Hypospadias

Hypospadias is a condition in which the urethra (the tube which carries semen and urine through the centre of the penis) doesn't develop normally. As a result, the opening of the penis - which is the end of the urethra - is located anywhere between the bottom edge of the glans and the scrotum.

Another effect of hypospadias is that the penis may be shorter on the underside than it is on the top side, which can cause a bend downwards at the end of the penis - this is called chordee. Chordee of the penis is often associated with more severe forms of hypospadias. In hypospadias it's also common for the glans to have a "mushroom" shape, so it looks flattened when compared to the usual glans shape. There's sometimes a twist along the length of the penile shaft. Most boys who have hypospadias have an incomplete or "hooded" foreskin which does not go all the way round the penis. (There are exceptions: sometimes a complete foreskin surrounds the penis, but the urethral meatus is rather larger than normal. This is called the megameatus intact prepuce.)

The location of the abnormal urethral opening is used to classify hypospadias. The location is "anterior", which means on the glans or just below the coronal ridge, in 50% of cases. It is "middle", which means somewhere along the penile shaft, in 20%. And it is "posterior", which means on the scrotum or perineum, in 30%. The most common hypospadias is the mild, anterior form. In my experience of counseling men with genital problems, the differences between a "normal" penis and a hypospadic penis may be noticed only by someone knowledgeable about this. Experience in this field has shown me, over and over again, that many men have mild hypospadias and remain unaware of the fact.

The most common genital anomalies associated with hypospadias are undescended testes and inguinal hernias. A review of over 1000 patients with hypospadias found the incidence of undescended testes and inguinal hernias at 9% each. As the severity of hypospadias increased, the incidence of undescended testes and inguinal hernias was more than 30% and ore than 20%, respectively.
 

Hypospadias occurs in about 1 in 100 live male births, but the incidence appears to be rising. Many factors have been blamed for this, including rising levels of female hormones in the environment (mostly from hormones from the contraceptive pill, excreted by women, entering waste disposal systems), and also from chemicals in the environment which have similar effects in the human body to estrogens. However, there is probably also a genetic factor, because hypospadias is eight times more common in identical twins than fraternal twins. Studies show that eight per cent of fathers of affected boys have hypospadias, while fourteen per cent of brothers are similarly affected. And males conceived by IVF have a five times increased risk of hypospadias compared to other boys. This may reflect the fact that mothers who have IVF are often given progesterone, which can presumably interfere with the hormonal system of the developing male baby. As for one possibly genetic influence: we know that to develop a normal set of genitals, a baby boy has to produce testosterone at very specific times while he grows in his mother's uterus. One study revealed that in 66% of boys with mild hypospadias and 40% with severe hypospadias, this process of testosterone production went wrong. This is presumably determined by some genetic abnormality.

Surgical treatment

Surgeons who work in the field aim to change the penis to what they consider a "normal" anatomical and functional state. This is an interesting concept, for one might think of a difference that was as common as 1 in 100 births to be a "normal" variation anyway. However, I certainly would support surgical correction in the most severe cases of hypospadias, but there is a profound philosophical question about whether correction of minor hypospadias is justifiable.

Various surgical options include chordee repair (straightening the penis), urethroplasty (moving the external urethral meatus to the tip of the penis), glanuloplasty (reformation of the flattened glans into a more natural conical shape), giving cosmetically and functionally acceptable penile skin coverage, and creating a normal-appearing scrotum. All surgeons would agree, I think, that the object of surgery is to allow a boy to have sexual intercourse, urinate standing and appear normal. (Although I know several men with mid-shaft hypospadias who have never had it corrected and who have excellent sexual relationships.) Currently, most surgeons repair hypospadias when a boy is aged between six and eighteen months. This is because they think there is less psychological damage or trauma from surgery at this age - which remains unproven.

Hypospadias in adults

There is a wide range of size and appearance of what is thought of as the "normal" penis. We do know, though, that the meatus is not always at the tip of the penis. Thirteen per cent of apparently "normal" men have a hypospadic meatus and in a further 32% it is in the middle third of the glans. Most of these men thought they were normal, all voided normally and had sexual intercourse. I would take the view, on the basis of this massive proportion, that they are in fact normal by any reasonable definition of that word. Obviously minor degrees of hypospadias, as defined by doctors, do not matter to men or to their partners.

