What is hypospadias?

In a boy, the opening from where urine comes out is called the urethral meatus, which is located at the tip of the penis. When this opening is located anywhere on the undersurface of the penis, it is called hypospadias.

What happens with a hypospadias?

The meatus opening lower down, and so the stream of urine will be deflected towards the thighs. Once a boy has grown up, and can pass urine while standing, this may be embarrassing. The meatus may also be very small, which can cause a very fine urine stream.
Besides this, the shaft of the penis is often bent downwards. If this bending is significant, then the penis appears very small in size. Also, in adult life, sexual intercourse may be compromised.
Often, the penile size is actually small, unrelated to the bend in the penis.
The foreskin is generally deficient on the undersurface of the penis, and is present like a hood on the tip.

Are all hypospadias patients the same?

No, hypospadias is present in grades. The meatus can be present very close to, but not at the tip of the penis – this is called a distal hypospadias. When it is present closer to the junction of the penis and the scrotum, it is called a proximal hypospadias. Between the two, it is called a mid-penile hypospadias.

The penile size and the degree of bending are often dependant on the grade of hypospadias. The more severe varieties, with proximal hypospadias, tend to have a greater degree of bending and may have a smaller penis than the more distal varieties. In the pictures below, you can see a mid-penile, and a proximal penile hypospadias.

Is surgery possible? What can be achieved with surgery?

Surgery is essential for treating hypospadias. With surgery , the bend in the penis can be straightened.

A meatus must be created at the tip, and a new urinary tube is made to bridge the gap between the old and new meatus. The foreskin can be reconstructed to appear normal. Alternately, the foreskin can be removed, to look like a circumcision has been done.

When should surgery be done?

This depends on the surgeon, and on the grade of hypospadias. In general, the size of the penis must be large enough to technically perform the operation. Psychologically, it has been found that the period from 6 months to 18 months is best, before genital awareness has set in.

Can I have my son circumcised in the meantime ?

No, a circumcision should not be done in boys with a hypospadias. In many types of operations, the foreskin is a valuable skin resource which is used to make the new urine tube, or to cover the shaft of the penis. Loss of this skin can compromise the ability of the surgeon to create a normal looking penis. After surgery, the penis can be made to look like a circumcision has been done.

Is it true that hypospadias needs many operations to correct?

Formerly, surgery of hypospadias was done in two or three stages. These days, most types of hypospadias can be corrected in a single stage. However, each surgeon has his/her own preferences for the surgical technique used, which will determine the number of steps needed.
Surgery for hypospadias is very delicate, and there is a chance that , in spite of  taking very good care, there may be a partial or complete failure of the first operation. If this happens, then another operation may be needed to finish doing the entire correction. The chances of this happening are less than 10%. In other words, 9 out of 10 children will have the problem sorted out in a single operation. 1 out of 10 may need another surgery.

What can go wrong with surgery?

Sometimes, the new urinary tube, or the new meatus may be smaller than expected. This will cause a very fine urine stream, or straining to pass urine.
If one of the stitches of the new urine tube does not heal, there may be an additional opening lower down from where urine may come out.
Unusually, the whole new tube may fail, with the result that the meatus appears to be the same as before surgery. A point to note is that if this happens, since the penis has now been straightened, this opening may appear as if it is lower than the original opening was.
Minor problems are temporary loss of skin after surgery.

What can be done in case of failure?

Some times, additional openings may close down spontaneously.
If the meatus, or the tube is narrow, stretching them may be needed. This is called dilatation, and may be done more than once, using sedation or a light anaesthesia.For other situations, surgery may be needed, and is usually done at least 6 months after the first operation.

Will the second surgery be the last one needed for my child?

Unfortunately, this cannot be said with certainty. A lot depends on how the original operation was done – in very severe cases, subsequent operations may need to be done in stages.
The most important thing is that the final result, be it after more than one operation, must be good.

What can be done about the small size of the penis?

If very small, a course of injections may be prescribed to attempt to enlarge the penis. This may make surgery technically simpler. But the enlargement is often temporary, and may last only a few months. After surgery, straightening the penis may make the size look larger.
After surgery, in childhood, not much is possible for enlarging the penis. At puberty, with the natural surge in hormones, the penis may enlarge further.

However, if the size is significantly small, consultation with an endocrinologist may be advised.
Are other tests needed? Is anything else wrong with my child?

The more severe grades of hypospadias may have other urinary structural problems associated. Tests may be needed to find out if it is so.
A hypospadias with an undescended testis may also need other tests, which are best discussed personally.

Can my son be normal?

After a successful correction at an appropriate age, your son should grow up like any other normal boy. Both the pictures below are of boys after hypospadias surgery. The first picture shows the same boy with the proximal penile hypospadias seen in the picture above.

What is epispadias?

Whereas in hypospadias, the opening of the urethra in on the undersurface of the penis, in epispadias, this in on the upper (visible) surface of the penis.