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Hypospadias

  • Amid the joys of welcoming your child into the world, it can be very stressful to learn that he has been born with any kind of abnormality—especially one that may need surgery in the early months of his life. In the case of hypospadias, the opening of your son’s urethra (through which both urine and semen passes) is located under the penis rather than at the tip; you may have concerns about what this means for everything from toilet training to his future life as an adult.

    • Hypospadias is fairly common, affecting about 1 in 200 boys.

    • It’s often readily corrected through outpatient surgery.

    • The outlook for infants who undergo this operation is extremely good: In most instances, they make a full recovery and have a normal-looking, fully functional penis within about six months.

    While some children with very mild forms of this condition may not require surgery, if your son has hypospadias you should seek an evaluation from a pediatric urologic surgeon.

    Note: Hypospadias also occurs in girls, but it’s extremely rare (affecting an estimated one in 500,000 babies) and a vastly different condition. If your daughter is born with hypospadias, your Children’s specialist will be your best source of information and support.

    How Boston Children’s Hospital approaches hypospadias

    At Children’s, we have a dozen surgeons with extensive experience caring for children with this condition: Our team sees some 250 to 300 children with hypospadias a year.

    Beyond using the most-up-to-date technology to treat children with hypospadias, our Department of Urology is also looking to the future. Our physicians and researchers are leading a number of studies and trials that hold great promise in the detection and treatment of this condition. Their projects include:

    • conducting ongoing research into the genetics of hypospadias, to understand what causes it and help identify it at the earliest possible stage

    • developing techniques that allow surgeons to do more kinds of hypospadias operations in a single repair session, rather than two

    • working to reduce the incidence of fistulas, a complication sometimes seen after hypospadias surgery in which a small hole opens up in the newly formed urethra

    • developing expertise in using buccal mucosa—tissue from the inside of the cheek—for surgical grafts when no local tissue (that is, foreskin) is available

    Reviewed by Alan Retik, MD
    © Children’s Hospital Boston, 2010

  • We understand that you may have a lot of questions when your child is diagnosed with hypospadias, such as:

    • What is it?
    • What are the treatments?
    • How will it affect my child long-term?

    We’ve tried to provide some answers to those questions here, and when you meet with our experts, we can talk with you more about your child’s specific situation.

    If your son has hypospadias, it means that the opening of his urethra (through which both urine and semen passes) is located under the penis rather than at the tip.

    In hypospadias, the urethral opening can be located at any point along the underside of the penis (also called the “ventral aspect”). Where the opening falls will determine how severe the condition is, and how your child’s medical team will approach repairing it.

    • Anterior or distal (near the tip of the penis): This is the mildest form of hypospadias, occurring in about 50 percent of cases.

    • Middle (midway up the penis): Considered moderate hypospadias, this accounts for about 30 percent of cases.

    • Posterior or proximal (at the scrotum or perineum): This is the most severe kind of hypospadias, and occurs in 20 percent of cases.

    Some parents may confuse hypospadias with epispadias, in which the urethra opens along the top of the penis, but these are two separate and distinct conditions with very different treatments.

    Complications

    If left untreated, more severe forms of hypospadias can interfere with sexual intercourse when your child is an adult.

    Causes

    Hypospadias is a congenital condition, meaning that it happens while the baby is developing in the mother’s womb. As the fetus develops, the tissue on the underside of the penis that forms the urethra doesn't completely close, shortening the passageway. In many cases, the foreskin—the fold of skin covering the penis tip, or glans—also doesn’t develop properly, resulting in extra foreskin on the top side of the penis and none on the underside.

    Hypospadias isn’t brought on by anything that parents do, or fail to do, during pregnancy. In fact, even though the number of cases has been on the rise since the 1970s, there’s no known cause of hypospadias. Researchers do know, however, that it appears to run in families: Hypospadias is slightly more common in boys whose father or brother also had the condition.

    Signs and symptoms

    The number one sign of hypospadias is that your son’s urethra is located on the underside of his penis, as opposed to the tip. Other signs that you might see in your child include:

    • a downward urinary spray (in older children with more severe hypospadias, this may mean he has to sit down to urinate)
    • a downward curve of the penis, called “chordee”
    • a “hooded” appearance to the penis, caused by extra foreskin along the top side
    • an abnormal appearance of the tip of the penis (the glans)

    In some cases, boys born with hypospadias may also have undescended testicles and/or inguinal hernias (that is, hernias of the groin).

    FAQ

    Q: How will I know if my baby has hypospadias?
    A:
    While it’s possible for physicians to detect signs of severe hypospadias on a fetal ultrasound, the vast majority of children are diagnosed at birth.

    Q: Is hypospadias painful?
    A:
    This condition won’t cause your son physical pain or block his urination (though if it goes untreated it can make it difficult for him to direct his urine spray).

