By Danelle Frisbie, Ph.D., M.A. © 2010Current citation: Frisbie, D. (2010). "Hypospadias: Surgery and Circumcision." At Peaceful Parenting: http://www.drmomma.org/2010/04/hypospadias-surgery-and-circumcision.html
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mother and newborn oil on canvas by Pam Fox
What is hypospadias?
Hypospadias in boys is a congenital condition in which the urinary opening is not at the typical position on the end of the glans (head) of the penis.
Typically recognized at birth, the urinary opening is instead located anywhere along the underside of the penis - from the underside of the glans (most common) to behind the scrotum (very rare). In addition, the prepuce (foreskin) is often not as long, or wide, and does not cover the glans as the prepuce on most boys. [Note: A boy may be born with a small or large, long or short, foreskin - this does not mean he has any form of hypospadias. Differentiation among penile/clitoral and prepuce size is normal from human to human, among both girls and boys, men and women.] The penis may curve downward among some boys with extreme hypospadias, especially when the urinary opening is a distance away from the glans (near the scrotum for example), which again is rare. (37) In 70% of hypospadias cases, the difference between the location of the urinary opening and where it would otherwise be is only marginal and makes little difference to the full functioning of penis. (1, 13, 18, 32, 36)
Locations along the urethral plate where urinary openings may be present in cases of hypospadias. Approximately 70% of boys with hypospadias have a urinary opening in the glanular or subcoronal location which is an insignificant distance from the typical location (top mark on the diagram).
Why does hypospadias occur?
The penis forms after a bodily response to testosterone washes inutero during weeks 9-20 of pregnancy (prior to the 9th week, male and female gonads inutero are identical and the penis and clitoris form from the same tissues - they are analogous and homologous organs). Up to about Week 12, the clitoris and penis look the same to the naked eye as well - they are indeed 'the same' organ. When a male fetus' hormones respond to his mother's, the way in which the urinary channel grows is stimulated, and the penis and prepuce develop differently from a female's clitoris and prepuce. If a male does not respond to these hormone 'washes' inutero (for whatever reason), he may be born chromosomally male (XY) but with external sex organs that appear female. Again, they are all the same organs, but respond to hormone washes differently, and as a result, end up 'looking' different at birth between girls and boys.
Ultrasound images of a male (left) and female (right) baby at approximately 11 weeks gestation. While differentiation has started to occur, the homologous and analogous nature of the clitoris/penis and related organs is readily apparent to the naked, untrained eye.
The location for the urinary tract starts off developmentally below the genital bulb - the organ which will become a clitoris or penis. In girls, this urinary tract stays short and below the genital bulb (clitoris). In boys, it typically elongates and grows into the genital bulb (penis) due to hormone response. The process is not always a smooth one, however, and therefore we occasionally see male babies born with this shorter urinary tract that did not grow to the end of the genital bulb (penis) inutero.
There is some debate about whether we see this occurring more in populations impacted by artificial hormones (in our diet) and toxins in our environment, which act upon developing babies and especially impact male sperm, male embryos and male babies. (9, 29, 32, 36, 41) Another theory is that we've seen more hypospadias in the past 50 years since we started circumcising and/or forcibly retracting healthy newborns in the United States - the majority of hypospadias cases are those which could otherwise just be seen as a normal variation in the penis and men grow up to do fine with a urethral opening just below where it would otherwise be. (1, 10, 13, 23)
Although the exact causes for the hormone related alteration that results in hypospadias are not fully known, problems during the 9-20 week time frame likely result in this condition. Typically, however, boys with hypospadias have no other atypical issues at birth (i.e. nothing else in their development was impacted during those same weeks inutero). In about 8% of boys with hypospadias, one testicle may not have fully descended into the scrotum, in which case a blood test (karyotype) is often recommended to check for other chromosome abnormalities. (32, 36) Usually, the testicle drops on its own, and there is also no cause for concern.
How often do we see hypospadias?
It is important to realize that boys born with hypospadias still have the organ tissues that would have developed into the urinary channel - they extend from wherever the urinary opening is, to the end of the glans where the channel would otherwise be. This strip of tissue is referred to as the "urethral plate."
