Hypospadias

What is hypospadias?

Hypospadias is a congenital condition, meaning it is present at birth, in which the opening of the urethra (the tube that carries urine out of the body) is not located at the tip of the penis. Instead, the opening — called the urethral meatus — sits somewhere on the underside of the penis. In milder forms it may be just below the tip, while in more significant forms it can be located along the shaft, at the point where the penis meets the scrotum, or even within the scrotum itself.

When people ask “what is hypospadias,” the simplest answer is that it is a difference in how the urethra formed during pregnancy. The urethra normally develops as a tube that closes along the underside of the penis before birth. In hypospadias, this closing process stops early, leaving the opening lower down than usual. Hypospadias is one of the more common congenital conditions affecting the penis, and it is usually identified in newborn boys during the physical examination shortly after birth.

Doctors often describe hypospadias by the position of the urethral opening:

• Distal (or anterior) hypospadias: the opening is near the head of the penis. This is the most common and generally the mildest form.
• Midshaft hypospadias: the opening is along the middle portion of the shaft.
• Proximal (or posterior) hypospadias: the opening is near or within the scrotum, or at the base of the penis. This form is less common and usually more complex.

Hypospadias is not an illness in the sense of an infection or disease, and it is not caused by anything that happens after birth. It is a structural difference that, in many cases, can be corrected with surgery during early childhood if treatment is recommended.

Symptoms and signs of hypospadias

Because hypospadias is present from birth, the term “hypospadias symptoms” mostly refers to visible physical signs rather than sensations such as pain. Most affected infants are otherwise healthy and comfortable. Parents or clinicians may notice one or more of the following:

• A urethral opening that is not at the tip of the penis — it may be on the underside of the head, along the shaft, or near the scrotum.
• An abnormal urine stream — urine may spray, dribble, or point downward rather than flowing in a straight, forward stream.
• A downward curve of the penis, called chordee, which may be more noticeable during an erection.
• An incompletely formed foreskin — the foreskin often covers only the top of the penis, giving a “hooded” appearance, while the underside is exposed.
• A flattened or split appearance of the head of the penis in some cases.

The signs vary with the type of hypospadias. In mild, distal cases, the opening may be only slightly out of position, the foreskin may appear almost normal, and the urine stream may be barely affected. Some very mild cases are noticed only when a family requests circumcision and the clinician examines the foreskin closely. In midshaft and proximal cases, the differences are usually more obvious: the curvature tends to be more pronounced, the urine stream is often directed downward, and older boys may find it difficult to urinate while standing.

Hypospadias itself does not usually cause pain, fever, or feeding problems in infants. If a baby seems to be in pain when urinating, has a fever, or produces very little urine, those signs point to a separate problem, such as an infection, and should be evaluated by a doctor promptly.

In some boys with proximal hypospadias, one or both testicles may not have descended into the scrotum (a condition called undescended testicle, or cryptorchidism). When hypospadias and undescended testicles occur together, doctors may recommend additional evaluation, because the combination can occasionally be associated with broader differences in genital development.

Causes and risk factors

The exact hypospadias causes are not fully understood. The urethra forms during roughly the eighth to fourteenth weeks of pregnancy, a process guided in part by male hormones called androgens. If this process is disrupted — for example, if hormone signaling is altered — the tube may not close completely along the underside of the penis. In most individual cases, no single cause can be identified.

Research and clinical experience point to several factors that may increase the likelihood of hypospadias:

• Family history: hypospadias occurs more often in boys whose father or brother also had the condition, suggesting a genetic contribution.
• Genetic factors: certain gene variations affecting hormone production or hormone response appear to play a role in some cases.
• Maternal age and weight: some studies suggest that pregnancies in mothers over a certain age or with obesity may carry a somewhat higher likelihood, though findings vary.
• Fertility treatments and hormone exposure: some research has explored a possible association with assisted reproduction or with certain hormone exposures before or during pregnancy; the evidence is not conclusive.
• Prematurity and low birth weight: hypospadias appears to be somewhat more common in babies born early or small for their gestational age.
• Environmental exposures: scientists continue to study whether certain chemicals that can interfere with hormones (sometimes called endocrine disruptors) contribute, but no specific exposure has been proven to cause hypospadias in an individual child.

It is important for parents to understand that hypospadias is not caused by anything a parent did or failed to do during pregnancy. In the great majority of cases, it occurs without any identifiable reason and is not preventable with current knowledge.

