bubble_chart Overview

The abnormal opening of the urethra on the ventral side is called hypospadias. It is a relatively common congenital developmental anomaly of the genitourinary system.

bubble_chart Etiology

Disease cause: The external genitalia and urethra begin to develop at 8 weeks of embryogenesis and complete by 15 weeks. The urethral groove gradually fuses along the ventral surface of the penis from the proximal to the distal end, forming the urethra until reaching the glans penis. Due to a deficiency or insufficient action of fetal testosterone, the urethral groove fails to fully close to the tip of the glans penis, halting at different stages and resulting in various types of hypospadias. Since the urethral groove fuses from the proximal to the distal end, distal hypospadias is more common.

The incidence of hypospadias is 1 in 300 male children. It is currently known that the use of estrogen and progesterone during pregnancy can significantly increase its incidence. Although a family history of hypospadias has been recognized, its genetic characteristics remain unknown.

bubble_chart Clinical Manifestations

Clinical manifestations:

① Symptoms and signs: Newborns and infants almost have no symptoms, while adolescents and adults often complain of curved urine stream, spraying urine, the penis bending toward the ventral side, which may interfere with sexual life. In perineal and penoscrotal types, patients need to squat to urinate and often suffer from infertility. Additionally, due to the lack of ventral skin, the penis appears hook-shaped, and the urethral meatus may be stenotic, requiring careful examination. If stenosis is present, a meatal incision is necessary. Hypospadias is often complicated by cryptorchidism, so careful examination is needed to check for the presence of testes in the scrotum.

② Classification: Based on the location of the urethral meatus, it can be divided into the following types: ① Glanular type: the urethral meatus is located at the proximal part of the glans; ② Coronal type: the urethral meatus is located at the ventral side of the coronal sulcus; ③ Penile type; ④ Penoscrotal type; ⑤ Perineal type. Approximately 70% of patients have the urethral meatus located at the distal penis or coronal sulcus.

Male hypospadias is considered a sign of feminization. Penoscrotal and perineal hypospadias are considered potentially indicative of intersex conditions, requiring gender differentiation. Newborns with hypospadias should not undergo circumcision because the foreskin will be used for urethral reconstruction in the future.

bubble_chart Auxiliary Examination

Laboratory, X-ray, and endoscopic examinations: In cases of penoscrotal and perineal hypospadias, scrotal splitting is often associated, making it difficult to determine the gender of the external genitalia. Therefore, oral buccal mucosa smears and chromosomal karyotype tests should be performed to confirm gender. Urethroscopy and cystoscopy can assess the development of male internal reproductive organs; excretory urography can determine whether congenital anomalies such as duplicated kidneys or ureters are present. Excretory urethrography can be considered a routine examination for hypospadias patients. However, it is of limited value for glanular hypospadias, as the incidence of upper urinary tract anomalies in these patients is not higher than in the general population.

bubble_chart Diagnosis

A diagnosis can be made based on symptoms and signs. However, any type of hypospadias is considered a sign of feminization. For penoscrotal and perineal hypospadias, careful examination is required to differentiate them from adrenogenital syndrome and true hermaphroditism.

bubble_chart Treatment Measures

There are more than 150 types of hypospadias repair surgeries, and considering psychological factors, most advocate completing the repair in the initial stage [first stage]. The surgical method involves using pedicle skin grafts and free skin flap transplantation, which has been increasingly adopted by urologists. Bladder membrane urethroplasty has also been successfully applied. The incidence of urinary fistula in the aforementioned surgeries is 15–30%, but repairing a urinary fistula is considered a simple and minor procedure. The intermediate stage [second stage] surgery yields satisfactory results and is the safest approach for surgeons with less experience in hypospadias repair.

For all repair procedures, the first step is to remove the fibrous cord on the ventral side of the penis to straighten it. Whether the fibrous cord has been completely removed can be confirmed during surgery by artificially inducing an erection, followed by urethral reconstruction. Most successful surgeries utilize local skin and foreskin to reconstruct the urethra. In recent years, advancing the urethral opening to the glans has become feasible, meeting aesthetic requirements.

bubble_chart Prognosis

After surgical correction of penile curvature and urethroplasty, the patient can urinate while standing and ejaculate inside the vagina. Overall, aesthetic appearance and fistula prevention remain critical issues that require high attention in various types of plastic surgeries.