Long term psychological aspects of hypospadias are difficult to clarify. Data on adults who were born with hypospadias are few and often imprecise. Adult patients who now are available for outcomes analysis were operated on in the 1970s and 1980s. Those surgical techniques of the 1970s are no longer practised nowadays in favour of current modern techniques with superior cosmetic and functional results.
Will my son suffer psychological problems after correcting his hypospadias?
Considering the large number of boys who are operated for hypospadias and the small number that present themselves in adult life with complications, it is reasonable to believe that the majority of patients have had a good enough result not to seek revision surgery.
The final outcome of hypospadias surgery and psychological impact depends on several factors including the degree of hypospadias, the size of the penis and glans, the presence of Chordee, the shape of the meatus, the surgical scar, the number of surgeries in addition to the erectile and ejaculatory function.
It is reasonable to expect children with Grade I, II and IIIa to lead a normal life after successful surgery by a surgeon experienced in hypospadias surgery. Several factors influence the outcome in children with Grade IIIb and Grade IV hypospadias including the size of the penis and glans, the persistance of Chordee, the shape of the meatus, the number of surgeries and the resultant scar in addition to the erectile and ejaculatory function.

Is the size of my son penis normal?

This is the commonest question one encounter from mothers (more than fathers!) after successful hypospadias surgery.

There is a wide range of size and appearance of the normal penis. Like other human features, there is a wide variation in the which is considered normal or beautiful.

Should my son be able to pass urine in standing?
Young men like to void standing up in a public urinal through their opened trousers. Inability to perform in this way is a serious social impediment. The stream must be well formed and directable, a goal that is easily achieved with modern surgical techniques. Children tend to show off with the length of urine stream.
However, some mothers tend to train their children to sit while passing urine to ensure that the toilet seat remains clean and dry after urination.
Will the good results obtained in Childhood be maintained through adulthood?
Fortunately, the results achieved in childhood seem to be maintained or may even improve. In a large series of patients of all ages up to 66 years, the proportion of men with a normal peak flow rate increased with age (9). The implication of this finding is that the neo-urethra grows appropriately with age.
My child had his hypospadias corrected but there is still a mild degree of chordee (curvature) will this affect him psychologically later?
As explained earlier, there are 4 degrees of Chordee. Chordee may be due to skin shortage, scarring, short urethra or due to penile body curvature. In general, curvature within 20 degree is considered normal and does not interfere with the function of the penis.
It is very important to confirm that the man actually has significant symptoms from the chordee before recommending surgery. There is a group of men for whom the bent appearance, even if not a physical impediment to penetration, is an emotional cause of sexual dysfunction. A recent study It is interesting that in Summerlad’s late review 13 patients were thought, objectively, to have chordee of whom only eight had symptoms while two of 47 complained of curvature that was not confirmed on examination(13). Recent results have been better with only 18% of men having significant chordee(1).

Figure 6. operative photograph of an artificial erection showing incompletely corrected chordee.

Chordee can occur many years after an apparently successful repair either at the site of the original operation or remote from the site of the hypospadias. In a group of 34 men referred for alleged recurrent chordee, 22 were identified who had adequate initial surgery, confirmed by intra-operative erection and reported absence of chordee during follow up. All had had proximal, or even peno-scrotal, chordee and had had a tubularised free-graft urethroplasty. The chordee developed during puberty from 12 to 18 years old. The median age of presentation was 21 years and a mean of 17 years after the original surgery. Although in two thirds of cases the urethra was shortened and fibrosed, its division did not correct the chordee in all cases. Disproportion of the corpora was present in 68% of men, with or without short urethra(14). The cause of this late deterioration is unknown.
Residual chordee is a well known and important cause of late morbidity. Even now many men are embarrassed to present themselves for treatment and sympathetic management is essential. The patient’s description of the chordee is usually inadequate to plan surgery. Sometimes a Polaroid photograph will be sufficient but direct inspection of the erection is invaluable. This can be achieved by injection of prostaglandin in the clinic. However, for an embarrassed patient with a difficult penile problem (often a hypospadias cripple), an erection under anaesthetic may be needed (figure 6). It is most important to induce the erection by infusion of the corpora under pressure without a tourniquet: the chordee is sometimes more proximal than the site of the original hypospadias and may be disguised by a tourniquet.

Sexual function

Sexual activity

Problems with sexual intercourse, both physical and emotional have been reported. The ‘physical causes’ include soft glans, poor ejaculation, tight skin and pain. ‘Emotional causes’ are of small size, poor appearance and the anxieties from the physical causes(1).
The difficulties in assessing these claims lie partly in the fact that similar problems are found in many adolescents (with or without genital anomalies) and partly that hypospadiac men appear to have intercourse in much the same way as everybody else. All reported series record that most men have sexual intercourse, even though the quality and quantity may be difficult to decipher from the data. Figures for successful intercourse range from 77% to 90%(1;15;16). Curiously, frequency of sexual intercourse does not seem to be related to the success of the repair, though it is probably related to the degree of severity of the original hypospadias.

