Hypospadias: what it is, classification, surgery and complications

Hypospadias is a congenital malformation in which the external urethral meatus does not open at the tip of the glans, but at some point along the ventral (under) surface of the penis. It is caused by incomplete development of the urethra during fetal life and may or may not be associated with penile curvature. It occurs in about 0.3% of male newborns and is corrected surgically. The term derives from the Greek and refers precisely to this abnormal opening.

Classification: where the meatus opens

Hypospadias is classified according to the position of the external urethral meatus, assessed after correcting any penile curvature. Three broad groups are distinguished:

• Anterior hypospadias (about 50% of cases): the most frequent and mildest form. Subdivided into glanular and subcoronal
• Middle hypospadias (about 20%): subdivided into distal penile, mid-penile and proximal penile
• Posterior hypospadias (about 30%): the most complex form. Classified as penoscrotal, scrotal and perineal

Incidence and associated anomalies

Hypospadias occurs in about 0.3% of healthy male newborns. In a proportion of cases it is associated with other conditions:

• Undescended testis (cryptorchidism): present in about 10% of cases
• Disorders of sex development: in patients with posterior hypospadias associated with a non-palpable testis, a karyotype is recommended to exclude these conditions

Diagnosis: evident at birth

The diagnosis of hypospadias is generally made at birth. There are two classic clinical signs:

• The abnormal position of the external urethral meatus
• The dorsal preputial hood: the foreskin is incomplete on its ventral aspect, as a consequence of the absent urethral spongiosum. In practice the foreskin is present only above and is missing below

Treatment: surgery

The treatment of hypospadias is essentially surgical. The operation has three aims: to reconstruct a straight penis, to bring the meatus back to as natural a position as possible, and thereby to ensure a forward-directed urinary stream and an adequate sexual life in adulthood.

The surgical techniques have been progressively refined over the years. The underlying principle is the distinction between anterior and posterior hypospadias, which entails operations of very different complexity.

Surgery for anterior hypospadias

Operations for anterior forms are generally simpler and have an essentially aesthetic-functional purpose: to bring the urethral meatus back to the centre of the glans. The most recommended age for these operations is between the 6th and 18th month of life. The most widely used procedures are:

• MAGPI (meatal advancement and glanuloplasty)
• GAP (glans approximation plasty)
• Mathieu technique
• Tubularised incised plate urethroplasty

More recently, techniques using buccal mucosa grafts to reconstruct the anterior urethra have been introduced.

Surgery for posterior hypospadias

Operations for posterior forms are considerably more complex: the segment of urethra to be reconstructed is longer and is associated with penile curvature of varying degree. For this reason they may require several surgical stages, performed at different times, even months apart. Here too the use of buccal mucosa for urethral reconstruction has become established.

Complications

The most feared complications of hypospadias surgery are:

• Stenosis of the external urethral meatus: a narrowing of the reconstructed opening
• Urethral fistulae: abnormal communications between the reconstructed urethra and the skin
• Diverticula of the reconstructed urethra: sac-like dilatations of the urinary tract

Frequently asked questions about hypospadias

Is hypospadias serious?

In most cases, no. A child with hypospadias is asymptomatic and the malformation has no impact on general health. The anterior forms, about half of all cases, are mild. Surgical correction mainly aims to ensure a forward-directed urinary stream and normal sexual function in adulthood. Posterior forms are more complex and require more elaborate surgery.

At what age is hypospadias operated on?

For anterior forms the most recommended age is between the 6th and 18th month of life. Posterior forms, being more complex, may require several operations at different times, even months apart. The specialist defines the timing for each case.

Does hypospadias affect fertility or sexual life?

The aim of surgical correction is precisely to ensure a straight penis and a meatus in a functional position, allowing normal sexual life in adulthood. In uncorrected forms, the abnormal position of the meatus can cause an abnormal direction of the urinary stream and, in adulthood, of the semen. Posterior forms, often associated with an undescended testis, should also be assessed for fertility.

What is a karyotype and when is it needed in hypospadias?

A karyotype is the test that analyses the chromosomes. In hypospadias it is recommended in posterior forms associated with a non-palpable testis, to exclude disorders of sex development. In most hypospadias cases no additional tests are needed, because the malformation is isolated.

What is buccal mucosa and why is it used?

Buccal mucosa is the inner lining of the cheek. Taken in small fragments, it is used to reconstruct the missing urethra, in both anterior and posterior forms. It is a particularly suitable tissue because it is accustomed to a moist environment, is resilient and grafts well.

Do you need an assessment for hypospadias? Ask Prof. Natali for a consultation or book an appointment at his practices in Florence and Empoli, Italy.

The information on this page is provided for general educational purposes and does not replace a medical examination, which remains the only diagnostic tool for correct and effective treatment.