Hypospadias - Definition Hypospadias is a congenital deformity where the opening of the urethra (the meatus) occurs on the underside (ventral) part of the penis, anywhere from the glans to the perineum. It is often associated with a hooded foreskin and chordee (ventral curvature of the penile shaft). It occurs in 1 in 250 live male births. There is an 8% incidence in off-spring of an affected male, and a 14% risk in male siblings.
Classification Hypospadias can be classified according to the anatomical location of the urethral meatus. - Anterior (or distal) : glandular, coronal, and subcoronal (~50%) - Middle : distal penile, midshaft, and proximal penile (~30%) - Posterior (or proximal) : penoscrotal, scrotal, and perineal (~20%)
Aetiology Hypospadias results from incomplete closure of urethral folds on the underside of the penis during embryological development. This is related to a defect in production or metabolism of fetal androgens, or the number and sensitivity of androgen receptors in the tissues. Chordee are caused by abnormal urethral plate development, and the hooded foreskin is due to failed formation of the glandular urethra and fusion of the preputial folds (resulting in a lack of ventral foreskin but an excess of dorsal tissue).
Diagnosis A full clinical examination will make the diagnosis. However, it is also important to seek out associated abnormalities which will need treatment (undescended testes, inguinal hernias, and hydroceles). Patients with absent testes and severe hypospadias should undergo chromosomal and endocrine investigation to exclude intersex conditions.
Treatment Surgery is indicated where deformity is severe, interferes with voiding, or is predicted to interfere with sexual function. Surgery is now performed between 6-12 months of age. Local application of testosterone for 1 month pre-operatively can help increase tissue size. Surgery aims to correct penile curvature (orthoplasty), reconstruct a new urethra, and bring the new meatus to the tip of the glans using urethroplasy, glanuloplasty, and meatoplasty techniques. Severe cases may require staged procedures. Common operations for anterior hypospadias include meatal advancement and glanuloplasty (MAGPI), meatal-based flaps (Mathieu procedure), and tubularization of the urethral plate. Posterior defects require free grafts (buccal mucosa), onlay grafts, and preputial transfer flaps.
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