Men who have had surgery for hypospadias often disagree with the surgeon on the success of the operation. Up to 80% of adolescents are dissatisfied with their penile appearance, although only about 40% desire further surgery. Where the final appearance of the penis is circumcised, as it will be after most hypospadias surgery, dissatisfaction is greater in societies where circumcision is not commonplace. One has to ask, even if surgeons can "correct" some features of the hypospadic penis, such as chordee, the hooded prepuce (especially if the circumcised appearance is acceptable), and the position of the meatus, is it right or necessary to do so, when many men live happy lives, with successful sexual relationships, with penises which have all these features.

You can find much more information on all aspects of hypospadias, including surgery and its consequences, here.
 

Hypospadias repairs currently in use put great emphasis on correction of chordee. The bend may be sufficient to prevent intercourse and therefore "demand" correction - though I believe, the man's own opinions are of great importance. Some men do not want their chordee correcting. There is, however, a group of men for whom the bent appearance, even if it doesn't stop penetration, is so traumatic that they cannot function sexually. In cases like this, and in cases where men are too embarrassed to consult a doctor, widespread publicity to reduce the shame associated with hypospadias is essential.
 

Sex with the hypospadic penis

Problems with sexual intercourse can result from the physical "difference" of the hypospadic penis, including the fact that it is small or its appearance is unusual, or from the anxieties associated with these physical differences. More information is available here on these aspects of hypospadias.

There is no significant difference in the ages at which boys with or without hypospadias started masturbating or having sexual intercourse. Indeed, perhaps surprisingly, most men with hypospadias (whether repaired or not) appear to have sexual intercourse in much the same way as everybody else. This is a tribute to the power of the male mind to overcome adversity of the most personal and potentially shaming kind - an abnormality with one's penis. On the other hand, men with hypospadias have reported significantly more erection problems, such as curvature of the penile shaft, shortness and pain, than non-hypospadic men. Hypospadic men have also described themselves as more sexually inhibited than other men. Ejaculation may be abnormal in men with severe hypospadias. Up to 33% of men had "dribbling ejaculation" and 4% were dry after surgery.

Emotional satisfaction or dissatisfaction with intercourse is particularly difficult to measure. But we know that one thing that makes men dissatisfied is a perception that their penis is shorter than average, and the hypospadic penis is often said to be short. Where a formal measurement has been made, 20% of hypospadic penises were below the tenth centile. The finding was most marked in adolescents, to whom, of course, penis size can be a source of considerable anxiety. As there is no realistic means of enlarging the penis in hypospadias, men and their doctors need to focus on changing perceptions and coming to terms with the condition. [ Having said that, comparative studies seem to indicate that hypospadic boys are not greatly different from their peers in their sexual activity and enjoyment.
See Hypospadias Emotions for much more on this subject .]

It seems probable that boys with uncomplicated hypospadias are normally fertile, for there is no excess of hypospadias in infertility clinics. In an apparently random group of 169 hypospadic men, 50% were found to have a sperm count below 50 million/mI and 25% below 20 million/ml. More than half of those with the lowest sperm counts had associated anomalies such as undescended testes, which might have accounted for the poor result.

Psychological consequences of hypospadias

There is much debate about the psychological consequences of hypospadias. You can find a whole series of personal accounts at
The-penis.com, some of which relate trauma on a grand scale, all of which mention a sense of "difference".  But basically, one thing that has become clear to me over the last few years is that millions of men have hypospadias and do not know anything about it. These men may have never been exposed to other penises, or they may never have become stressed or concerned about the appearance of their penis. In other words, one has to ask if perhaps many men with mild hypospadias who have serious emotional problems or low self-esteem issues are actually projecting their insecurities about other aspects of their lives onto their penises and blaming the emotional consequences of these things on their hypospadias. There have been several studies on the psychological effects of hypospadias, but they don't really tell us much more than one could learn by talking to a small group of men with hypospadias. However, for the sake of completeness, here's a brief review. The information comes from here: physical and psychological effects of hypospadias.

In Sweden in the 1980s, Svensson and his colleagues studied 34 adult men aged between 21 and 34 years who'd been treated for hypospadias during their childhood in the 1950's and 1960's. They were compared with a control group. He found was that the men's first sexual experiences (e.g., first flirtations, first sexual relationship) happened later than those of the control group, and the men reported having fewer sexual partners. However, in spite of these differences, the majority of the men interviewed reported having a relatively satisfying sex life.

