What happens under normal conditions?
The penis serves a dual role in males by providing a pathway for urine to exit the bladder and for semen to enter the vagina. Both tasks are facilitated when the urethral opening (meatus) is positioned normally at the tip of the head (glans) of the penis.

At birth, the foreskin usually cannot be pulled back to expose the head of the penis. In most boys the foreskin becomes retractable in the first few years of life, although in others it may not be able to be pulled back until as late as puberty.

What is hypospadias?
The most crucial steps in the development of the penis take place between weeks nine and 12 of pregnancy. During this time, male hormones act to stimulate formation of the urinary channel and foreskin. Various problems with hormone action may result in a congenital condition called hypospadias.

Hypospadias is a common birth defect, occurring in one out of every 150 to 300 boys. Most often it is the only problem in these infants and does not imply there are other defects in the urinary system or other organs. It is a condition in which the urethral opening does not form completely to the tip of the penis. Instead, the opening may be located anywhere along the underside of the penis. While the urethral opening is most often found near the head, a position referred to as distal, it also may be located from the middle of the penile shaft to the base of the penis or even behind the scrotum, a position called proximal. About 70 percent of boys with this condition have distal hypospadias. In 15 percent of those cases, it is associated with mild downward curvature of the penis. In contrast, when the urethral opening is located more proximally, curvature occurs in more than 50 percent of patients.

Usually hypospadias is apparent at birth. Not only is the urethral opening in the wrong position, but the foreskin typically is also incompletely developed, resulting in what is called a dorsal hood that leaves the tip of the penis exposed. In fact, it is the appearance of the foreskin that most often calls attention to the problem. However, some male newborns have an abnormal foreskin with a normally positioned urethral opening, while in others, a complete foreskin may hide an abnormal urethral opening. About 8 percent of boys with hypospadias, also have a testicle that is not fully descended into the scrotum.

How is hypospadias treated?
Physicians have been correcting hypospadias with surgery since the late 1800s. But while more than 200 operations have been described, only a handful of techniques have been used by pediatric urologists since the modern era of hypospadias reconstruction began in the 1980s.

Regardless of the approach, the goal is to create a normal straight penis with a urinary channel that ends at the tip of the head of the penis. The operation usually involves four steps: straightening the shaft; creating the channel; positioning the urethral opening in the head and either circumcising or reconstructing the foreskin.

Hypospadias repair is usually accomplished in a ninety-minute to three-hour same-day surgery. In a few instances, however, it is done in stages, usually when the surgeon wants to separately straighten the shaft before constructing the urinary channel.

For a variety of reasons doctors prefer to do childhood hypospadias surgery in full-term and otherwise healthy boys, between the ages of three and 18 months. Yet the repair can be corrected at any age in childhood and even into adulthood. Occasionally, when the opening is proximal, treatment with the male hormone testosterone previous to surgery may be recommended.

What can be expected after treatment for hypospadias?
Many surgeons prefer that their patient not urinate through the fresh repair during the first few days after surgery. So they leave a small catheter in the penis that drains into the diaper. Antibiotics, and sometimes bladder antispasmodics, are given while the catheter is in use.

In general, the repair is not very painful. In fact, when the operation is done, as most pediatric urologists recommend, in boys three months to one year old they have no memory of it. Yet, even older boys and adults tolerate this surgery well, especially with the availability of current pain medications.

Modern hypospadias surgery creates a penis with good function that looks normal or nearly normal. The complication rate in boys with distal hypospadias repair is less than 10 percent. Problems can occur more often after a proximal correction.

The most common dilemma after surgery is the development of a hole — or fistula — from the urinary channel to the skin. Scarring within the channel or urethral opening also can occur, interfering with urination. In addition, the wound may fail to heal. If your child complains of urine leakage from a second opening or a slow urinary stream after hypospadias repair, he should see his pediatric urologist.

Most complications surface within the first few months after surgery, although fistulas or blockages may not be found for years. Otherwise a successful repair should last a lifetime, including during rapid penis growth spurt at puberty. Also, most complications are easily repaired with additional surgery after the tissue has healed from the first operation. Further repairs should not interfere with a surgeon's ultimate goal of creating a functional and normal appearing penis.

Physicians differ in opinion as to how long after surgery patients should continue returning for check-ups. Some pediatric urologists believe the risk for problems after the first few months is so low that routine office appointments are not necessary thereafter. Others think boys should be seen throughout childhood until after puberty. The final decision will be up to you and your son's doctor.