Hypospadias

Definition

Hypospadias is a birth (congenital) defect in which the opening of the urethra is on the underside of the penis. The urethra is the tube that carries urine and semen through the penis and outside the body. In males, the opening of the urethra is normally at the end of the penis.

Causes

Hypospadias occurs in about 1 in 200 newborn boys in the United States. The cause is often unknown.

Certain factors may be associated with the condition, such as:

Family history
Genetic factors that affect how the urethra develops
Maternal age over 35
Maternal overweight or obesity
Premature birth
Low birth weight

Other factors may also play a role:

Exposure to certain hormones
Exposure to substances in the environment

Symptoms

Symptoms depend on how severe the problem is.

Most often, boys with this condition have the opening of the urethra near the tip of the penis on the underside.

More severe forms of hypospadias occur when the opening is in the middle or base of the penis. Rarely, the opening is located in or behind the scrotum.

This condition may cause the penis to curve down during an erection. Erections are common in infant boys.

Other symptoms include:

Problems peeing without it spraying to the side or down (this can make it difficult to urinate while standing)
Foreskin that makes the penis looks like it has a "hood"

Some boys with hypospadias have one or both testicles that have not moved down into the scrotum (undescended testicle).

Exams and Tests

This problem is usually diagnosed soon after birth during a physical exam. Imaging tests may be done to look for other congenital defects.

Infants with hypospadias who have one or both testicles that have not moved down into the scrotum may need genetic testing (karyotyping) to check for genetic conditions.

Treatment

The goals of treatment are:

To ensure that urine and semen can pass normally through the urethra
To have the opening of the urethra at or near the tip of the penis
To correct any curvature so the penis is straight during an erection

Infants with hypospadias should not be circumcised. The foreskin should be kept intact for use in later surgical repair.

In most cases, surgery is done before the child starts school. Most urologists recommend repair when the child is between 6 and 12 months and before 18 months old. During the surgery, the penis is straightened and the opening is corrected using tissue grafts from the foreskin. For more complex cases, the repair may require several surgeries.

In some cases, if the hypospadias is very mild and there is no curve in the penis, surgery may be optional. However, even very mild cases may need to be repaired to prevent possible future problems. It's important to discuss the benefits and risks of treatment with your health care provider when deciding what is best for your child.

Outlook (Prognosis)

Results after surgery are most often good. In some cases, more surgery is needed to correct:

Fistulas (abnormal connection between the urethra and skin)
Narrowing of the urethra
A return of the abnormal penis curve

Most males can have normal adult sexual activity.

When to Contact a Medical Professional

Contact your provider if your son has:

A curved penis during an erection
Opening to the urethra that is not on the tip of the penis
Incomplete (hooded) foreskin

References

Chan Y-M, Hannema SE, Achermann JC, Hughes IA. Disorders of sex development. In: Melmed S, Auchus, RJ, Goldfine AB, Koenig RJ, Rosen CJ, eds. Williams Textbook of Endocrinology. 14th ed. Philadelphia, PA: Elsevier; 2020:chap 24.

Di Carlo HN, Crigger CB. Anomalies of the penis and urethra. In: Kliegman RM, St. Geme JW, Blum NJ, et al, eds. Nelson Textbook of Pediatrics. 22nd ed. Philadelphia, PA: Elsevier; 2025:chap 581.

Long CJ, Zaontz MR, Canning DA. Hypospadias. In: Partin AW, Domochowski RR, Kavoussi LR, Peters CA, eds. Campbell-Walsh-Wein Urology. 12th ed. Philadelphia, PA: Elsevier; 2021:chap 45.