- Don't Panic! (and don't circumcise)

Hypospadias is a condition in which the urinary meatus (the pee-hole) points downward rather than forward. (The word hypospadias comes from the Greek for "drawn under".)

Photograph of hypospadias (NSFW)
In the most serious cases the opening may be at the base of the penis or even behind the scrotum.

Degrees of hypospadias

Hypospadias occurs in about one boy in 300 in the US. (but the rate has increased in the last three decades, and is currently one in 125 - New Scientist, 29 June 2002: exposure during pregnancy to anti-androgens and oestrogen-mimics generated by industrial pollution is suspected.) Hypospadias is an absolute contraindication for circumcision, because the foreskin can be used for its repair, but many boys with hypospadias are circumcised regardless. It may be iatrogenic, a consequence of circumcision (picture). It may be repaired without circumcision, using the Byars' flaps technique or its "Batman excision" refinement, or the techniques of the papers below. Surgical repair is in any case contentious.

American Journal of Epidemiology, February 1, 2008.

NEW YORK (Reuters Health) - New research indicates that genetics rather than the intrauterine environment are mostly responsible for a relatively common birth defect of the penis. ...

Although hypospadias is one of the most common birth defects, little is known about its cause, Dr. Tine H. Schnack, from Statens Serum Institute in Copenhagen, and colleagues note in a report in the American Journal of Epidemiology.

They investigated genetic and environmental factors contributing to hypospadias in a study that involved 5,380 boys with the defect, drawn from a cohort of 1.2 million boys born in Denmark between 1973 and 2005.

The investigators observed a roughly 51-fold increased risk of hypospadias in male twin pairs. Moreover, the presence of a brother, sister or other "first-degree" relative with hypospadias increased the odds of the defect by nearly 12-fold, relative to having no close relatives with hypospadias.

The presence of a grandmother or other "second-degree" relative with hypospadias increased the odds of the defect by more than 3-fold, while having a more distant third-degree relative raised the odds of the defect by 33 percent, relative to having no close relatives with hypospadias.

"These findings indicate that genetic factors have a principal role in causing familial hypospadias," Schnack and colleagues conclude.


The main problems from hypospadias are psychological

The Guide to Getting It On

... Hypospadias is usually a minor birth defect that often looms far more massively in the mind of the guy who's got it than in mind of a potential partner. There is nothing about hypospadias that makes a man any less of a man, or any less of a lover, although sometimes it results in a condition where the penis curves more than normal.

The real damage from hypospadias is usually the shame and aloneness that a guy feels when he's growing up. One of the reasons for feeling so different is because he's often got to sit down to pee, given how the pee shoots out the side of his penis instead of the end. The guy knows he's different from other males, and often lives in terror that others will find out and make fun of him. Of course, this never happens, given how kind, understanding and uncruel children are about others who are different...

Aside from feeling like he's got this huge and horrible secret in his pants, most men with hypospadias have a medical history where they had to have their penis repeatedly inspected and examined by this doctor and that. And not being able to leave well enough alone, surgeons are frequently called in to do what often turns out to be multiple surgeries. (While medical intervention is sometimes helpful in certain cases, there are plenty of guys who would have been far better off if their penis had been spared the surgeon's knife.)

As is the case where any kid grows up feeling his body is defective, the most important issues to deal with are often the psychological. Men with hypospadias usually feel great emotional relief when they can meet and talk to other men who have the same condition. Fortunately, the Internet is making this much more possible than in times past.

Men with hypospadias sometimes grow up fascinated by other guys' penises. This makes perfect sense when you consider how often their penis gets handled by parents and doctors, often without a helpful explanation. It also makes sense given how focused a guy with hypospadias can be about the way his penis is different from other penises. However, there is no evidence that hypospadias results in a different sexual orientation unless that's what you were going to do from the start, hypospadias or not.

As for sex and relationships, the main difference between a penis with hypospadias and one without is where the cum shoots out, and that's not going to make a bit of difference to most women. As one female reader said, "I can name you hundreds of other things women are more concerned about in a man than if his pee or cum shoots out straight or from the side--most women wouldn't give a rat's ass. Only guys worry about things like that."

Rest assured there's no reason why you can't become a father, so birth control is just as necessary for a man with hypospadias as for any other guy. The urethral opening for men with hypospadias is sometimes a little bigger, and some guys are prone to urinary tract infections, so drinking extra water and peeing after sex might be a good habit to get into.

Men with hypospadias recommend that you tell a partner about your hypospadias sometime after you've gotten to know each other but before you've got your hands in each other's pants. ...


Studies describing repair of hypospadias without circumcision

Dewan PA. Distal Hypospadias Repair with Preputial Reconstruction. J Paediatr Child Health. 1993; 29:183-184.

Persson-Junemann C, Seemann O, Kohrmann KU, Potempa D, Junemann KP, Alken P. Correction of Distal Hypospadias: Ventral Adaptation of the Prepuce and Meatal Advancement. Urol Int. 1993; 51:216-219.

Hoebeke PB, De Kuyper P, Van Laecke E. 'Batman Excision' of ventral skin in hypospadias repair, clue to aesthetic repair (point of technique). Eur Urol. 2002; 42(5):520-2.

Gray J, Boston VE. Glanular reconstruction and preputioplasty repair for distal hypospadias: a unique day-case method to avoid urethral stenting and preserve the prepuce. BJU Int. 2003; 91(3):568-70.

