History

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.^[30]

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.

View Media Gallery

Differential Diagnoses

van der Horst HJ, de Wall LL. Hypospadias, all there is to know. Eur J Pediatr. 2017 Apr. 176 (4):435-441. [QxMD MEDLINE Link]. [Full Text].
Hadidi AT. History of hypospadias: Lost in translation. J Pediatr Surg. 2017 Feb. 52 (2):211-217. [QxMD MEDLINE Link].
Baskin LS. Hypospadias and urethral development. J Urol. 2000 Mar. 163 (3):951-6. [QxMD MEDLINE Link].
Barcat J. Current concepts in treatment. Horton CE, ed. Plastic and Reconstructive Surgery of the Genital Area. Boston: Little Brown; 1973. 249-62.
Duckett JW. Hypospadias. Walsh PC, Retik AB, Vaughan ED, et al, eds. Campbell's Urology. 7th ed. Philadelphia: WB Saunders; 1998. 2093-119.
Visser R, Burger NC, van Zwet EW, Hilhorst-Hofstee Y, Haak MC, van den Hoek J, et al. Higher Incidence of Hypospadias in Monochorionic Twins. Twin Res Hum Genet. 2015 Oct. 18 (5):591-4. [QxMD MEDLINE Link].
Joodi M, Amerizadeh F, Hassanian SM, Erfani M, Ghayour-Mobarhan M, Ferns GA, et al. The genetic factors contributing to hypospadias and their clinical utility in its diagnosis. J Cell Physiol. 2019 May. 234 (5):5519-5523. [QxMD MEDLINE Link].
Aaronson IA, Cakmak MA, Key LL. Defects of the testosterone biosynthetic pathway in boys with hypospadias. J Urol. 1997 May. 157 (5):1884-8. [QxMD MEDLINE Link].
Silver RI, Russell DW. 5alpha-reductase type 2 mutations are present in some boys with isolated hypospadias. J Urol. 1999 Sep. 162 (3 Pt 2):1142-5. [QxMD MEDLINE Link].
Simpson JL. Birth defects and assisted reproductive technologies. Semin Fetal Neonatal Med. 2014 Jun. 19 (3):177-82. [QxMD MEDLINE Link].
Silver RI. What is the etiology of hypospadias? A review of recent research. Del Med J. 2000 Aug. 72 (8):343-7. [QxMD MEDLINE Link].
Raghavan R, Romano ME, Karagas MR, Penna FJ. Pharmacologic and Environmental Endocrine Disruptors in the Pathogenesis of Hypospadias: a Review. Curr Environ Health Rep. 2018 Dec. 5 (4):499-511. [QxMD MEDLINE Link].
Wang MH, Baskin LS. Endocrine disruptors, genital development, and hypospadias. J Androl. 2008 Sep-Oct. 29 (5):499-505. [QxMD MEDLINE Link].
Kalfa N, Philibert P, Baskin LS, Sultan C. Hypospadias: interactions between environment and genetics. Mol Cell Endocrinol. 2011 Mar 30. 335 (2):89-95. [QxMD MEDLINE Link].
Gatti JM, Kirsch AJ, Troyer WA, Perez-Brayfield MR, Smith EA, Scherz HC. Increased incidence of hypospadias in small-for-gestational age infants in a neonatal intensive-care unit. BJU Int. 2001 Apr. 87 (6):548-50. [QxMD MEDLINE Link].
Paulozzi LJ, Erickson JD, Jackson RJ. Hypospadias trends in two US surveillance systems. Pediatrics. 1997 Nov. 100 (5):831-4. [QxMD MEDLINE Link].
Källén B, Bertollini R, Castilla E, Czeizel A, Knudsen LB, Martinez-Frias ML, et al. A joint international study on the epidemiology of hypospadias. Acta Paediatr Scand Suppl. 1986. 324:1-52. [QxMD MEDLINE Link].
Yu X, Nassar N, Mastroiacovo P, et al. Hypospadias Prevalence and Trends in International Birth Defect Surveillance Systems, 1980-2010. Eur Urol. 2019 Oct. 76 (4):482-490. [QxMD MEDLINE Link].
Gallentine ML, Morey AF, Thompson IM Jr. Hypospadias: a contemporary epidemiologic assessment. Urology. 2001 Apr. 57 (4):788-90. [QxMD MEDLINE Link].
Long CJ, Canning DA. Hypospadias: Are we as good as we think when we correct proximal hypospadias?. J Pediatr Urol. 2016 Aug. 12 (4):196.e1-5. [QxMD MEDLINE Link].