Hypospadias appears to run in families. About 7% of boys born with hypospadias also have a father born with the condition. (9, 18, 29) If one son has hypospadias, the chance a second will be born with it increases to 12%. (29, 32, 36) If both a father and his son have hypospadias, the likelihood of another boy being born with hypospadias is 21%. (32, 36) Hypospadias impacts 1 in every 150 to 300 boys born. (9, 18, 29, 32, 36) As a result, hypospadias is one of the more common concerns parents of healthy, intact boys deal with after birth -- and one which involves their son's most sensitive member.
What do we do for boys born with hypospadias?
The 'treatment' for hypospadias in the United States today is to surgically move the urinary opening to the end of the glans and to straighten bending of the penis that may be present in extreme cases (although there are no bones or muscle in the penis except for the smooth muscle of the prepuce organ). (33, 37) Surgery is often performed on an infant of 3-18 months of age (but is often more successfully performed later in childhood or adulthood). The theory behind this early age of genital reconstruction is that baby boys are "not yet aware of their penis" - although I would adamantly disagree with this justification.
Hypospadias surgery is typically completed within 3 hours and can often be done in 1 surgical attempt. There have been over 200 different methods developed to complete this surgery over the last century that it has been performed. (26, 27, 31) Today only a handful of techniques are still used, but the type of hypospadias surgery conducted on any given baby will depend on the doctor cutting him, what his/her training is, and what his/her preference is. (16, 35, 43) A boy will not receive the same hypospadias surgery from one doctor to the next.
There are many U.S. doctors who continue to routinely perform prepuce amputation (circumcision) and cut off the foreskin during hypospadias surgery. (9) This is never necessary. Surgeons occasionally advocate for circumcision during hypospadias surgery because (while this is typically not mentioned as the reason to parents) by cutting away more of the penis, there is less to 'mess' with, which can make penile reconstructive surgery easier to complete - less organs in the mix to worry about. (1, 9, 13, 23) In addition, more money is brought in because circumcision surgery is added to the tab.
However, surgeons informed and up to date on the important functions of the foreskin, the many purposes of the prepuce, and the harm that results from its amputation, will leave the foreskin alone (or reconstruct it as well) and not circumcise during hypospadias 'repair'. (13, 16, 27, 34, 38, 39) There is no problem in having a short (or partially covering) prepuce. Typically, the prepuce will elongate, loosen and grow as the boy grows into and throughout his years of puberty. The prepuce can also be surgically altered in cases of partial covering (or 'hooded' foreskin) to cover the whole glans.
Below is a diagram of the prepuce being reconstructed to cover the glans during hypospadias surgery. This is commonly performed in the majority of the world today during hypospadias 'repair'. Only in the U.S. does circumcision surgery often come into the surgical mix with hypospadias.
Healing and Side Effects from Hypospadias Surgery
The healing process from hypospadias surgery typically lasts several weeks to several months (6 months is not uncommon). (5, 26, 31, 46) The penis is bandaged, and a urinary catheter is in place for about 1 week following surgery. In addition, antibiotics are prescribed while the catheter is in to fight foreign invaders that are common to post-surgical infection. An antispasmodic medication is typically given to reduce bladder irritation from a catheter being in place for so long. None of this is 'fun' for a baby, toddler, child or adult to endure - but I would argue it may be especially difficult to deal with when you are already a tiny human being with a new, wild world around you, and you do not yet have the ability to understand why this pain is being inflicted upon your little body. In addition, post-op infection in an infant can be much more life-threatening than infection in an older child or adult. (1, 27, 43, 46)
The Children's Medical Center in Dallas, TX (home to the nation's top pediatric urologist) highlights the surgical problems that can occur from hypospadias surgery:
* The most common problem that results is "fistulas," which are abnormal openings under the penis that leak urine during voiding.
* Sometimes part, or all, of the repair comes open (dehiscence), returning the urinary opening back towards its original location.
* Scar tissue at the urinary opening (meatal stenosis) or along the new urinary channel (urethral stricture) may cause blockage to urination.
* If the new urinary channel enlarges, a "diverticulum" results, which looks like a swelling under the shin during urination from which urine dribbles after voiding.
