Hypospadias and Epispadias
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Direct answer
Hypospadias is a congenital defect in which the urethral meatus opens on the ventral surface of the penis rather than at the glans tip. Epispadias is the rarer opposite defect, with the meatus on the dorsal surface, and it lies within the exstrophy-epispadias complex. Repair is usually planned between six and eighteen months of age, and circumcision is deferred because the foreskin is needed for reconstruction.
What you must remember
- Hypospadias: ventral meatal opening, graded by position as glanular, penile, penoscrotal or perineal, with distal forms the most common.
- Chordee: ventral curvature from a fibrous band or a short urethral plate, most evident on erection, and released at repair.
- Hooded prepuce: dorsal foreskin with deficient ventral skin, and because the foreskin is used in repair, circumcision is avoided.
- Epispadias: dorsal meatus with dorsal chordee, and it is often associated with urinary incontinence.
- Exstrophy link: epispadias lies within the exstrophy-epispadias complex, which includes bladder exstrophy, so urinary tract evaluation is needed.
- Associations: undescended testis and inguinal hernia are common in hypospadias, and severe perineal forms need endocrine and karyotype evaluation when genitalia are ambiguous.
- Timing: repair around six to eighteen months, once the child is healthy and the tissue is adequate.
Classification and the repair decision
Hypospadias is graded by meatal site, and the grade predicts the complexity of repair. The table compares the two defects side by side, which is how exam questions usually frame them.
| Feature | Hypospadias | Epispadias |
|---|---|---|
| Meatal position | Ventral, on the underside of the penis, graded by site | Dorsal, on the upper surface of the penis |
| Chordee | Ventral curvature, released at repair | Dorsal curvature, which can be marked |
| Usual association | Undescended testis and inguinal hernia | Bladder exstrophy spectrum |
| Continence | Usually normal | Often impaired, particularly with exstrophy |
| Typical repair age | About 6 to 18 months | Often early childhood, sometimes staged with bladder surgery |
| Main repair goal | Urethral reconstruction and chordee release | Penile and bladder neck reconstruction |
Epispadias needs a wider urological evaluation than hypospadias, because the bladder neck and sphincter may be involved and continence must be assessed. Hypospadias is usually an isolated genital problem, but proximal forms with chordee, and those with undescended testes, make the repair more complex and call for careful endocrine review when genitalia are ambiguous.
Where the exam tries to catch you
Hypospadias and epispadias are often tested through the management decision rather than the anatomy alone.
- Trap: circumcising a boy with hypospadias at birth. Correct: the foreskin is needed for the reconstruction, so circumcision is deferred and the foreskin is preserved for repair.
- Trap: assuming epispadias is only a cosmetic dorsal opening. Correct: epispadias is linked to bladder exstrophy and incontinence, so the bladder and continence need assessment.
- Trap: missing a disorder of sex development when hypospadias is severe. Correct: severe perineal hypospadias with undescended testes or a small penis needs karyotype and endocrine evaluation.
Frequently asked questions
What is the commonest site of hypospadias?
The distal, glanular or subcoronal meatus is the commonest site of hypospadias, and mild distal forms need the least complex repair. Proximal and perineal hypospadias are less common and more complex to reconstruct.
Why is circumcision deferred in hypospadias?
Circumcision is deferred in hypospadias because the foreskin is often used as a graft or flap in the urethral reconstruction. Removing it beforehand would reduce the tissue available for repair.
What is chordee in hypospadias?
Chordee is a ventral curvature of the penis, caused by a fibrous band or a short urethral plate, that is most evident on erection. Surgeons release it during the repair so that the penis is straight.
Why is epispadias associated with bladder exstrophy?
Epispadias is associated with bladder exstrophy because both lie within the exstrophy-epispadias complex, which reflects a shared defect in midline closure of the lower abdominal wall and genital tubercle. The bladder and sphincter are often affected in both conditions.
When should hypospadias repair be performed?
Hypospadias repair is usually performed between about six and eighteen months of age, once the child is healthy and the tissue is adequate. Timing is set by surgical practice and the child's overall condition.