Wednesday, April 14, 2010

Hypospadias: Surgery and Circumcision

By Danelle Frisbie, Ph.D., M.A. © 2010
Current citation: Frisbie, D. (2010). "Hypospadias: Surgery and Circumcision." At Peaceful Parenting: http://www.drmomma.org/2010/04/hypospadias-surgery-and-circumcision.html

For reprint permission in publication, email DrMomma.org@gmail.com


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.


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 through Doctors Opposing Circumcision.


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.



Note:

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 Are You Fully Informed?


References

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46) Wilcox D. & Snodgrass W. (2006). "Long-term Outcome Following Hypospadias Repair." World Journal of Urology, 24(3):240-3.

51 comments:

  1. Great post! I have 4 sons (3 girls too) and my second son has mild hypospadias. It was seen at birth and confirmed at one month old. i chose not to circumcism him before we found that out. I am so glad we didn't. His hypospadias is mild enough that because he has his foreskin he has a natural funnel and has no problem urinating. If I would have had his foreskin removed he would not be able to urinate without a lot of accomidations. (It just goes everywhere!!) Nature knows what its doing!! He leads a normal life because he has his foreskin!!

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  2. We have a teenage son with hypospadias and thankfully we also had some wonderful friends willing to speak up and provide us with information on circumcision prior to his birth. Because of this, he remained intact and we made certain that he was never forcibly retracted (common practice during his time of birth). Due to him being intact, we actually didn't find out he had hypospadias until much later in his life when he was retracting on his own.

    He has a subcoronal exit and it posed no problems because urine was directed out by the foreskin (as it should be). If we had had him circumcised, we would have likely caused even more problems for him because then he would have needed to surgery just to avoid spraying all over the place. As I mentioned, he's now a teenager, healthy, happy, and has no qualms about his condition. It makes zero difference on his ability to pee standing and I presume because it is near the end of his penis, it will not impair his ability to procreate if this is something he chooses to do at some point.

    Thank you for posting this and allowing other parents to see that in most cases, the hypospadias diagnosis is NOT a reason for surgery, and certainly not a reason for circumcision.

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    1. What did your friends say to your that helped convince you to leave your son whole?

      Delete
  3. Thanks for this terrific article. I work with children with intellectual disabilities so often these kids have a congenital or genetic disorders. I've had several kids with hypospadias and they've all been operated on before the age of 4. Poor buggers.

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  4. There is only one doctor in my state who will perform the surgery without circumcision.

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  5. The surgery itself is usually not necessary. Again, just cosmetic. Unless the urinary opening is so far down the shaft that they will not be able to inseminate a woman later in life.

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  6. My son just turned 3. He was born w/ hypospadias and chordee. He has had 4 urological surgeries starting at age 12mths. And then every 6months or so there after. He has had 2 different surgeons.

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  7. I am an Adult man, 50, who is a Hypospadias Survivor - though barely these days. My 3-attempt surgeries in 1962/63/64 took place in Houston at Texas Children's Hospital. It left me decades of grief, scar tissue, fistulas, and chordee was never really addressed. Now I'm 50 and the after effects have been harsh.

    There is a script line from the movie HOPE FLOATS in which Bullock's character says: "Childhood is what you spend the rest of your life trying to overcome." That seems to apply best to us Hypospadias kids who in our adult lives have to deal with the consequences of the sum of our surgeries.

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  8. I'm in the midst right now of PTSD (Post Traumatic Stress Disorder) therapy using EFT (Emotional Freedom Techniques) with a Christian Psychologist, in order to get past some phobias / anxiety to have more surgery in the near future. Most of the original fears and experiences come directly as a result of hypospadias surgeries, anesthesia and other events that transpired in situations very similar to or a part of those events.

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    1. Thomas Tiltmann (thomas.tiltmann@hotmail.comJuly 26, 2012 11:23 PM

      Hi there. My name is Thomas and I have moved to Australia in 1982 from Germany. I was born with hypospadias in 1967 in Germany and had several operations as well and suffered psychologically as a result. I also had some phobias and still have anxiety disorders as a result of my childhood. I have only found these sites on the web a few months ago and i am now 45 years of age. If you like to write, please contact me on thomas.tiltmann@hotmail.com
      This address is in Australia, state of QLD and I live in Booval near the city of Ipswich.
      I became a Christian in 1993 and have had support from several Christian Chaplains as well. It has helped me deal with s lot of the anxiety and stress disorders. God bless you and I hope that you find peace in your struggles.
      Cheers Thomas T.