Other complications can also occur, but these four account for most of the post-op problems in hypospadias cases. (25, 30, 43) It is not unheard of for infants to undergo as many as 20 surgeries over the course of their lifetime after the first cut is made in an effort to 'fix' and 're-fix' problems that arise from genital cutting. (30) The Children's Medical Center offers parents this information on the frequency of these surgical complications:
Rate of surgical repair complications depends upon several factors. One is the severity of the condition, as distal hypospadias operations have fewer problems after surgery than do more severe proximal ones. Various techniques used to correct the defect are known to have different rates and types of complications. Finally, experience of the surgeon may also affect the likelihood of problems after the repair. It is reasonable to ask about the personal experience of the surgeon when deciding who is going to operate upon your son. Nevertheless, even the most experienced pediatric urologist occasionally has complications after hypospadias repair.
One of the most common forms of hypospadias - the urinary opening is at the bottom of the glans and there is no bending or other atypical aspect of the penis.
Is Surgery Necessary?
Cases of hypospadias in boys vary in severity - the vast majority are minor and do not require surgical alterations for a boy/man to live normally. (1, 13, 23) In fact, there are multitudes of adult men the world over who were born with hypospadias, have never been surgically altered, and they function just fine. They are able to pee standing up, and engage in intercourse with no issues. They are able to reproduce equally as well, as semen leaves the penis in relatively the same area as it otherwise would during intercourse. Approximately 70% of hypospadias cases are those in which the urinary opening is on the bottom side of the glans. (1, 13, 18, 32, 36)
There are also healthy adult men born with more rare forms of hypospadias (further down the shaft, or near the scrotum for example) who are happy with their intact body and never chose to be surgically altered. (1, 13, 23, 29) They may urinate while sitting down, and may need alternative methods for procreation (to effectively place semen into a female partner, for example). But their penis functions fully as any other would. Men with severe hypospadias continue to experience vascocongestion (erection) and orgasm (muscle contraction) the same as any other man.
Rare, extreme case of hypospadias - the urinary opening is near the scrotum along the shaft of the penis. The penis also has a bend to it due to the atypical formation of the tissues and organs.
With a shorter urethra that is not fully covered/protected by the prepuce, there is an increased chance of UTI (in the first 12 months of life), but this is no greater than the risk of UTI for an infant girl as she, too, has a shorter urethra. UTIs are easily treated with antibiotics and this is not reason to surgically and permanently alter or amputate body organs. Even in cases of repeated UTIs (which happens often among baby girls prone to them) circumcision is not the answer.
In preparation for this article, I interviewed several colleagues in the fields of human sexuality, as well as those in pediatric urology who are well informed in all areas regarding the prepuce, the urethra, hypospadias, and circumcision. When asked if they would operate on their own infant or child with minor hypospadias (the most common form) the response was a unanimous, NO. Especially not at a young (toddler or infant) age. Many said that even in more extreme forms, they would wait to give their son a voice in the decision.
There are simply too many risk factors and no definite benefits in operating on an infant. At 15 months old (for example) the penis is small and the tissues and organs have not yet developed or elongated as they will do as a boy ages (throughout puberty). Any genital modification at this point via surgery is going to impact the way that his body is able to grow/stretch/develop, naturally. It may not seem like a big deal, but because each individual surgeon decides how much to cut, what repairs to do/not do, how the technique will be performed, how to treat the prepuce (foreskin), etc., all these small cuts on a tiny penis equal BIG changes when a penis gets to be...well, "BIG".
The results can be compared to the way that a balloon looks if we write on it in tiny letters when it is deflated and then blow it up, vs. the way it looks if we write on it in tiny letters when it is already blown up. The impact of the writing on the balloon changes based on size/shape/growth and what still needs to occur in getting bigger (developmentally).
Another issue brought up among the panel I interviewed said that by waiting until a boy is older, he is given the option of his own body choices. This allows him to be fully anesthetized at a time when surgery is not as risky, should he choose surgery, and it allows him to understand what is being done, while preventing him from having the exacerbated painful recovery due to diaper wearing over a surgical wound. Diapers alone agitate a surgical site and I've heard from many parents with toddlers in agony for weeks (one recently said for MONTHS) because of circumcision and/or hypospadias surgery. It is no way to live your days when you are so very young and do not yet fully understand what is going on. Especially not at a stage in developmental growth when time really 'stands still' when you are in pain.
