Hypospadias: Parent's Guide to Surgery
What is hypospadias?
Hypospadias refers to a urethral meatus ("pee-hole") which is located along the underside, rather than at the tip of the penis. In minor, or distal hypospadias, the meatus may be located on the underside of the penis, in the glans. In more pronounced hypospadias, the urethra may be open from mid-shaft out to the glans, or the urethra may even be entirely absent, with the urine exiting the bladder behind the penis.
How will hypospadias affect my child?
Hypospadias is essentially a cosmetic difference. A person with hypospadias may have to urinate sitting, rather than standing. He may also be prone to urinary tract infections.
More important is the emotional impact of having a penis that "looks different." This is why your doctor may advocate surgery for your child's hypospadias. Our discussions with men who have had hypospadias surgery lead us to believe that the physical damage and emotional trauma of genital surgery are frequently far worse than the hypospadias itself.
Hypospadias does not in itself cause infertility. Infertility may be present in the more extreme forms of hypospadias, where the testes are irregular and cannot produce viable sperm. Hypospadias surgery cannot make an infertile male fertile.
A hypospadic penis is entirely capable of pleasurable sexual sensation and orgasm. Plastic surgery on the genitals damages erotic sensation; it cannot improve it. There are some conditions however, which may require surgery to save your child from pain or illness, such as chordee which bends the penis causing painful erections, exposed mucous membrane, or adhesions.
Did I cause it?
Hypospadias is not caused by any parental negligence. Because genital difference is so stigmatized in our culture, there are no good statistics, but hypospadias is quite common, probably occurring in one of two or three hundred births.
Does my son need surgery?
Although surgeons usually counsel early surgery to repair the hypospadias, we have found that surgery is frequently very harmful, both physically and psychologically. Surgeons, of course, are trained in surgery; they are not experts in child psychological development or human sexuality.
Many complications can occur with hypospadias surgery. Unfortunately, it is usually performed on children before puberty, and few doctors do extensive follow up on their hypospadias patients. A young man who finds that his sexual function was irreversibly damaged by surgery during childhood is often too embarrassed to discuss it.
Natural vs. surgically constructed urethra
The urethra, the tube which carries urine and semen out of the penis, is made of mucosal tissue, like the inside of your nose or mouth. This mucosal tissue is designed to resist both the irritating effect of urine, and the growth of bacteria, which would otherwise flourish in such a warm, wet, protected environment.
When surgeons use a flap of skin to construct or extend the urethra, the skin tube that results is poorly equipped to resist irritation from urine, or infection by bacteria. Further, the surgically created urethra is not as smooth as a real urethra, and may grow hair.
Urinary tract infections, fistulae
Urine may collect in a surgically constructed urethra. Pressure during urination can force urine to escape into the body of the penis. These factors can result in pain and a life-long tendency toward urinary tract infections, which may involve the bladder and kidneys, and become quite serious. The surgical scar can break down, forming fistulae, or holes, in the urethra, resulting in pain and more surgery.
Hair in the urethra
The penis heals poorly after surgery, because of its midline, distal location. Surgeons often resort to cortisone to promote healing. Unfortunately, cortisone can cause hair to grow in the skin which was used to build the urethra. This hair exacerbates the urinary tract infections that can plague boys and men who have had hypospadias surgery.
Poor healing also leads to extensive scarring. The penis is an unfortunate part of the body on which to have thick, inflexible scars. More important than the appearance is the fact that scar tissue has little sensation, and is very stiff. Instead of a penis capable of exquisitely pleasurable sensation, many men who have had hypospadias surgery report that they have little or no sensation, or even that the stiff scar tissue causes them pain upon erection.
Local infection, sloughing
Skin which is transplanted to the penis from another part of the body, or penile or scrotal skin which is wrapped around to form a urethra, is at risk of infection or sloughing away. The result is often more pain, emotional trauma, and repeated invasive genital surgeries for the unfortunate boy.
We have found that genital surgery performed on infants and children who are too young to understand the implications for their sexual future can be emotionally traumatic. The hidden message is that the child's genitals, although not causing him any physical discomfort, made adults so uncomfortable that they had to be surgically "fixed" before he was old enough to have a say in the matter.
Counseling is essential
We believe that your child will be best helped by minimizing genital surgery. No surgery should be performed unless it is absolutely necessary for his comfort and safety. Whatever you decide, we urge you to obtain help from a professional therapist with training in sexuality. Education and counseling for the whole family, including parents and siblings, will help you to help your son deal with his difference.
You can locate a sex therapist through the American College of Sexology, 1523 Franklin Street, SF CA 94109. Tel (415) 928-1133, or contact us at the Intersex Society.
After puberty, when your son is sexually mature, and able to make responsible decisions for himself, he may wish to consider hypospadias repair surgery. He will be able to weigh for himself the inevitable trade-off of sexual feeling for a possible improvement in appearance. Furthermore, the surgical prospects are improved when working with a mature, full grown organ, after the dramatic size and shape changes of puberty are complete.