Van Dorpe EJ. Correction of distal hypospadias with reconstruction of the preputium. Plast Reconstr Surg. 1987; 80(2):290-3.

Terzioglu A, Gokrem S, Aslan G. A modification of the pyramid procedure: the correction of subcoronal hypospadias with complete prepuce (letter). Plast Reconstr Surg. 2003; 112(3):922-3.

Leclair MD, Camby C, Battisti S, Renaud G, Plattner V, Heloury Y. Unstented tubularized incised plate urethroplasty combined with foreskin reconstruction for distal hypospadias. Eur Urol. 2004; 46(4):526-30.


Is "repair" even necessary?

Intersexed people take a special interest in hypospadias because if falls on the Intersex spectrum (at the very beginning, so again, don't panic). The Swiss Intersex human rights NGO, Zwischengeschlecht.org, put out a report that includes this:

Human Rights Violations Of Children
With Variations Of Sex Anatomy


p 15

b) Hypospadias “Repair”

Hypospadias is a medical diagnosis describing a penis with the urethral opening (“meatus”, or “pee hole”) not situated at the tip of the penis, but somewhere below on the underside, either still on the glans (“distal” or “anterior”), or farther below somewhere on the shaft (“middle”), or on the scrotum (“proximal”, or “posterior”), due to incomplete tubularisation of the urethral folds during prenatal formation of the penis (see p. 10 “Genital Development and Appearance”).

In addition, hypospadias is often associated with a downward curvature of the penis, especially when erect (“chordee”), in shape resembling the (mostly internal) structures of the clitoris. In about 10% of cases, hypospadias is associated with undescended testes. Sometimes, hypospadias is also associated with an unusually small penis (“micropenis”). Mostly, hypospadias is associated with a hooded appearance of the foreskin (untubularised foreskin), again slightly resembling the clitoral hood.

Hypospadias “repair” surgery aims at “relocating” the urethral opening to the tip of the penis, and, if applicable, to straighten the penis. The penis is sliced open, and an artificial “urethra” is formed out of the foreskin of skin grafts (see Supplement 3 “Medical Textbooks”, p. 77). Switzerland was leading in introducing hypospadias surgeries in German language European countries after World War II.228

While in very rare cases hypospadias can be associated with an urethral opening too small to allow unobstructed passing of urine, which makes appropriate surgical intervention (and only such) a medical necessity, and in older boys curvature can sometimes be associated with pain during (involuntary) erections, which also constitutes an actual medical problem, these are the only exceptions to the rule that hypospadias per se does not constitute a medical necessity for interventions.

Furthermore, since the ongoing 2nd “Hypospadias Boom” (Supplement 1 “Historical Overview,” p. 59) doctors are so bent on operating, that in a sample of 500 adult “normal” men presenting for prostate surgery, 225 men, i.e. 45% were classified as “suffering” from an “abnormal” position of the meatus – despite no complaints, “normal” function and lack of awareness of their “abnormality”: “However, all patients participated in sexual intercourse without problems and were able to void in a standing position with a single stream,” all were “without complaints about cosmetic or functional aspects,” even those with “significant hypospadias.” What’s more, all but one homosexual patient had fathered children, and even in patients diagnosed with “significant hypospadias,” 60% of the patients and 55% of their partners were “unaware of the abnormality.” 229

Hypospadias “repair” is notorious230 for very high complication rates, e.g. 42%–57%,231 as well as for grave complications which can result in serious medical problems where none had been before (for example urethral strictures have lead to kidney failure requiring dialysis), and frequent “redo-surgeries”. Tellingly, for more than 30 years, surgeons have been officially referring to “hopeless” cases of repeat failed “repair” surgeries as “hypospadias cripples” (i.e. made to a “cripple” by unnecessary surgeries, not by the condition!).232 However, as a 2012 international medical conference in Switzerland revealed, in medical publications on hypospadias, “[d]ocumentation on complication rates has declined in the last 10 years.” 233



228 E.g. Ernst Bilke, born 1958 in South Germany, was sent to Basel for paediatric hypospadias “repair”, because the local German doctors refused to do it, wanting to make him into a girl instead, see Ulla Fröhling (2003) Leben zwischen den Geschlechtern. Intersexualität – Erfahrungen in einem Tabubereich, at 90–105

229 J. Fichtner, D. Filipas, A. M. Mottrie, G. E. Voges, R. Hohenfellner (1995), Analysis of meatal location in 500 men: Wide variation questions need for meatal advancement in all pediatric anterior hypospadias cases, Journal of Urology 154:833-834

230 e.g. Guido Barbaglia (2010), Failed Hypospadias Repair. How Often Is It, and How to Prevent It?, http://www.failedhypospadias.com/files/Belgrado2.pdf

231 Pierre Mouriquand (2006), Surgery of hypospadias in 2006 – Techniques & outcomes, SymposiumIn ternational de Paris – Surgery of hypospadias in 2006, slides 13, 15, http://www. canal-u.tv/video/canal_u_medecine/symposium_international_de_paris_surgery_of_hypospadias_ in_2006_techniques_and_outcomes.2212

232 e.g. ibid., slide 19

233 Katherine Pfistermuller, Peter Cuckow (2012), Analysis of Data Quality from 30 Years of Published Data on Hypospadias Outcomes, Programme of the 23rd Annual Meeting of ESPU, Zurich May 09-12, at 204, http://www.espu2012.org/images/ESPU_2012_Programme.pdf


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