General Health and Medical Sciences, Vol(1), No (1), October, 2014. pp.

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Hypospadias pathophysiology and treatment principles, not as recent as

we think.
Georgios Kampouroglou *
Department of Surgery, GHOL Nyon Hospital, Vaud, Switzerland.

Venetia-Sofia Velonaki
University Institute of Graduate Studies and Research in Care, Department of Community Medicine and Public Health, Lausanne, Switzerland.

George Androutsos
History of Medicine Department, Faculty of Medicine, University of Athens, Greece.
*Corresponding author: gkampouroglou@gmail.com

Keywords

Abstract

Hypospadias
Antiquity
Surgery

Although the surgical treatment of hypospadias in ancient Greece and Rome is not acceptable today, the
complete description of this entity, the mechanical causes leading to it and its association with infertility
were described and could be considered as the basis of modern hypospadiology.

1.

Introduction

Hypospadias is a hypoplasia of the tissues forming the ventral aspect of the penis beyond the division of the corpus spongiosum. It is an
association of three anatomical anomalies: an abnormal ventral opening of the urethral meatus, a ventral curvature (chordee) of the penis and a
hooded foreskin, which is deficient ventrally. However, not all three of these features are present in every case [1].
Numerus surgical techniques have been proposed during the last two centuries for hypospadias repair. But what was the understanding and
treatment for hypospadias in antiquity?

2.

Methodology

A review of relevant sources, in Greek, English and French language, for hypospadias history in ancient Greece and Rome was conducted.

3.

Hypospadias in ancient Greece and Rome

Although Hippocrates (460 to 370 BC) was familiar with the urethral shape, no mention of hypospadias or other external genital deformities
have been found in his writings [2]. The first description of this entity comes from Aristotle, in the 4th century BC [3] [4] [5]. Aulus Cornelius
Celsus (25 BC to 50 AD) has described in details the treatment of various disorders of the external genitalia, but one cannot find any traces of
hypospadias or hermaphroditism or their treatment in his work [2]. Nonetheless, he was one of the first to describe catheterization, which is
mandatory in every hypospadias repair described in the next millennium and afterwards [2], and nowadays has become the gold standard in
urethral reconstruction.
3.1 Etymology
The word hypospadias was first used by Galen (130-199 AD). Etymologically, the term hypospadias is derived from the Greek , meaning
'under' and , a 'fissure' or crack [3]. In his writings, he described the great importance of the chordee. Here, we should note that
references to chordee and its interference with intercourse, after Galen and a brief reference by Oribasus (325-403 AD), cannot be found for
1,500 years [6]. Not only did he underline the mechanism underlying penis curvature (chordee), but he also explicated the pathophysiologic
mechanism of sterility in men suffering from hypospadias. He stated that men afflicted with hypospadias cannot have children, not by lacking
normal sperm, but because of the curvature of the penis [6] and that this theory is confirmed by the ability to beget children if the frenum is
divided [7].
3.2 Hypospadias repair
The first detailed and complete description of hypospadias along with a proposal of a surgical repair was given by Heliodorus and Antyllous, in
the 1st and 2nd century AD respectively. The proposed surgery consisted of amputation distal to the existing meatus. The authors gave detailed
information on perioperative bleeding control with bandages and vinegar water, medications and cauterization according to the severity of the
bleeding [2]. The amputation operation may seem today somehow crude, but we cannot ignore the fact that it was a first attempt to place the
ectopic urethral meatus in an anatomically correct position. Nonetheless, Heliodorus and Antyllous did not neglect the cosmetic aspect of the
surgical repair they proposed, as it is indicated by their emphasis on leaving intact a distal portion of the penis by using an incision which
resembled a delicate circular carving, leaving a projection representing the form of a gland [2].
Severe forms of hypospadias (penoscrotal and scrotal) were considered impossible to repair [4]. Concerning treatment attempts, we should not
neglect to mention Galen, who stretched the skin over the orifice up to the glans, anchored it with tape and cut off the excess [6].

Georgios Kampouroglou *, Venetia-Sofia Velonaki, George Androutsos

General Health and Medical Sciences Vol(1), No (1), October, 2014.

3.3 Hypospadias and hermafroditism

The problem of mistaking a man with hypospadias for a woman was common in the ancient times. A relevant reference is found at a text from
Diodorus Siculus, who described the history of a man with hypospadias who was raised as a woman and after marriage denied sexual
intercourse. He was then examined by doctors and after a surgical operation his masculine nature was revealed [4].
Aristotle, has underlined the false impression that boys who seat to urinate have both male and female genitalia: there have been instances of
boys in whom the termination of the penis has not coincided with the passage through which the residue from the bladder passes out, so that the
passage came too low; and on this account they sit in order to pass water, and when the testes are drawn up they seem from a distance to have
both male and female generative organs. [5] [8]
3.4 Hypospadias and Art in Ancient Greece
Only one representation of hypospadias in ancient Greek art has been so far identified. It is the so-called phallus-vulva vase, which dates to
circa 610 BC. It is a part of the archaic Greek pottery of Chios and was discovered at Naucratis in Egypt in a sanctuary, probably belonging to
Aphrodite [5].

4.

Conclusion

The techniques of hypospadias surgery described in the ancient times, mainly the partial penectomy, are of course, not acceptable today.
Nonetheless, the complete description of this pathology, its association with infertility and the understanding of the mechanical causes leading to
it were some great steps to the management of hypospadias, for which, even today, the ideal repair with minor complication rates has not been
described.

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