The treatment usually recommended for hypospadias is surgery, with the goal to restore normal appearance and function to the penis. A urinary opening that is not surrounded by glans tissue is more likely to “spray” the urine, which can cause a man to sit to urinate because he cannot reliably stand and hit the toilet. Downward curvature of the penis can impair sexual activity as an adult. In addition, the partially developed foreskin looks neither circumcised nor natural.
Surgery extends the urinary channel to the end of the penis, straightens bending, and corrects the foreskin abnormality by either circumcision or by repairing it to look normal (“prepucioplasty”), depending on the desire of care-givers.
When the hypospadias is third degree, or there are associated birth defects such as chordee or cryptorchidism, the best management can be a more complicated decision. A karyotype and endocrine evaluation should be performed to detect intersex conditions or hormone deficiencies. If the penis is small, testosterone or human chorionic gonadotropin (hCG) injections may be given to enlarge it before surgery.
Surgical repair of severe hypospadias may require multiple procedures and mucosal grafting. Preputial skin is often used for grafting and circumcision should be avoided before repair. In a minority of patients with severe hypospadias surgery produces unsatisfactory results, such as scarring, curvature, or formation of urethral fistulas, diverticula, or strictures. A fistula is an unwanted opening through the skin along the course of the urethra, and can result in urinary leakage or an abnormal stream. A diverticulum is an “outpocketing” of the lining of the urethra which interferes with urinary flow and may result in post-urination leakage. A stricture is a narrowing of the urethra severe enough to obstruct flow. Reduced complication rates even for third degree repair (e.g., fistula rates below 5%) have been reported in recent years from centers with the most experience, and surgical repair is now performed for the vast majority of infants with hypospadias.
Age at surgery
Hypospadias repair can be done in full-term, healthy infants at any time from 9 months of age. Premature babies generally have surgery done at one year or older. Using these guidelines, most babies can undergo repair as one day surgery, with need to stay in the hospital only for one or two days afterwards.
The results of surgery are probably not influenced by the age at which repair is done, but older boys are more likely to recall the event. Teens and adults typically spend two days in the hospital after surgery.
Hormones potentially increase the size of the penis, and have been used in boys with proximal hypospadias who have a smaller penis. Numerous articles report testosterone injections or topical creams increase the length and circumference of the penis. However, few studies discuss the impact of this treatment on the success of corrective surgery, with conflicting results. Therefore the role, if any, for preoperative hormone stimulation is not clear at this time.
Hypospadias repair is done under general anaesthesia, most often supplemented by a nerve block to the penis or a caudal block in order to reduce the general anesthesia needed, and to minimize discomfort after surgery.
There are many techniques which have been used during the past 100 years to extend the urinary channel to the correct location. Today the most common operation, known as the tubularized incised plate or “TIP” repair, rolls the urethral plate from the low meatus to the end of the glans. This procedure can be used for all distal hypospadias repairs, with complications afterwards expected in less than 10% of cases.
There are fewer consensuses regarding proximal hypospadias repair. TIP repair can be used when the penis is straight or has mild downward curvature, with success in 85%. Alternatively, the urinary channel can be reconstructed using the foreskin, with reported success in from 55% to 75%.
Most distal and many proximal hypospadias are corrected in a single operation. However, those with the most severe condition having a urinary opening in the scrotum and downward bending of the penis are often corrected in a 2-stage operation. During the first operation the curvature is straightened. At the second, the urinary channel is completed.