      Delete
  9. I've lived with a more drastic form of hypospadias my whole life (now 54). When I was born my parents wished to surgically alter me (well meaning, of course) but could not afford the procedures and did not have insurance coverage that would enable them to be done. I was apologized to many times over. My mother thinking I would be miserable as a teen or adult with this condition. However, the reverse it true. I feel their lack of funding was a blessing in disguise because I've met many others through hypo support groups who are miserable as a direct result of their surgical alterations as infants and children. I, on the other hand, have learned to work with what I have.

    Sex is enjoyable (while it is painful for many who endured surgical alterations).

    I must sit to pee, but believe in no way this makes me less of a man. Do we define our masculinity according to how we urinate?

    My wife and I have 3 children who were conceived with a little extra assistance, but each one of them was well worth it! And (as an added bonus) we didn't have to worry about birth control during the times in our life when we weren't wishing to conceive.

    I cannot speak to the trauma that is endured as a result of all the unnecessary hypo surgeries being conducted on children and infants today - thankfully I was spared this. But I have heard from more than enough men to know that articles like this are sorely needed. You likely won't be published in the parenting pop magazines laying around in the surgeons waiting room, but hopefully parents care enough to investigate the issue deep and wide before diving into genital cutting on their child.

    I'll be sharing this with our group.

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    1. I am african in my mid twenties,I have noticed I have a hole which looks like an unhealed wound(though not painful at all)somewhere under my penis,it makes me spray urine when standing, I am quite disturbed about this, because I don't know what it is, how it developed etc. Can u help?

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  10. My fiance has mild hypospadias (opening is at the base of the glans). Has caused absolutely no problems at all for him, and it actually greatly enhances pleasurable sensations for me during sex (when he ejaculates) (as compared to my ex-husband who had typical structure).

    Thanks for posting such a thorough and educational piece about this important issue! I'll pass it on!

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  11. There's a doctor in Boston, pro-intact and fixes hypospadias without circumcising! :)

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  12. Stephanie: thanks for the message. What is the doctor's name in Boston? Which hospital he belongs to? how to contact him? Thanks a lot...

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  13. I have a son with hypo. I will not operate on him unless there is a more physical reason to( ie : if he is in pain)I don't see the opening as being a problem really. He will just have to aim better. My question though is (because there is not that much on the subject)...how to care for his foreskin? He was born with a hooded one. Also, he has chordee :( Is it possible for it to straighten more once it grows, or will he eventually need repair for this? ( I have read how painful sex can be :(

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  14. This posting has been very helpful. I was against circumcising our son and thankfully his father followed my lead - 6/2009. A surgeon who was referred by our Pri-Ped to perform a hydro-seal pushed toward a circumcision. I felt pressured and agreed. This past Friday was his surgery. The surgeon informed us that due to mild hydrospadias the circ was not performed. He told us to see a ped urologist to have the corrective surgery and circ performed. I've been stressed and sick to my stomach. I am so relived I found this site. We will see a urologist just to have our son checked out. But we have no intention of putting our son through such a procedure. I'm also happy that the circ was NOT performed. Thank you everyone for such great information.

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  15. Does the surgery need to be repeated ever?

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  16. I have a son with hypospadias and found this article. At first blush, I found it quite interesting. Upon reading the actual references, though, wow. There is a lot of cherry-picked information and incorrect citation of references. Some of them don't even mention hypospadias, but other foreskin abnormality conditions.

    As a perfect example, the 46th referenced article only mentions that occasionally, there is longer-term follow-up and suggests it discusses a more serious impact of post-op on infants vs adults. The actual conclusion of that article, based on repairs from infants - not even looking at adult hypospadias repairs? "In this series, despite high initial complication rates, most patients reported excellent long-term functional results and were quite satisfied with their overall outcome."
    It is also a small study, but it's quite telling that the blog cherry-picks points that aren't relevant (no comparison of infant to adult repair), and ignores the main conclusion of the paper.

    It's not true that the US is the only country that does circumcision as part of hypospadias repair (note no reference given for that!): sometimes the foreskin is needed to repair the urethra. In those cases, of course circumcision would be required.

    While 70% may have the urethra still located within the glans (a number which I couldn't locate in ANY of the reference and would appreciate that information), a large percent have chordee, or bending of the penis, which is important both from a observational perspective as well as a functional and fertility perspective. Chordee repair while young is important in proper penile development.

