Warren Snodgrass, MD; Nicol Bush, MD, MSCS
PARC Urology, Dallas, TX
Is distal hypospadias repair a “cosmetic” operation?
This is a common question from mothers of infants with distal hypospadias. It is usually followed with the comment that, if so, maybe it is best to do nothing now, and let the boy decide himself later if he wants surgery. The idea that it is cosmetic surgery usually comes from mom’s internet research, but sometimes was told to her by a pediatrician or even a pediatric urologist.
The American Society of Plastic Surgeons provides helpful descriptions. Cosmetic procedures “enhance and reshape (normal) structures of the body to improve appearance and confidence”. Reconstructive procedures “treat structures of the body affected aesthetically or functionally by congenital defects…”. Obviously, by these definitions, hypospadias repair is a reconstructive, not cosmetic, operation. Even if repair is done only to restore normal appearance, it is imperative that we use proper terminology.
This distinction does not lessen the importance of achieving normal appearance by hypospadias surgery, since an abnormal appearance can cause body image anxiety. Older teens and adults we have seen with untreated distal hypospadias tell us that they don’t feel “whole”, even if they stand to urinate with little or no difficulty. The usual story is that they learned to change quickly in the gym without others being able to see their penis. They also say they are anxious before sex with a new lover, concerned what the reaction might be to the different appearance.
In this regard, we can compare distal hypospadias to isolated cleft lip. Even though cleft lip repair is done primarily to restore normal appearance, plastic surgeons appropriately refer to the surgery as “reconstructive” and not “cosmetic”.
But distal hypospadias can also result in significant functional impairment. Normally the glans encloses the meatus, serving as a nozzle to focus the stream. This ventral “glans fusion” between the lower lip of the meatus and the corona measures an average of 4.7mm in prepubertal boys, with a minimum of 2mm. Less than 2mm fusion, or no fusion at all, increases the risk for urine deflection and/or spraying when the older patient stands to void. Not all will experience this, but many do, and there is no way currently to predict which infants will grow up to have this problem.
The mess this creates results in significant social embarrassment, from either soiling the bathroom and/or their clothes, and also from the resulting need to void sitting. A 60 year old man with distal hypospadias told me this week how, from time to time, he has soiled his clothes and had to slip away until they dried or he could change. He also remembers that in 1st grade the other boys taunted him for sitting to pee like a girl.
So the point of this discussion is that words matter. Caregivers wrestle with a decision for hypospadias repair more often when they have the impression it is ‘only a cosmetic operation’ than when it is accurately described as reconstruction. In fact, we have learned not to use the word “cosmetic” at all, but rather to refer to “appearance” or “aesthetics”, which do not seem to trigger the same anxiety. Most importantly, we inform parents that, when the glans fusion is less than 2mm, the opening is outside the normal range, increasing the possibility their child will grow up having some difficulties managing his stream.