Hope for boys born with misplaced urethral opening

Dr Eric Irungu, Senior Instructor, Aga Khan University Medical College and Consultant Paediatric Surgeon at Aga Khan University Hospital, Nairobi.

For a long time, families of boys born with this condition did not know where to go.

The condition is hypospadias, a birth defect where the opening of the urethra (the tube that carries urine from the bladder) is not located at the tip of the penis, but rather on the underside.

Dr Eric Irungu, a consultant paediatric surgeon at Aga Khan University Hospital, Nairobi, says this condition is treatable in Kenya and does not have to define a boy’s future or his family's hope.

 “The urethra typically opens at the tip of the penis. However, in boys born with this condition, the urethra opens along the underside of the penis at various locations, with some as far down as the scrotum,” he explains.

He says that this condition is normally detected at birth during the newborn's physical examination. Paediatricians and nurses identify the misplaced urethral opening and any associated penile curvature.

In cases where it is missed at birth, the abnormal morphology of the foreskin associated with hypospadias may lead to the diagnosis, which is detected during circumcision.

Dr Irungu says that about one in every 200 to 300 boys globally is born with hypospadias. However, in Sub-Saharan Africa, it’s less common. He estimates it in one in every 1,000 boys.

He says the cause of the condition is yet to be established, though it is linked to a myriad of issues, including pre-natal (during pregnancy, before delivery) exposure to pesticides, chemicals in plastics, synthetic hormones in foods, fertility treatments (such as in vitro fertilisation) and premature deliveries.

He refutes the suggestion that it could be hereditary from either parent. However, he says: “If one boy is born with the condition, there’s a small chance (5-10 per cent) his brother might be born with it. If a man had hypospadias, there’s a slightly higher chance (10-15 per cent) his son could be born with the condition.”

Dr Irungu explains that due to the abnormal position of the urethral opening, boys with this condition often experience difficulties urinating while standing upright.

Boys with the more severe types may need to squat or sit we passing urine. Even in boys with the distal types, the urine stream may spray, leading to unintentional wetting of clothes while passing urine. Due to the associated shorter urethral length, they may be at an increased risk of developing urinary tract infections.

“The associated bending of the penis (chordee) is often problematic. If left untreated, chordee would lead to challenges with sexual function later in life, whereby there would be difficulty in achieving penetration during intercourse. Even with mild forms of bending, chordee may lead to painful erections,” he notes.

He further says that hypospadias also leads to an incompletely formed foreskin, where it forms on the back side of the penis only and not the whole way around, giving the penis an abnormal morphology.

This condition prevents toddlers and teenagers from using urinals similar to other boys, in addition to constantly smelling of urine due to unintentional wetting of clothes, which leads to low self-esteem and poor social interactions with their peers. Thus, early detection and intervention are crucial to avoid these issues.

The primary treatment for hypospadias is surgical correction, ideally performed between four to 18 months of age. “The goal of surgery is to restore the abnormal anatomy in hypospadias to normal penile anatomy as much as possible. This includes correcting any penile curvature, reconstructing the urinary channel (The urethra), relocating the urethral opening to the tip of the penis and restoring symmetric skin coverage around the penis,” recommends Dr Irungu

He says that surgical reconstruction may be undertaken in either a single operation or multiple / staged operations, depending on the severity. In the less severe cases where the urethral opening is closer to the tip of the penis and there is minimal curvature, single-stage surgery is recommended because it can correct the abnormality. 

On more severe forms, Dr. Irungu says that staged Surgery is often required, particularly those with significant curvature or a urethral opening far from the tip. 

He says ongoing research aims to better understand the genetic and environmental factors contributing to this condition, paving the way for improved prevention and treatment strategies.