    Finally, the studies are pretty small scale with relatively poor participation. The "controls" are matched on age, but not by race, income, education, or access to health care information (from the time they were small). As she points out in bold, different repairs will happen with different surgeons. There are really only limited conclusions that can be drawn and she's definitely stretched the limit.

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  17. Yvonne, what a blessing in disguise!
    I have never received support from two people who should be supportive, my mother and my husband, in my decision to let it be our son's choice when he is old enough to understand AND DONE GROWING. And when we cross that bridge, I will support HIS decision. His is also subcoronal and I had him evaluated at TX Children's in Houston. The doctor gave me a long list of complications, arrogantly stated that out of thousands he's only had one patient needing further treatment, and honestly stated that it was for cosmetic reasons only, he would not have any urination, sexual, or reproductive problems except that he may pee differently. He told me he would do it so he could "look like the other boys in the locker room". I asked him if he had EVER seen two identical penises. Needless to say my son will just have to learn to aim a little high when potty learning :)

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  18. Hy, I'm 20 years old and i have hypospadias. i was first shocked when i realized that i have two holes and most of the other males have one. but i can say that i have never had any problems. it doesent hurt while urinating or during sex. if you dont have problems like pain or something you dont need the surgery. feel specail one in a 500. enjoy

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  19. Thanks so much for this article! We just had a new baby boy born last night at home unassisted. I could tell right away he had this. Our other sons are intact, and this one has an exposed glans with the pee coming from underneath and missing foreskin. Your article is so reassuring to let us know that he will still have a normal, fully functioning penis. We would never have any surgery done on a baby or child unless it was absolutely necessary. Thank you again so very much!!!

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  20. My son just had hypospadias surgery yesterday. So far its looking good. The drs and nurses where fantastic at the hospital. I believe he needed it done because I did not want to be the one causing him hardships and making him uncomfortable in his skin. Now he shouldn't have problems starting a family or urinating. I love my child and I thought this was the best for him. No one talks about hypo, so its nice to have a website where people can come together.

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  21. One thing that many (particularly-females, mothers) seem to miss about this condition is the social norms of boys, particularly in their formative years, i.e., from about 5-18 yrs old. It is rather the norm for boys to urinate in front of each other, particularly out doors, or to have "target practice", as such around a toilet. Most boys will accept a foreskin as being "normal" regardless of their own state. However, if a boy were to show up , and attempt to join in, with a urethral meatus in an unusual location, or if he were to sit or squat,he would be quickly singled out, and open to ridicule. This, more so than the surgery(s) can have a lasting impact on his psyche. I am 47 , and experienced 6 surgeries as a child , between 3-10 years of age. At the time , it was the practice of surgeons to excise the remnants of the incomplete urethral plate, and rebuild it, often with foreskin grafts. Many boys with this condition have only a partial , or hooded foreskin, which is insufficient to act as a "funnel". Such has been my experience. If i were born in the present day with the same conditions, they would have simply closed up the open and exposed urethral plate, using what is there, rather than trying to re-invent the wheel as was done then. Having a coronal, or somewhat sub-coronal meatus, is not impossible to aim, but can spray and be difficult, which other boys would probably notice. My situation was mid-shaft, which if left untreated, would be rather difficult to aim, and would difficult to hide in such boyhood social situations. Would i recommend waiting until the child is old enough to at least comprehend the options, -absolutely. The more tissue available, the lesser chance of complications, and the easier it is to get him to know how to participate in the recovery process. I dont regret having it done, i only regret that the first doctor i had had been a bit less old-fashioned. Due to some recent complications from stricture and other things, i am about to undergo another repair with the esteeemed Dr. Snodgrass, which , should restore normalcy in all respects.

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  22. i am 30 year old i am indian my 5 times opretions but unsecsessfull dr ask me no secses your life but on dr yes one to two big opretion secsees full

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  23. I undergone hypo surgery when i was 13 yrs old. at first I found it uncomfortable and it seem not normal with the other guy. but when i had this operation every thing changed, even its size did not improved. but i found it normal specially when I Urinating. now I'm already 27 and i had my wife I ask her if she's satisfied with my penis size she answered me YES she's so satisfied. now we had 1 year old baby, so i can say with the help of surgery I live normal Thanks... to the doctors who take more time studying on hypospadias... thanks a lot.

