Hypospadias in Children: Diagnosis, Surgery & Recovery in Kuala Lumpur
Hypospadias in Children: Diagnosis, Surgery & Recovery in Kuala Lumpur
Overview
Hypospadias is a condition present at birth in which the opening of the urethra (the tube that carries urine out of the body) is located on the underside of the penis rather than at its tip.
It is one of the more common congenital conditions affecting boys, occurring in approximately 1 in 200–300 male births.
Hypospadias varies considerably in appearance and severity. Some children have an opening just below the tip of the penis, while others have the opening further down the shaft or near the scrotum.
Not every child with hypospadias requires surgery. Assessment by a paediatric urologist helps determine the type of hypospadias, whether treatment is necessary, and the appropriate timing.
What Does Hypospadias Look Like?
Hypospadias is usually recognised during a newborn examination or when parents notice an unusual appearance of the penis.
Three features are commonly associated with hypospadias:
An abnormal urethral opening: The urinary opening is situated below its usual position at the tip of the penis.
An incomplete foreskin: The foreskin may cover the upper part of the glans but be absent underneath, creating a hooded appearance.
Penile curvature (chordee): The penis may curve downwards, particularly during an erection.
Not all children have all three features.
In some cases, the urinary opening appears close to its normal position, but there may still be significant penile curvature.
Parents may also notice that their child passes urine in a downward direction or has difficulty directing the urinary stream.
If hypospadias is suspected in a newborn, circumcision should generally be deferred until assessment by a paediatric urologist, as the foreskin may be needed for reconstruction.
Types of Hypospadias
Hypospadias is commonly classified according to the location of the urethral opening.
Distal Hypospadias
The urethral opening is located near the tip of the penis, such as on the glans or just below it.
This is the most common form of hypospadias. Penile curvature may be absent or mild, although the appearance alone does not always indicate the complexity of repair.
Midshaft Hypospadias
The opening is located along the middle portion of the penile shaft.
Surgical assessment considers the position of the opening, the quality of surrounding tissues, and whether penile curvature is present.
Proximal Hypospadias
The opening is situated closer to the base of the penis, at the penoscrotal junction, within the scrotal region, or near the perineum.
Proximal hypospadias is often associated with more pronounced curvature and may require more complex reconstruction.
The position of the urethral opening is only one part of the assessment. Penile curvature, glans size, urethral plate quality, and surrounding tissues also influence the surgical approach.
What Causes Hypospadias?
Hypospadias develops during pregnancy when the urethra and surrounding penile structures do not form in their usual position.
Its development involves several factors, including genetic influences, hormonal signalling, and other factors affecting genital development.
In most children, there is no single identifiable cause.
Hypospadias is not caused by anything the child or parents have done after birth.
Most boys with hypospadias are otherwise healthy.
However, children with severe proximal hypospadias, particularly when accompanied by undescended testes or atypical genital development, may require additional assessment.
Does Every Child with Hypospadias Need Surgery?
Not necessarily.
Some boys with distal hypospadias have a normal urinary stream, minimal or no penile curvature, and no significant functional concerns.
In these cases, observation may be an appropriate option after discussion with the family.
Surgery may be considered when there is:
A urethral opening that affects the direction or control of urination
Significant penile curvature
An opening located further down the penile shaft
Anatomical features that may affect future sexual function
A reconstructive concern that the family wishes to discuss after understanding the benefits and risks
The decision depends on the child’s anatomy, anticipated function, and the potential benefits and complications of surgery.
When Is the Best Age for Hypospadias Surgery?
When surgery is indicated, hypospadias repair is commonly performed between 6 and 18 months of age, although the appropriate timing varies.
This age range is generally preferred because surgery can be completed before toilet training and before children develop greater awareness of their genital anatomy. Surgical, developmental, and practical considerations also influence the timing.
The child’s overall health and suitability for general anaesthesia are assessed before surgery.
However, hypospadias can also be repaired in older children and adolescents. Children who were not treated during infancy can still undergo assessment to determine whether surgery is appropriate.
The timing of surgery depends on the child’s anatomy, general health, and the complexity of the planned repair.
How Is Hypospadias Surgery Performed?