Diagnosis

Hypospadias diagnosis is usually straightforward and is made by physical examination. In most cases, a pediatrician or neonatologist identifies the condition during the routine newborn examination shortly after birth. No blood test or scan is needed to confirm typical hypospadias; the appearance of the urethral opening, the foreskin, and the shape of the penis provides the diagnosis.

During the examination, the doctor will typically assess:

• The location of the urethral opening — to classify the hypospadias as distal, midshaft, or proximal.
• The degree of curvature (chordee), if any.
• The appearance of the foreskin, which is often incomplete on the underside.
• The position of the testicles, to check that both have descended into the scrotum.
• The urine stream, when it can be observed.

Additional testing is not needed for most boys. However, doctors may recommend further evaluation in specific situations:

• Severe or proximal hypospadias, especially when combined with undescended testicles, may prompt hormone tests, chromosome analysis (karyotyping), or imaging to evaluate the internal reproductive anatomy. This is done to rule out broader differences of sex development.
• Ultrasound of the kidneys and urinary tract may be suggested in selected cases, particularly when other congenital differences are present, since the urinary system develops around the same time in pregnancy.
• Referral to a pediatric urologist — a surgeon who specializes in the urinary and genital systems of children — is standard once hypospadias is identified, so that the family can discuss whether and when treatment is appropriate.

One practical point deserves emphasis: circumcision should generally be postponed when hypospadias is suspected. The foreskin tissue is often used during surgical repair, so preserving it keeps all reconstructive options open. If your newborn has been diagnosed with hypospadias, mention this to anyone planning a circumcision before a urologist has been consulted.

Treatment options

Hypospadias treatment depends on the type and severity of the condition, the degree of curvature, and the family’s preferences after discussion with a specialist. Care is usually coordinated by pediatric urology; at hospital groups such as Acibadem, this condition is managed within the urology department, where pediatric urologists evaluate each child individually. Detailed information about the condition and its surgical management is also available on the dedicated hypospadias page.

Observation for very mild cases

In some very mild, distal cases — where the opening is close to the tip, there is no curvature, and the urine stream is normal — a doctor may discuss the option of not operating at all. This is a genuine choice in selected situations, because the condition does not always cause functional problems. The decision is individual and should be made together with a pediatric urologist after a careful examination.

Surgery is the standard corrective treatment

For most boys whose hypospadias affects the urine stream, causes noticeable curvature, or places the opening well away from the tip, surgical repair is the standard treatment. There is no medication, cream, or exercise that can move the urethral opening; correction requires surgery. The goals of hypospadias repair are to:

• Bring the urethral opening to the tip of the penis, or as close to it as safely possible.
• Straighten any curvature so the penis is straight, including during erections.
• Create a normal, forward-directed urine stream that allows standing urination later in life.
• Achieve a natural appearance of the penis and, where possible, reconstruct the foreskin or complete a circumcision, according to the family’s preference and the surgical plan.

Surgery is typically performed in infancy or early childhood, often between about six and eighteen months of age, though the timing is individualized. Operating at a young age is generally preferred because healing tends to go well and the child is unlikely to remember the procedure, but repair can also be performed later in childhood or, when necessary, in adulthood.

What the operation involves

Hypospadias repair is performed under general anesthesia, meaning the child is fully asleep. The surgeon uses the child’s own tissue — often including tissue from the foreskin — to construct or extend the urethra and reposition the opening. Mild distal cases can usually be corrected in a single operation. Severe proximal cases may require a planned two-stage repair, with operations several months apart. A small, soft tube (catheter or stent) is often left in place for a period after surgery to allow urine to drain while the new urethra heals.

In selected complex cases, doctors may recommend a short course of hormone treatment (such as testosterone) before surgery to increase tissue size and improve surgical conditions. This is a preparatory step decided case by case, not a treatment for hypospadias itself.

Possible complications and reoperation

Most repairs heal well, but as with any surgery, complications can occur. The most commonly discussed include a fistula (a small abnormal opening through which urine leaks), narrowing of the new urethra (stricture or meatal stenosis), breakdown of part of the repair, or recurrent curvature. Some of these problems appear months or even years after surgery, which is why follow-up visits matter. When a complication develops, an additional operation is often able to correct it. Families should have an honest conversation with the surgeon about the likelihood of needing more than one procedure, which is generally higher in severe forms of hypospadias.

Living with hypospadias and outlook

The long-term outlook for boys with hypospadias is generally favorable, particularly for the mild and moderate forms that make up most cases. After successful repair, the majority of boys urinate normally, can stand to urinate, and go on to have typical sexual function and fertility in adulthood. Fertility problems, when they occur, are more often related to associated conditions such as undescended testicles than to the hypospadias itself.

