Hypospadias is an abnormality of the urethra and penis that is present at birth. This can cause problems with passing urine and also with erections. It can range in severity. Surgical correction is usually very successful.
What is 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). 7 out of 10 cases are usually the mild type.
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.
About 1 in 300 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 still not clear. The development of the penis whilst the baby is growing in the womb (uterus) 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. Although it is not a genetic condition, hypospadias can run in some families.
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.
- Mild erection difficulties and premature ejaculation have been reported in adulthood in patients who have had surgery for hypospadias in childhood.
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Are any tests needed?
The diagnosis is usually obvious from examining the penis. No other tests are routine. However, 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 is hypospadias treated?
If the hypospadias is mild, with the opening of the urethra just a little down from normal and with no bending of the penis, no treatment may be needed.
However, in most cases an operation is required to correct the hypospadias. This can usually be done in one operation. However, if the hypospadias is more complicated, two operations may be necessary. The operation is usually done when the child is around 4-18 months old.
A full discussion with a surgeon is needed to decide what can be done. The goals of treatment are:
- For urine to be passed in a forward way.
- For the penis to be straight when erect.
- For the penis to look as normal as possible.
The position of the opening of the urethra is altered. Also, if chordee is present then this is corrected to allow the penis to straighten. The foreskin is usually used during the operation to make the new urethra so it is important that a circumcision is not done before the corrective surgery is performed.
What is the outlook (prognosis) for hypospadias?
The success of the operation and the 'normality' that can be achieved, depend on the severity of the hypospadias.
Further reading and references
van der Horst HJ, de Wall LL; Hypospadias, all there is to know. Eur J Pediatr. 2017 Apr176(4):435-441. doi: 10.1007/s00431-017-2864-5. Epub 2017 Feb 11.
Winberg H, Arnbjornsson E, Anderberg M, et al; Postoperative outcomes in distal hypospadias: a meta-analysis of the Mathieu and tubularized incised plate repair methods for development of urethrocutaneous fistula and urethral stricture. Pediatr Surg Int. 2019 Nov35(11):1301-1308. doi: 10.1007/s00383-019-04523-z. Epub 2019 Aug 1.
White JT, Kovar E, Chambers TM, et al; Hypospadias Risk from Maternal Residential Exposure to Heavy Metal Hazardous Air Pollutants. Int J Environ Res Public Health. 2019 Mar 1516(6). pii: ijerph16060930. doi: 10.3390/ijerph16060930.
van Rooij IA, van der Zanden LF, Brouwers MM, et al; Risk factors for different phenotypes of hypospadias: results from a Dutch case-control study. BJU Int. 2013 Jan 10. doi: 10.1111/j.1464-410X.2012.11745.x.
EAU Paediatric Urology Guidelines. Edn. presented at the EAU Annual Congress Copenhagen; European Association of Urology, 2018