Hypospadias

Understanding the normal penis and urethra

The urethra is the tube that urine flows through out of the bladder. It passes through the penis. The opening of the urethra (meatus or 'pee-hole') is normally at the end of the penis, partly covered by the foreskin.

What is the penis like in hypospadias?

The main problem is that the urethra opens on the underside of the penis instead of at the end of the penis. The opening can be anywhere from just below the normal position (mild) to as far back as the base of the scrotum (severe).

Hypospadias may also include the following.

• A hooded appearance of the foreskin. This is because the foreskin does not develop on the underside of the penis.
• Tightening of the tissues on the underside of the penis (called 'chordee'). This pulls the penis down and it cannot fully straighten. The further back the urethral opening is the more severe the chordee tends to be. Mild hypospadias may not have any chordee.

What problems can hypospadias cause?

Problems are likely to occur if hypospadias is left untreated. The further back the opening of the urethra is, the more severe the problems are likely to be.

• Passing urine is different to normal. A baby in nappies will have no problem. However, when older the urine stream may not be able to be directed forward into a urinal. When going to the toilet the urine is likely to 'spray' backwards. Sitting on a toilet may be needed to pass urine without mess.
• Chordee which causes bending of the penis. This is more noticeable when the penis is erect. Sexual intercourse may be difficult or impossible in severe cases.
• Psychological problems about being 'different' to normal are common.

Are any tests needed?

The diagnosis is usually obvious from examining the penis. No other tests are routine.

A small number of people with severe hypospadias (when the urethral opening is at the base of the scrotum) may have other abnormalities of the genitals. The appearance of severe hypospadias may be part of a rare 'intersex' syndrome. Therefore, tests of the chromosomes and scans of the genitals may be made to determine if it is part of a wider syndrome. Note: these syndromes are rare and most boys with hypospadias are truly 'male' and have no other abnormalities.

How common is hypospadias and what causes it?

About 1 in 400 boys are born with some degree of hypospadias. It seems to be getting more common.

The reason why the penis does not develop properly is not clear. The development of the penis whilst the baby is growing in the womb is partly dependent on the male sex hormones such as testosterone. The effects of testosterone on the growing penis may be blocked in some way. One study found that vegetarian mothers were five times more likely to have a son with hypospadias than meat eaters. The reason for this is not known. One theory is that chemicals such as fertilisers, pesticides, etc, that are more commonly eaten by vegetarians may have something to do with it.

What is the treatment for hypospadias?

A full discussion with a surgeon is needed to decide what can be done. The goal of treatment is for urine to be passed in a forward way, for the penis to be straight when erect, and for the penis to look as normal as possible.

If the hypospadias is mild, with the opening of the urethra just a little down from normal and with no bending of the penis, then no treatment may be needed. However, if the urethral opening is further back, or if there is any chordee (causing bending), then an operation is usually advised. The position of the opening of the urethra is altered. Also, if chordee are present then these are cut to allow the penis to straighten.

Most surgeons recommend an operation before the child is two years old. The success of the operation and the 'normality' that can be achieved may depend on the severity of the hypospadias.

© EMIS and PIP 2004   Updated: December 2003   CHIQ Accredited