occur after hypospadias repair, especially in a reoperation. Steroid cream applied to this area beginning a month after surgery can avoid this complication in some patients.
Otherwise, treatment can involve another operation to remove the scarred tissues and replace them with a skin flap or a skin graft.
Hypospadias Reoperations
Most complications will need to be fixed. Sometimes just the problem can be repaired, whereas in other cases the whole repair has to be redone.
Many studies show that complications are more likely in reoperations than in first-time surgeries, which emphasizes the importance of seeking out a surgeon with large experience with these procedures. The average number of redo surgeries done by pediatric urologists is probably about 3 a year, about the same as the number of proximal hypospadias repairs, and likely not enough to gain expertise.
A hairy penis after scrotal skin flaps were used earlier in childhood.
Sometimes, a repair can be done in a single operation such as a redo TIP. If there is persistent bending, or extensive scarring or blockage, then the unhealthy tissues have to be removed and replaced with new tissue. This is often gotten from the mouth, preferably from inside the lip.
Generally, repairs that do not use penis skin are recommended for reoperations, since otherwise there might not be enough skin remaining to re-cover the penis. While some surgeons have used flaps of skin from the scrotum moved onto the penis, hair will grow from these flaps during puberty.
Will hypospadias surgery affect penis sensation or erections?
Hypospadias repair does not cause problems with erections, although parents sometimes report that they notice fewer erections in their sons with hypospadias than their other sons without hypospadias have.
Even teens and adults who have had many hypospadias operations do not report having decreased sensation in their penis. Furthermore, patients who have hypospadias surgery as teens and adults report there is no change in sensation afterwards, and they can resume sexual relations about 6 weeks after hypospadias repair.
Will a hypospadias repair in childhood last beyond puberty?
Successful hypospadias repair should last indefinitely. Unfortunately, some urologists have suggested on internet postings that new problems can develop during puberty and/or when sex begins. Other specialists report this is not the case, but rather some problems that were overlooked, or even ignored, during childhood can finally demand attention at puberty when the penis grows.
Approximately 10,000 hypospadias repairs are done each year in the US, so if a large percentage of boys with successful operations developed new problems during and after puberty, adult specialists would be overwhelmed with patients needing redo surgeries. When all the recent published reports of men with problems related to their hypospadias surgery in childhood are added together, including those from centers outside the US, they total less than 500, and these typically involve patients collected over a 10-year period.
Again, it is important for patients to have follow up after surgery to confirm good healing without complications. If there is any question about a result, especially if the surgeon suggests “ don’t worry, it will be ok”, it might be reasonable to seek out another opinion from a hypospadias specialist.