Hypospadias

What is Hypospadias?

Hypospadias is a congenital condition in which the opening of the urethra (the tube that carries urine out of the body) is located on the underside of the penis instead of at the tip. It develops during pregnancy when the urethra does not form completely, typically between the 8th and 14th weeks of fetal development.

In addition to an abnormally placed urinary opening, the foreskin may be underdeveloped, creating a hooded appearance. In more severe cases, the urethral opening may be located near the scrotum or perineum. The severity of hypospadias varies from mild forms that may require little or no treatment to severe forms that often need surgical correction.

Types of Hypospadias

The following are the types of hypospadias, depending on the position of the urethral opening:

How Common is Hypospadias in India?

One of the common birth differences in India is hypospadias. The Hypospadias Foundation India estimates that about 1 in every 150 newborn boys in India has hypospadias. This accounts for one of the most prevalent birth conditions in children diagnosed by paediatric urologists throughout the country. Hypospadias is among the congenital conditions screened during early childhood health evaluations under national health programs like RBSK.

The incidence of hypospadias has been observed to be rising in various parts of the world, including India. Prenatal exposure to oestrogenic or anti-androgenic pesticides and industrial chemicals plays a major role in the rise, a finding applicable to the agricultural and urban settings of India.

What are the Symptoms of Hypospadias?

Hypospadias is a birth defect and is often found during the physical checkup of the newborn or by parents. Some common symptoms to look for hypospadias include:

What are the Causes and Risk Factors of Hypospadias?

Hypospadias can result from genetic, hormonal and environmental factors that affect the normal development of the penis during pregnancy. Some of the causes and risk factors of hypospadias includes:

Diseases Similar to Hypospadias

Hypospadias, epispadias and congenital penile curvature are conditions present at birth that affect the penis or urethral opening. However, they differ in their location, urinary symptoms and treatment needs.

A comparative overview of these 3 conditions is given below for better understanding:

Hypospadias vs Epispadias vs Congenital Penile Curvature

What are the Complications of Hypospadias?

If left untreated, hypospadias may cause the following complications:

• Chronic Urinary Difficulty: Uncorrected hypospadias can lead to lifelong urinary dysfunction, including a deflected urine stream, spraying, and incomplete bladder emptying.

• Urinary Tract Infections (UTIs): Stagnant urine caused by incomplete bladder emptying allows bacteria to proliferate, raising UTI risks.

• Complications of Chordee: Penile curvature can make it difficult or painful to achieve an erection and to have a sexual relationship.

• Infertility in Severe Cases: Natural fertility is reduced in severe cases because the opening of the urethra is close to the scrotum or the perineum, making it difficult for sperm to enter the cervix during sexual intercourse.

• Meatal Stenosis: This condition is a narrowing of the opening of the tube (urethra) in the penis, either due to a natural cause or surgery, which may prevent normal urine flow.

• Post-Surgical Urethrocutaneous Fistula: An abnormal small hole between the skin and the urethra may develop after surgery and may need another repair.

• Recurrence Requiring Revision Surgery: Recurrent penile curvature or persistent urethral defects can occur in severe cases, requiring additional corrective operations.

• Psychological Impact: Anxiety and issues with body image, as well as social withdrawal, are linked to delayed treatment or a visible deformity in childhood and adolescence.

When Should I See a Healthcare Provider?

The majority of cases of hypospadias are detected by a paediatrician or obstetrician when the child is born. In the following cases, parents should seek medical evaluation:

• At the time of the first physical exam, if the newborn's urethral opening is not seen at the tip of the penis.

• If the foreskin looks incomplete and is bunched on top (in a dorsal or top shape).

• If the baby's urine stream is weak, deflected downward, or spraying out uncontrollably.

• The penis seems to bend downwards (even slightly), particularly during an erection.

• If the child is approaching 6 to 12 months of age, performing surgery within this window yields better toilet-training and psychological outcomes.

• In the event that any complications are showing up after surgery (discharge, swelling, new opening along the shaft or problems with urination), it is advisable to inform your surgeon.

• If pain occurs with erections, a blockage in urination, or concerns about fertility occur in an adult with uncorrected or incomplete treatment of hypospadias.

• If hypospadias runs in your family, inform your obstetrician during prenatal care so the delivery team knows to check the newborn immediately and delay any routine circumcision.

How is Hypospadias Diagnosed?

Typically, a physical exam provides the diagnosis of hypospadias soon after birth. Usually, no further testing is required. In more serious or complicated cases, however, additional assessments may be necessary, which can include:

• Physical Examination: The doctor checks the position of the urethral opening, the appearance of the foreskin, and whether the penis is curved (chordee). Diagnosis can usually be made at birth.

• Renal Ultrasound: A painless, radiation-free imaging test. While not routinely required for all cases, it may be recommended if severe (proximal) hypospadias occurs alongside other suspected congenital anomalies or complex urinary tract symptoms.

• Hormonal Testing: Evaluates endocrine function when hypospadias presents alongside undescended testicles, micropenis, or ambiguous genitalia.

• Genetic Testing (Karyotyping): Used to confirm patterns in cases of genital ambiguity to help with treatment.

• Cystoscopy: Reserved for select complex or proximal cases. A small camera is inserted into the urethra and bladder to view the inside of the bladder before planning surgery.

Diagnostic Overview Table

Note: The doctor can conduct one or a combination of the above tests for an accurate diagnosis and assess treatment options.

How is Hypospadias Treated?

