Hypospadias in neonates

Please note that some guidelines may be past their review date. The review process is currently paused. It is recommended that you also refer to more contemporaneous evidence.

Hypospadias is a common condition affecting newborn males where the urethra opens on the ventral surface of the penis and doesn't reach the tip. This topic covers types, differential diagnosis and management of the neonate with hypospadias.

Hypospadias is a common condition affecting one in 350 newborn males. When hypospadias is present the urethra opens on the ventral surface of the penis and does not reach the tip of the glans. In more severe cases the urethra may open in the scrotum or perineum. All but the mildest cases of hypospadias involve some degree of chordee. Chordee is a lack of ventral tissue on the penis leading to a bowstring effect causing longitudinal bending of the shaft.

Hypopadias is usually apparent at birth, and no immediate management is necessary as long as the testes are descended and there is a good urinary stream. Severe hypospadias with a bifid scrotum and undescended testes is a disorder of sexual development and ambiguous genitalia.

Clinical findings

The clinical findings in hypospadias are as follows:

• There is a downward deflection of the urinary stream.
• The urethra opens on the ventral surface of the penis and does not reach the tip of the glans. In mild cases the meatus is at the base of the glans. In severe cases the urinary meatus may open in the scrotum or perineum.
• The prepuce lacks ventral tissue so it is hooded.
• Penis is bent ventrally with chordee.

Source: CDC - Hypospadias

Source: Patient.co.uk

Differential diagnosis for hypospadias

Differential diagnosis for hypospadias involves:

• If the infant presents with undescended testes an intersex disorder should be considered.
• Gender assignment should be delayed until the sex of rearing has been decided. Urgent expert assessment is required (see ambiguous genitalia).

Investigation for hypospadias

Careful examination is required since hypospadias can be associated with a large number of other anomalies and syndromes.

Infants with penoscrotal or perineal abnormalities should be assessed to exclude intersex disorders (see ambiguous genitalia).

Management of hypospadias

Issues to note about management of hypospadias:

• No immediate management is required as long as the meatus is not stenosed and there is a good urinary stream.
• The parents should be advised not to circumcise the child as the prepuce is required in reconstructive surgery.
• Referral should be made to a paediatric surgeon.
• Occasionally surgery is not required if hypospadias is proximal.
• To reduce the psychological impact surgical correction is usually performed in infancy between 6-18 months, if possible as a one-stage procedure but more than one surgery may be required.
• If a chordee is present surgical correction is required because when standing there will be difficulty with directing urinary stream. Intercourse may also be difficult or painful because the chordee is accentuated during an erection.
  
  

Hypospadias with severe chordee and bifud scrotum