The men also showed signs of having been more timid and isolated in childhood.  As adults, they had more depression and anxiety, and found personal relationships more difficult. They also seemed to have lower self-esteem.

These researchers also looked at gender identity and sexual orientation and found that the men who had been operated on for hypospadias were less sure about their masculinity. Indeed, the men seemed to have a tendency to adopt more feminine behavior. Even so, most chose a female partner.

As I mentioned earlier, it's my experience that many men show no effects of hypospadias, and may not even know they have it. These will be men with mild hypospadias. It is not surprising, perhaps, that those operated on for surgery, who by definition must have had severe hypospadias, show some differences in psychological, psychosexual and psychosocial development. Need we ask why? It is, after all, their penis, the most obvious outward symbol of masculinity for most men, that is "abnormal". But let us look a little deeper. Perhaps the level of hormones in the hypospadias patients has affected their psychosexual development? Research seems to suggest this is generally not the case, though I believe a deficiency of testosterone, with all the implications that has for masculinization of the boy, can happen in some men with hypospadias. Of course, we also need to remember that genital surgery at a young age may itself cause psychosexual problems.

But given the importance of the penis as a symbol of maleness and all it represents in our society, perhaps any deficiency of this organ leads to fears of deficiency of in psychological development, social relations and sexual behavior. And low self-esteem could easily be the product of the reaction of a child's peers to the abnormal penis.

Another series of studies has been published by a team of Dutch researchers. These studies, conducted in the 1990s, were designed to establish how men hypospadias perceived differences between their penis and that of others. In theory, if the child is operated on, he should later have a penis with which he can stand to pee, and which looks more normal. But hypospadias surgery never gives the penis a perfectly normal appearance (e.g., after surgery it looks like it has been circumcised). Also, parents of boys with hypospadias may be concerned about their future masculinity, and these parental anxieties may be conveyed to the child - which may affect the child's ability to accept his penile variation. More importantly, perhaps, the child's peer group can emphasize his awareness of difference - especially if he is unable to urinate standing up or pee with a strong stream. This may cause him to see his penis negatively, and avoid situations where it may be discovered, such as urinating in groups or undressing publicly. It's also important to know that boys whose expectations of surgery are not fully realized will be disappointed and may then become obsessed by the appearance of their penis. (In my experience, this is very common among men with psychological problems caused by hypospadias.)

So, most men who had hypospadias surgery were still well aware that their penis looked different to the norm. And about 25% of them were dissatisfied with the appearance of their penis, compared to 5% of the other children/adolescents and 12% of other adults. Their dissatisfaction centered on the size and shape of their penis and the position of the urethral opening. Almost 40% of children/adolescents and 37% of adults who underwent urethral reconstruction had a negative genital perception, and said they would like improvement in function and appearance. What effect does all this have? As you might guess, men who have had hypospadias surgery report feeling inhibited or embarrassed, and hide their genitals in situations such as public showers or public toilets. The majority of patients continue to perceive differences between the appearance of their own penis and that of others: they are more dissatisfied with the appearance of their penis, and often reported receiving comments about it in public changing areas or toilets; they are also more self-conscious and embarrassed by the appearance of their genitals, and this often leads to  inhibitions in seeking out sexual relationships. Men with hypsospadias are also more inhibited in undressing in front of other people (e.g. in showers or communal changing rooms).

What makes this worse is that hypospadias is often treated as a secret, even within the family, which can have a shaming effect. Other common characteristics of men with hypospadias, with or without surgery, discussed by Patrick Walker in an unpublished PhD thesis on hypospadias are as follows:

• Lack of emotional support in the family

• Feeling different and keeping hypospadias a secret

• Feeling embarrassed about it

• Doubt about  their capacity to have normal sex

• Feeling Shame and poor self-esteem

• Anxieties and fear about sexual intimacy

• Solitude, isolation and mistrust  

• Feelings of loss and incomplete masculinity

• A process of personal growth, acceptance of self and body after an extreme level of physical and psychological suffering

• A need to enter into contact with other men who had hypospadias

• A process of coming to understand that hypospadias is only a part of their overall life experience