Hypospadias: Why the Opening Is in the Wrong Place, and the Right Age to Repair It

Normally, the opening through which urine comes out (the meatus*) sits at the tip of the penis. In hypospadias, this opening is on the underside of the penis instead. It may be just below the tip, along the shaft, or, less commonly, near or on the scrotum.

Hypospadias often comes with two other features: the foreskin is incomplete underneath, so it looks like a hood sitting on top, and the penis may bend downward, which is called chordee. It is one of the most common conditions boys are born with, and it is not caused by anything the parents did.

Hypospadias is usually noticed at birth by the paediatrician. Sometimes parents notice it first:

• the foreskin looks like a hood, open on the underside
• the urine opening is below the tip
• the urine stream sprays or goes downward
• the penis bends downward during erections, which even babies have

In one variant, the foreskin looks completely normal, and the hypospadias is found only when the foreskin is pulled back, sometimes during a circumcision. If this happens, the circumcision should be stopped, and your son should be seen by a paediatric surgeon or urologist.

In the first few months of life. Early consultation gives you time to understand your son’s type of hypospadias and to plan surgery within the recommended age window, without rushing.

Within days, when:

• The opening is far down (near or on the scrotum) and one or both testes cannot be felt. This combination needs early evaluation, including blood tests, to fully understand your baby’s development.
• Your baby strains to pass urine, or urine comes only in drops
• You are unsure whether your baby’s genitals look typical

Hypospadias is diagnosed by examination. The surgeon notes where the opening is, how the foreskin looks, whether the penis bends, how the scrotum looks, and whether both testes are in place.

Most boys with distal hypospadias need no tests at all. Blood tests (including chromosome and hormone tests) and an ultrasound are needed mainly when the hypospadias is proximal, especially when one or both testes are undescended, or when the genitals look atypical in other ways.

The final assessment of the opening’s position and degree of bend is sometimes made in the operating theatre under anaesthesia, when the tissues can be fully examined.

Hypospadias is treated with surgery, called hypospadias repair or urethroplasty. It is usually done between 6 months and 2 years of age. In this period, anaesthesia is well tolerated, the tissues heal well, and the repair is completed before your son becomes aware of his genitals.

How the repair works. The operation straightens the penis if it bends, builds a new channel so that the opening comes to the tip, and reshapes the foreskin and skin for a natural appearance. Most distal forms are repaired in one operation. Some proximal forms are repaired in two stages, about six months apart. Occasionally, doctors give hormone treatment before surgery to help the tissues grow.

On the day, the operation is done under general anaesthesia, usually with a numbing injection near the tailbone (caudal block) for comfort afterwards. Your son goes home with a dressing and a small tube (catheter) that drains urine into the nappy.

The catheter usually stays for about 5–10 days. Urine drains into the nappy, and many families use a double-nappy method: the catheter passes into an outer nappy, so the inner nappy catches stool and the outer one catches urine.

Comfort and care: give pain relief and antibiotics as prescribed. Keep the dressing clean and dry until it is removed at the clinic. Your son can return to normal feeding and gentle play, but avoid straddle toys (ride-on toys, walkers) for about 3–4 weeks. Some swelling and bruising is expected at first.

Follow-up continues as your son grows, to check his stream and appearance, ideally until after puberty.