Hypospadias 'Repair' as Cosmetic Surgery
Overall, most baby boys with minor hypospodias do NOT go on to have any issues later in life - without ever having any type of surgery on their penis. The question then becomes, why do cosmetic surgery on an infant/toddler when we do not know for sure there will ever exist the need or desire for it later?
As mentioned, the majority of hypospodias 'repair' surgeries are done on mild cases - not for medical/bodily need, but for cosmetic reasons (to make the urethral opening on the penis 'look like' other penises). (1, 5) The Children's Hospital states that, "The final cosmetic appearance is assessed at 6 months to allow adequate time for healing and to identify the most common surgical complications that can occur." It is the appearance of a child's penis that is of most concern in most cases of hypospadias surgery - not the functioning of his organ.
Marilyn Milos, founder of The National Organization for Circumcision Information Resource Centers, reports, "In the case of minor hypospadias, the advice we have today is to leave it alone. What's the worse that can happen? That a boy must sit to urinate? Many men sit to avoid the splash factors, and their wives are happy, too. The surgery is much more traumatic for a child than a minor malady, which can always be repaired if that is what the boy wants when he can make the decision for himself."
In fact, there are many adult men I spoke with who did undergo surgical hypospadias 'repair' as infants, and are unhappy with the results today. They wish their penis had been left alone. Most Americans were also circumcised during the surgery, so it does become difficult to determine whether it is the actual hypospadias reconstruction, or the prepuce amputation, that causes their grief.
One man shared his experience:
Many of you know my personal experience in this area, and know that I have time and time again advised mothers to NOT get hypospadias "repair" surgery on a child of theirs. I say this because often those boys can do everything normally, (like peeing standing up, and having sex/reproduction) and the surgery often becomes a "well I think his penis should look 'normal' argument. Which suddenly makes this all a cosmetic issue. But studies that have been done have shown time and again that men with mild hypo were overall happier with their penis then men who had mild hypo and had it "fixed" in infancy.
There are RARE cases where the urethra opens so low, (i.e. midshaft, or at the base of the penis, where it really is a medical problem). For these cases, where surgery truly is needed, there are hypo repair doctors in the United States who provide the surgery that keeps the foreskin intact! Because hypospadias is getting more common each year, please take my story and this doctor's page, and save it for the next time you find a parent concerned about hypo repair, and worried their son will have to be circumcised.
Not only is it beneficial to wait for any type of hypospadias surgery until your son is older and can decide for himself, but in waiting his genitals are allowed to become fully developed. If he elects for surgery, foreskin-saving methods are easier to perform on an adult penis than on a very small infant/toddler's penis. There is more to 'work with' on an adult, and surgical mistakes are not as common.
Inutero differentiation of external sexual organs.
My Son Won't Remember It Anyway...
I do appreciate parents' good intentions when they say that they wish to have hypospadias surgery performed upon their infant son when he cannot 'remember' it on a conscious level. Parents are certainly well meaning for their little loved one. However, we have countless studies that demonstrate surgical procedures and pain in infancy and toddlerhood impact the brain, enzymes, cortisol and other stress hormones, blood pressure, vascoconstriction, and that even pain response and sensitivity in adulthood is impacted. (2, 3, 4, 6, 7, 8, 11, 12, 14, 15, 19, 20, 22, 24, 44, 45) Obviously the brain knows what is going on and there are memories being formed through the pain and discomfort.
The body and brain DO seem to remember traumatic events in infancy/toddlerhood - and it may even be more damaging when a little person cannot understand what is going on, or why they feel the way they do, or what is being done to them. (2, 6, 7, 8, 14, 15, 24, 44) There are cases when pain and surgery cannot be avoided in infancy - when the medical need and benefit outweigh the detriments on a child. But mild hypospadias, and especially circumcision, is not one of those cases.
