Objective and Subjective Sexual Outcomes in Adult Patients after

Hypospadias Repair Performed in Childhood

Boris Chertin,* Aladin Natsheh, Itzhak Ben-Zion, Dan Prat, Stanislav Kocherov,
Amicur Farkas and Ofer Z. Shenfeld
From the Departments of Pediatric Urology and Urology, Shaare Zedek Medical Center, Jerusalem and Leumit National Health Services,
Tel Aviv, Israel

Purpose: We evaluated sexual function and psychosexual adjustment in adults who

Abbreviations
underwent hypospadias repair in childhood.
and Acronyms
ED erectile dysfunction
Materials and Methods: After receiving institutional review board approval, 119 of 449
adult patients (26.6%) who underwent hypospadias repair between 1978 and 1993
MAGPI meatoplasty and responded to questionnaires on penile appearance and sexual life. Patients were divided into
glans incorporation
3 groups according to primary meatal location in childhood, including group 1d45 (37.8%)
MCS mental with glanular hypospadias, group 2d56 (48.2%) with distal hypospadias and group 3d18
component summary (14%) with proximal hypospadias.
PCS physical
Results: All group 1 and 2 patients, and 11% in group 3 were satisfied with the penile
component summary
appearance. Of group 1 patients 8.9% reported mild erectile dysfunction, as did 50% and
PE premature ejaculation 72.2% in groups 2 and 3, respectively. A total of 99 patients (83.2%) complained of
SEAR Self-Esteem and premature ejaculation. All group 1 and 2 patients reported excellent self-esteem and
Relationship relationship on the Self-Esteem and Relationship questionnaire. Most group 3 patients were
satisfied with their relationship and only 1 (5.6%) was not satisfied. Two-thirds of the
Accepted for publication December 27, 2012. Study
received institutional review board
patients in groups 1 and 2 reported that sexual quality of life was excellent and the others
approval. described it as good. In group 3 sexual quality of life was somewhat decreased in all patients
* Correspondence: Department of Pediatric and 1 (5.6%) had poor sexual quality of life. Physical and mental component sum-maries
Urology, Shaare Zedek Medical Center, were satisfactory in all patients reviewed.
Jerusalem, 91031, P.O.B 3235, Israel
(telephone: 972-2-6555560; FAX: 972-2-
6666955; e-mail: chertinb@ szmc.org.il). Conclusions: Our data show that the high incidence of mild erectile dysfunction and
premature ejaculation should not be disregarded and requires appropriate counseling before
surgery.

Key Words: penis, hypospadias, erectile dysfunction,

psychosexual development, questionnaires

DURING the years, hundreds of surgical
procedures have been suggested to repair
1 8
hypospadias. A significant number of
scientific articles have been published that
discuss short-term function and the
incidence of early problems after
hypospadias repair, such as urethral
1,5 7
stricture and fistula. Surprisingly, scant
atten-tion has been given to the long-term
results of hypospadias repair and
what influence there may be on sub-
sequent patient social and sexual behavior.
The sexual function of patients who
underwent pediatric hypospadias repair
remains an enig-matic problem frequently
raised upon penile reconstruction by the
9 12
parents of children with hypospadias.
As the child grows into adulthood,
sexual function becomes an important
issue. Sexual dysfunction in adults