Weber DM, Landolt MA, Gobet R, Kalisch M, Greeff NK. The Penile Perception Score: an instrument enabling evaluation by surgeons and patient self-assessment after hypospadias repair. J Urol. 2013 Jan. 189 (1):189-93. [QxMD MEDLINE Link].
van der Toorn F, de Jong TP, de Gier RP, Callewaert PR, van der Horst EH, Steffens MG, et al. Introducing the HOPE (Hypospadias Objective Penile Evaluation)-score: a validation study of an objective scoring system for evaluating cosmetic appearance in hypospadias patients. J Pediatr Urol. 2013 Dec. 9 (6 Pt B):1006-16. [QxMD MEDLINE Link].
Krull S, Rissmann A, Krause H, Mohnike K, Roehl FW, Koehn A, et al. Outcome after Hypospadias Repair: Evaluation Using the Hypospadias Objective Penile Evaluation Score. Eur J Pediatr Surg. 2018 Jun. 28 (3):268-272. [QxMD MEDLINE Link].
Snodgrass W, Bush NC. Persistent or recurrent ventral curvature after failed proximal hypospadias repair. J Pediatr Urol. 2019 Aug. 15 (4):344.e1-344.e6. [QxMD MEDLINE Link].
Kiss A, Sulya B, Szász AM, Romics I, Kelemen Z, Tóth J, et al. Long-term psychological and sexual outcomes of severe penile hypospadias repair. J Sex Med. 2011 May. 8 (5):1529-39. [QxMD MEDLINE Link].
Lorenzo AJ, Pippi Salle JL, Zlateska B, Koyle MA, Bägli DJ, Braga LH. Decisional regret after distal hypospadias repair: single institution prospective analysis of factors associated with subsequent parental remorse or distress. J Urol. 2014 May. 191 (5 Suppl):1558-63. [QxMD MEDLINE Link].
Bethell GS, Chhabra S, Shalaby MS, Corbett H, Kenny SE, BAPS NOAH Contributors. Parental decisional satisfaction after hypospadias repair in the United Kingdom. J Pediatr Urol. 2020 Apr. 16 (2):164.e1-164.e7. [QxMD MEDLINE Link].
Winship BB, Rushton HG, Pohl HG. In pursuit of the perfect penis: Hypospadias repair outcomes. J Pediatr Urol. 2017 Jun. 13 (3):285-288. [QxMD MEDLINE Link].
Springer A, Reck CA, Huber C, Horcher E. Online hypospadias support group data analysis. J Pediatr Surg. 2011 Mar. 46 (3):520-4. [QxMD MEDLINE Link].
Nemec SF, Kasprian G, Brugger PC, Bettelheim D, Nemec U, Krestan CR, et al. Abnormalities of the penis in utero--hypospadias on fetal MRI. J Perinat Med. 2011 Jul. 39 (4):451-6. [QxMD MEDLINE Link].
Khuri FJ, Hardy BE, Churchill BM. Urologic anomalies associated with hypospadias. Urol Clin North Am. 1981 Oct. 8 (3):565-71. [QxMD MEDLINE Link].
[Guideline] Kolon TF, Herndon CDA, Baker LA, Baskin LS, Baxter CG, Cheng EY, et al. Evaluation and treatment of cryptorchidism (2014). American Urological Association. Available at https://www.auanet.org/guidelines/guidelines/cryptorchidism-guideline. April 2014; Accessed: June 11, 2021.
Kaefer M, Diamond D, Hendren WH, Vemulapalli S, Bauer SB, Peters CA, et al. The incidence of intersexuality in children with cryptorchidism and hypospadias: stratification based on gonadal palpability and meatal position. J Urol. 1999 Sep. 162 (3 Pt 2):1003-6; discussion 1006-7. [QxMD MEDLINE Link].
Ikoma F, Shima H, Yabumoto H. Classification of enlarged prostatic utricle in patients with hypospadias. Br J Urol. 1985 Jun. 57 (3):334-7. [QxMD MEDLINE Link].
Kim KH, Lee HY, Im YJ, Jung HJ, Hong CH, Han SW. Clinical course of vesicoureteral reflux in patients with hypospadias. Int J Urol. 2011 Jul. 18 (7):521-4. [QxMD MEDLINE Link].
Hester AG, Kogan SJ. The prostatic utricle: An under-recognized condition resulting in significant morbidity in boys with both hypospadias and normal external genitalia. J Pediatr Urol. 2017 Oct. 13 (5):492.e1-492.e5. [QxMD MEDLINE Link].
Timing of elective surgery on the genitalia of male children with particular reference to the risks, benefits, and psychological effects of surgery and anesthesia. American Academy of Pediatrics. Pediatrics. 1996 Apr. 97 (4):590-4. [QxMD MEDLINE Link]. [Full Text].
