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Hypospadias and epispadias
In hypospadias the urethral opening lies on the underside (ventral) of the penis, with a ventrally deficient "hooded" foreskin and sometimes downward curvature; repair is done at 6 to 18 months, circumcision before it is forbidden, and hypospadias combined with an undescended testis requires evaluation for a disorder of sex development (DSD).
Why it matters in the exam
Hypospadias affects about 1 in 200 to 300 boys, and most cases (about 70 percent) are distal — the opening is near the glans. Exam questions deal with the contraindication to circumcision (the foreskin is needed for repair), timing of surgery, complications and the required evaluation. Isolated hypospadias, even proximal, does not need upper urinary tract imaging. In contrast, proximal hypospadias with one or both testes impalpable requires a karyotype and hormonal evaluation, because this may be a disorder of sex development, including congenital adrenal hyperplasia in a virilised baby girl.
The standard operation for distal hypospadias is TIP (Snodgrass): incision of the urethral plate and tubularisation; in proximal hypospadias with severe curvature a two-stage repair is sometimes done. The commonest complication is a urethrocutaneous fistula; other complications: meatal stenosis, urethral diverticulum, wound breakdown and residual curvature. Before repair of a small penis, topical or injected testosterone is sometimes given to enlarge it.
In epispadias the opening lies on the upper (dorsal) side of the penis; it is part of a spectrum of anomalies that includes bladder exstrophy — an open bladder on the abdominal wall with separation of the pubic bones. In epispadias near the base of the penis urinary incontinence is common, because the bladder neck is incomplete. Exstrophy carries a late risk of bladder adenocarcinoma. Micropenis is defined as a stretched penile length over 2.5 standard deviations under the age-specific mean, and it requires hormonal evaluation rather than surgery.
Key points
- Urethral opening on the underside.
- Repair at 6 to 18 months.
- No circumcision before repair.
- With an impalpable testis — DSD.
- Epispadias — part of the exstrophy spectrum.
Summary table
| Condition | Finding | Evaluation | Treatment |
|---|---|---|---|
| Distal hypospadias | Opening near the glans, hooded foreskin | Not needed | TIP at 6 to 18 months |
| Proximal hypospadias | Opening at the penile base or scrotum, curvature | If a testis is impalpable — karyotype | Repair, sometimes in two stages |
| Hypospadias with an impalpable testis | Suspected DSD | Karyotype and hormones | According to the diagnosis |
| Epispadias | Opening on the upper side | Bladder assessment | Repair and bladder neck reconstruction |
| Bladder exstrophy | Open bladder, pubic diastasis | Congenital assessment | Staged closure |
In the full version for subscribers
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Sources
- EAU Guidelines on Paediatric Urology, 2025 edition — Hypospadias; Exstrophy-epispadias complex
- AAP Policy Statement: Timing of Elective Surgery on the Genitalia of Male Children, 1996 — Timing of hypospadias repair
- Campbell-Walsh-Wein Urology, 12th edition (2020) — Hypospadias
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.