Though it affects around one in every 150 male births, chances are good you have never heard of hypospadias — a condition in which the penis, rather than having a hole at the tip through which urine passes, has a hole on the underside. It’s a condition that can cause issues with urination, as well as sexual function, if it isn’t corrected early.
Dan Wood, PhD, MBBS, FRCS Urol, and Duncan Wilcox, MD, both professors of urology in the University of Colorado Department of Surgery, recently published a paper in the International Journal of Impotence Research that gives a high-level look at hypospadias, including incidence, epidemiology, surgery, research, complications, and outcomes.
“We wanted to give an overview as to what patients can expect further down the line,” Wood says. “There was a tweet about our paper from a urologist in Ireland saying. ‘This is a great summary; please can we use this as patient information?’ That's a nice acknowledgment of where the paper sits — to offer an updated and comprehensive overview of hypospadias surgery in general.”
How hypospadias happens
Hypospadias occurs during development, when the penis doesn't form as it should. In addition to the misplaced opening for urine — which can be as low as between the testicles — it also can cause a bend in the penis, especially during erection, and an incomplete foreskin that is wrapped around the back of the penis, instead of completely encircling it. Males with the condition typically have to urinate sitting down, and they may have issues later in life stimulating or inseminating a sexual partner. Urologists aren’t certain what causes it, though there are indications it may be associated with a nutritional deficiency or an older mother. It also has a higher rate of occurrence in in vitro fertilization.
Hypospadias can be corrected; techniques vary, depending on how close the hole is to the tip of the penis. The procedure involves reconstructing the urethra to move the opening to the proper spot, sometimes using skin from other parts of the body — including the foreskin, cheek lining, and behind the ear — to create a new tube through which urine can pass.
“We have historically corrected it somewhere between six months and 18 months of age, the idea being that if you do the procedure at that age, the patient won’t notice it much or won’t recall the operation,” Wilcox says. “The operation also appears to be easier to do at that age.”
To correct or wait
Though hypospadias has historically been surgically corrected shortly after birth, Wood and Wilcox’s paper notes an increasing number of parents who opt not to correct the condition, citing concerns about the child’s inability to consent to the procedure. Hypospadias also often goes untreated in parts of the world with more limited access to health care. Some milder forms of hypospadias may not even need to be treated.
“There’s a wide variation, from something that is largely cosmetic and may not need correcting to something that impacts function and there's a much greater surgical imperative for correcting it,” Wood says. “There's a spectrum along the way, and that requires judgment from good clinicians and a clear discussion with parents about how you might take that forward.”
When complications arise
Hypospadias that occurs near the tip of the penis, which represent around 80% of all hypospadias, are easiest to correct, Wood and Wilcox say. When the hole is closer to the testicles and the penis is bent, however, it can be a much more difficult procedure. Their paper notes a 60% reoperation rate in those cases, after two previous operations to correct the issue.
“What we as pediatric urologists think is a once-and-done thing, fixed and never to be a problem again — actually, that's not the case,” Wilcox says. “We are seeing a 24% to 25% complication rate later in life.”
Those complications can include lower urinary tract symptoms such as needing to urinate more often or issues with the urinary stream, as well as fistulas and a residual bend in the penis.
“One of the things we wanted to highlight in the paper was the more recent research in which people have looked at the complication rate more honestly, and highlighting that in the more complex hypospadias, the outcomes can be poor,” Wood says. “Even good centers are reporting poor outcomes. This is not a problem that is resolved in childhood and never needs to be reviewed or thought of again.”