In males the urethra is a crucial component of both the urinary and reproductive systems.

The urethra is a fibro-muscular tube that extends from the urinary bladder to the tip of the penis and out to the external environment; it allows for the passage of urine and semen.

What is hypospadias?

Hypospadias is a congenital birth defect in boys, where the urethral opening is not located at the tip of the penis but, instead, is located on the underside of the penis.

The urethral opening on the baby’s penis might be located anywhere from below the tip of the penis to the scrotum.

Hypospadias is usually an isolated condition and it not associated with any other health conditions. It rarely presents as part of a syndrome.

How common is hypospadias?

It is estimated that 1 in 200 baby boys are born with hypospadias, making it one of the most common birth defects in males.

Hypospadias is present in all races and ethnicities and sometimes runs in families. However, it is more common in babies where there is no family history.

Hypospadias is thought to occur when the urethra develops abnormally between weeks 8 and 14 of pregnancy.

Risk factors for hypospadias

Although the exact cause of hypospadias is unknown, research tells us that there are certain factors in the mother which appear to increase the chances of hypospadias in male infants.

The factors are:

Mothers who are over the age of 35 when pregnant, and who are also obese, have a greater chance of having a baby boy with hypospadias
Fertility treatments. Certain reproductive technologies and medications can increase the chances of having a male infant affected by the condition
Certain hormones, taken either just before or during pregnancy – for example, progesterone. This is sometimes prescribed for women with a history of recurrent miscarriage or second trimester pregnancy loss
Family history. Boys whose father or brother have hypospadias have a greater chance of the condition
Small for gestational age and low birth weight. Interestingly, both are common features amongst those with hypospadias.

To find out more, read BellyBelly’s article Excess Pregnancy Weight Increases Risk Of Birth Defects, Study Finds.

What causes hypospadias?

The exact causes of hypospadias are still unknown but it is thought that it could be caused by a combination of genetic, hormonal and environmental factors, possibly including dietary factors or medications used in pregnancy.

How is hypospadias diagnosed?

Hypospadias is usually diagnosed at birth during a routine physical examination of the newborn.

Rarely, blood tests and x-rays are required to confirm the diagnosis.

Hypospadias can be detected prenatally with an ultrasound, by an abnormal shaping of the tip of the penis. One study showed ultrasound reflected a positive predictive value for hypospadias as 72%. However, as many cases of hypospadias are mild, these will go unnoticed during routine prenatal ultrasounds and therefore will not be detected before birth.

There doesn’t appear to be any connection between hypospadias and abnormal amniotic fluid levels.

Low Amniotic Fluid Levels – Oligohydramnios.

Hypospadias – types

There are different degrees of hypospadias, ranging from mild to severe. They are classified based on the location of the urethral opening.

The types are:

Anterior. The urethral opening is located near the head of the penis. This is also known as distal hypospadias and includes subcoronal or glandular
Middle. The urethral opening is located somewhere on the penile shaft or mid-section of the penis. It is also known as distal penile, proximal penile, proximal hypospadias or mid shaft.
Posterior. The urethral opening is located where the base of the penis and the scrotum meet. This type includes scrotal, penoscrotal and perineal.

Posterior hypospadias is the least common of all the types, with an estimated 20% of cases. Anterior hypospadias is the most common with approximately 50% of cases.

Hypospadias – symptoms

Hypospadias is usually diagnosed around the time of birth, during a routine physical examination of the newborn. However, in some infants who have hypospadias but also have a complete foreskin, the condition might only become obvious after newborn circumcision. If hypospadias is discovered before circumcision, then the procedure should not be performed.

For more information about this, read our article Circumcision And Parental Rights – Can They Be Taken Away?

Due to the abnormal location of the opening of the urethra, it’s common for patients to experience problems during urination, or during sexual activity.

Possible problems are:

Undescended testicle. There is a link between hypospadias and undescended testis, meaning a small percentage of boys with hypospadias might not have a fully descended testicle at birth
Incompletely formed foreskin on the underside of the penis. This creates what’s known as a dorsal hood of foreskin, which leaves the tip of the penis exposed
Downward curve of the penis. In about 10% of those with an anterior hypospadias, the penis curves downward. This might be more apparent during an erection. A curved penis is also called ‘chordee’
Pain during sexual intercourse. Severe chordee can cause discomfort during erection and might lead to problems during intercourse and, possibly, an inability to penetrate during sex
Abnormal spraying during urination. Because the urethra is the tube that carries urine from the bladder to the outside of the body, its abnormal location can affect the urinary stream. It therefore might be necessary to sit down to pee rather than stand, which could have some negative social implications. Although patients might have problems during peeing, hypospadias doesn’t appear to increase the incidence of urinary tract infections.