A mother recently shared her story with us:
My son was just 2 1/2 years old when he and I were watching Jurassic Park together. There is a scene when the mother dinosaur is fighting to protect her egg. My son was troubled by this - why would the mommy dino kill people? I explained to him that she would do anything to protect her baby inside the egg - just like I would do anything to protect him. My son seemed to be in deep thought, but nothing could have prepared me for what he said next. "Yeah, I know. Except the one time when you let them do this [and he made chopping motions with his hands and arms on his penis] to me." In that moment I almost died of guilt and remorse and shock that everything I had assumed to be true of infant memories is wrong. My son was circumcised after birth and this is not a subject we had ever discussed. In fact, I had never even thought about it until this day. If I had it to do over again, I would protect him against the pain and suffering and loss of any unnecessary surgery - especially the cosmetic one of circumcision.
The number of boys cut today in the United States for cosmetic excuses does not match up with pro-cutting numbers that advocate for circumcision/hypoplasia surgery 'packages.' Even if ALL boys born with hypoplasia underwent surgery and ALL of them were also circumcised during the surgery, this would still be just 0.3 - 0.6% of boys who faced genital cutting and the loss of their prepuce. (1, 13, 18, 32, 36) The rate of intact boys and men in the U.S. would match the rest of the intact world at 99.4 - 99.7%. This statistic is significantly different than the current 50% intact rate in the United States, which tells us this is a subject that continues to warrant our immediate and astute attention.
The "Foreskin-Friendly" Approach
Dr. Warren Snodgrass is Chief of Pediatric Urology at Children's Medical Center (Dallas, TX) and Professor of Urology at UT Southwestern. He is internationally renowned for his version of hypospadias surgery - the Tubularized Incised Plate (TIP) operation, which most surgeons refer to as the "Snodgrass Repair" and he is 'foreskin-friendly' - i.e. he will perform hypospadias surgery without amputating the prepuce (circumcision).
While some physicians in the U.S. continue to automatically circumcise boys during hypospadias surgery, Snodgrass offers foreskin reconstruction even in extreme cases of hypospadias. He has a success rate of 95% and has helped boys and men who have endured as many as 20 previous 'failed' operations and side-effect complications due to hypospadias surgery. (16, 25, 30, 38, 39, 40)
The fact that Snodgrass advocates for hypospadias surgery while keeping boys intact is significant because he is a leader among pediatric urologists and surgeons operating on boys with hypospadias. No other active surgeon has published more scholarly articles on hypospadias surgery than he has. No other method to correct hypospadias has been the subject of more publications than Snodgrass' technique. Surgeons travel from around the world to observe him performing hypospadias surgery (which does not include circumcision unless parents/patients request it) at the Children’s Medical Center in Dallas, TX. He has taught and practiced in more than 20 countries throughout North and South America, Europe, the Middle East and Asia.
Additional 'foreskin-friendly' physicians and surgeons can be found here or through your local chapter of The Intact Network.
What would I do?
I am frequently posed with the question, "What would you do?" This I know for certain: If I had a son born with mild hypospadias (as is generally the case), I would leave his body alone and let him decide if he wanted to do anything when he was old enough to fully understand and make the choice for himself. I am 100% certain that the many men with hypospadias who function perfectly well (urinary, sexually, and reproductively) are testimony to the less-is-more intervention response in this situation.
If I had a son born with severe hypospadias (urinary opening under his scrotum for example), I would wait as long as possible (for the reasons stated above in not performing infant surgery and having the risk of consequences on a baby/toddler), and then if I felt it was absolutely necessary for his well being, or if my son chose the surgery for himself, I would seek the services of someone who was well-informed in prepuce-sparing techniques (a 'foreskin-friendly' doctor like Snodgrass) and one who I knew regularly does effective hypospadias surgery in one attempt without also circumcising babies. A large part of me would caution to wait, and let my son decide, no matter the severity of hypospadias. The British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) reminds parents in Britain that even the rare and severe hypospadias cases are not urgently in need of treatment. There is nothing wrong with allowing a boy to decide for himself as he grows to understand the implications of his options and choose for himself.
As parents it is our job to protect, to love, to nurture, and to wisely do what is best for our children - to seek out information and make educated choices along the way. One in 150-300 of you will face this hypospadias decision. May it be a fully informed one.
For photographs of actual hypospadias cases in infants and adults, see this page [in progress - link soon to be added].
For additional information on circumcision, see resources at Should I Circumcise My Son? Pros and Cons of Infant Circumcision.
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