Surgery

Depending on the type of hypospadias, surgery is often carried out with the aims of: closing the penis opening (urethral meatus) in its current position and bringing it to the head of the penis; straightening the penis; and/or making the head of the penis more conical in shape. Many of these surgical procedures require the use of the foreskin, so the penis gains a circumcised appearance during the surgery.

Should Surgery Be Performed?

In cases of severe hypospadias, it is highly likely that some surgery should be performed.

However, by far the majority of men who have mild or moderate hypospadias do not have surgery, and they appear to function without difficulty even when they have their opening located quite far down the shaft of their penis, or when they have chordee. Many of these men do not even know they have hypospadias or that they are “different” from other men.

Whether surgery should be performed or not is open to debate and is obviously even more complex and difficult for parents having to make the decision for their baby son.

Even when the hypospadias is mild or moderate, and the decision is left until the person is a young teenager or an adult man, there are no easy answers.

Surgery is not always successful, and in some cases it may leave the penis looking worse than it was before the operation. In other cases, the surgery does not seal up the old hole, meaning that urine and semen leak from the penis, and the original operation has to be repeated, often several times over several years. This is not an attractive prospect, and one that can often leave men severely

traumatised and unable to cope easily with sexual relationships in later life. These complications can also lead to a poor body image, which may cause difficulties in forming relationships and produce low self-esteem.

The view of the surgeon about the success of an operation may be totally different from that of the boy or man with hypospadias or his parents. Many urologists and plastic surgeons who perform a large number of these operations appear to take the view that hypospadias surgery should be performed because:

• Every man should be able to stand to urinate
• Every man should be able to have “normal” sexual intercourse with a woman, with the aim of trying for a pregnancy
• A urine stream that sprays is embarrassing
• A penis that is bent sideways or downwards is embarrassing
• A penis head that is shortened and blunted is “deformed”

This somewhat paternalistic approach appears to be based on the idea that there is a “perfect penis”; that all men should look alike so that there is no mocking by peers or sexual partners; and that the “perfect penis” also contributes to a healthy body image.

Because there have been so few follow-up studies it’s hard to know how men feel about their surgery. One study found that surgeons thought a satisfactory outcome depended on things like the position of the urethral opening, while the patients might be more concerned about things like penis size or overall shape (which at the moment are generally not things that can be influenced by surgery).

There are basically eight characteristics which a surgeon or patient might look at after the operation to decide how satisfied they are with the appearance of the penis. The first five are surgically correctable to a greater or lesser extent. They are: meatal position, glans shape, scars, scrotum, and general appearance. But the last three are not, usually, surgically correctable. These are: volume of the glans, penile size, penile thickness.

Much disagreement among surgeons and patients centres on the non-correctable features like size and thickness. Things like penis size and shape, rather than the position of the urethral opening, seem to be most important to patients.

Research into the long-term effects of hypospadias surgery on a boy’s body image when he becomes a man (roughly, how he feels about his body in general and his penis in particular) has found that hypospadias patients are more embarrassed than other men about their penis, and have more sexual inhibitions as a result.

This means that getting into a relationship can be more challenging, and men with hypospadias tend to have their first experience of intercourse later than men without. Not surprisingly, the worse the original degree of difference, the more emotional difficulties men tend to have, with feelings of shame and embarrassment around their penis. And, also unsurprisingly, the better a man feels about his body and his genitals, the fewer emotional and psychological difficulties he has.

What this all means in simple terms is this: if a child is has an operation for hypospadias, his emotional well-being, and how relaxed about sex and relationships he will be as a man, depends on how good the appearance of his penis is after the operation.

This might be because having surgery raises an expectation of a perfect outcome, or because there is an intrinsic desire to have a perfect penis or to be like other boys of the same age.

The big problem, of course, is that you can never know how a man would have felt about his penis if he had not had surgery: would he have felt better or worse?

This is an impossible question to answer, but we do know that – at least in mild cases – the things that matter to a man appear to be the things that surgery can’t influence so much, like penis size and shape.

In our work with men who have hypospadias, we have met many men with mild degrees of difference who are not in the least bothered by it. In fact, there are probably a great many men who have mild hypospadias and do not even know about it until it is somehow pointed out to them, perhaps when they go into hospital for an operation, or when they come across it by chance on the internet.

Clearly, these men have not been affected by their anatomical issues, and neither they nor their parents have ever found it necessary to seek out surgery.

So why, we should perhaps ask, do some men have such a problem with their hypospadias later in life and some appear to have no problems at all?

Obviously part of the answer is that the degree to which hypospadias affects a man depends on how bad it is in the first place or how traumatic his surgery has been; but a large part of this difference is probably connected with how different the boy’s penis appears to him and to his friends and family.

If it is small, or obviously unusual, or if he has to sit down to urinate, then he is much more likely to be made aware of his difference by other boys, and perhaps also mocked or teased by them. This can be very traumatic and lead to a poor self-image, shyness and inhibition around issues such as nudity and sexuality.

This would be especially true if his hypospadias was treated as a shameful secret at home and never discussed. In this case, the emotional effects of such a problem might be much more severe than it would be for other boys.

Finally, we know that a large proportion of men with hypospadias have a penis smaller than average. So it is certainly possible that if a boy with mild hypospadias grows up with a poor body image and feelings of shame it may have a lot to do with penis size and shape, because penis size is a source of considerable anxiety for many adolescents. And of course, many men who do not have this condition still have problems with penis size or shape!

Approximately 100 different procedures have been designed over the years to correct hypospadias. Today, there are perhaps two or three procedures that have gained the most favour worldwide. Some of these surgeries are done in one stage and usually as an outpatient. Others are done in two or three stages and may require extended hospitalisation over a period of a few weeks.

When Should Surgery Be Performed?

There is a debate about the most appropriate age to perform surgery on the penis with hypospadias. It appears that many urologists prefer to perform the surgery when the child is under six months of age. There are plastic surgeons, however, with good records of successful surgery, who wait until the child is three years of age.

The generally accepted view is that there are more complications if the surgery is performed on the adolescent or adult man. This may reflect the fact that after adolescence, males can have strong erections that may disrupt the surgery, even if attempts to moderate these are made through use of drugs.

What Are The Problems Relating To Surgery?

The extent of complications following hypospadias surgery is obviously related to how complex the surgery was. However there are some commonly occurring problems:

• In most operations the surgeon is attempting to move the opening on the penis (the urethral meatus) from its original position on the shaft to the tip of the penis. However, the original opening sometimes reopens and may then leak urine and semen. This is referred to as a fistula, and will probably need further surgery.
• In some men, a narrowing of the tube that carries urine and semen (the urethra) occurs after surgery. This narrowing or stricture (stenosis) can cause a decrease in the force of the urine stream and/or ejaculation. Mild strictures can usually be eased by using an instrument that will gradually widen the tube.
• Sometimes the new opening becomes smaller than it was after surgery (this is known as a meatal stenosis). This can often be dealt with by inserting an instrument that is larger than the opening, and gradually stretching it.
• In the older methods of hypospadias repair, a skin graft using skin with hair was used to repair the hypospadias, and these hairs could form blockages or infections in the urethra. In modern repairs, non-hair bearing skin is used.
• A man may develop urinary tract infections if he has problems urinating after the operation.

Circumcision and Hypospadias

Circumcision should be avoided in boys and men with hypospadias since the foreskin is often used in any repair that may be required. In most infants with hypospadias, the foreskin does not completely surround the head of the penis and is incomplete on the underside of the penis.

In cultures where circumcision is common for religious reasons, a small cut or removal of a tag of foreskin can be done for religious purposes and called a circumcision.