Hypospadias: what it is, causes, surgery and recovery

During development before birth, the tube that carries urine (the urethra) forms along the length of the penis. In hypospadias it does not reach the tip, so the opening, called the meatus, lies lower down. Cambridge University Hospitals say this affects approximately three per 1000 births, and University Hospitals Plymouth describe a common birth anomaly occurring in about 1 in 300 male births.

Plymouth lists the usual features: a hooded foreskin, an abnormal position of the opening and sometimes a bend in the penis, which means that during an erection it would curve downwards rather than point up. They say about 10% of boys have a family history and that it is more common in first-born boys.

How far down the opening sits varies. Both hospitals explain that this matters because it decides which operation is used: the lower the opening and the greater the bend, the more complex the repair.

Cambridge says the surgery is undertaken to give the penis a more normal appearance and to allow the boy to pass urine standing when he is older. Plymouth sets out the aim as a penis that looks and functions like any other: the opening at the end so a child can stand to pass urine without spraying, and a straight shaft when erect so that sexual intercourse is possible later in life.

Not every difference needs the same approach, and decisions about whether and how to operate are made by the paediatric surgical team after examining the child. Plymouth says boys are treated by plastic surgeons and paediatric urologists.

Cambridge says hypospadias surgery usually takes place when the child is between 12 and 18 months old. Plymouth says most consultants like to operate when boys are around 1 year old, explaining that at this age the anaesthetic is as safe as it would be for a healthy adult and that boys grow up with no memory of the surgery. They prefer to operate before toilet training, usually between 2 and 3 years, although other medical problems or particular features of the hypospadias may mean it is delayed.

Before admission, Cambridge says a health screening questionnaire is usually completed by telephone, blood tests are not required unless there is a known bleeding disorder in the child or a close relative, and the operation will be postponed if the child has a cold, cough, Covid or an illness such as chickenpox. Parents are asked to have children's paracetamol and ibuprofen at home, with stronger pain relief supplied by the hospital if needed.

There are many techniques, but Plymouth says most surgeons use a limited number shown to give consistent results. Cambridge says the child has a general anaesthetic, sometimes with a local anaesthetic or a caudal injection into the lower back to numb the area. Plymouth explains that this injection leaves the penis, scrotum and legs numb for a few hours after surgery.

Cambridge says the foreskin is sometimes reconstructed, but where it is not the penis looks circumcised at the end of the operation, and that findings during surgery can change the plan. Plymouth adds that both options are usually possible after a single-stage repair, while after a two-stage repair there is often not enough foreskin to reconstruct. It says that if a foreskin repair is done there is a 10% chance it will open up partly and a small chance (1%) it will become tight, either of which may need a further operation, while circumcision wounds almost always heal well.

Cambridge says the catheter, or stent, is left because the surgery creates a new urethra which needs time to heal without contact with urine. It stays five to ten days and is removed in clinic, usually by a specialist nurse while the child is awake. For nappy-wearing boys a catheter may drip into a second nappy, called the double nappy technique, while older boys may use a leg bag with a night bag, and occasionally a suprapubic catheter is added after more extensive surgery. A dressing stays for 5 to 10 days.

Constipation matters because straining can cause bladder spasm and put the repair at risk, so Cambridge advises plenty of fluids and fruit and says laxatives may be needed. If poo gets on the dressing, wipe it gently with a wet wipe and contact the nurse specialist if that is not enough, and phone for advice if the nappy or bag stays dry in case the tube is blocked or twisted.

After the stent is out, the child stays in hospital until he has passed urine. Bubble bath should be avoided for a few weeks, and Cambridge says boys should avoid sitting astride things such as bikes or rocking horses and avoid climbing and sport until swelling and bruising settle, which may take six to eight weeks. The urine stream may spray or go to one side at first because of swelling, which should have settled by the follow-up appointment.

Cambridge University Hospitals gives a problem-solving guide for the time the catheter (stent) is in place. It says that in all cases of doubt you should phone the numbers on your leaflet. The table below summarises what it says.

Cambridge says complications are not common but include bleeding, infection (which can make the repair break down and need further surgery), a hypospadias fistula and meatal stenosis. A fistula is a tiny hole that appears after the operation where the repair was carried out and usually needs a smaller further operation. Meatal stenosis is a narrowing that produces a narrow, higher-pressure stream and can occur within months or years of the first surgery, needing treatment. Follow-up is part of the plan, and parents should phone the surgical team if worried between visits.

Hypospadias is usually noticed at birth or at the newborn check, and an NHS GP or paediatrician refers the child to a specialist paediatric surgical or urology team. University Hospitals Plymouth says boys are treated by plastic surgeons and paediatric urologists. The operation is planned, and the hospital arranges pre-operative information, the catheter removal visit and follow-up.

Some families also use private paediatric surgeons. The techniques, aftercare and the need to contact the operating team with any concerns in the first weeks are broadly the same. Plymouth stresses that GPs and local hospitals may know little about hypospadias surgery, so concerns after surgery should be directed to the surgical team that carried out the repair.