Bermudez DM, Canning DA, Liechty KW. Age and pro-inflammatory cytokine production: wound-healing implications for scar-formation and the timing of genital surgery in boys. J Pediatr Urol. 2011 Jun. 7 (3):324-31. [QxMD MEDLINE Link].
Dodson JL, Baird AD, Baker LA, Docimo SG, Mathews RI. Outcomes of delayed hypospadias repair: implications for decision making. J Urol. 2007 Jul. 178 (1):278-81. [QxMD MEDLINE Link].
Korvald C, Stubberud K. High odds for freedom from early complications after tubularized incised-plate urethroplasty in 1-year-old versus 5-year-old boys. J Pediatr Urol. 2008 Dec. 4 (6):452-6. [QxMD MEDLINE Link].
Hensle TW, Tennenbaum SY, Reiley EA, Pollard J. Hypospadias repair in adults: adventures and misadventures. J Urol. 2001 Jan. 165 (1):77-9. [QxMD MEDLINE Link].
Snodgrass W, Villanueva C, Bush N. Primary and reoperative hypospadias repair in adults--are results different than in children?. J Urol. 2014 Dec. 192 (6):1730-3. [QxMD MEDLINE Link].
Carmack A, Notini L, Earp BD. Should Surgery for Hypospadias Be Performed Before An Age of Consent?. J Sex Res. 2016 Oct. 53 (8):1047-1058. [QxMD MEDLINE Link].
Roen K, Hegarty P. Shaping parents, shaping penises: How medical teams frame parents' decisions in response to hypospadias. Br J Health Psychol. 2018 Nov. 23 (4):967-981. [QxMD MEDLINE Link].
Schlomer B, Breyer B, Copp H, Baskin L, DiSandro M. Do adult men with untreated hypospadias have adverse outcomes? A pilot study using a social media advertised survey. J Pediatr Urol. 2014 Aug. 10 (4):672-9. [QxMD MEDLINE Link]. [Full Text].
Sun LS, Li G, Miller TL, Salorio C, Byrne MW, Bellinger DC, et al. Association Between a Single General Anesthesia Exposure Before Age 36 Months and Neurocognitive Outcomes in Later Childhood. JAMA. 2016 Jun 7. 315 (21):2312-20. [QxMD MEDLINE Link]. [Full Text].
Davidson AJ, Disma N, de Graaff JC, Withington DE, Dorris L, Bell G, et al. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet. 2016 Jan 16. 387 (10015):239-50. [QxMD MEDLINE Link]. [Full Text].
McCann ME, de Graaff JC, Dorris L, Disma N, Withington D, Bell G, et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial. Lancet. 2019 Feb 16. 393 (10172):664-677. [QxMD MEDLINE Link].
Sepúlveda PO, Epulef V, Campos G. Why do We Use the Concepts of Adult Anesthesia Pharmacology in Developing Brains? Will It Have an Impact on Outcomes? Challenges in Neuromonitoring and Pharmacology in Pediatric Anesthesia. J Clin Med. 2021 May 18. 10 (10):[QxMD MEDLINE Link]. [Full Text].
Kerstein RL, Sedaghati T, Seifalian AM, Kang N. Effect of human urine on the tensile strength of sutures used for hypospadias surgery. J Plast Reconstr Aesthet Surg. 2013 Jun. 66 (6):835-8. [QxMD MEDLINE Link].
Bilici S, Sekmenli T, Gunes M, Gecit I, Bakan V, Isik D. Comparison of dartos flap and dartos flap plus spongioplasty to prevent the formation of fistulae in the Snodgrass technique. Int Urol Nephrol. 2011 Dec. 43 (4):943-8. [QxMD MEDLINE Link].
Chang PC, Yeh ML, Chao CC, Chang CJ. Use of double pigtail stent in hypospadias surgery. Asian J Surg. 2011 Jan. 34 (1):28-31. [QxMD MEDLINE Link].
Xu N, Xue XY, Wei Y, Li XD, Zheng QS, Jiang T, et al. Outcome analysis of tubularized incised plate repair in hypospadias: is a catheter necessary?. Urol Int. 2013. 90 (3):354-7. [QxMD MEDLINE Link].
Daher P, Khoury A, Riachy E, Atallah B. Three-week or one-week bladder catheterization for hypospadias repair? A retrospective-prospective observational study of 189 patients. J Pediatr Surg. 2015 Jun. 50 (6):1063-6. [QxMD MEDLINE Link].
Chua M, Welsh C, Amir B, Silangcruz JM, Ming J, Gnech M, et al. Non-stented versus stented urethroplasty for distal hypospadias repair: A systematic review and meta-analysis. J Pediatr Urol. 2018 Jun. 14 (3):212-219. [QxMD MEDLINE Link].