0022-5347/13/1904-1556/0 http://dx.doi.org/10.1016/j.juro.2012.12.104
THE JOURNAL OF UROLOGY Vol. 190, 1556-1560, October 2013
j
1556 www.jurology.com
 2013 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC. Printed in U.S.A.
 SEXUAL OUTCOMES IN ADULT PATIENTS AFTER HYPOSPADIAS REPAIR IN CHILDHOOD
who underwent hypospadias surgery may take many forms,
including body image issues due to a history of genital
surgery and genital scarring, residual or recurrent penile
curvature, possibly causing cosmetic and functional
difficulty, erectile dysfunction and ejaculatory problems.
Not surpris-ingly, data on these questions are sparse and
difficult to assess since most pediatric urologists do not
follow patients well into adulthood and are not ex-perts in
sexual medicine. On the other hand, most adult urologists
see only patients who complain of problems and may be
led to believe that sexual problems in patients with
hypospadias are more common than they actually are. An
additional con-founding factor is the fact that most reports
in the literature on the long-term results of hypospadias
surgery generally and sexual outcomes in particular are
based on patients operated on decades ago using
reconstructive techniques that today would be considered
outdated or less often in use. Thus, these reports do not
provide the answers that we need to dependably predict the
long-term sexual outcomes of currently used surgical
techniques.
Therefore, we evaluated the sexual function of adult
patients who underwent hypospadias repair in childhood
using standardized outcome measures of sexual function.
Some surgical techniques used in this operative series are
still in use at many centers of excellence. We believe that
validated data on sexual outcomes in patients with
hypospadias will allow proper preoperative counseling.
PATIENTS AND METHODS
After receiving institutional review board approval, we reviewed
the medical files of all patients who underwent primary
hypospadias repair at our department. We pre-viously reported
our surgical regimen and outcomes in
patients with primary hypospadias treated with operative repair at
our department in the last 3 decades.13,14 Our
surgical protocol slightly changed during the years. Briefly, all
patients were considered for surgery after age 6 months.
Hormonal supplementation was given to those with a small
phallus, as we previously reported. All hypospadias repairs were
done as an outpatient procedure using loupe magnification in 87%
of cases. Silicone stents remained in all patients between 24 hours
and 6 to 7 days postoperatively according to repair type and
primary meatal location.
All patients had 1 routine followup visit 6 months and 1 year
after surgery. Subsequently, those without com-plications were
advised to return to the clinic at age 12 to 13 years and at age 18
years upon the completion of adolescence or before recruitment
into the army unless there were urological problems or
dissatisfaction with the surgical or functional outcome.
We reviewed the hospital and office charts of study patients,
noting age at surgery, meatal location, type of hypospadias repair,
chordee, operating surgeon and rate of
1557
complications such as closure breakdown, fistula, meatal stenosis
and the need for reoperation. Complications were divided into
immediatedall complications within the first 6 months of
followup and latedcomplications that devel-oped 6 months or
more postoperatively.
Included in study were 449 adult patients who under-went
primary hypospadias repair as children between 1978 and 1993,
had reached age 18 years at the time of the study and had at least
1 year of postoperative followup. They were asked to respond to
questionnaires, including the International Index of Erectile
Function (IIEF), SEAR, SF-12 , PE and Sexual Quality of Life-
Male. In addition to these internationally validated question-
naires, we used a locally developed and yet unvalidated
questionnaire on patient perception of psychological well-being
and penile appearance. All questionnaires were translated to the
native language of the responders. Questionnaire scores of patient
satisfaction with penile appearance included full satisfactiond46
to 62, mild botherd32 to 45, moderate botherd17 to 31 and severe
botherd0 to 16 points.
We used GraphPad Prism , version 5.00 for Win-dows with the
chi-square and Fisher tests for statistical evaluation with p <0.05
considered significant.
RESULTS
Of the 449 adult patients 119 (26.6%) responded to the
questionnaires. Patients were divided into 3 groups by the
15
primary meatal localization. Group 1 included 45 patients
(37.8%) with glanular hypo-spadias, group 2 consisted of
56 (48.2%) with distal hypospadias and group 3 included
the remaining 18 (14%) with proximal hypospadias in
childhood. The mean age SD of these adult patients at sur-
gery was 2.7 3.9 years. Of the operations 69% were
performed by fellowship trained pediatric urologists and
the remaining cases were performed by adult urologists or
senior residents under the supervision of a senior surgeon.
Only 64 patients (14.2%) required corporoplasty to
straighten the penis. In the remaining patients penile skin
degloving was sufficient to correct chordee.
In group 1 meatal advancement or meatoplasty, MAGPI,
and Thiersch-Duplay and Mathieu flap hypospadias repair
were done in 3 (6.7%), 20 (44.5%), 3 (6.7%) and 19
(42.1%) children, respectively. In group 2 Mathieu and
Thiersch-Duplay hypospadias repair, MAGPI and preputial
island flap as onlay hypospadias repair were done in 28
(50%), 5 (8.9%), 20 (35.7%) and 3 children (5.5%),
respectively. In this group MAGPI was performed only in
patients with a coronal meatal location. In group 3, 2-stage
hypo-spadias repair was done in 4 patients (22.2%) and 1-
stage surgery was done in 14 (77.8%), including a preputial
island flap as onlay hypospadias repair in 9 (64.3%),
tubularized preputial island flap hypo-spadias repair in 2
(11.1%) and Thiersch-Duplay hypospadias repair in 3
(16.7%).
1558 SEXUAL OUTCOMES IN ADULT PATIENTS AFTER HYPOSPADIAS REPAIR IN CHILDHOOD