    Q: Do all boys with hypospadias need surgery?
    A:
    If your son has a very mild case, he may not require surgery because his condition will not have a large impact on his life. However, sometimes parents of boys born with minor abnormalities still opt for surgery for cosmetic reasons.

    Q: Are there any medical alternatives to surgery?
    A:
    No, surgery remains the best and only way to resolve your son’s urinary difficulties; to straighten and repair his penis so it will look more normal; and to help ensure that he will have full sexual function as an adult.

    Q: When should the operation be scheduled?
    A:
    This depends on what kind of hypospadias your child has, and whether he was diagnosed at birth (most boys are). Typically, if he requires surgery, we recommend that it be scheduled when he is between 4 and 6 months old.

    Q: What kind of care will my son need after surgery?
    A:
    This depends on whether your child is diagnosed at birth, and how severe his hypospadias is. But if he’s like the vast majority of boys that Children’s treats—infants ages 4 to 6 months who undergo a one-step operation—you’ll be able to take him home on the same day of the surgery. Our nurses will teach you how care for your son at home while he heals.

    Q: Will this affect when and whether my son will be circumcised?
    A:
    Babies who have hypospadias that requires surgery shouldn’t be circumcised, because the foreskin may be needed for tissue grafts during the operation.

    Q: If my son’s hypospadias doesn’t require surgery for medical reasons, can it still be done to make his penis look more normal?
    A:
    Yes—surgeons will often perform hypospadias repairs for more “cosmetic” reasons, like straightening the penis and removing excess foreskin.

    Q: Will this affect when and how I potty-train my son?
    A:
    At Children’s, we believe that the best window for hypospadias surgery is between 4 and 6 months, which means your son will have healed well before the age of potty-training.

    Q: How soon after surgery will my son’s penis looks like other little boys’?
    A:
    It varies from patient to patient, but typically you’ll be able to see the full results of your son’s surgery after six months.

    Useful medical terms

    Anterior hypospadias: The mild form of hypospadias, in which the urethra opens beneath the tip or upper shaft of the penis. Also called distal hypospadias.

    Chordee: An abnormal downward curve of the penis, especially during erection.

    Circumcision: Removing all or part of the foreskin from the penis.

    Congenital: Present at birth.

    Dorsal hood: Incompletely formed foreskin that covers the top (dorsal) part of the penis but leaves the underside (ventral) part exposed.

    Foreskin: The loose fold of skin that covers the head of the penis.

    Glans: The bulblike tip of the penis. Also called the glans penis.

    Meatus: The opening of the urethra.  

    Middle hypospadias: The moderate form of hypospadias, in which the urethra opens beneath the midshaft of the penis. Also called midshaft hypospadias.

    Orthoplasty: Surgical straightening of the penis.

    Posterior hypospadias: The severe form of hypospadias, in which the urethra opens beneath the base of the penis or behind the scrotum. Also called proximal hypospadias.

    Stent: A narrow, soft artificial tube placed in the new urethra to hold it open during healing. Also called a catheter.

    Urethra: A tube that carries urine from the bladder to the tip of the penis; it also carries semen from the prostate to the tip of the penis.

    Urethroplasty: The surgical creation of a new urethra (neourethra).

  • The first step in treating your child is forming an accurate and complete diagnosis. Hypospadias can only rarely be seen on ultrasound, so doctors typically diagnose it just after the baby is born, during his first physical examination. The location of the urethral opening (or “pee hole”) on the underside of your child’s penis indicates what type of hypospadias you’ll be dealing with:

    • mild, near the tip of the penis
    • moderate, midway up the penis
    • severe, at the scrotum or perineum

    It’s possible that the mildest forms of hypospadias can be overlooked, so you should contact your doctor if you notice that your son’s urethral opening is not at the tip of his penis, that his penis curves downward or his foreskin is not fully developed.

    Upon diagnosing hypospadias, your doctor should refer your son to a pediatric urologic surgeon.


  • It's entirely natural that you might be concerned, right now, about your child's health; a diagnosis of hypospadias can be frightening. But you can rest assured that, at Boston Children's Hospital, your child is in good hands. Our physicians are bright, compassionate and committed to focusing on the whole child, not just his condition—that's one reason our urology department is frequently ranked as one of the best among U.S. pediatric hospitals.

    Surgery can correct hypospadias and give your child a normal-looking, fully functional penis. In most cases, the procedure is relatively simple and boys make full recoveries within six months or so.If your son has a very mild form of hypospadias, he may not need surgery because his condition is unlikely to affect his future as a husband and a father. But otherwise, a pediatric urological surgeon can perform the procedure to correct the hypospadias, ideally when your son is between 4 to 6 months old.

