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Hypospadias is a congenital condition where the opening of the urethra (where urine and semen exit) is not at the tip of the penis but somewhere along the underside of the penis. The location of the opening can vary from a mild one (near the tip) to a severe one (at the base of the scrotum). Nearly 70% of all hypospadias also have an associated penile curvature where the penis bends downwards, known as chordee. Hypospadias repair surgery is typically performed between 6-18 months of age. A successful hypospadias surgery aims to reposition the urethral opening to the tip of the penis, straighten the penile curvature and align the skin to give a final circumcision type of cosmetic outcome.

When it comes to fertility in men, penis and testis play a crucial role. Here is a detailed information on how hypospadias can have an impact on fertility:

1. Production of semen:

In isolated cases of hypospadias with normal testes, the sperm production is not impacted, and fertility is normal. But upto 10% of patients with hypospadias may have associated undescended testis, and this association is mostly present in severe hypospadias. Testis is the core organ for male fertility. It produces sperms and male sex hormone called as testosterone. Testosterone is essential for development of penile growth. Both sperm production and testosterone production will be impacted if the testis is not functioning fully. Hence if the person has both hypospadias and undescended testis, there may be an impact on fertility, especially if there was undescended testis on both sides. In these cases, where we have both hypospadias and undescended testis, we need to investigate for DSD (Disorder of sex development) which is seen in 15% of such cases.

2. Presence of penile curvature:

While mild chordee may not impair sexual activity, presence of chordee more than 30 degree can make sexual activity difficult and painful. Hence straightening of the penis (chordee correction) is a very crucial step in hypospadias repair.

3. Problems with ejaculation in hypospadias:

In uncorrected hypospadias with urinary opening located far below on the shaft of the penis or near the scrotum, the sperm may not deposit correctly in the vagina. Also, if the hypospadias repair has not healed properly leading to a narrow urethra (stricture urethra) or loose and bulged out urethra (severe urethral diverticulum), the semen may not ejaculate with good force. Failure of semen to reach the vagina is the cause of infertility in these cases. Hypospadias repair is essential in these patients to bring the opening to the tip of the penis and reconstruct the narrow or bulged part to allow for proper ejaculation.

4. Psychological impact:

Uncorrected Hypospadias or failed hypospadias can have psychological impact on individuals affecting their quality of life, self-esteem, social interactions when transitioning from childhood into adulthood. Adults who had hypospadias repair in childhood have reported being more timid and more isolated in childhood. In spite of successful hypospadias repair, some individuals may feel that their genitalia look different from others, leading to feeling of inadequacy and shame. This can make relationships with the opposite gender difficult and hence may be an indirect cause of infertility. Hence our advice to parents of children with hypospadias is that they should provide information about hypospadias and disclose it to their child so that they know why their penis will look different from others. This disclosure is best done during puberty between 12-15 years of age because the boys will understand the situation better at this age. Often parents bring the boys around puberty to our hypospadias centre and then we also discuss and provide full information to the boys in front of their parents. Once they are aware, accepting the situation will help them gain confidence and develop in their sexuality and also prevent any negative feelings of inadequacy.

Key message for parents

If your child has isolated hypospadias then post successful hypospadias surgery by an expert hypospadias surgeon, most likely he will not suffer from infertility in adulthood. Hence early identification, timely surgical intervention is necessary to treat the physical challenges which could impede fertility. After a successful hypospadias surgery, the ability to perform intercourse and have a normal ejaculation will significantly improve the ability to have a child.

Even after a successful hypospadias repair if an adult has difficulty conceiving, then he needs to consult a hypospadias surgeon to make sure that the previously reconstructed urethra is normal followed by a fertility specialist for further evaluation to rule out other causes of infertility. With modern surgical techniques and medical care, even a boy with severe hypospadias can lead a normal adult life and have children.

About Hypospadias Foundation

Hypospadias foundation is a specialized centre in India dedicated to the care and treatment of children and adults with hypospadias and related conditions. It is located in Kharghar, Navi Mumbai, Maharashtra. The foundation’s sole focus on a single condition hypospadias allows them to develop specialized techniques and protocols aimed at achieving the best possible outcomes for their patients. Their success rate for hypospadias correction surgery is more than 95% making them one of the top centres in the world for hypospadias repair.

Dr A.K. Singal is a highly respected and experienced Pediatric urologist and hypospadias specialist in India. He is widely recognized for his expertise in surgical treatment of hypospadias and considered as the best hypospadias surgeon in India and the world. He has developed innovative surgical techniques and treatment algorithms particularly for complex and failed cases, with strong emphasis on achieving successful functional and cosmetic outcomes.

Dr Shenoy specializes in pediatric urology and hypospadias providing advanced surgical techniques for both primary and failed hypospadias repair in children and adults. Their combined experience and shared focus on a single, complex condition contribute to the foundation’s high success rate.

Hypospadias is a common congenital condition in which the urethral opening is located on the underside of the penis rather than at the tip. Surgical repair is required to correct this and to restore both function and appearance of the penis. One of the most frequent complications following hypospadias repair is the development of a urethral fistula which is an abnormal channel that forms between the urethra and the overlying skin after surgery, resulting in leakage of urine. So, there is urine coming from 2-3 places instead of from the tip. In the hands of an expert hypospadias surgeon, the incidence of urethral fistula should be less than 5%.