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  24. THank you for this article. My son is 19 months old and we are going to see a urologist soon. I am all for waiting for my son to make the decision for himself, my husband isn't sure. I figure if it works, don't mess with it. The forskin reconstruction is very interesting. I will have to look into the surgeon from tx. thanks

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  25. Let us not forget that study that just came out linking ADHD to infants who have been administered general anesthesia before the age of two. It is yet another good reason to wait for elective surgeries.

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  26. my son was born with hypospadia with the opening in the base of the penis, but the skin was perfect and there was no chordee. So he had to sit to pee. He never had any problem with urinating before hte operation.
    Drs alwas say it need to get the operation done. we had two operation already from 3-5 y and now there is a problem to pee, it has gone 5 cystoscopy and i hope the operation were never done....He used to have a perfect looking penis before and now it is not the same any more...There are surgeons who are very dangerous and some don,t have so much experience and they could cause harm.

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  27. what happens when your son has a hypospadias surgery done, and has a small leaking at the bottom tip of the penis? does another surgery have to be done? its a small leak. but urine comes out of the tip and the other area. Anyone have any information?

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    Replies
    1. My son has similar problem. please reply to us. We want to know what happened in your case

      Delete
  28. Thank you for perhaps the best post I have seen on hypospadias repair! I am 25, and was born with proximal/penoscrotal hypospadias with chordee. Despite the severity,I had NO problems voiding, and NO urinary tract infections. Still, I had unnecessary surgery at age 2, which, due to complications, was followed by 5 more over the next THREE MONTHS, and another 4 before the age of 5. After that, I was told that I was "fixed." However, that was not the case. At 12, I developed a fistula, and had to sit to urinate, and at 22 I began getting UTI's due to urethral strictures. I have had 5 surgeries over the past 2 years, and at best 20 before requiring another full reconstruction.

    The whole process has been very traumatic. Despite the assurance from doctors that I would not remember the surgeries, I have body memory from the earlier procedures, and image memory from the later ones. I have difficulties with physical touch and intimacy, and each further procedure complicates things. Thankfully, I have great therapists, and supportive friends who have helped me to work through some of the trauma. In addition, I have lost much sensation on the underside of my penis. In fact, in the area just below the glans, an area which is supposed to be the most sensitive part of a man's body, I have little feeling at all. Despite what doctors may say, loss of sensation can and does occur.

    As I have begun to confront my hypospadias, I realize that I cannot and do not identify as male, but rather, intersex. I have never really felt "male." And, as many studies are now beginning to show, this may be due to prenatal androgens that likely played a role in the development of my hypospadias. Not only affecting secondary sex development, but also brain development, these androgens, I believe, have affected my brain in such a way that hypospadias feels like my natural state.

    In addition, in between portions of a 2-stage reconstruction, I was required to have an open skin graft and urinate forward from the original urethra at the base of my penis for one year. During this time, I realized that it felt more natural and "right" to urinate from this location. So, after much deliberation, I have decided that, after this second stage heals, I will have one final operation to put the opening BACK in it's original location.

    The moral of my story is, that, after 15 medically unnecessary, non-consensual surgeries, I have come to realize that having the opening in it's original location is what truly feels correct to me. This, I'm sure, is not the case with all hypospadics, however, it makes a strong argument for later, consensual surgeries. If your child has hypospadias, you and they will likely have some difficult times ahead. Being 'different' in an intolerant world is not easy. Please realize that there is help out there, both in the form of psychologists and others with hypospadias. And please, PLEASE, do NOT have your child operated on unless absolutely medically necessary (i.e. they have problems with voiding). Ethically, they should be given the right to make decisions about their own body.

    If you are looking for more information or support, please visit heainfo.org. There, you can find other individuals and parents of children with hypospadias to message with, share stories, and consult. If you or someone you love is struggling with hypospadias, please, get help. It can make a world of difference.

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  29. Thank you for this! my son is 2 and i've been putting off the recommended visit to the pediatric urologist because just the thought of having surgery on such a tiny person, not to mention the apparently incorrect information that he would need to be circed, was making me ill. My son has no problems urinating, he has sufficient foreskin to cover his glans but it is loose at the end. it doesn't seem to bother him at all, he's never had any sort of infection, and i'm afraid uninformed doctors would retract him so i think we'll just wait until he's old enough to decide for himself!

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  30. I found this article after someone directed me to it when I asked about something I've always wondered about my own penis, knowing it was different from others. I pee slightly off center and things aren't all symmetrical. I never knew there was such a thing as hypospadias, and no one ever told me about this, but from reading, I am pretty sure this is what it is. I have to say, though, I'm 42 and have been this way my whole life and am really just thankful that no one ever subjected me to the surgeries. It works fine the way it is, and so what if it's a little unique. I guess even not knowing what was up didn't have too much of an impact on me, and now that I do know, I'm more grateful that the choice is mine to make. I think I'll be keeping things as is.