Nowhere in medicine is it more necessary to have control patients than in the assessment of adolescent sexual function. The greatest difficulty lies in the identification of a satisfactory control group to compare with the hypsospadiac patient. Without controls it is impossible to know whether the myriad of sexual problems that have been identified are caused by the hypospadias. There is no group that mirrors all of the features of hypospadias but infant circumcision, herniorrhaphy and appendicectomy have all been used.
Two studies have shown that there was no difference in the number of sexual episodes or their perceived quality between hypospadiacs and controls (herniorrhaphy patients and circumcision patients respectively)(6;8). This was despite the observation that the hypospadiacs had significantly more erectile problems such as curvature, shortness and pain, than the controls(8). There was no significant difference in the ages at which boys started masturbating, necking or having sexual intercourse. Hypospadiac men described themselves as more sexually inhibited than controls who had had a hernia repair (24% v. 1.8%)(6)
The quality of sexual satisfaction may be different when the hypospadiac man has suffered complications as there is a correlation between more complications, dissatisfaction with the surgical outcome and dissatisfaction with sexual performance(17). More complications are seen with the old Denis-Browne operation which is no longer used and it may be reasonable to assume that the current surgical techniques with fewer complications may give a better sexual result.

Figure 7. Operative photograph of a patient who had undergone a Denis-Browne repair of hypospadias in childhood.

Men with major complications in the surgical outcome often have physical difficulty with intercourse. Apart from chordee, tight scarred skin makes penetration painful and may even tear with intercourse (figure 8). Matters may be worsened if BXO has developed.

Figure 8. Clinical photograph of an unsuccessfully reconstructed hypospadiac penis (hypospadiac cripple)

In the patients with most severe hypospadias there is a considerable overlap with intersex abnormalities especially androgen insensitivity syndromes. In one series of posterior hypospadias 13 of 42 men had a major intersex anomaly. All had severe hypospadias (usually perineo-scrotal) and micropenis(10). None of the 13 patients had sperm in their ejaculate. Even with hypospadias as severe as this intercourse still occurs. In a series of 19 patients born with ambiguous genitalia, subsequently determined to be caused by perineal hypospadias alone, it was reported that 63% had had intercourse. However, only four had a regular partner(18). Less good figures were given in the series of Eberle et al: although 25 of 42 reported satisfactory erections, masturbation and ejaculation, few had sexual intercourse. Nine of 42 were married and three had children but only six had a stable relationship(10).

Ejaculation

The first, or prostatic, phase of ejaculation is normal in men with hypospadias. The next stage is the expulsion of the semen by the bulbospongiosus muscle. In proximal hypospadias, this muscle is likely to be absent. It is, therefore, not surprising to find that ejaculation is unsatisfactory in 63% of severe hypospadiacs even though orgasm is normal in most(18). Poor surgical results from the distal urethroplasty may cause a baggy urethra (figure 7) or even a diverticulum, further slowing the ejaculation.
The reconstructed urethra lacks the support of corpus spongiosum. Even in the unoperated hypospadiac penis it is apparent that the urethra for some distance proximal to the meatus consists of little more than skin (figure 9)

Figure 9. Clinical photograph of an unoperated penis with hypospadias to show the deficiency of the spongiosus in the distal urethra.

In more general reviews most authors state that ejaculation is normal though, by asking the right questions, Bracka found that 33% had ‘dribbling ejaculation’ and 4% were dry(1).

Psychological aspects of intercourse

Emotional satisfaction with intercourse is particularly difficult to measure and series without controls are valueless. Most teenagers, exploring their sexuality, have anxieties that are unrelated to any penile abnormality though a penis that is perceived to be abnormal may get the blame.

Size may be a cause of dissatisfaction. The hypospadiac penis is often said to be short. However, where a formal measurement has been made, 20% of hypospadiac penises were below the 10th centile. The finding was most marked in the adolescents with four of seven being below the 10th centile (figure 2)(7).

Penile size is a source of considerable anxiety in many adolescents. Limited research is available on the relationship of penile size to sexual satisfaction. Men with micropenis and with epispadias have intercourse that is satisfactory to themselves, though the opinions of their partners has not been investigated(19). An investigation of women with multiple sexual partners has suggested that intercourse with an uncircumcised penis gives greater pleasure than a circumcised one(20).

