What is the treatment for hypospadias?

Management of Hypospadias

Surgical correction is the primary treatment for hypospadias, ideally performed between 6 and 18 months of age to achieve both cosmetic and functional normality. 1, 2

Diagnostic Evaluation

• For proximal hypospadias, especially when accompanied by undescended testes, endocrinological evaluation is necessary to exclude disorders of sexual development 3, 1
• Renal and bladder ultrasound should be performed to screen for associated urinary tract anomalies, particularly in cases of posterior (proximal) hypospadias 3
• Voiding cystourethrogram (VCUG) may be indicated in cases with moderate to severe hydronephrosis to evaluate for vesicoureteral reflux and other urinary tract abnormalities 3

Classification and Surgical Planning

• Hypospadias is classified based on the location of the urethral meatus:
  • Distal (70% of cases): Located on the distal penile shaft, considered mild and not typically associated with other urogenital abnormalities 1, 2
  • Proximal (30% of cases): Located more proximally on the shaft or scrotum, often more complex and requiring more extensive evaluation 1, 2

Surgical Treatment

• The goals of hypospadias repair include:

  • Correction of penile curvature (orthoplasty) 4
  • Creation of a functional neourethra (urethroplasty) 4
  • Proper positioning of the urethral meatus at the tip of the glans (meatoplasty and glanuloplasty) 4
  • Correction of scrotal abnormalities if present (scrotoplasty) 4
  • Appropriate skin coverage with cosmetically acceptable results 4

• Common surgical techniques include:

  • For distal hypospadias:
    • Meatal advancement and glanuloplasty (MAGPI) 5
    • Tubularized incised plate (TIP) technique (Snodgrass procedure) 5
  • For proximal hypospadias:
    • Vascularized foreskin flap-plasty 5
    • Two-stage repair for severe cases 4

• Technical advances that have improved surgical outcomes:

  • Preservation of the urethral plate when possible 4
  • Incision of the urethral plate when necessary 4
  • Dorsal midline plication for chordee correction 4
  • Deepithelialized urethroplasty dartos flap coverage to reduce fistula formation 4
  • Two-stage alternative techniques for complex cases 4

Timing of Surgery

• Current guidelines recommend surgical correction between 6 and 18 months of age 1, 2
• This timing minimizes psychological impact while allowing for optimal tissue handling and anesthetic safety 1
• Although repair can be performed at any age with comparable complication risks, early intervention is preferred 2

Long-term Considerations and Follow-up

• Potential long-term complications include:

  • Lower urinary tract symptoms (occur twice as often in patients after hypospadias repair) 1
  • Sexual function concerns (men may be more inhibited in seeking sexual contact) 1
  • Cosmetic issues that may require revision surgery 1, 2

• Regular follow-up is essential to monitor for:

  • Urethral strictures or fistulas 2
  • Persistent chordee 2
  • Abnormal urinary stream 1
  • Psychological adjustment 1

Surgical Expertise

• Hypospadias repair should be performed by surgeons with sufficient experience due to the relatively high complication rate 5
• Specialized pediatric urologists typically achieve better outcomes due to their familiarity with the various techniques and potential complications 5