Table 1 lists immediate complications. Overall Table 2. Patient satisfaction with penile appearance, and
SF-12 PCS and MCS scores
complications developed in 7 patients (15.5%) in group 1,
in 16 (28.6%) in group 2 and in 11 (61.1%) in group 3. In Hypospadias Type
group 1 fistulas were noted in 4 pa-tients (8.9%), an Glanular Distal Proximal
unsatisfactory cosmetic outcome was found in 4 (8.9%), 6 No. pts 45 56 18
(13.3%) required additional hypospadias repair surgery and % Satisfaction:*
5 (11.1%) had meatal stenosis. In group 2 fistulas were Full 93.3 91.1 11.1
noted in 11 patients (19.6%), an unsatisfactory cosmetic Mild bother 6.7 8.9 77.8
Moderate bother 0 0 11.1
outcome was found in 14 (25%), 9 (16%) required Av SD SF-12 score: 50.07 12.4 52.92 6.5 4.3
additional hypospadias surgery and 7 (12%) had meatal PCS 44.4
stenosis. In group 3 fistulas were noted in 6 patients MCS 40.644.4 40.49 4 43.84 2.6
(33.3%), an unsatisfactory cosmetic outcome was found in * No patient had severe bother.
6 (33.3%), 5 (27.8%) required additional hypospadias
repair surgery and 9 (50%) had meatal stenosis. In all patient reported greater than moderate ED. PE was
patients an average of 1.22 surgeries was required to common in 99 (83.2%) patients overall with an 88.9%
achieve satisfactory functional and cosmetic results with an incidence in those with proximal hypospa-dias. A total of
average of 1.42 operations required in group 3. During 30 (66.7%), 19 (34%) and 3 patients (16.7%) complained
adolescence, 70 patients continued to be followed, of of mild PE in groups 1, 2 and 3, respectively. Moderate PE
whom 38 (54.2%) required additional surgery dur-ing or was noted in 7 group 1 patients (15.6%), 22 (39.3%) in
after adolescence. Of these patients 17 required redo group 2 and 11 (61.1%) in group 3. Severe PE was reported
hypospadias repair and 21 underwent fistula closure. We by 1 patient in each of groups 2 and 3.
recently reported our 3-decade experience with
hypospadias repair, which clearly demonstrates similar All group 1 and 2 patients reported excellent self-esteem
complications rates in these patients who responded to the and relationship on the SEAR question-naire. In group 3
questionnaires and those who elected not to reply to the most patients were satisfied with relationships and only 1
16
survey. (5.6%) was not satisfied. Of patients in groups 1 and 2,
66.7% reported that sexual quality of life was excellent and
others described it as very good. In group 3 sexual quality
In patients who responded to the questionnaires, almost of life was somewhat decreased in all patients and 1 (5.6%)
all those in groups 1 and 2 were satisfied with the penile reported poor sexual quality of life (see figure). Finally, the
appearance. In groups 1 and 2, 3 (6.7%) and 5 patients mean SF-12 PCS score was 50.07 12.4, 52.92 6.5 and 44.4
(8.9%) reported mild dissat-isfaction with the penile 4.3, and the mean MCS score was 40.64 4.4, 40.49 4 and
appearance. However, only 2 of 18 patients (11.1%) in 43.84 2.6 in groups 1, 2 and 3, respectively (table 2).
group 3 were pleased with the penile appearance (table 2).

Only 4 of the 45 patients (8.9%) in group 1 re-ported

ED. However, 28 (50%) and 13 of patients (72.2%) in
groups 2 and 3, respectively, reported mild ED. Moderate
ED was reported by 1.8% of group 2 patients and by 16.7% DISCUSSION
in group 3. No study The implications of hypospadias on the affected child, such
as an abnormal voiding pattern, the
Table 1. Immediate complication rates

No. Cases/No. Immediate Total No.

