History

It is important to obtain a thorough history and physical examination, including any history of a familial pattern of hypospadias, any past medical history or comorbidity, and a physical assessment focusing on the meatal location, glans configuration, skin coverage, and ventral curvature (chordee).

A history of parental difficulties in conceiving and treatment should also be documented; in-vitro fertilization (IVF) has been associated with a higher incidence of hypospadias.

Physical Examination

Although the appearance of hypospadias has been identified with both antenatal fetal ultrasonography (US) and magnetic resonance imaging (MRI), the diagnosis is generally made upon examination of the newborn infant.^[31]

A dorsal hood of foreskin and glanular groove are evident, but upon closer inspection, the prepuce is incomplete ventrally and the urethral meatus is noted in an abnormal proximal location. Rarely, the foreskin may be complete, and the hypospadias is revealed at the time of circumcision. If hypospadias is encountered during neonatal circumcision, after the dorsal slit has been performed, the procedure should be halted, and the patient should be referred for urologic evaluation.

Penile curvature may be readily apparent or may be discernible only during erection. Proximal hypospadias is commonly associated with a bifid scrotum and penoscrotal transposition (see the image below), in which the rugated scrotal skin begins lateral to the penis rather than in its normal posterior origin.

Penoscrotal transposition. Note rugated scrotal skin lateral to penis, cephalad to its normal position.

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Differential Diagnoses

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Media Gallery

Proximal shaft hypospadias. Note deficient ventral foreskin, blind urethral pit at glanular level, and lighter pigmented urethral plate extending to true meatus at proximal shaft level.
Proximal shaft hypospadias. Note typical dorsal hood of foreskin and ventral penile skin deficiency.
Penoscrotal hypospadias. Note associated ventral chordee and true urethral meatus located at scrotal level.
Penoscrotal transposition. Note rugated scrotal skin lateral to penis, cephalad to its normal position.
Pedicled preputial island flap is shown. This hairless skin flap will be rotated on its vascular pedicle to ventral aspect of penis for repair of urethra.
Tubularized incised plate (TIP) technique. Urethral plate has been incised in dorsal midline; this expands width of plate and allows it to hinge forward for tubularization.
Urethrocutaneous fistula has appeared after hypospadias repair. Note one stream from true urethral meatus and second stream through more proximal fistula.
Severe penile chordee. Note extreme ventral curvature of penile shaft.
Tubularized incised plate (TIP) technique. Urethral plate has been isolated (dissected) prior to midline incision. Note starting position of urethral opening at base. Assistance with image editing provided by Joseph Borer, MD.
Tubularized incised plate (TIP) technique. Urethral plate has been incised to allow expansion for tubularization. Note deep midline incision (cut edges marked in blue) and widening of urethral plate. Assistance with image editing provided by Joseph Borer, MD.
Tubularized incised plate (TIP) technique. Incised plate has been tubularized over 8-French tube. Note final position of urethral opening at tip of penis, and note that meatus is left quite wide. Assistance with image editing provided by Joseph Borer, MD.
Megameatus intact prepuce (MIP) variant of hypospadias.
Megameatus intact prepuce (MIP) variant of hypospadias, apparent once foreskin is retracted.
Subcoronal hypospadias. Note distal blind-ending false pit at level of glans.
Glanular (balanic) hypospadias with "figure-eight" meatus. Dorsal pit is blind ending; ventral opening is actual urethral meatus.

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Author

John Michael Gatti, MD Chief of Division of Pediatric Urology, Director of Minimally Invasive Urology, Department of Pediatric Surgery and Urology, Children’s Mercy Hospital; Professor, Department of Pediatric Surgery and Urology, University of Missouri-Kansas City School of Medicine; Clinical Professor, Division of Urology, University of Kansas School of Medicine

John Michael Gatti, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Urological Association, International Pediatric Urology Junior Organization, Kansas City Medical Society, Kansas City Urologic Society, Kansas Urological Society, Midwest Society for Pediatric Research, Society for Fetal Urology, Societies for Pediatric Urology

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew J Kirsch, MD, FAAP, FACS Clinical Professor of Urology, Chief of Pediatric Urology, Emory University School of Medicine, Children's Healthcare of Atlanta; Partner, Georgia Urology, PA

Andrew J Kirsch, MD, FAAP, FACS is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, Society for Fetal Urology

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Harry P Koo, MD Chairman of Urology Division, Director of Pediatric Urology, Professor of Surgery, Virginia Commonwealth University School of Medicine, Medical College of Virginia; Director of Urology, Children's Hospital of Richmond

Harry P Koo, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Urological Association

Disclosure: Nothing to disclose.

Chief Editor

Marc Cendron, MD Associate Professor of Surgery, Harvard School of Medicine; Consulting Staff, Department of Urological Surgery, Children's Hospital Boston

Marc Cendron, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, New Hampshire Medical Society, Societies for Pediatric Urology, Society for Fetal Urology, Johns Hopkins Medical and Surgical Association, European Society for Paediatric Urology

Disclosure: Nothing to disclose.

Additional Contributors

Martin David Bomalaski, MD, FAAP Pediatric Urologist, Alaska Urology; Clinical Assistant Professor, Seattle Children's Hospital

Martin David Bomalaski, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Urological Association

Disclosure: Nothing to disclose.

Hypospadias Clinical Presentation

History

Physical Examination

References

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