That said, honest expectations are important:

• Some boys, especially those with proximal hypospadias, need more than one operation over time.
• Long-term follow-up through childhood and puberty is often recommended, because the penis grows and some issues become apparent only later.
• A small number of men who had hypospadias repair in childhood report concerns in adulthood, such as spraying of the urine stream, curvature, or dissatisfaction with appearance. These concerns can usually be evaluated and often addressed by a urologist.

For untreated mild hypospadias, many men live without significant problems, though some experience difficulty directing the urine stream or curvature during erections. Adults with unrepaired hypospadias who develop bothersome symptoms can still be assessed for corrective surgery, although repair in adulthood may involve a somewhat different risk profile than repair in infancy.

Parents sometimes worry about the emotional impact of genital surgery on their child. Open, age-appropriate communication as the child grows, along with routine follow-up, helps many families navigate these questions. If a child or teenager expresses distress about the appearance or function of the penis, discussing this with the treating urologist — and, where helpful, a counselor — is a reasonable step.

Frequently asked questions

What is hypospadias in simple terms?

Hypospadias is a condition a boy is born with in which the opening that urine comes out of is on the underside of the penis rather than at the tip. It happens because the urethra, the tube that carries urine, did not finish forming before birth. It is a structural difference, not an infection or a disease, and it is usually noticed during the newborn examination.

Can hypospadias heal on its own?

No. Hypospadias does not close or correct itself over time, because it is an anatomical difference rather than a wound or illness. Very mild cases may never need treatment if they cause no functional problems, but when correction is needed, surgery is the only way to move the urethral opening and straighten the penis. A pediatric urologist can advise whether repair is recommended in a specific case.

How serious is hypospadias?

Hypospadias is generally not dangerous to a child’s overall health, and most affected babies are otherwise well. Its significance depends on the type: mild distal forms may cause few or no problems, while proximal forms can affect the urine stream, cause curvature, and require more complex surgery. In many cases, timely evaluation and, where appropriate, repair lead to good long-term function.

What are the main hypospadias symptoms parents should look for?

The key signs are a urethral opening that is not at the tip of the penis, a foreskin that looks incomplete or “hooded” on the underside, a downward curve of the penis, and a urine stream that sprays or points downward. These signs are usually visible from birth. Hypospadias does not typically cause pain, so a baby who seems uncomfortable when urinating should be checked for other causes such as infection.

At what age is hypospadias treatment usually done?

Repair is often performed in infancy or early childhood, commonly between about six and eighteen months of age, although the exact timing is decided individually with the surgical team. Surgery at a young age is generally well tolerated and allows healing before toilet training, but hypospadias can also be repaired later in childhood or in adulthood when circumstances require it.

What is recovery like after hypospadias surgery?

Most children go home the same day or after a short hospital stay. A small tube may remain in place for several days to a week or two to drain urine while the repair heals, and there is usually some swelling and bruising that settles over a few weeks. Doctors typically advise avoiding straddle toys and rough play for a period. Follow-up visits check that the opening is healing well and the urine stream is normal.

Does hypospadias affect fertility or sexual function later in life?

In most cases, no. Boys who have a successful repair usually develop normal erections, sensation, and fertility as adults. Severe forms, or hypospadias combined with undescended testicles, can occasionally be associated with fertility concerns, which is one reason long-term follow-up is recommended. Any adult with questions about function after childhood repair can be evaluated by a urologist.

When to see a doctor

Hypospadias is usually identified at birth, but families should seek medical advice in any of the following situations:

• You notice that your baby’s urine comes out from the underside of the penis rather than the tip, or the foreskin looks incomplete or hooded.
• Your son’s urine stream sprays widely, points downward, or he strains or dribbles when urinating.
• You see a curvature of the penis, at any age.
• A circumcision is being planned and there is any question about the position of the urethral opening — the procedure should be postponed until a urologist has examined the child.

Seek urgent medical care — especially after hypospadias surgery — if any of these red-flag signs appear:

• The child cannot pass urine, or produces very little urine, for several hours.
• Fever, chills, or increasing redness, swelling, or discharge around the surgical site.
• Significant bleeding from the penis or blood-soaked dressings.
• The catheter or drainage tube falls out or becomes blocked.
• Severe pain that is not relieved by the prescribed pain medication.
• Urine leaking from a new opening on the underside of the penis after the repair has healed, which may indicate a fistula.

Prompt evaluation in these situations allows problems to be identified and treated early. For routine concerns — such as questions about the timing of repair, follow-up after surgery, or issues noticed as a boy grows — an appointment with a pediatric urologist is the appropriate next step.