Hypospadias surgery aims to reconstruct the urinary passage and correct associated penile curvature where present.
The main surgical objectives are to:
Straighten the penis if significant curvature is present.
Reconstruct the urethra to allow urine to pass through an appropriately positioned opening.
Reconstruct the glans and surrounding penile skin where indicated.
Achieve a functional result with an acceptable appearance.
The technique depends on the type of hypospadias and the condition of the penile tissues.
Single-Stage Repair
Many distal hypospadias cases can be repaired in one operation.
One commonly used technique is tubularised incised plate (TIP) urethroplasty, also known as the Snodgrass repair.
In suitable cases, the existing urethral plate is used to create a new urinary channel.
Other techniques may be selected depending on the anatomy.
Staged Hypospadias Repair
Some children with proximal hypospadias, severe curvature, or inadequate urethral tissues may benefit from a staged approach.
The first operation may involve correcting curvature and preparing or grafting tissue for future reconstruction.
A subsequent operation creates the new urethral passage.
The interval between operations depends on tissue healing and the planned reconstruction.
There is no single surgical technique suitable for every child with hypospadias. The final approach may also depend on findings during surgery, particularly after the penis has been straightened and the anatomy reassessed.
What Happens During Hypospadias Surgery?
Hypospadias repair is performed under general anaesthesia.
Depending on the procedure, additional regional anaesthesia may be used to help manage postoperative pain.
During surgery, the surgeon examines the penile anatomy, assesses curvature, and performs the required reconstruction.
A small urinary catheter or stent is commonly placed to allow urine to drain while the reconstructed urethra heals.
The duration of surgery and whether the child requires an overnight hospital stay depend on the complexity of the repair and postoperative needs.
Parents are given instructions on wound care, catheter management, medication, and follow-up before discharge.
Recovery After Hypospadias Surgery
Recovery varies depending on the extent of reconstruction.
The First Few Days
Some swelling, bruising, and mild blood staining around the surgical site are expected.
The penis may appear swollen or different from its final appearance during the early healing period.
Pain relief is prescribed according to the child’s needs.
A dressing may be applied to protect the wound, although dressing practices vary between techniques.
Urinary Catheter Care
A urinary catheter or stent may remain in place for approximately 7–10 days, sometimes longer for complex repairs.
Parents will be shown how to care for the catheter and recognise problems such as poor drainage or accidental displacement.
Activity and Bathing
Straddling activities, such as riding bicycles or using ride-on toys, may need to be avoided temporarily.
Bathing instructions depend on the type of dressing and the surgeon’s postoperative protocol.
Follow-Up
Follow-up appointments assess wound healing, urinary stream, the position of the urethral opening, and any signs of complications.
Longer-term review may be recommended, especially after proximal or complex repairs.
What Are the Possible Complications of Hypospadias Surgery?
Hypospadias repair is a reconstructive procedure, and complications can occur even when surgery is performed carefully.
Potential complications include:
Urethrocutaneous fistula
A small opening may develop between the reconstructed urethra and the penile skin, causing urine to leak from an additional site.
Some fistulas require further surgery.
Meatal stenosis
The new urinary opening may become narrowed, resulting in a thin or difficult urinary stream.
Urethral stricture
Scar tissue may narrow part of the reconstructed urethra.
Wound breakdown
Part of the reconstruction may separate during healing.
Persistent or recurrent curvature
Penile curvature may remain or become apparent as the child grows.
Cosmetic concerns
Differences in the appearance of the glans, urethral opening, or penile skin may remain after repair.
The likelihood of complications varies with the severity of hypospadias, the technique used, tissue characteristics, and whether previous surgery has been performed.
Proximal and revision repairs generally carry a higher risk of complications than straightforward distal repairs.
Some complications become apparent only years later, particularly during puberty.
What If a Previous Hypospadias Repair Has Failed?
Children who have undergone hypospadias surgery may occasionally develop persistent urinary leakage, narrowing, recurrent curvature, or concerns about the appearance of the penis.
Revision surgery can be more complex because previous operations may have altered the available tissues and blood supply.
Assessment usually includes examination of the urinary opening, urinary stream, penile curvature, and the condition of the surrounding skin.
