We Have Questions: Adult Hypospadias Surgery

If you've seen the FXX show "Dave," a fictional depiction of rapper Lil Dicky's life, then you've probably heard of hypospadias. In fact, an episode in the show's first season was named after this congenital condition, because the title character is a sufferer who's constantly grappling with crippling self-doubt because he doesn't like the way his penis looks.

Hypospadias is best known as a birth defect in which the opening of the urethra—the tube that carries urine from the bladder through the penis—is located somewhere other than the tip of the penis. While it sounds bad, the condition is generally harmless and fairly rare: About 1 in 200 boys are born with hypospadias, according to urologyhealth.org.

While hypospadias is typically diagnosed at birth, it's possible a man may not be aware of having the condition until later in life. Most cases that could cause major complications are surgically repaired on children, typically between the ages of 3 and 18 months, but men may seek a urologist if they make the discovery later in life. To better understand the rare occurrences of men seeking treatment for the condition, we spoke to Petar Bajic, M.D., a member of the American Urological Association and a urologist at the Cleveland Clinic.

What should people who may have never heard of hypospadias know about it?

Most cases of hypospadias that are deemed troublesome are fixed when the person is an infant, but some are not, and sometimes men experience issues as adults that lead them to seek surgery.

So it's essentially a developmental problem. When a baby is developing in the fetus, the opening that's eventually at the tip of the penis appears lower in the perineum, just below the scrotum, and slowly that opening moves outward along the shaft, before arriving eventually at the tip. For any reason, that opening may not make it to the end of the penis. Commonly, it's just short or on the underside or even right where the shaft meets the head, but it can be anywhere.

If it wasn't repaired while he was a child, what would cause a man to notice hypospadias?

A lot of the time, folks don't even know they have it, and some people have such a minor case that it's 99.9 percent of the way to the tip, with a wall of tissue separating where it is and where it's supposed to be. However, if it's a severe case, it's typically identified when the child is an infant, and it could be associated with chordee and other developmental issues.

Some folks are not diagnosed as a child and might not know about it, and then maybe later in life, they go see the doctor in order to see if they can have something done about it. It usually doesn't affect function in any way at this point, but if a man is very bothered or if they are experiencing some complications, they can get it repaired. Many people who have it repaired as a child would probably need to have it followed up on.

Why would a person with hypospadias not have it treated at birth? What would cause that surgery to be delayed or put off altogether?

Yeah, so when a newborn has hypospadias, doctors will converse with parents, and in the past, parents would want their child to have a "normal" penis, which would lead to surgery. Nowadays, more parents may want to leave the decision to the child, so it's a shared decision between the pediatric urologist and the family.

Now, when I see adults with the condition, we have a general conversation about if it's interfering with function or body self-image. Then we talk about how it's not all that uncommon and that many sexual partners may not even notice. Sometimes just talking about it and explaining that it's not dangerous or life-threatening is all they need.

Obviously, this is rare, but why would an adult man want to get this surgery when reaching adulthood? Would there be other complications that could affect his decision? Who are common candidates for this procedure?

It's fairly uncommon. Most people who have it as an adult just don't need surgery. For those who do opt for it, most commonly there are complications such as an effect on the flow of urine or if they're having a difficult time directing their streams; it could be a few symptoms.

Sometimes, we encounter hypospadias when we do other procedures. In doing so, we find they have a tight opening caused by hypospadias and then we'd do other procedures to open it up. That's a scenario I encounter some.

What issues are most pressing for guys seeking the surgery? And are there any inherent differences between the surgery performed on infants and on men, medically speaking?

So first off, once again, the type of surgery would depend on what the issue is. If they want their penis to appear as if they don't have hypospadias, we can move the opening to the tip of the penis. If they have a tight opening, we do a meatoplasty, in which we open up the hole more, which has minimal complications such as the possibility of it tightening up again. If we're doing a full reconstruction, that has more risks; the number one is there's a chance they could develop a fistula, which is an abnormal connection between the urethra and something else. That would require additional surgery to fix.

For the really severe hypospadias, those are often fixed in childhood; we're almost never doing those in adults. The bottom line is the spectrum for children is wider because we see more different types. If we see adults, they probably have a fairly mild variant.

Are there any other common side effects from surgery on an adult?

Yeah, the most common is just opening the opening more, and this could close back up and form scar tissue. Also, they might spray urine after because of the way the urine flows out. The more involved repairs, where they're moving the opening further up, then you're looking at the fistula and other more severe problems.

Is there anything else about hypospadias in adults that people should know about?

Having this is not anything to worry about if it's not interfering with function. I have many patients who had long-term partners, and they have no idea they have it. It's usually a very mild type that adults experience and a lot of guys just aren't looking that close. If you're worried about it, come see [a doctor] and get it checked out.