Diagnosis

The diagnosis of urethral fistula is typically clinical, based on observation of urine leakage from the repaired site. Documentation of the urine stream is important in fistula after hypospadias repair to rule out presence of stricture or diverticulum in the urethra beyond the site of fistula. The number of leaks also has to be documented before planning the surgical repair. Sometimes, we also place a urethral catheter to check the calibre of urethra beyond the fistula.

Timing of Fistula Repair

It is standard practice to wait at least 6 months after the initial repair before attempting urethral fistula closure surgery, as this allows inflammation to subside, tissues to soften, and vascularity to improve. Also, small fistulas may close spontaneously hence it’s recommended to wait for atleast 6 months before planning anything.

Surgical Principles for Successful Urethral Fistula Repair

The goal of surgery is to close the urethral fistula and restore the integrity of the neourethra while minimizing the risk of recurrence. Key steps include:

• Fistula tract excision: The tract is identified, excised, and the edges are refreshed to healthy tissue.
• Layered closure without tension: Multi-layered closure is crucial, typically involving the urethral mucosa, spongiosum (if available), dartos fascia, local tissues and skin. A hypospadias surgeon must make sure that the layers are not under any tension.
• Use of vascularized tissue: An intervening vascularized tissue flap (such as dartos fascia or tunica vaginalis in proximal fistula) is often placed between the urethra and skin to prevent recurrence.
• Fine absorbable sutures: Used to minimize tissue reaction and foreign body response.
• Catheterization: A urethral catheter is left in place for 7-10 days postoperatively todivert urine and protect the repair.

Techniques for Urethral Fistula Repair Surgery

Urethral Fistula closure can be performed in various ways.

• Simple closure: Reserved for small, well-defined fistulas with healthy surrounding tissue. Remember in these repairs also a layered closure with well vascularised tissues is important. One can utilize dartos or tunica vaginalis flap for additional coverage and vascular support.
• V-Y Flap Repair: In large fistulae, we often use a skin advancement flap from surrounding skin to provide non-overlapping suture lines. The flap can be laterally based or proximally based.
• Complex repairs: For large or recurrent fistulas, entire urethral reconstruction may be required which is done using local flaps or oral mucosa graft. Staged repair may be required in fistula cases with unhealthy urethra beyond the site of fistula.

Postoperative Care

Meticulous postoperative care is pivotal to ensure successful healing:

• Maintain catheter patency, monitor for obstruction or kinking.
• Keep the surgical site clean and dry. Gentle wound care as instructed by the surgical team.
• Monitor for signs of infection: swelling, redness, discharge, or fever.
• Avoid strenuous activity, straining or pressure on the site until fully healed.
• Follow up as recommended with your surgical team for wound checks and early detection of complications.

Prevention of Urethral Fistula Formation

Preventing fistula formation is an important aspect of hypospadias surgery

• Use of meticulous surgical technique with tension-free, multi-layered closure.
• Ensuring well-vascularized tissue coverage over the neourethra.
• Surgical site care and managing infection if any in the post operative period
• Make sure the passage beyond the fistula site is not narrow and of adequate calibre
• The meatus should be checked and if found to be narrow, meatotomy should be performed.

Prognosis and Outcomes

With appropriate timing and technique, most urethral fistulas can be successfully repaired. Prognosis depends on several factors:

• Location of the fistula site: Fistula far away from the coronal region can be repaired by simple closure.
• Tissue quality: Healthy, non-scarred tissue improves the likelihood of long-term closure.
• Number of previous repairs: Each additional surgery slightly reduces the success rate due to increasing tissue scarring and reduced vascularity.
• Surgeon’s experience: Experienced pediatric urologists have higher success rates for complex repairs.

Conclusion

Urethral fistula is the most common complication after hypospadias repair, but with proper diagnosis, patient selection, and surgical technique, most cases can be effectively managed. Families and patients should be reassured that while the development of a fistula is distressing, it can often be successfully treated, and most children go on to have normal urinary and functional outcomes. If you suspect a urethral fistula or have concerns about post-hypospadias surgery care, it is important to consult a pediatric urologist or specialized hypospadias surgery team for
individualized assessment and management.

About Hypospadias Foundation

Hypospadias foundation is a centre located in Kharghar, Navi Mumbai, Maharashtra, India with best surgeons having expertise in hypospadias repair in children and adults. We regularly manage both primary hypospadias repairs and complex cases including those with previous multiple failed repairs. A significant focus of our patient base consists of children and adults who have had failed hypospadias surgeries elsewhere, including persistent fistulas. Our approach involves not just good surgical technique but also diligent pre-operative assessment, focussed post-surgery care and critical decision making for good long-term outcomes.

Dr A.K. Singal is the founder and head of hypospadias foundation, India. He is considered the best hypospadias surgeon in India and the world and has successfully treated thousands of children and adults with hypospadias with excellent results.

Dr Ashwitha Shenoy is an expert hypospadias surgeon with special interest in the field of hypospadias and pediatric urology. Both Dr Singal and Dr Shenoy strive to achieve excellent outcomes in adults and children with hypospadias. Our success rate at hypospadias foundation for all types of repairs including complex and failed repairs are more than 95%.