Hypospadias

Disease Description (Causes and Symptoms)

• Disease name: Hypospadias (Hypospadias)
• Definition: A congenital malformation in which the urethral opening (meatus) is located not in its normal position (the tip of the penis) but on the underside rather than the dorsal side of the penis (subglanular, penile, penoscrotal, perineal, etc.).
• Causes/Pathophysiology: During the fetal period (approximately weeks 8–15 of pregnancy), the urethral folds (urethral plate) do not fuse normally, so the urethra does not fully form. The symptoms and severity of accompanying malformations vary depending on the extent of the defect.
• Main symptoms:
  • The urethral opening is located lower than normal (subglanular → just below the glans; penoscrotal → locations ranging from the penis to the scrotum and perineum)
  • Difficulty aiming the urine stream or a dispersed stream (urine sprays); particularly when the opening is located on the scrotum or perineum, urinating while standing is difficult → urinating while seated
  • Penile curvature (ventral curvature, chordee) may be present, interfering with sexual activity or urination
  • On external appearance, the foreskin is displaced toward the dorsal side (dorsal hood appearance)
  • Associated findings: Cryptorchidism may be present; in severe cases, ambiguous external genitalia may occur → if both testes are not palpable, sex determination evaluations such as chromosome testing are necessary
• Prevalence: Occurs in approximately 1 in every 300–500 male births (relatively common among congenital anomalies)

Treatment Methods

• Principle: Surgical correction aimed at restoring function (urination and ejaculation) and normal appearance is the primary treatment. Surgery is generally performed in pediatric urology or urology departments.
• Timing of surgery: Recommended before school age, generally before 2 years of age (determined according to severity and health status).
• Surgical methods:
  • One-stage surgery: Straightening the penile curvature and forming the defective urethra (urethroplasty, reconstruction of the urethral tube using skin). Mainly performed for mildly displaced openings (such as subglanular openings).
  • Two-stage surgery: When the urethral opening is located on the scrotum or perineum and the surrounding skin is insufficient in severe cases, skin grafting (autologous skin) is required, so surgery is performed in two stages.
  • Additional procedures include correction of penile curvature (chordee) and foreskin reconstruction.
• Medication/adjunctive treatment:
  • Before surgery, topical or intramuscular testosterone (or hormone therapy) may be used to temporarily enlarge the penis and facilitate surgery (indications and side effects should be considered).
  • Short-term antibiotics may be prescribed after surgery, with pain-management medication as needed.
• Postoperative care (lifestyle management):
  • Maintain the catheter/stent after surgery and manage dressings and wounds (follow the hospital’s instructions)
  • Restrict bathing, swimming, and similar activities for a certain period according to the medical team’s instructions
  • Activity restrictions (such as strenuous exercise and sexual activity) are recommended during the recovery period
  • Preventive measure: Avoid circumcision before surgery (removal of the foreskin) because the foreskin may be needed as reconstructive material during hypospadias repair or may be considered for cosmetic reasons
• Precautions (risk of complications and self-care):
  • Possible complications: Urethrocutaneous fistula (urethra-to-skin fistula), urethral stricture, residual penile curvature, urethral diverticulum (pouch-like dilation), wound infection, and cosmetic dissatisfaction
  • Long-term follow-up is necessary: urination function, the presence of urethral stricture, sexual function, and psychosocial evaluation (after puberty)
  • Inform the medical team in advance about medical history, including medications, allergies, and bleeding disorders (such as use of anticoagulants), before and after surgery

Outpatient Visit Checkpoints (Including Example Questions)

• Items/materials to prepare:
  • List of currently used medications (including supplements)
  • History of previous surgeries and hospitalizations, and birth history (neonatal records if available)
  • Previous imaging and test results (abdominal/pelvic ultrasound, blood tests, hormone tests, etc.) and medical certificates or reports (if available)
  • Record of symptom changes: urination pattern (whether the stream is forceful or dispersed), pain or blood during urination, symptoms of urinary tract infection, urinary frequency, and bed-wetting
  • Observational photographs (photos showing the appearance of the external genitalia; if taken before the appointment, contact the hospital and follow its privacy and photography guidelines)
• Things to check during the outpatient visit:
  • Whether the testes are palpable (if neither testis is palpable, additional testing is recommended)
  • Degree of penile curvature and location of the urethral opening (examined directly by the physician: the location of the urethral opening is observed by pulling the dorsal penile skin)
  • Growth and developmental status (especially in cases after puberty)
• Visit in an emergency situation:
  • Inability to urinate (urinary retention), excessive bleeding, severe redness, purulent discharge, or high fever (suspected postoperative infection)

General Example Questions to Ask the Doctor

• "Is surgery necessary for the current condition? When do you recommend having surgery?"
• "What functional and cosmetic results and success rate can be expected from the surgery?"
• "What are the major complications of the surgery, and how often do they occur?"
• "Are there any medications that need to be stopped specifically before or after surgery?"
• "How will long-term follow-up of urination, sexual function, and fertility be conducted?"

Examples of Condition-Specific Questions

• "The urethral opening is currently located in the middle of the penis. Would one-stage surgery be sufficient, or would a skin graft be necessary?"
• "Do you recommend increasing the penile size with a hormone (testosterone) injection before surgery? What are its advantages and disadvantages?"