The urethra is the tube that carries urine from the bladder to the outside. Defects in this tube occur in both boys and girls.
However, they are far more common in boys. In both genders, repair is performed by a Pediatric Urologist.
The most common urethral abnormality in males is hypospadias. It occurs in about 1 in every 200 – 250 boys. Hypospadias refers to any condition where the opening of the urethra, known as the meatus, does not end at the tip of the penis. It represents a spectrum of findings. In mild cases (95%), the opening is located near the tip of the penis, or just below of the glans (head of the penis). In more severe cases the opening may be located along the underside of the shaft of the penis, in the scrotum, or behind the scrotum. Hypospadias is due to a failure of the urethra to roll into a tube during formation of the penis. Findings associated with hypospadias include: incomplete formation of the foreskin, resulting in a “hooded” appearance to the penis (sometimes called a “natural circumcision”), a “D” or “V” shaped glans, and a downward curvature of the penis (sometimes called chordee).
Surgery to repair hypospadias is recommended for several reasons, the most basic of which is appearance. In addition, if the opening is too far off the glans, it may not be possible for semen to be delivered to an appropriate spot in the vagina. This may result in fertility issues. However, the most significant reason for which surgery is recommended is for urination. In order for a boy to have a straight stream of urine, the urethra needs to end at the tip of the penis. Most patients with unrepaired hypospadias will have a urine stream which is directed downward.
Repair of hypospadias is typically performed before age 1. Surgery involves four basic steps: (1) creating a tube to extend to the tip of the penis, (2) creating a cone shaped glans penis to cover the reconstructed urethra, (3) correcting any curvature of the penis, and (4) correcting the abnormal appearance of the foreskin by either performing a circumcision or reconstructing the foreskin. Surgery is usually performed as an outpatient.
In the past, the urethra was reconstructed using the patient’s foreskin. It was either rolled into a tube or used to create part of a new tube. Due to poor outcomes and improved technology this is now rarely the case. Currently, in most cases, the urethra is now created using the portion of the urethra which failed to roll into a tube during the formation of the penis. Outcomes are significantly improved, and the penis has a more satisfactory cosmetic appearance. In addition, since the foreskin is not used, parents who do not wish their child circumcised can have it reconstructed. In cases of severe hypospadias, the urethra may cause a severe curve of the penis. In these cases, a two-step surgery is necessary. In the first operation, the penis is straightened and tissue from the foreskin or lower lip is attached to the bottom of the penis. This will later be used to make a new urethra. The penis is then allowed 6 months to heal. The tissue is then rolled into a tube to make a new urethra.
Although the severity of hypospadias may vary, with modern surgical techniques, complication rates have been significantly reduced while improving patient functional and cosmetic outcomes.