Complications (%) Complications (%)
Glanular: 45/7 (15.5) 9 (20)
Mathieu flap 19/4 (20.1) 5 (26.3)
Meatal 3/0 0
advancement
MAGPI 20/2 (10) 3 (15)
Thiersch-Duplay 3/1 (33.3) 1 (33.3)
Distal: 56/16 (28.6) 22 (39.2)
Mathieu flap 28/12 (42.9) 15 (53.6)
MAGPI 20/2 (10) 3 (15)
Onlay flap 3/1 (33.3) 2 (66.6)
Thiersch-Duplay 5/1 (20) 2 (40)
Proximal: 18/11 (61.1) 13 (72.2)
Denis-Browne 4/3 (75) 3 (75)
Onlay flap 9/5 (55.5) 5 (66.7)
Thiersch-Duplay 3/1 (33.3) 3 (100)
Tubularized flap 2/2 (100) 2 (100) SEAR results
 SEXUAL OUTCOMES IN ADULT PATIENTS AFTER HYPOSPADIAS REPAIR IN CHILDHOOD
inability to void while standing, possible sexual
dysfunction, the psychological impact of a genital
abnormality, potential fertility problems and the prospect of
1 or more corrective surgical procedures as a child, cannot
be brushed aside and should be discussed in detail with the
16 23
parents of the affected child before surgical repair.
Despite these potentially significant medical and
psychosexual sequelae, little has been published in the
literature on the long-term outcomes of hypo-spadias
surgery. Early reviews of sexuality after hypospadias repair
showed that in general patients with hypospadias were in
some emotional distress and more inhibited sexually, while
many were un-happy with the genital appearance, although
most had no difficulty with intercourse if residual or
12
recurrent chordee was absent. Another dysfunc-tion
typical of older reconstructive techniques and proximal
hypospadias is poor ejaculatory function due to the
accumulation of semen in a lax tube (the neourethra) with
no spongious support.
More recent studies of modern reconstructive
techniques as well as standardized outcome mea-sures of
sexual function are generally reassuring. One such study,
although in only 11 patients, used the standardized IIEF
questionnaire and showed excellent erectile function and
23
moderate to excellent overall sexual satisfaction. Those
pa-tients had undergone complex oral mucosa graft
urethroplasty for complex previously failed hypo-spadias
repairs. A larger study of 66 patients in The Netherlands
compared sexual outcomes in adults operated on for
19
hypospadias in childhood to normal controls. Again, IIEF
domains (desire, erection and satisfaction) were equivalent
except for orgas-mic function, which was decreased in
patients with hypospadias compared to controls.
Interestingly, in this study patients who formerly had
hypospa-dias tended to masturbate less than their peers,
possibly indicating that they were less comfortable with
sexuality.
Our data further address these questions. Most group 1
and 2 patients were satisfied with the genital appearance
postoperatively. However, only 11% of patients with the
proximal, more severe type of hypospadias were satisfied
with the penile appearance after hypospadias surgery. We
attribute this finding to the fact that these patients under-
went hypospadias repair using older techniques, resulting
in an inferior cosmesis compared to that of current
techniques.
Although a relatively large number of patients in groups
2 and 3 reported mild ED, the other sexual function
domains, such as sexual desire and orgasmic function, were
mainly unaffected. More-over, when examining the general
sexual satisfac-tion of patients and their self-esteem, we
found that
1559
all except 1 were satisfied with sexual performance and
reported overall high self-esteem. Therefore, we speculate
that even cosmetically imperfect penises do not undermine
sexual performance or negatively influence patient self-
esteem.
Another finding was a high incidence of PE in study
patients at an overall incidence of 88%. The PE rate
increases with severity of the hypospadias type. However,
again we noted no difference in overall sexual satisfaction
and self-esteem in our patients, even those who reported
almost 90% PE. We do not know the general incidence of
PE in Israeli men but the general incidence of PE in the
24
same age group is about 50%, significantly less than in
our adult patients treated with hypospadias surgery in
childhood. Again, it seems that this high incidence of PE
did not disturb our patients or decrease their overall sexual
satisfaction.
One of the most important goals of this study was to
evaluate perceptions of the physical and mental health of
our responders and the possible influence of genital surgery
on these parameters. The SF-12v2 health survey measures
the 8 health domains and provides psychometrically based
PCS and MCS scores. These surveys are for adults 18
years old or older and can be self-administered or interview
administered. Scores are calibrated so that 50 is the average
score or norm. The SF health surveys are the most widely
used tools worldwide to measure patient reported
outcomes. Our patients reported normal PCS and MCS
scores with a trend toward lower scores. However, scores
were within the normal range in patients who underwent
prox-imal hypospadias repair (table 2).
Our study is not without limitations. We present surgical
data from a retrospective study, which was subject to all
the flaws inherent to any such study. The use of different
techniques and significant improvement in hypospadias
surgery in the last decade with improvements in surgical
instruments and sutures may have had a significant impact
on the clinical outcome in our patients. Again, not all
reviewed patients returned the questionnaires. However,
our 23% response rate is generally acceptable in this type
of review and it provides valid data. Although we did not
compare our find-ings with data on controls of similar age,
we compared them with available data from the liter-ature
on the incidence of ED and PE in healthy in-dividuals of
the same age. We have no data on the quality of sexual life
from the sexual partners of our patients, which may have
shed additional light on the overall sexual performance and
satisfaction of the study patients. Finally, we cannot
comment on the urination pattern of our patients after
surgical correction. This is a subject for further study,
which is currently ongoing at our department.
1560 SEXUAL OUTCOMES IN ADULT PATIENTS AFTER HYPOSPADIAS REPAIR IN CHILDHOOD
CONCLUSIONS
Our data show that, excluding those who had proximal
hypospadias, most patients who underwent hypospa-dias
repair in childhood were satisfied with the penile
appearance. Although overall sexual satisfaction and
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