2. Introduction
• Greek – “hypo” – under, “spadon” – rent / fissure
• Urethral opening proximal to the normal glanular
location.
• Occurs in 1 in 250-300 males (0.25 - 0.3%).
• Increase in incidence over last 25 yrs.
3. Introduction
• 70-85% have mild distal meatus variant.
• 90% are isolated penile defects.
• Considered arrested development of prepuce & glans.
• Correction is surgical.
4. EVALUATION
Careful history and physical examination.
Associated Penile anomalies – Meatal stenosis, Penile
torsion, penoscrotal webbing, penoscrotal
transposition.
Associated common anomalies- Inguinal
hernia/hydrocele
5. History
• Proximally located meatus
• Ventrally deflected or spraying urine stream
• Curved penis.
• Split scrotum.
• Urine trickling & ballooning of urethra – meatal
stenosis
• Presentation at circumcision – concealed variants
• Assessment of risk factors
6. Risk Factors
1. Genetic – Family history and Hx. of Endocrine disorders
2. Premature birth.
3. Birth weight – associated with low birth weight
4. Intrauterine growth restriction
5. Assisted reproduction techniques
6. Environmental – Use of OCP after conception and
Pesticide exposure.
7. Examination
• Asymmetrical prepucial development – dorsal hood & ventral
deficiency exposing glans & proximal meatus.
• Downward glans tilt
• Deviation of the median penile raphe
• Ventral curvature (VC)
• Scrotal encroachment onto penile shaft
• Midline scrotal cleft
• Peno-scrotal transposition – scrotum anterior & superior
8. Associated abnormalities
• No relation between the severity of the hypospadias
and associated anomalies of the upper- or lower
urinary tract
• Isolated hypospadias regardless of severity –
NOT an indication for Upper tract imaging
9. Isolated vs Syndromic
Hypospadias
• Syndromic Hypospadias –
– WAGR syndrome – del 11p13
– Smith-Lemli-Opitz syndrome
– Wolf-Hirschhorn syndrome
• Suspected in patients with –
– Developmental delay
– Dysmorphic facies
– Anorectal malformations
10. Isolated vs DSD with
Hypospadias
• DSD suspected in Phenotypic boys with both –
– Hypospadias
– Undescended testis
• It is an indication for Karyotyping – DSD in 25%
• Most common associated DSDs
– Mixed Gonadal Dysgenesis
– Ovotesticular DSD
– 5-alpha reductase deficiency
• More likely if – Proximal hypospadias + Nonpalpable testes
11. Concealed Hypospadias
• Normal prepuce concealing glanular to distal shaft meatus
• Megameatus with intact prepuce –
deeply grooved urethral plate extending laterally under skin edge
• Detected at circumcision
• Circumcision should NOT be stopped
12. Chordee without Hypospadias
• Asymmetrical prepucial development with a
normal glanular meatus
• Congenital Ventral Penile Curvature
• Classified as hypospadias if distal urethra is thin
with deficient corpus spongiosum
16. SURGERY – CORRECTION
AIMS
1. Abnormal ventral curvature or chordee, by orthoplasty
2. Abnormal proximal meatal insertion, by urethroplasty
3. Abnormal looking glans penis, by glanuloplasty and
meatoplasty
17. Age for Surgery
• Healthy full term baby ≥ 3mon – daycare procedure
• Preterm baby >56 gestational weeks
• AAP – surgery to be done by 18mon – ↓ psychosexual
stress
• Usual age at primary repair – 6-18 months.
• 1° TIP repair complication rate – 2.5 times higher in adults.
• Younger the child, lesser the discomfort following repair
18. Pre-operative Hormonal
Treatment
• Small glans size (< 14 mm width) associated with
increased risk of complications.
• Androgens (testosterone / DHT / β-hCG) increase penile
length & glans circumference.
• Weak evidence for local / parenteral use in –
– Proximal hypospadias
– Small appearing penis
– Reduced glans circumference
– Reduced urethral plate
• s/e – genital pigmentation, pubic hairs, ↑ erections
19.
20. Functional indications for
surgery
• Proximally located (ectopic) meatus
• Ventrally deflected or spraying urinary stream
• Meatal stenosis
• Curved penis
21. Cosmetic indications for
surgery
• Abnormally located meatus
• Cleft glans
• Rotated penis with abnormal cutaneous raphe
• Penoscrotal transposition
• Split scrotum
22. Ventral Curvature
• Distal hypospadias
– VC in 10% – <30° after degloving
• Proximal hypospadias –
– 50% have no or <30° VC after degloving
– 50% have >30° after degloving
23. Ventral Curvature
• VC corrected in 70% by degloving & excision of chordee
• Artificial erection – intra-operative corporeal hep-saline
inj.
• VC correction –
– <30° - Dorsal plication
– >30° - Ventral corporotomies with or without grafting
27. Postoperative Management
• Anticholinergics for bladder spasms
• No difference in outcome with / without bandages
• No consensus on duration of dressing & stenting
• No data indicating benefit of SPC.
• No recommendation on medical prevention –
Ketoconazole, phenobarbitone, diazepam
• Post-op antibiotics - controversial
28. Risk factors for complications
• Proximal meatus
• Redo repair
• Glans width <14mm
• Complication rate –
– 10% in distal & 25% in proximal one-stage repairs
– Higher and variable rates (30-70%) in two-stage repairs.
29. Follow-up
• Long term follow-up recommended till adolescence
– Urethral stricture & Meatal stenosis
– Voiding dysfunctions
– Recurrent penile curvature
– Diverticula
– Glanular dehiscence
– Ejaculatory disorder
• 50% complications requiring re-operation present >1yr after
surgery