Bennett AH, Gittes RF. Congenital penile curvature without hypospadias. Urology. 1980 Oct. 16 (4):364-6. [QxMD MEDLINE Link].
Kogan BA. Intraoperative pharmacological erection as an aid to pediatric hypospadias repair. J Urol. 2000 Dec. 164 (6):2058-61. [QxMD MEDLINE Link].
Villanueva CA. Goniometer not better than unaided visual inspection at estimating ventral penile curvature on plastic models. J Pediatr Urol. 2019 Dec. 15 (6):628-633. [QxMD MEDLINE Link].
Villanueva CA. Ventral penile curvature estimation using an app. J Pediatr Urol. 2020 Aug. 16 (4):437.e1-437.e3. [QxMD MEDLINE Link].
Snodgrass W, Bush N. Staged Tubularized Autograft Repair for Primary Proximal Hypospadias with 30-Degree or Greater Ventral Curvature. J Urol. 2017 Sep. 198 (3):680-686. [QxMD MEDLINE Link].
Asgari SA, Safarinejad MR, Poorreza F, Asl AS, Ghanaie MM, Shahab E. The effect of parenteral testosterone administration prior to hypospadias surgery: A prospective, randomized and controlled study. J Pediatr Urol. 2015 Jun. 11 (3):143.e1-6. [QxMD MEDLINE Link].
Gorduza DB, Gay CL, de Mattos E Silva E, Demède D, Hameury F, Berthiller J, et al. Does androgen stimulation prior to hypospadias surgery increase the rate of healing complications? - A preliminary report. J Pediatr Urol. 2011 Apr. 7 (2):158-61. [QxMD MEDLINE Link].
Rynja SP, de Jong TPVM, Bosch JLHR, de Kort LMO. Testosterone prior to hypospadias repair: Postoperative complication rates and long-term cosmetic results, penile length and body height. J Pediatr Urol. 2018 Feb. 14 (1):31.e1-31.e8. [QxMD MEDLINE Link].
Pfistermuller KL, McArdle AJ, Cuckow PM. Meta-analysis of complication rates of the tubularized incised plate (TIP) repair. J Pediatr Urol. 2015 Apr. 11 (2):54-9. [QxMD MEDLINE Link].
Jiang DD, Chakiryan NH, Gillis KA, Acevedo AM, Austin JC, Seideman CA. Perioperative complications within 30 days of hypospadias surgery: Results from NSQIP-Pediatrics. J Pediatr Urol. 2020 Jun. 16 (3):316.e1-316.e7. [QxMD MEDLINE Link].
Wilkinson DJ, Green PA, Beglinger S, Myers J, Hudson R, Edgar D, et al. Hypospadias surgery in England: Higher volume centres have lower complication rates. J Pediatr Urol. 2017 Oct. 13 (5):481.e1-481.e6. [QxMD MEDLINE Link].
Lee OT, Durbin-Johnson B, Kurzrock EA. Predictors of secondary surgery after hypospadias repair: a population based analysis of 5,000 patients. J Urol. 2013 Jul. 190 (1):251-5. [QxMD MEDLINE Link].
Ekmark AN, Svensson H, Arnbjörnsson E, Hansson E. Postpubertal examination after hypospadias repair is necessary to evaluate the success of the primary reconstruction. Eur J Pediatr Surg. 2013 Aug. 23 (4):304-11. [QxMD MEDLINE Link].
Yildiz T, Tahtali IN, Ates DC, Keles I, Ilce Z. Age of patient is a risk factor for urethrocutaneous fistula in hypospadias surgery. J Pediatr Urol. 2013 Dec. 9 (6 Pt A):900-3. [QxMD MEDLINE Link].
Chung JW, Choi SH, Kim BS, Chung SK. Risk factors for the development of urethrocutaneous fistula after hypospadias repair: a retrospective study. Korean J Urol. 2012 Oct. 53 (10):711-5. [QxMD MEDLINE Link]. [Full Text].
Nguyen S, Durbin-Johnson B, Kurzrock EA. Reoperation after Hypospadias Repair: Long-Term Analysis. J Urol. 2021 Jun. 205 (6):1778-1784. [QxMD MEDLINE Link].
Kanaroglou N, Wehbi E, Alotay A, Bagli DJ, Koyle MA, Lorenzo AJ, et al. Is there a role for prophylactic antibiotics after stented hypospadias repair?. J Urol. 2013 Oct. 190 (4 Suppl):1535-9. [QxMD MEDLINE Link].
Chertin B, Natsheh A, Ben-Zion I, Prat D, Kocherov S, Farkas A, et al. Objective and subjective sexual outcomes in adult patients after hypospadias repair performed in childhood. J Urol. 2013 Oct. 190 (4 Suppl):1556-60. [QxMD MEDLINE Link].

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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