Hypospadias is a birth defect found in boys in which the urinary tract opening is not at the tip of the penis. Bending of the penis on erection may be associated and is known as chordee. Hypospadias occurs in about 1 in 100 to 1 in 200 boys. When we see a boy with hypospadias there is a 20% chance of finding this in another family member such as father or a brother. There are different degrees of hypospadias, some minor and others more severe. We name the types of hypospadias according to their anatomic location, but one must always determine whether or not there is associated chordee.
This is caused by a defect in the formation of the urinary tube called the urethra. The incomplete formation of the urethra makes the urinary opening on the underside of the penis. The severity of the deformity depends on the length of the urethra formed. The lesser the length, more proximal is the opening.
There are no regular symptoms or complains like pain, swelling, redness or straining to pass urine, and hence the anomaly can be easily overlooked early after birth. As the boy begins to grow, stand, walk, run, he also begins to pass urine standing up. At this time, an observant parent will notice that the child passes urine in a stream that is not directed away from the body, but downwards and on his own feet or clothes. As this deformity causes no obvious discomfort, there is no need for early correction. The ideal age for operative correction is about 1½ years. By this time the tissues and the skin of the penis are more supple, mature, firm and can be properly sutured.
Surgical correction of hypospadias involves straightening of any chordee and then extension of the urinary tube (urethra) out to the tip of the penis (the glans). The ability to stand and urinate is important for boys. When the urethra opens before it reaches the glans a boy may be unable to stand and urinate with a direct stream. The youngster who has to sit down to urinate on a toilet is at a painful social disadvantage. A straight penis is necessary for satisfactory sexual function. Although this may not seem to be an important matter in childhood, this is a crucial concern later in life. Early childhood is generally the best time for correction of hypospadias and/or chordee.
How are hypospadias and chordee repaired?
We recommend that the children have surgery to correct hypospadias at about six to nine months of age. Although we try and correct most children with one operation, about 10% will require a second surgical procedure to manage complications. If that is necessary, the second operation is delayed for one year. By performing the first operation early in life, both operations can be completed before the child is finished toilet training.
The operations performed to correct the hypospadias vary according to the degree of abnormality. The extra foreskin is sometimes needed to construct a new urethra. When the operation is completed, the extra skin is removed so the child will look circumcised. To protect the newly constructed urethra (neourethra) the urine is usually diverted with a stent (a silastic tube through the neourethra). We also leave a plastic dressing on the penis, which can be removed by the parent at home.