Hypospadias is a condition where the urethral opening is located on the underside of the penis. It occurs in about 1 in 300 male births. Risk factors include family history and certain genetic conditions. Associated anomalies include undescended testes and inguinal hernias. Evaluation for intersex conditions is recommended for severe or proximal hypospadias, especially with cryptorchidism. Over 150 surgical techniques have been described to repair hypospadias, depending on the location and severity. The goal of surgery is to relocate the urethral opening to the tip of the penis.

1. Hypospadia

2. Any condition in which the
meatus occurs on the
undersurface of the penis
Usually 3 features
– ventral meatus
– ventral curvature
–
(chordee)
Dorsal "hood“;
deficient foreskin
ventrally

3. Classification

4. Variations of Hypospadia

5. Incidence
1:300 live male births
6000 boys each year in the US
Some genetic component
– 8% of patients have father with hypospadias
– 14% of patients have male siblings with
hypospadias
– If child with hypospadias, risk to next child
12% risk with negative family history
19% if cousin or uncle with hypospadias
26% if father or sibling
More common in Caucasians (Jews andItalians)
Higher incidence in monozygotic twins (8.5x)

6. Associated Anomalies
Undescended testes 9% and inguinal
hernia 9%
Upper tract anomalies rare (1-3%)
Ut r ic ulus m a s c u l i n u s
– 10 to 15% in perineal or
penoscrotal hypospadias
– Incomplete mullerian duct
regression

7. Associated Anomalies
R
c
r
u
y
l
p
e
to
r
u
ct
hindtiesrmsex,especially with
– Adrenogenital syndrome
– Mixed gonadal dysgenesis
– Incomplete
pseudohermaphroditism
– True hermaphrotidism

8. Associated Anomalies
hypospadias and cryptorchidism
– high index of suspicion for an intersex
state
Walsh reported the incidence of intersexuality
in children with cryptorchidism, hypospadias,
a
2
n
7
d
%otherwise nonambiguous genitalia to be
– nonpalpable testis were at least
threefold more likely to have an intersex
condition than those with a palpable
undescended testis (50% versus 15% )

9. Associated Anomalies
The idea that evaluation for an endocrine
abnormality and/or intersex state should be
undertaken in those with posterior
hypospadias, regardless of gonadal position
or palpability, is controversial but is supported
in the literature, because significant,
identifiable, and treatable abnormalities are
common

10. Further Evaluation
Only with severe hypospadias and sexual
ambiguity
– Includes testicular abnormalities
– Up to 25% of these patients haveenlarged
utricles or other female structures
The incidence of abnormalities with other
forms of hypospadias approximates that of
the general population
– Therefore no further evaluation is indicated

11. Acute Complications
Wound infection
Poor wound healing 2 to ischemia o
f
flaps
Edema
Drain tubes if free graft is used
Erections

12. Chronic Complications
Urethrocutaneous fistula
Urethral diverticulum
Residual chordee
Persistent hypospadias
Urethral stricture
H
M
a
e
i
a
r
t
b
a
e
la
s
t
r
e
i
n
n
g
oskisin
Excess skin
Balanitis xerotica obliterans

13. Hypospadias Repair
Over 150 operations have be described
Distal hypospadias
– Tubulization of the incised urethral plate
(Snodgrass)
– Meatal advancement (MAGPI)
– Meatal-based flaps (Mathieu)
Proximal hypospadias
– Onlay grafts
– Vascularized inner preputial transfer flaps
(Duckett)
– Free grafts (skin, buccal mucosa)

14. MAGPI

15. Mathieu

16. Redman and
Barcat

17. I
O
s
l
n
a
l
n
a
d
y

18. Buccal Mucosal Graft

19. Hypospadias - Conclusions
Common
Genetic component exists
Evaluation for associated anomolies
with severe proximal hypospadias
Rule out intersex, especially with
cryptorchidism
Multiple repairs exist, tailor to the
patient, anatomy, and previous repairs