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  31. my son who is 3 months old is diagnoded with hyospadia, he can urinate well and the through is also correct.we have consulted a surgeon who have diagnosed it as"hypospadia with minimal chordee".
    According to this doc, circumsition will be done and the surgery has to be done within 2and half years. After reading this page I wonder what should i do?

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  32. Thank you to everyone for their honesty in these comments. I'm a science writer doing a piece about how people cope with hypospadias and other male birth defects. If you'd like to be interviewed for this piece please get in touch. I'd love to hear your story (and of course would respect your privacy.)

    My email is stone [.] zak [@} gmail [.] com . I'm especially interested in hearing from parents who have seeked advice from many doctors with mixed results, men with hypospadias who have undergone corrective surgery, and LGBTQ men who have hypospadias. Thank you for getting in touch.

    Sincerely,
    Zak

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  33. I am in the same boat as "Anonymous" two comments above me. My son is about to be 4 months old, has been diagnosed with hypospadias and mild chordee, and is scheduled to have surgery/circumcision in three weeks. I need more information about the success vs. complication rate and about what it is like for babies/children/teens/adults who have the surgery. Please email me...[arceli][long][at][gmail][dot][com].

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  34. I love this article! Thank you so much. I've lived with mild hypo for 27 years and am glad to have not been put through corrective surgery of any kind. Here are a few additional items that were also of interest to me -

    Adaptation of Adults to Uncorrected Hypospadias:
    "Conclusions: Of the adults we surveyed with hypospadias, most stated that they were satisfied with the appearance of the penis, voided in the standing position, and did not have infertility associated with the abnormal position of the urethral meatus." http://www.deepdyve.com/lp/elsevier/adaptation-of-adults-to-uncorrected-hypospadias-WOHqdjK8tX

    Intersex Genitalia Illustrated and Explained:
    "Unless there is an actual rare functional problem, our bodies should not be altered in infancy, and only those functional problems should be addressed. Our genitals should be altered only if we ourselves request it, to make ourselves comfortable in our own skin, not to make society comfortable by our medical erasure. Society must come again to embrace the diversity that is nature's gift to us."
    http://intersexroadshow.blogspot.co.uk/2011/04/intersex-genitalia-illustrated-and.html

    Men Talk About Hypospadias:
    "I'm more annoyed at being circumcised than with having the hypospadias."
    http://www.hypospadias-emotions.com/chapter5.html

    Hypospadias: Parent's Guide to Surgery:
    http://www.isna.org/node/81

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  35. My son, now 4 1/2 has subcoronal hypospadias with a hooded foreskin. Although his pediatrician has told me he should have surgery so he is "normal looking" I have resisted because I don't want my child to go through such a traumatic experience when it is unnecessary. He has no trouble urinating standing up and does not splash or anything. I not only want to avoid any physical problems down the line, but I also don't want him to suffer from psychological repercussions. The doctor tried to shame me into having the surgery done by saying he will be different and adding that I don't have the right to make the decision because it's not my penis, but that's exactly my point. It isn't mine and he will have the right to make that decision when he's older. In the meantime, it's my job to make sure he's strong enough emotionally in case he gets teased because of it.
    I live in a country where most males are not circumcised and was told he would have to be to have the surgery, so he would still be different afterwards.
    He will make the decision when he is old enough and I will make sure he has the proper information so he can make an informed decision. In the meantime, he's a happy, healthy 4 year old who has never had a UTI, no problems toilet training, etc.

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    Replies
    1. My son 2 1/2 has also the same subcoronal hypospadias with a hooded foreskin. I have lots of confusion regarding my sons (urination, erection, sexual activities, reproduction) then I met a urologist surgeon and he said that don't go for surgical operation unless until problem regarding urination, if he has no absolute problem regarding urinate, just wait 4-5 years.

      Advise me is surgery required or wait for adult

      Delete
  36. I've lived with mild hypo my whole life. Actually, I never knew what made my penis slightly different had a name until I was older. My parents never talked to me about it. And I wish they had, just so I knew, but otherwise, there has been zero impairment on my ability to function normally. My wife and I have a great sex life and, while I don't wish to get into details, I am living proof that mild hypospadias (and maybe even moderate?) does not hurt functioning growing up or in adulthood.