Hypospadias – complications

Depending on its severity, hypospadias can cause certain emotional concerns, such as shame and embarrassment or poor self esteem when it comes to sexual relationships.

Some men might be hesitant to engage in sexual activities due to the appearance of their penis, problems during erection or because of impaired ejaculation.

Can hypospadias be corrected?

Not all boys will require hypospadias repair. In some mild forms of the condition, the opening of the urethra is not too displaced and therefore does not cause any functional problems. If this is the case, surgery might not be necessary.

People who have severe hypospadias might require surgery. Surgical repair can be used to correct hypospadias and is best performed by a paediatric urologist.

The purpose of hypospadias surgery is to straighten the penis and to correct the abnormal opening of the urethra, therefore straightening the urinary channel.

How is hypospadias treated?

Many paediatric urologists prefer to perform the surgery on babies somewhere between 3 and 18 months of age. Sometimes, however, this is not possible. Hypospadias repair can be done at any age during childhood and into adulthood.

It’s unclear whether a child’s age has an impact on the effectiveness of the surgery. Naturally, the younger the child is at the time, the less fear he is likely to have as he approach the surgery; ideally he will have no memory of the procedure or recovery.

Most hypospadias repairs can be performed on an outpatient basis, meaning the corrective surgery can be performed under general anaesthesia, so the patient is not awake. He will usually be able to go home later the same day without the need to be admitted.

Sometimes, however, more than one surgery is required, as the process might need to be performed in stages. This is more common in proximal hypospadias, where there is significant curvature of the penis. Paediatric urologists often need to correct the curve and create a straight penis before trying to reconstruct the urinary system.

In complex hypospadias, tissue grafts are sometimes required from the foreskin to help correct the urinary channel. Therefore it’s important that when hypospadias is detected at birth, circumcision should not be performed on those babies, in case surgical techniques require the foreskin during the process of repair.

Hypospadias surgery is often very successful, and should not affect performance or sexual sensation in adulthood, or the ability to reach orgasm. Your baby’s healthcare provider will probably want to see your child a few times after the surgery, to make sure all is as it should be and then, most likely, around the time of potty training and at puberty.

Hypospadias repair – complications

As with any procedure, there are some risks and potential complications involved with hypospadias surgery.

Common complications include:

Bleeding
Infection
Pain
Bladder spasms
Narrowing of the urethra.

Speak to your child’s healthcare provider if you have any concerns regarding your child’s recovery after hypospadias repair.

Can a man with hypospadias get a woman pregnant?

Hypospadias does not directly affect fertility; however, men with severe hypospadias might have infertility problems due to associated complications with the testes.

Severe hypospadias can also cause difficulties or pain with erection, penetration and ejaculation, making sex more challenging.

Research suggests that males with hypospadias are more likely to be given a diagnosis of infertility compared with those without the condition. They are also more likely to become biological fathers with the use of assisted reproductive technologies.

For more on infertility diagnosis, read our article Male Infertility | What Causes Male Infertility?

How can I prevent hypospadias?

As the exact cause of hypospadias is still relatively unknown, it’s hard to say definitively what to do to try to prevent such birth defects.

The best advice, in general terms, would be to address any ongoing health problems, eat well and avoid, as far as possible, exposure to any unnecessary toxins.

Also:

Speak to your healthcare providers about any current medical conditions or medications you might be on before or in the early stages of pregnancy
Try to maintain a healthy weight prior to and during pregnancy
Exercise regularly
Eat a well balanced diet including a variety of fresh fruits and vegetables
Try to incorporate organic produce as much as possible
Avoid smoking or alcohol consumption
Make sure you have the recommended dose of folic acid or folate as part of your daily routine.

Learn more about the differences between folic acid and folate in our article Folic Acid For Pregnancy – Facts You MUST Know.

Key points

Hypospadias is one of the most common birth defects in male infants, where the urinary opening is in the wrong place and is not located at the tip of the penis.

The degree and severity of hypospadias depends on where the opening is located, which can vary and might occur anywhere from the head of the penis to the scrotum.

Most complications of hypospadias involve problems related to urination, sexual pleasure and sexual performance in later life.

Anterior or distal hypospadias is the most common type, occurring in approximately 50% of cases.

Unless very mild, hypospadias treatment involves surgery to correct the placement of the urinary opening, to improve the urine stream. Sometimes hypospadias surgery is performed in stages if more than one surgery is needed. For example, if there is significant curving of the penis, it might need to be corrected before further surgery.