The Facts About Hypospadias

Hypospadias is a condition where the opening of the urethra—the tube that carries urine and semen through the length of the penis and eventually out the end—isn't in its usual place at the tip of the penis.

The condition may cause physical issues, including with urination and sexual functioning, but also can contribute to psychological and social problems.

Hypospadias occurs in about 1 in 200 newborn males, according to the Centers for Disease Control and Prevention (CDC). In some cases of hypospadias, the opening to the urethra may be slightly farther down the bottom of the shaft than what is considered typical. However, it can be located even farther down, as low as where the scrotum meets the shaft of the penis or on the perineum.

Boys with hypospadias may spray when they urinate. They may have associated conditions such as a sharply curved penis—a condition called chordee—or an undescended testicle.

If left untreated, hypospadias may mean a lifetime of sitting down to urinate, and it may cause trouble conceiving. That's because, depending on where the opening of his urethra is, when the man ejaculates, his semen may not reach far enough into the vaginal canal to fertilize an egg.

Hypospadias is a congenital birth defect believed to be due to a combination of genetics and environmental factors.

There is evidence boys who have close relatives with hypospadias are more likely to have it. It's also believed to be associated with substances the mother comes into contact with during pregnancy, such as foods, beverages, medications and substances in her environment.

According to CDC research, some commonalities among mothers who have babies with hypospadias may exist. These include:

• Weight and age. Mothers who were obese and 35 or older had a significantly higher risk of having a baby with hypospadias.
• Fertility treatment. Women who used assisted reproductive technology (ART) such as in vitro fertilization (IVF) had higher rates of babies with hypospadias.
• Hormones. Women who took hormones such as progestin before or during pregnancy showed higher rates of hypospadias births.
• Pesticides. Further research is needed, but as rates of hypospadias appear to be rising in Western cultures, some evidence suggests it may be associated with the increased use of pesticides and pollutants.

Diagnosing the condition is straightforward. The routine examination the doctor conducts on a newborn includes checking for conditions such as hypospadias. The doctor will also check for certain associated conditions of the genitalia, such as:

• Chordee. With this condition, the penis curves sharply, usually downward.
• Undescended testicle. This occurs when a testicle fails to fully drop down into the scrotum while the child is developing in the womb. It's present in about 10 percent of hypospadias cases, according to Cleveland Clinic.
• Undeveloped foreskin. This is a condition in which the foreskin doesn't completely cover the head of the penis.
• Abnormal urination. This occurs when hypospadias causes the child's urine to spray or have a divergent stream.

If the doctor detects hypospadias during the exam, they will determine which type it is:

• Subcoronal. This is when the urethral opening is located near the head of the penis but below where it typically would be.
• Midshaft. This type of hypospadias occurs when the opening of the urethra is found to be somewhere along the shaft of the penis.
• Penoscrotal. Penoscrotal hypospadias is when the opening of the urethra is located in the area where the penis and scrotum meet.

Adults who have had hypospadias surgically repaired may still have obstacles to overcome. For starters, they may need more than a single surgery. One study of men who needed hypospadias repair revealed they needed an average of three surgeries to get the job done. Ten percent of them required five surgeries or more.

Even after multiple surgeries, these adults could still end up with a penis that curves downward, making urination and sex uncomfortable. In some cases, the opening of the urethra may be considered close enough to where it is typically located, and they may decide to decline surgery.

However, even if the opening is near the end of the penis, men may need to sit down to pee or they risk spraying. They may have to accommodate a deviated stream for life.

Treating hypospadias is ideally done while the child is an infant. Most surgeons will recommend waiting until the child is 6 to 18 months old. A little more development makes it easier for the parents to care for the child's surgical site. It also means the infants can better tolerate the anesthesia needed to perform the two- to three-hour procedure.

Another consideration for parents is the timing of circumcision. Many people in the medical community agree it's best not to circumcise the child until after the hypospadias repair. This may be difficult for some parents with strong religious beliefs, especially considering that most circumcisions are done within 24 to 72 hours of birth. It's important, though, because the foreskin is often used to help create a new urethral tube in order to place the opening at the typical location.

Hypospadias repair surgery typically includes the following:

• Constructing a new urethra
• Placing the urethral opening at the tip of the penis
• Straightening the penis shaft
• Reconstructing the foreskin

Sometimes, hypospadias repair requires a two-stage procedure, especially if it is the penoscrotal type. This means the child will need to undergo a second surgery some months later.

It's possible for adults to undergo hypospadias repair surgery. However, given the larger size of adult genitalia, among other factors, it's a more complex and difficult procedure. In adults, hypospadias repair will frequently require multiple procedures.

Most people who have hypospadias repair surgery as babies go on to live comfortable lives with few issues. Sometimes, though, complications may develop over time as the child grows into an adult. They may need surgeries to reposition the urethra, straighten the shaft of the penis or other reconstructive surgeries.

Hypospadias repair surgery can be complicated. Some children develop an extra hole from the urethra to the surface of the skin called a fistula. Sometimes, the procedure may cause scarring that affects urine flow or the appearance of the penis.

Adults who have had repair surgery for hypospadias frequently continue to face challenges throughout their lives. These can include post-urination dribbling, a diverted urinary stream and a "surplus of skin."

The psychological complications of hypospadias—both the condition itself and the results of surgical repair—are difficult to quantify since everyone is different.

However, one long-term study indicated many men who have undergone hypospadias repair are unhappy with the appearance of their genitals, which may lead to general low self-esteem. These kinds of concerns may contribute to sexual dysfunction.

Counseling can help, and there are support groups specific to men who have undergone hypospadias repair.

The prognosis for children and adults who have hypospadias repair procedures is very good. Modern surgical techniques ensure these repairs can endure for their entire lives, and most patients go on to live with penises that are healthy and function normally.

What is the main cause of hypospadias?

It's difficult to pinpoint the exact cause of hypospadias, but genetics play a key role. Also, women who do the following during pregnancy may help prevent hypospadias in the fetus:

• Take 400 to 800 milligrams of folic acid daily.
• Avoid smoking and drinking alcohol.
• Control their weight.
• Avoid certain hormones.
• Avoid frequent contact with pesticides and pollutants.

Does hypospadias need to be corrected?

Not always. Sometimes, the urethral opening may be close enough to the typical spot that parents and their medical team may opt to forgo surgery.

Why are children with hypospadias not circumcised?

In performing hypospadias repair surgery, the successful reconstruction of the penis and building a new urethra frequently benefit from using the foreskin. Leaving it intact until the repair surgery helps surgeons with the procedure.