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  37. Our son has little foreskin - it covers the top like a hood and he has what appears to be subcornal hypospadia. We did elimintion communication for a short while and I was able to watch him pee I feel completely comfortable letting it be. Parents who have sons with hypo that they are concerned about may want to try holding them above a sink and watching in the mirror to see how the urine stream is. The only way we were going to consider reconstructive surgery was if we thought he would have trouble urinating while standing. My hubby really did not want him to be the only boy who had to sit to pee. But it was easy to tell after watching his stream that this was not the case.

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  38. Hypospadias is actually what saved my son from being circumcised. It also looked hooded/subcornal in nature and that's how our doctor could see that the hole wasn't where it was supposed to be, to put it in layman's terms. She told us to wait until he was 6 months old to have it looked at so that it had some time to grow because if we did choose to have it repaired, they would probably use the foreskin to do so, so the longer we waited the better.

    The urologist we saw said that it was a mere cosmetic abnormality and that if we chose to have it repaired he could use the foreskin if we wanted, or he could use a skin graph from inside our son's mouth. He would be put under for it and all that good stuff.

    No thank you. Not worth the risk. My son is now 2.5 and his stream does go to the side, but it's nothing detrimental. He can learn to aim. For now he sits on the potty when he chooses to use it and we have not had problems.

    So yes, it can definitely be left alone.

    ~Mandi

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  39. Note that Great Ormond St Hospital in London does not even mentioned circumcision as part of the treatment/surgical options for hypospadias.

    http://www.gosh.nhs.uk/parents-and-visitors/general-health-advice/a-z-child-health/genital-problems-in-boys/

    I wonder if this is yet another North American bound practice being carried out on our boys?

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  40. Thanks for this article. It has made us reconsider surgery for our 6 month old son who has mild Hypospadia.

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  41. Thank you for this information! My SO was born with hypospadias and had surgery in his childhood years to correct the opening so he could "pee straight." (He was also circumcised at birth). He had had no other issues. We now have two little boys we decided to not circumcise. Our three year old was born with no problems. Our 10 month old was born with a minor hypospadias and a natural circumcision. We were told that he may be offered to have surgery to fully remove the little bit of extra loose forskin to make him look fully circumcised but we knew we wouldnt want to do this unless medically necessary. We have been avoiding urologists since. He has had no problems and after reading this article, we have decided to wait until he's old enough to understand and make the decision on his own (with encouragment to just leave it alone if there's no medical reason to operate)! Thanks again for the great info!

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  42. Our 6 month old son has mild Hypospadia and was due to have a repair done tomorrow which would also involve circumcision. I felt uncomfortable about this as I did not want him to undergo unnecessary surgery with risks etc. Further circumcision is not routine or recommended in Australia generally. We have cancelled the surgery and while we will discuss it further with the doctor, I feel that it is not necessary as it should not impede our son in any way (given it is only minor). THANK YOU!

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  43. My son just turned three years old. We are in the middle of scheduling a hypo repair (between subcoronal and distil with hooded appearance - from top looks normal). After re-finding this article which I originally read about two years ago, we have decided to put off the surgery again, and perhaps never do it unless our son decides he wishes to have it done. We do not know if peeing while standing will be a problem yet, but we can at least wait a couple of years to see if a problem exists. One thing we are certain of is that there is no reason to have TWO surgeries for ONE problem; in other words, no reason to circumcise (for our son's case). I appreciate all of your posts -- particularly men who have lived with this, and parents who are struggling with the decision.

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  44. hi.iam Maldivian.My son just turned 5. He was born w/ hypospadias and chordee. we can't do this surgery here. so please help me, which hospital is the best for this surgery.

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  45. Thank you for this! Our 7 month old has a mild case of hypospadias and the urologist is really advocating surgery. We have deep mixed feelings about this, for many of the reasons you listed here. Hearing the perspective of a man, and a doctor of urology on this means a lot. We want to do right by our son, and your points, I believe, argue for a level head and the consideration of the great risks that can go along with this surgery. I feel much more confident about our decisions to decline surgery. I think we may just have a very knife happy urologist, though he was nice.

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  46. 47 years ago my parents left me be. I have mild hypospadias and it has never - not once - impaired my functioning sexually or in the bathroom. I believe they left things alone because they didn't really know much better at the time, and did not have the funds for surgery - but thank goodness this was the case. I can only imagine what otherwise may have occurred.

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