The usual treatment of hypospadias is surgery. The surgery is designed to bring the urethral opening to the tip of the penis, straighten any curvature (chordee) and improve the normal flow of urine.

The treatment or management of hypospadias includes:

• Surgery Timings: Most surgeries are done between 6 and 12 months of age, when recovery is most likely to be speedy and successful.

• Surgical Approach: The approach depends on the severity of the condition and the type of surgery that is to be performed. Mild cases require simpler single-stage urethroplasty, whereas severe cases may demand complex, multi-stage urethroplasty procedures. If healing complications or failures arise after the initial operation, a secondary revision surgery may be required to correct them.

• Post-Surgical Care: A temporary urinary catheter is typically left in place for a few days after surgery. Good wound care and follow-up visits are critical to watch for a problem that may occur with healing, like narrowing of the urethral opening or the formation of a fistula.

• Preoperative Hormone Therapy: In cases with a small penile size or narrow glans, a short course of preoperative testosterone (topical or injectable) may be prescribed to stimulate tissue growth and improve surgical outcomes. Routine hormone therapy is not required after surgery.

Common Medicines Used to Treat Hypospadias

Hypospadias cannot be cured with medications. Doctors usually recommend surgical correction as the only definitive treatment. Some medicines, however, can be administered before or after surgery to improve the results and recovery.

Some common medicines used to treat hypospadias include:

• Testosterone: A short course of preoperative testosterone (topical or injectable) may be prescribed for select children with proximal hypospadias, a small penile size, or a narrow glans to stimulate tissue growth and improve surgical outcomes. It is not routinely required for mild cases.

• Paracetamol: Paracetamol is commonly given after hypospadias repair to control mild to moderate pain.

• Ibuprofen: Ibuprofen may be used after surgery for additional pain relief when it is suitable for the child.

• Oxybutynin: An anticholinergic medication prescribed to control painful bladder spasms caused by the presence of a urinary catheter or stent. It is discontinued once the catheter is removed.

• Cephalexin: Some paediatric urologists may prescribe cephalexin around surgery, particularly while a catheter or stent remains in place. However, routine postoperative antibiotics are not required in every case and depend on the surgeon’s protocol.

Note: These medicines are prescribed only when clinically necessary and should be used under medical supervision.

Living with Hypospadias: Daily Challenges and Caregiving

Hypospadias may affect urination and penile appearance, particularly in more severe cases. Most caregiving needs arise around surgical treatment, catheter care and recovery. Routine postoperative follow-ups allow the paediatric urologist to monitor tissue healing, stream adequacy, and early signs of complications.

Critical challenges and care points for hypospadias include:

What is the Prognosis of Hypospadias?

The surgical outcome for hypospadias repair is generally excellent, particularly for distal cases managed by an experienced paediatric urologist. Most children achieve a functional urinary stream and satisfactory penile appearance after treatment. Primary distal repairs usually have a very high success rate.

Proximal or severe hypospadias has a greater risk of complications because it may involve significant penile curvature and require staged surgery. Possible complications include a urethral fistula, narrowing of the reconstructed urethra, wound separation, recurrent curvature or the need for revision surgery.

Long-term follow-up is important because some complications may appear several years after surgery or during puberty. With appropriate treatment and monitoring, most individuals can urinate normally and have satisfactory sexual and reproductive function in adulthood.

How to Prevent Hypospadias?

There is no proven method to prevent hypospadias. It develops while the urethra and penis are forming during early pregnancy, and most cases result from a combination of genetic, hormonal, placental and environmental factors that cannot be controlled.

While hypospadias cannot be prevented, good prenatal care may support healthy fetal development:

• Attend preconception and regular antenatal checkups.

• Maintain a healthy weight before and during pregnancy.

• Manage diabetes and other medical conditions with medical guidance.

• Avoid smoking, alcohol and recreational drugs.

• Take medicines, hormones and supplements only after consulting a doctor.

• Discuss any hormone treatment or fertility treatment with the treating specialist.

• Minimise or eliminate exposure to agricultural pesticides, industrial pollutants, and known endocrine-disrupting chemicals during pregnancy.

• Follow a balanced diet and take folic acid as advised for general pregnancy health.

These measures support overall fetal development but cannot guarantee that hypospadias will be prevented. Parents should not blame themselves when a child is born with the condition.

Hypospadias Treatment Cost in India

The hypospadias treatment cost in India depends upon the severity of the condition, the type of required surgery, the hospital and the experience of the surgeon. Mild hypospadias cases are typically corrected in a single-stage surgical procedure, but severe cases might require phased surgeries, increasing the final cost.

An approximate of hypospadias treatment costs in India is given in the table below:

Note: These are approximate costs and may vary depending on the city, hospital, surgeon's experience, room category, and whether additional procedures are required.

Does Health Insurance Cover Hypospadias in India?

Hypospadias is usually not covered under health insurance as it is a congenital condition. Many policies exclude such congenital conditions because they are present from birth and may be considered conditions that existed before the policy was purchased.

Coverage can vary depending on the insurer and the terms of the policy. Check with your insurer to confirm whether hypospadias treatment is covered under your health insurance policy.

How Much Health Insurance Coverage is Needed for Hypospadias?

The amount of health insurance coverage needed for hypospadias treatment depends on the severity of the condition, the type of surgery required, hospitalisation needs and the city where treatment is received. A cover of ₹5 lakh to ₹10 lakh may help manage expenses such as surgery, hospitalisation, diagnostic tests, specialist consultations, medicines and treatment for complications.