As part of their Hypospadias Mythbusters YouTube series, Dr Nicol Bush and Dr Warren Snodgrass analyze this common phrase. You can watch their full webinar here.
Hypospadias is a birth defect, which means repair is reconstructive surgery, not cosmetic surgery. Reconstructive surgery is done when a body part is abnormal due to a birth defect, cancer, or injury. On the other hand, cosmetic surgery is performed when someone desires an otherwise normal body part to be enhanced or have a different (but still normal) shape. You can read more about common reconstructive surgeries compared to cosmetic surgeries here.
There are different degrees of hypospadias. Some types of hypospadias are so mild that appearance and function are normal. Surgery is typically not recommended in these circumstances. For instance, when the meatus (urine opening) is located a bit lower on the head of the penis (called the glans penis), but is otherwise normally enclosed by the tissue of the glans penis (called glans fusion), then functional problems are rare. On the other hand, when the head of the penis does not enclose the urinary opening, functional problems such as urinary spraying and a splattering stream are much more common. This usually begins during the middle- and high-school years. What’s the reason for this? In most patients with hypospadias, the head of the penis is open like a book. The goals of reconstructive surgery are to position the urine channel in a normal spot AND to achieve a normal glans fusion by enclosing the head of the penis around the urine channel.
When should reconstructive surgery be performed? The penis grows in length and width quickly in the first 3 months of life due to a surge of hormones, often called “mini-puberty”. After that, the penis grows more slowly in length – but not in width – between the ages of 1-10 years. At puberty, it will grow both in length and width until adult size is reached. The amount of urine channel that needs to be sewn is shorter in infants compared to older children and adults due to this natural growth of the penis. Since less length needs to be sewn – even for the same extent of hypospadias – hypospadias repair is often faster and simpler at younger ages. Most surgeons recommend repair after the age of 3-6 months for this reason. Since most boys with hypospadias also have short skin on the underside of the penis, early reconstruction is also easier for skin management. However, hypospadias repair can be successful in teens and adults. Some teens and men will benefit from additional wound-healing therapies such as hyperbaric oxygen treatments to help with their skin healing.
Who does reconstructive hypospadias surgery? This often depends on where you live. In the United States and some countries around the world, hypospadias repairs are performed by pediatric urologists. But since pediatric urologists also treat a variety of conditions like undescended testes and bed-wetting, their individual experience will vary. In some countries, repairs are done by pediatric surgeons, general urologists, and plastic surgeons. No matter what the credentials, hypospadias repair is complex reconstructive surgery. Complex surgery is best done by experienced, high-volume centers according to multiple studies. It is important to find out how many hypospadias repairs your surgeon does a year for this reason.
The term “cosmetic surgery” has long been associated with strong feelings, some of which are very negative. For this reason, we believe it is important for families and your medical providers to use correct terminology: reconstructive surgery. Of course, when it comes to hypospadias repair, the final appearance is very important. Your expectations should be discussed with your surgeon. Your surgeon should be able to provide before and after pictures of similar patients. And be sure to ask if you aren’t sure about how things should look down there. Just because it isn’t cosmetic surgery, it doesn’t mean cosmesis doesn’t matter!