As there is no realistic means of enlarging the penis in hypospadias, it seems wise to help the patient to make the best use of that which he has, rather than embark on surgery for lengthening which has a most uncertain outcome. If the comparative trials of Mureau et al and Aho et al are correct, hypospadiac boys are not greatly different from their peers in their sexual activity and enjoyment.

There is conflict over the effect of the success of the repair. Bracka made the interesting observation that those who were satisfied with the results of their repair had a sexual debut at a mean of 15.6 years old, while those who were dissatisfied had a debut at 19 years old(1). On the other hand, it has been reported that in a group of boys whose ‘curative repair’ was delayed beyond 12 years old, 50% had their sexual debut before the definitive surgery(21). It could be said that the experience of intercourse, acknowledged by the authors to be less satisfactory, drew attention to the shortcomings of the repair.

Fertility

It seems probable that boys with uncomplicated hypospadias are normally fertile. There have been no studies of a large cohort of hypospadiac patients. There is no excess of hypospadiacs in infertility clinics. In an apparently unselected group of 169 hypospadiac men, 50% were found to have a sperm count below 50 million/ml and 25% below 20 million. More than half of those with the lowest sperm counts had associated anomalies such as undescended testes which might have accounted for the poor result(1). In a detailed study of 16 hypospadiacs, true oligo-astheno-teratozoospermia (OATS) was only found in the two patients with perineal hypospadias; low counts were seen in one of three with glanular and two of six with penile hypospadias but other parameters were normal. With two minor exceptions of slightly elevated LH, all the patients had normal hormone profiles(22).

Psychological consequences

There is much debate about the psychological consequences of hypospadias and, again, there is a great need for control patients in the analyses. The problem is the selection of the controls. In the studies quoted above, the control patients had had circumcision or a hernia repair respectively(11,13). In the very extensive psychological reviews undertaken by Berg and Berg the control patients had had appendicectomies(23). Faults can obviously be found with all of these controls, none having undergone the same scale of surgery as hypospadiacs. On the other hand, there is no other condition that could be compared to hypospadias in terms of diagnosis and surgical trauma.

From the uncontrolled series, it seems that about 20% of adults remembered their surgery as traumatic(1). A third of men avoided changing in public(13).

In the controlled studies, the main outcomes have been in sexual development discussed above. There is no difference (compared to circumcision patients) in success in the military in Finland were there is conscription, or in the number of men cohabiting (13). In the Dutch study, there was no evidence that hypospadiac men had less good psychosocial adjustment than the age matched controls(6).

Similarly, there were no differences in I.Q., general health or socio-economic background in the Swedish men reviewed by Berg and Berg. However, the men were, in general, found to be ‘under achievers’ and were less assertive and self-confident(23).

New adult patients

From time to time a man will present with hypospadias who has had no previous surgery. Most often BXO will have caused a stricture. Occasionally, a man will present with an unconnected symptom and the hypospadias will be a chance finding (figure 9). Even an uncomplicated hypospadiac meatus may not be large enough to accept a conventional cystoscope or resectoscope. The distal urethra is often fragile with no supporting corpus spongiosum and may easily be damaged by instrumentation (figure 9).

Before deciding on treatment, it is essential to establish that which the patient hopes to achieve from surgery. With limited objectives, such as enlargement of the meatus, simple, local surgery will suffice.

For complete reconstruction, the same techniques may be used as in children. Unfortunately, the complication rate of around 33% is much higher than that seen in younger patients(24). Wound healing seems to be slower and the infection rate higher, than in children. Careful discussion with the patient about objectives and possible outcomes is essential.

Future

As the latest instruments, sutures, dressing materials, and antibiotics have improved, so to have the outcomes. Newer technologies are being developed further to improve the results, such as tissue adherence techniques (glues and laser-activated soldering) that improve wound healing and reduce fistula formation, and urethral tissue substitutes (matrices impregnated with urethral epithelium and mesenchyme)(25). Prevention may be a reality as the understanding of the embryology of hypospadias improves.

Reference List

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(2) Woodhouse CRJ, Christie D. Nonsurgical factors in the success of hypospadias repair. British Journal of Urology International 2005; 96:22-27.
(3) Wilson C, Christie D, Woodhouse CRJ. The ambitions of adolescents born with exstrophy – a structured survey. British Journal of Urology International 2004; In press.
(4) Schonfeld WA. Primary and secondary sexual characteristics. American Journal of Diseases in Childhood 1943; 65:535-549.
(5) Fichtner J, Filipas D, Mottrie AM, Voges GE, Hohenfellner R. Analysis of meatal location in 500 men: wide variation questions the need for meatal advancement in all pediatric anterior hypospadias cases. Journal of Urology 1995; 154:833-834.
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