Depending on the findings, revision may involve fistula closure, treatment of a narrowing, or further urethral reconstruction.
In some cases, staged reconstruction using graft tissue may be required.
The approach depends on the nature of the complication and the child’s previous surgical history.
Why Long-Term Follow-Up Is Important
The outcome of hypospadias repair is not assessed solely by how the wound looks shortly after surgery.
As a child grows, changes in penile size and development may reveal problems that were not apparent during early childhood.
Follow-up may consider:
Urinary stream and ease of passing urine
Position and size of the urethral opening
Penile straightness
Recurrent narrowing or fistula
Appearance and concerns arising during puberty
Children with proximal hypospadias or complex repairs may benefit from longer-term follow-up into adolescence.
Hypospadias Assessment in Kuala Lumpur
Dr Roger Anthony Idi is a Consultant Urologist with training and clinical experience in paediatric urology.
He completed paediatric urology fellowship training at Great Ormond Street Hospital in London and has undertaken further training in paediatric urology through Aarhus University Hospital.
He is also an Adjunct Professor with the Paediatric Urology Unit at the University of Malaya, where he participates in paediatric urology clinics and hypospadias surgery.
At Prince Court Medical Centre, Kuala Lumpur, consultations for children with hypospadias focus on assessing the anatomy, discussing whether surgery is necessary, explaining possible surgical approaches, and reviewing the expected recovery and risks.
Families may seek assessment following a newborn diagnosis, for an older child who has not undergone repair, or for concerns following previous hypospadias surgery.
Frequently Asked Questions
Can hypospadias correct itself as my child grows?
No. The position of the urethral opening does not move to the tip of the penis naturally as the child grows. However, mild hypospadias does not always require surgery.
Should my baby be circumcised if he has hypospadias?
Circumcision is generally deferred until a paediatric urologist has assessed the penis. The foreskin may be useful during reconstruction, particularly in certain types of hypospadias.
If your child has already been circumcised, repair may still be possible, depending on the anatomy and available tissues.
Will my child be able to urinate normally after surgery?
The aim of surgery is to create a functional urinary passage and improve the direction of the urinary stream. Many children achieve satisfactory urination after repair, but narrowing, fistula formation, or other complications may affect the outcome.
Will hypospadias affect fertility later in life?
Mild hypospadias usually does not affect fertility. More severe forms, particularly when associated with significant curvature or other genital abnormalities, may affect sexual or reproductive function.
Surgery aims to address relevant anatomical and functional problems, but long-term outcomes depend on the severity of the condition and the results of reconstruction.
Is hypospadias surgery painful?
Surgery is performed under general anaesthesia, and pain management is provided during and after the procedure. Some discomfort, swelling, and irritation from the catheter may occur during recovery.
Can hypospadias return after surgery?
The original congenital condition does not return, but complications such as fistula, narrowing, or recurrent curvature may develop. Some children require further surgery.
Can hypospadias surgery be performed in an older child?
Yes. Although repair is commonly undertaken during infancy, older children and adolescents can also be assessed for surgery. The technique and recovery considerations depend on their anatomy and previous treatment.
How many operations will my child need?
Many children with distal hypospadias undergo a single operation. More complex cases may require staged reconstruction, and additional procedures may occasionally be needed if complications develop.
The expected number of stages should be discussed after examination.
Consultation for Hypospadias in Kuala Lumpur
If your child has been diagnosed with hypospadias, or you have concerns about the appearance of the urinary opening, penile curvature, or a previous repair, a urological assessment can help clarify the findings and available options.
Dr Roger Anthony Idi
Consultant Urologist
Prince Court Medical Centre, Kuala Lumpur
Related Reading
Phimosis in Children – Understanding a tight foreskin, when treatment is necessary, and the available options.
Buried Penis in Children – Causes of a concealed penis, how it differs from hypospadias, and when surgical correction may be considered.
Micropenis in Children – Understanding penile size, possible hormonal causes, and the importance of early assessment.
Posterior Urethral Valves (PUV) – A congenital condition affecting urinary outflow in boys, including diagnosis and management.
Bedwetting in Children – Common causes of nighttime wetting, when further assessment is needed, and treatment approaches.