Interestingly, reports suggest that both the incidence and the severity of Hypospadias may be increasing.
Evidence suggests that an antiandrogen mechanism (one that hampers the activity of male hormones) is most likely (Baskin et al.2001).
Potential endocrine-disrupting chemicals include dioxins and furans, PCBs and organochlorine pesticides, and also dietary phyto-oestrogens (such as in soy products) (Colborn 1995; Burdorf and Nieuwenhuisen 1999; Joffe 2001) The ALSPAC cohort study (North et al.2000) found vegetarian diet to be a risk factor for hypospadias, with the implication that high soy (a phyto-oestrogen) intake or pesticide intake might be causal factors, although numbers were too small for detailed analysis.
To date no further published studies have looked at vegetarian diet. A study of residents near hazardous waste landfills found an increased risk of hypospadias and some other congenital anomalies, but no specific chemical exposures could be characterised in that study (Dolk et al.1998).
Farmers and gardeners have been one occupational group of concern because of their work with pesticides, many of which have potential endocrine-disrupting properties. Studies have suggested both no relationship between hypospadias risk and parental work in agriculture or gardening (Schwarts et al.1986; Weinder et al. 1998; Garcia et al. 1999) and a positive relationship (Kristensen et al.1997).
A study based on the England and Wales National Congenital Anomaly Notification System looked at the relation between potential endocrine-disruptor exposure based on job title and risk of hypospadias (EUROCAT Working Group 2002a; Vrijheid et al. 2002).
There was little evidence of any increased risk of hypospadias, although further surveillance of hairdressers as a relatively large potentially exposed group was recommended.
The deformity In Hypospadias the urethra does not develop completely and opens on the underside of the penis, in the scrotum, or occasionally in the perineum.
The more severe variants of hypospadias are usually associated with chordee , or a downward curvature of the penile shaft. The prepuce is usually abnormally developed as well, with a dorsal hood of foreskin covering the top of the glans but absent ventrally. Hypospadias may affect both urinary and sexual functioning of the penis.
When the urethral meatus opens ventrally, micturition is affected, and the urinary stream is directed downward rather than straight ahead, making it difficult for these males to stand while
voiding.
In general, hypospadias is not associated with internal anomalies of the urinary tract, with no increased risk of urinary infections. Sexual intercourse may be difficult because of the small size and downward curvature of some hypospadiac penises. In severe cases, fertility can be impaired.
Frequently Asked Questions
Why does hypospadias happen?
The exact cause is not known but the deformity occurs during the first 3 or 4 months of life in the womb, during the time when the genitals are forming. In hypospadias, the penis does not quite complete all of its development. There is a familial tendency, because in at least 20% of cases 1 or more male relatives also have hypospadias.
What if we have more children?
If you have one son with hypospadias and this has not happened before in the family, then there is probably a 1 in 10 chance that if you have another son, he will also be affected. If there is already hypospadias in the family, then the chances will be much higher maybe as much as 1 in 3 or 4.
My child has no problems from his hypospadias, so why should he have an operation?
During early childhood the less severe forms of hypospadias usually cause no symptoms or concerns, so parents will naturally wonder whether surgery is justified for what seems like just a minor cosmetic problem.
We know however that when hypospadias is left untreated, the great majority of boys will develop spraying or misdirection of their urine by the time they reach their teens. The abnormal appearance may also cause social embarrassment or psycho-sexual difficulties once they realise that their penis is different.
Hypospadias could be operated on at any time but the periods between the 4th and the 8th month of life (first “no go” time window) and the 18th month and the 3rd year of age (second “no go” time window), are best to be avoided.
Because a normal penis grows only about 0.8 cm between the ages of 1 and 3 years (Schonfeld and Beebe 1942) the size of the phallus is not an important technical consideration.
We prefer to operate at the age of 9 months up to the 18th month. If not possible, we prefer to operate at the age of 3, by which time most boys are out of nappies and are mature enough to make co-operative and easily managed patients.
What does surgery involve?
Surgery involved straightening the penis and repositioning the meatus in its normal place on the tip of the glans. In most cases it is not possible to reconstruct a normal foreskin and so the end result will usually look circumcised.
We usually correct distal or mid-shaft hypospadias in a single operation employing the “Snodgrass” and “Snodgraft” repairs. In other more proximal cases we recommend the 2-stage Bracka’s repair, as this usually gives the most natural results and has the least complications.
Bracka’s repair:
Stage One: Involves straightening the curvature, and grafting some of the excess foreskin onto the underside of the penis, where it will form the foundation for the missing bit of urethra. This will require an overnight stay in hospital.
Stage two: Is done 6 months later and again may require an overnight stay as an inpatient. On this occasion the skin graft from the first operation will be formed into a tube that will open on the tip of the glans, and the remaining foreskin hood is trimmed off.
Can I stay with him?
Usually the boys cope very well with their stay in hospital. A familiar face is reassuring and so we encourage and provide facilities for one parent to stay with them on the ward and to accompany them to the anaesthetic room in theatre.
Will he be in much distress?
Although the surgery sounds rather painful, in actual fact there is usually very little discomfort. A mild pain-killer is usually all that is required. With TV, videos and games most of the boys actually look forward to coming back into hospital for their 2nd operation if need be (2 stage Bracka’s repair).
Will the surgery be successful?
A full general anaesthetic will be necessary for the operation(s). Modern anaesthetics are now safe, and serious problems are fortunately extremely rare.
To further minimise any risks, the anaesthetist may wish to postpone the surgery if your child has a significant cold, cough or chest infection at the time of admission. In that case we would arrange a new date when he is fully recovered.
Hypospadias repair is skilful and delicate surgery but it is not major high risk surgery. With modern treatment the great majority of repairs are successful without the need for more than the planned number of operations.
However, even with the best and most specialised care, unexpected problems do sometimes arise. The repair may occasionally develop a leak or a narrowing in the new tube, or there may be cosmetic imperfections. In those cases an extra operation or operations may be necessary to achieve the ideal result. Any dos and donts after the surgery?
How many days the catheter will stay in, is an on table (during the operation) decision according to the intra-operative findings and method of repair. You may be asked to apply a mild antiseptic cream to the operation site several times a day for the first 10 days, but there is otherwise little in the way of specialised aftercare required.
Obviously the healing operation site should be protected from injury if possible, and so we advise against high risk activities such as contact sports and riding bikes for up to 2 months.
After that however, no restrictions are necessary. What problems will he have when he is older? Usually None. You can expect the penis to develop and to function perfectly well after the deformity has been corrected.
As a precaution we do like to see our patients for a check up from time to time, until they have finished their development around their 18th year of age. Then if there are any adolescent worries or questions about the hypospadias, we can deal with these.