    Surgery

    There are a number of different techniques your child's surgeon may use. We will discuss these with you, and answer any questions you might have, while planning the surgery best suited to correct your son's hypospadias. But whatever the individual techniques may be, the surgeon will be working toward three main goals:

    • to reposition the opening of urethra at the tip of the penis (urethroplasty)
    • to straighten the penis, if chordee is present (orthoplasty)
    • to improve the outward appearance of the penis (removing the hooded foreskin)

    Your son will receive general anesthesia for the procedure, which typically lasts one-and-a-half to two hours. Most of the time, the surgeon will complete the repair in one session. Some of more severe cases, however, require two sessions spaced about six months apart.

    And though the prospect of surgery may feel daunting for some parents, Children's has extensive experience and a very high success rate with hypospadias repair.

    After surgery

    Depending on the extent of surgery, your child may either go home the same day or stay in the hospital overnight. The Children's nurses will talk with you how to care for him at home and will provide detailed instruction sheets (how to manage his dressing, what activities should be avoided, etc.).

    For your child's recovery period, your doctor may prescribe any or all of the following:

    • acetaminophen (Tylenol), to help ward off soreness in the first few days after surgery
    • antibiotic ointment, to be applied to the penis several times a day
    • oral antibiotics
    • antispasmodic medication, to alleviate bladder spasms

    Also, your son's surgeon will likely have inserted a soft drainage catheter, or stent, into the new urethra during the procedure. The stent will remain in your child's urethra (you will be able to see the tip) to hold it open while it heals and to allow urine to drain from the bladder.

    Follow-up care

    Your child's doctor will remove the stent during a follow-up appointment 7 to 10 days after the surgery.

    You and your son will return to see your doctor a month after the surgery, and then again a few months later, so we can make sure the healing is coming along. You typically can expect to see the full results of successful surgery within six months.

    Coping and support

    We understand that hypospadias can be disruptive and frightening—not only for your child, but for your whole family. From your first visit, you'll work with a team of professionals who are committed to supporting you. There are a variety of resources at Children's to help you and your family:

    Patient education: From the office visit to pre-op to the recovery room, our nurses will be on hand to walk you through your child's treatment and help answer any questions you may have—How long will I be separated from my child during surgery? What will the operating room be like? They will also reach out to you by phone, continuing the care and support you received while at Children's.

    Parent to parent: Want to talk with someone whose child has been treated for hypospadias? We can often put you in touch with other families who have been through the same procedure that you and your child are facing, and share their experience.

    Faith-based support: A diagnosis of hypospadias may affect how and when your son is circumcised. If this is a religious consideration for you, or if you are simply in need of spiritual support, we will help connect you with the Children's chaplaincy.

    Social work: As part of Children's broader social work program, our pediatric urology department has a dedicated professional who has helped many other families in your situation. Your social worker can offer counseling and assistance with issues such as coping with your child's diagnosis; dealing with financial difficulties; and finding temporary housing near the hospital if your family is traveling to Boston from another area.

    On our For Patients and Families website, you'll find all you need to know about:

    • getting to Children's
    • accommodations
    • navigating the hospital experience
    • other resources that are available for your family

  • Research & Innovation

    Beyond using the most-up-to-date technology to treat children with hypospadias, the Department of Urology at Boston Children’s Hospital is also looking to the future. Our physicians and researchers are leading a number of studies and trials that hold great promise in the detection and treatment of this condition. Their projects include:

    • conducting ongoing research into the genetics of hypospadias, to understand what causes it and help identify it at the earliest possible stage
    • developing techniques that allow surgeons to do more kinds of hypospadias operations in a single repair session, rather than two
    • working to reduce the incidence of fistulas, a complication sometimes seen after hypospadias surgery in which a small hole opens up in the newly formed urethra
    • developing expertise in using buccal mucosa—tissue from the inside of the cheek—for surgical grafts when no local tissue (that is, foreskin) is available

    Clinical trials

    There are many ways in which your child might benefit from Children’s medical research program. Our doctors and scientists have made many breakthrough discoveries about diseases like polio and leukemia; our ongoing innovative research continues to push the boundaries of the way pediatric medicine is practiced.

    It’s possible that your child will be eligible to participate in one of Children’s current clinical trials. These studies are useful for a multitude of reasons: Some trials are designed to evaluate the effectiveness of a particular drug, treatment or therapy on a specific disease; others help doctors to better understand how and why certain conditions occur. At any given time, Children’s has hundreds of clinical trials under way.

    And participation in any clinical trial is completely voluntary: We will take care to fully explain all elements of the treatment plan prior to the start of the trial, and you may remove your child from the medical study at any time.

    Search current and upcoming clinical trials at Children’s.

    Search the NIH’s list of clinical trials taking place around the world.

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