Hypospadias Treatment & Management

Updated: May 15, 2017
  • Author: John M Gatti, MD; Chief Editor: Marc Cendron, MD  more...
  • Print
Treatment

Approach Considerations

The treatment for hypospadias is surgical repair. Hypospadias is generally repaired for functional and cosmetic reasons. The more proximally ectopic the position of the urethral meatus, the more likely the urinary stream is to be deflected downward, which may necessitate urination in a seated position. Any element of chordee can exacerbate this abnormality. Fertility may be affected. The abnormal deflection of ejaculate may preclude effective insemination, and significant chordee can preclude vaginal insertion of the penis or can be associated with inherently painful erections.

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. It must be kept in mind, however, that although the most minor forms of hypospadias are insignificant in physiologic terms, they too may merit repair on the basis of the potential psychological stress associated with having a genital anomaly.

Next:

Surgical Care

The goals of surgical treatment of hypospadias are as follows:

  • 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
  • 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 months) 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, with a trend toward earlier intervention. This has been associated with an improved emotional and psychological result. A benefit in wound healing with earlier repair has also been perceived and may have a basis in the reduced proinflammatory cytokine production noted at younger ages. [20]

Late hypospadias repair, in the pubertal and postpubertal period, is associated with complications, primarily urethrocutaneous fistula, in nearly half of patients. [21] Some reports cite a higher rate of complications in 5-year-old patients than in 1-year-old patients, suggesting that earlier repair is generally better. [22]

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 a full assessment of 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 by 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 the image below). 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.

Tubularized incised plate (TIP) technique. 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.

The TIP repair has proved adaptable to various settings, and current surveys indicate that it is the procedure of choice for most repairs by most urologists.

Various sutures have been used in the repair of hypospadias, but polyglycolic acid–based sutures may offer the best balance of resilience when exposed to urine, without excessive time to absorption resulting in a foreign body reaction. [23]

Studies support the general concept that increasing the layers of tissue between the urethra and overlying skin coverage makes subsequent development of urethrocutaneous fistula less likely. [24] Temporary urethral stents are a common adjunct to hypospadias repair and are felt to decrease the likelihood of fistula formation. Various drainage tubes have been utilized for this purpose. [25] To stent or not to stent is an ongoing controversy, balancing the risk of irritative symptoms and urinary tract infection with the risk of urinary retention. [26]

In a retrospective-prospective observational study of 189 patients that compared 1 week of transurethral bladder catheterization after hypospadias repair with 3 weeks of catheterization, Daher et al found the longer catheterization period to be associated with better outcomes and fewer complications. [27]

In the setting of repeat repair 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 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 corrective medical therapy for hypospadias is known, hormonal therapy has been used as an adjuvant to surgical therapy in infants with exceptionally small phallic size. Preoperative treatment with testosterone injections or creams, as well as human chorionic gonadotropin (HCG) injections, has been used to promote penile growth; some have reported improvement in chordee with lessening in the severity of hypospadias. That prepubertal androgen therapy may limit normal genital growth at puberty is a concern, but this has not been confirmed clinically.

In a study of 182 children with midshaft or distal hypospadias (mean age, 30 months) who underwent TIP repair for hypospadias, Asgari et al found preoperative parenteral testosterone administration to be beneficial in decreasing complication rates (from 13.18% to 5.45%). [28]

Previous
Next:

Complications

It is clear that repairs that are more proximal are associated with a greater incidence of complications. [29] Older age at surgery and low surgical experience have also been associated with poorer outcomes. A study from England by Wilkinson et al found that staged repairs were associated with higher complication rates and that high-volume centers had lower complication rates. [30]

With longer follow-up, it is apparent that late complications can occur, and thus, most advocate continued evaluation through puberty. [31, 32, 33, 34]

Immediate postoperative concerns

Local edema and blood spotting can be expected early after repair and generally do not cause a significant problem.

Postoperative bleeding rarely occurs and is usually controlled with a compressive dressing. Infrequently, reexploration may be required to evacuate a hematoma and to identify and treat the source of bleeding.

Infection is a rare complication of hypospadias repair in the modern era. Skin preparation and perioperative antibiotics are generally used. Patients are often maintained on an antibiotic course until any stents are removed, though this has not clearly been shown to be beneficial. [35]

Long-term issues

Urethrocutaneous fistulization is a major concern in hypospadias repair. The rate of fistula formation is generally less than 10% for most single-stage repairs but rises with the severity of hypospadias, approaching 40% with complex reoperative efforts. Fistulas rarely close spontaneously and are repaired by using a multilayered closure with local skin flaps 6 months after the initial repair. After repair, fistulas recur in approximately 10% of patients. (See the image below.)

Urethrocutaneous fistula has appeared after hyposp Urethrocutaneous fistula has appeared after hypospadias repair. Note one stream from true urethral meatus and second stream through more proximal fistula.

Meatal stenosis, or narrowing of the urethral meatus, can occur. A urethral stent prevents any problems initially, but a fine-spraying urinary stream that is associated with straining to void likely requires operative meatal revision.

Urethral strictures may develop as a long-term complication of hypospadias repair. These are generally repaired operatively and may require incision, excision with reanastomosis, or patching with a graft or pedicled skin flap.

Urethral diverticula may also form and are evidenced by ballooning of the urethra while voiding. A distal stricture may cause outflow obstruction and may result in a urethral diverticulum. Diverticula can form in the absence of distal obstruction and are generally associated with graft- or flap-type hypospadias repairs, which lack the subcutaneous and muscular support of native urethral tissue. The redundant urethral tissue is generally excised, and the urethra is tapered to an appropriate caliber.

Hair-bearing skin is avoided in hypospadias reconstruction but was used in the past. When incorporated into the urethra, it may be problematic and can result in urinary tract infection or stone formation at the time of puberty. This generally requires cystoscopic depilation using a laser or cautery device or, if severe, excision of hair-bearing skin and repeat hypospadias repair.

Some surveys have suggested that milder forms of erectile dysfunction may be more common with more proximal hypospadias repairs. [36]

Previous
Next:

Consultations

Consultation with a pediatric endocrinologist is indicated in cases where a child may be suspected of having a disorder of sex development.

Previous