eMedicine Specialties > Pediatrics: Surgery > Urology
Hypospadias: Treatment & Medication
Updated: Sep 25, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Minor cases of hypospadias, in which the meatus is located up toward the tip of the glans, may not require surgical repair and may simply be managed with observation.
Surgical Care
The goals of treating hypospadias are to create a straight penis by repairing any curvature (orthoplasty), to create a urethra with its meatus at the tip of the penis (urethroplasty), to re-form the glans into a more natural conical configuration (glansplasty), to achieve cosmetically acceptable penile skin coverage, and to create a normal-appearing scrotum. The resulting penis should be suitable for future sexual intercourse, should enable the patient to void while standing, and should present an acceptable cosmetic appearance.
- Timing of surgery
- Before 1980, hypospadias repair was performed in children older than 3 years because of the larger size of the phallus and a technically easier procedure; however, genital surgery at this age (genital awareness occurs at about age 18 mo) can be associated with significant psychological morbidity, including abnormal behavior, guilt, and gender identity confusion.
- Currently, most physicians attempt to repair hypospadias when the child is aged 4-18 months, trending toward earlier intervention. This has been associated with an improved emotional and psychologic result.
- Late hypospadias repair, in the pubertal and postpubertal period, is associated with complications, primarily urethrocutaneous fistula, in nearly half of patients. More recent reports suggest a higher rate of complication in 5-year-old patients than in 1-year-old patients, suggesting that earlier repair is generally better.11
- Types of repair
- The specific techniques for hypospadias repair are beyond the scope of this article (see Urogenital Reconstruction, Penile Hypospadias); however, the types of repairs can be generically grouped, and the approach to the repair is relatively standard.
- After fully assessing the penile anatomy, the shaft skin of the penis is degloved to eliminate any skin tethering, and an artificial erection is performed to rule out any curvature. Mild-to-moderate chordee may be repaired by excising any ventral fibrous tethering tissue or by plicating the dorsal tunics of the corporal bodies, compensating for any ventral-to-dorsal disproportion. More severe chordee may require grafting of the ventral corporal bodies using synthetic, animal (small intestinal subunit), cadaveric, or autologous tissues (tunica vaginalis or dermal grafts) to avoid excessive shortening of penile length. On rare occasion, the urethral plate may be tethered and transection of the plate may be required, precluding the use of native urethral tissues for urethroplasty.
- The urethra may be extended using various techniques. These techniques are generally categorized as primary tubularizations, local pedicled skin flaps, tissue grafting techniques, or meatal advancement procedures.
- The tubularized incised plate (TIP) repair has become the most commonly used repair for both distal and midshaft hypospadias. This technique is a primary tubularization of the urethral plate, with incision of the posterior wall of the plate, which allows it to hinge forward (see Media file 7). This creates a greater diameter lumen than would otherwise be possible, obviating the routine use of a flap or graft to bridge a short narrow segment of urethral plate. The procedure has proved adaptable to various settings, and current surveys indicate that this is the procedure of choice for most repairs by most urologists.
Tubularized incised plate (TIP) technique. The urethral plate has been incised in the dorsal midline, expanding the width of the plate and allowing it to hinge forward for tubularization.
- For repeat repairs after unsuccessful surgery for hypospadias when local tissues are unavailable, buccal mucosa has been used for urethral grafting. This tissue is well suited for this purpose because of its availability, characteristics that favor graft success, and its resilience to a moist environment. Urethral stents are generally used for bladder drainage while healing occurs in all but the most distal hypospadias repairs.
- Steps of repair
- Glans flaps are generally mobilized to cover the distal urethral repair, bringing the divergent ventral components to the midline and creating a more conical configuration. The excess dorsal skin is mobilized to the deficient ventral aspect of the penis for final skin coverage.
- The repair of penoscrotal transposition is often performed as a staged procedure because the necessary incisions may compromise the vascular pedicle to skin flaps used in the primary urethroplasty. The repair of penoscrotal transposition is usually deferred at least 6 months to allow for adequate formation of collateral blood supply.
- The repair of hypospadias is generally planned as a single-stage procedure, but excessive chordee (especially if transection of the urethral plate is required), poor skin availability, and small phallic size may be better approached in a staged manner. The chordee is repaired and the skin is mobilized to the ventral penile shaft during the first stage, and the urethroplasty and glansplasty are repaired after the first stage has completely healed.
- Adjuvant hormonal therapy: Although no medical therapy for the correction of hypospadias is known, hormonal therapy has been used as an adjuvant treatment for infants with exceptionally small phallic size. Presurgical treatment with testosterone injections or creams, as well as HCG injections, has been used to promote penile growth, and some have reported improvement in chordee with lessening in the severity of the hypospadias. The fact that prepubertal androgen therapy may limit normal genital growth at puberty is a concern but has not been confirmed clinically.
Consultations
Consultation with a pediatric endocrinologist is indicated in cases in which a child may be suspected of having a DSD (intersex).
More on Hypospadias |
| Overview: Hypospadias |
| Differential Diagnoses & Workup: Hypospadias |
 Treatment & Medication: Hypospadias |
| Follow-up: Hypospadias |
| Multimedia: Hypospadias |
| References |
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Further Reading
Keywords
hypospadias, chordee, penile deformity, anterior urethral anomaly, penile development anomaly, subcoronal hypospadias, ventral curvature of the penis, circumcision, human chorionic gonadotropin, undescended testes, inguinal hernias, disorder of sexual development, DSD, penis development
