Adult hypospadias

What hypospadias is

Hypospadias is a condition present from birth in which the opening of the urethra is not at the tip of the penis but somewhere along the underside of the shaft, at the junction with the scrotum, or in the perineum. It is one of the more common congenital conditions in boys. It is frequently accompanied by a downward bend of the penis, known as chordee, and by an incompletely formed foreskin.

Why adults present

There are three distinct groups of adult patients, and they need different things:

• Men who had childhood repair that has failed years later. This is the largest group. Surgical techniques have changed considerably over the decades, and repairs performed in the 1970s, 80s and 90s can break down long after they were considered successful. Problems typically emerge in the teens or twenties.
• Men who have never been treated. Milder distal hypospadias is sometimes never diagnosed, or a decision was taken at the time not to operate. These men often present when it starts affecting their sex life, their fertility or their confidence.
• Men who have had multiple previous operations and have significant scarring, a shortage of usable skin, and a complex problem needing staged reconstruction. These are among the most technically demanding cases in urology.

Symptoms and problems

• Spraying, splitting or downward-directed stream, and having to sit to pass urine
• A fistula — an abnormal opening leaking urine from elsewhere on the shaft
• Urethral stricture at or near the previous repair, causing a slow stream and straining
• Persistent or recurrent chordee, making intercourse difficult or painful
• Recurrent urinary or urethral infections
• Difficulty depositing semen, with consequences for natural conception
• Hair growing inside the urethra where hair-bearing skin was used in an older repair, sometimes with stone formation
• Cosmetic concerns and the psychological impact of these, which are a valid reason to seek treatment

How I assess adult hypospadias

Assessment is more involved than for a straightforward stricture, because the anatomy has usually been altered by previous surgery. It includes a detailed history of every previous operation — original operative notes are extremely valuable if you can obtain them — examination of the penis, the meatus, the quality and quantity of available skin, and any chordee. Investigations include flow rate measurement, flexible cystoscopy, urethrography to map the urethra, and assessment of the genital skin for lichen sclerosus, which changes the reconstructive plan because affected skin cannot be used as graft material.

Where fertility or sexual function is affected, those are assessed at the same time rather than separately.

Treatment

The plan depends on what is wrong and what tissue is available:

• Fistula closure where the urethra is otherwise sound
• Meatoplasty, including staged and Malone techniques, where the opening itself is the problem
• Correction of chordee to straighten the penis
• Single-stage urethroplasty where there is enough healthy local tissue
• Two-stage repair — the first operation lays down graft tissue and creates a healthy bed, and the second, some months later, tubularises it into a new urethra. This is often the right approach in heavily scarred cases and gives more reliable results than forcing a single-stage repair.
• Buccal, lingual or preputial grafting to provide the tissue needed
• Hair removal before reconstruction where hair-bearing skin will be used

See adult hypospadias repair for more on the operations themselves.

My practice

I set up and lead the Southeast London Urethral Reconstruction Team at Guy's Hospital, established in 2012, and perform primary and redo adult hypospadias repair as a core part of my practice. I teach these techniques nationally and internationally, and accept tertiary referrals from other units for men whose previous repairs have failed.