Why are the testes important in the management of proximal hypospadias?

Why Testes Are Critical in Proximal Hypospadias Management

The testes are essential in proximal hypospadias because testicular status (descended vs. undescended, palpable vs. nonpalpable) is the single most important clinical indicator for identifying underlying differences/disorders of sex development (DSD), which occur in 15-21% of these patients and fundamentally alter surgical planning and long-term management. 1, 2

Testicular Status as a DSD Screening Tool

The position and palpability of the testes serve as critical diagnostic markers:

• Undescended testes significantly increase DSD risk: 44% of infants with proximal hypospadias and undescended testes have DSD, compared to only 12% with descended testes (p=0.046) 1
• Nonpalpable testes carry even higher risk: 75% (6/8) of boys with at least one nonpalpable testis had genetic anomalies, versus 21% (11/52) with bilateral palpable testes (p=0.005) 2
• All patients with DSD had additional genital abnormalities involving either testicular position, scrotal anatomy, or both 1

Clinical Algorithm for Testicular Assessment

When evaluating proximal hypospadias, systematically document:

1. Bilateral testicular palpability (palpable vs. nonpalpable)
2. Testicular descent status (fully descended to scrotal base vs. undescended)
3. Scrotal anatomy (bifid scrotum, hypoplastic scrotum)
4. Penile size (micropenis present in most DSD cases) 3

Genetic and endocrine evaluation should be considered for ALL infants with proximal hypospadias, not just those with undescended testes, since not all DSD patients present with cryptorchidism 1. However, the urgency and depth of investigation escalates with:

• Any undescended testis
• Nonpalpable testis
• Micropenis
• Severe scrotal abnormalities

Impact on Surgical Decision-Making

Testicular evaluation directly influences surgical timing and approach:

• Hormonal treatment is typically limited to proximal hypospadias patients with small glans diameter 4, but underlying DSD diagnosis may alter hormone therapy protocols
• Surgical repair timing (typically 6-18 months) 4 may be delayed pending complete DSD workup
• Staged procedures are increasingly preferred for proximal hypospadias due to lower ventral curvature recurrence rates 4, but DSD diagnosis may necessitate different reconstructive strategies
• Proximal hypospadias carries 48% reoperation rate in first 15 years of life 4, making accurate initial diagnosis critical

Long-Term Monitoring Considerations

Acquired undescended testes develop in 3.2% of boys with hypospadias, with significantly higher incidence in proximal cases (p=0.001) 5. This means:

• Testicular position must be monitored regularly until after puberty 5
• Initial descended testes do not guarantee continued scrotal position
• Long-term follow-up is essential given high late complication rates 4

Common Pitfall to Avoid

Do not proceed with masculinizing surgery without preoperative evaluation in proximal hypospadias 6. The 28% genetic anomaly rate and 15-21% DSD prevalence 1, 2 mandate investigation before irreversible surgical intervention. While endocrine testing is useful, genetic testing (exome/genome sequencing) is most diagnostically revealing 1, 2 and should be first-tier for patients with congenital anomalies.

The 2025 EAU-ESPU guidelines emphasize that hormonal treatment consideration and surgical planning in proximal hypospadias require careful preoperative assessment 4, with testicular examination serving as the cornerstone of this evaluation.