Dear Dr G,

My husband and I are reaching out to you during your focused month on pediatric urological conditions. We seek your insight on an issue concerning our newborn son.

We are both in our early 40s, happily married for two years, and after some time trying for a child, we turned to fertility assistance. With ART and specialist help, we achieved a successful pregnancy.

Our son, David, was born premature and, after a three-week hospital stay, thankfully returned home healthy. However, at a recent check-up following his first birthday, our pediatrician diagnosed him with hypospadias. His urethral opening is positioned abnormally, leading to a downward curvature of his penis.

We were advised that corrective surgery is recommended as he gets older. David is thriving despite his premature birth, and aside from the atypical position of his penis, all his functions seem normal.

We are somewhat bewildered by this unexpected condition and would greatly appreciate Dr. G’s opinion on managing hypospadias.

What exactly is hypospadias? What causes the opening to be misplaced during gestation? Can this condition affect his sex life or reproductive life? Is there corrective surgery to reposition the opening? How would the operation affect David as a man?


Downwards David

Hypospadias is a congenital disorder characterised by a meatus opening (pee hole) that is not located at the tip of the penis. Instead, the opening is wrongly located at the lower part of the glans. In severe cases, the opening may be abnormally located on the penile shaft or at the base near the scrotum. Hypospadias is the second most common birth abnormality of the male reproductive tract, after undescended testicles, affecting one in 300 males at birth.

Hypospadias typically presents with three main features. Firstly, there is often an incomplete development of the foreskin, which fails to “wrap” around the glans fully, leading to what is known as a hooded foreskin. This means the foreskin remains draped over only the top part of the glans and leaves the underside exposed. Additionally, there may be a downward curvature of the penis, known as chordee. This bending can sometimes make the penis appear somewhat shorter.

The etiology of hypospadias is believed to be related to defective penis development during gestation. Normally, penis formation requires the protrusion of penile structure, surrounded by a urethral plate, to extend the opening to the penis tip. In hypospadias, this growth is prematurely halted, resulting in incomplete tabularisation. The exact cause of this developmental interruption is unknown. However, experts believe premature birth or excessive prenatal exposure to estrogen-like chemicals may contribute to the rising incidence of hypospadias.

Medical literature suggests a slight increase in erectile dysfunction among men with hypospadias, particularly with severe chordee. Most men with mild hypospadias have normal sexual and reproductive functions, and the condition does not typically lead to infertility.

Reconstructive surgery is available to correct the “lost opening”, “hooded foreskin”, and “downward bending”. This surgery is usually performed in infancy from three months of age. While most adults with mild hypospadias do not require surgery as it does not affect their urinary or sexual functions, those who experience difficulties may benefit from the procedure.

The process of human creation, from conception to the miracle of life is a mystery. Development is oftentimes near perfection, however for some, the flaws in life are what make us unique.

When concerned parents put Dr G on the spot, his view is: “When imperfection is not affecting the function, acceptance is often better than correction.”

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