Iatrogenic hypospadias is a condition where the opening of the urethra is displaced onto the underside of the penis, resulting from a medical procedure rather than a birth defect. The term “iatrogenic” signifies a complication arising from a medical intervention that was intended to be helpful or necessary. This acquired anatomical anomaly deviates from the typical meatus position at the tip of the glans penis, leading to functional and cosmetic issues. The resulting tissue damage, scarring, or erosion necessitates complex reconstructive surgery to restore proper urinary function and penile appearance.
Understanding the Condition: Hypospadias
Hypospadias is an anatomical irregularity involving the male urethra and external genitalia. In normal development, the urethra is a tube that extends through the penis, with the meatus positioned centrally at the glans tip, permitting a straight urinary stream.
The congenital form involves incomplete closure of the urethral folds during fetal development, causing the meatus to open along the ventral side of the penis. This displacement is classified by location, ranging from mild distal forms, such as glandular or subcoronal, to complex proximal forms, including penoscrotal or perineal. Approximately 70% of congenital cases are the less severe distal type.
Congenital hypospadias is often accompanied by an incomplete foreskin, giving the glans a hooded appearance, and sometimes a downward curvature of the penis called chordee. The iatrogenic form, by contrast, is a structural breakdown of previously normal or repaired tissue, creating a defect that mimics this congenital condition.
The Iatrogenic Factor: Procedures Leading to Complication
Iatrogenic hypospadias arises primarily from two distinct medical contexts: complications related to indwelling catheters and failures following prior genitourinary surgery. The most direct and specific cause, particularly in adults and neurologically impaired patients, is prolonged indwelling urethral catheterization. Downward pressure exerted by the catheter on the ventral aspect of the glans and urethra compromises blood supply, leading to ischemic necrosis and erosion of the urethral wall.
This mechanical pressure injury causes the septum glandis to tear, resulting in a physical separation of the glans wings and the formation of a cleft-like defect. The extent of this urethral erosion can range from a minor meatal cleavage to damage extending along the entire ventral urethra. Factors such as improper catheter securing, large catheter size, or reduced patient sensation can exacerbate this tissue trauma.
Another significant source of acquired defects is the failure of a previous hypospadias repair, known as failed urethroplasty. Each re-operation introduces more scar tissue and diminishes the quality and vascularity of the remaining penile skin and urethral tissue. Complications like urethral strictures (abnormal narrowings of the urethra) or urethrocutaneous fistulas (abnormal openings between the urethra and the skin) are common manifestations of this surgical failure.
Injury During Circumcision
Iatrogenic injury can occur during elective procedures like neonatal circumcision. Though rare, direct surgical trauma or the use of clamps and sutures can inadvertently injure the distal urethra or the frenulum. A poorly placed suture intended to stop bleeding can cause localized tissue necrosis, which may result in a sub-glandular fistula that functionally resembles a form of hypospadias.
Identifying and Diagnosing Post-Surgical Damage
Recognition of iatrogenic hypospadias often begins with the patient or parents noticing abnormal urinary symptoms following a procedure. The most common sign is an abnormal urinary stream, which may present as a spray, a forked stream, or the need to sit down to urinate. This is a direct consequence of the misplaced meatus or the presence of a urethrocutaneous fistula.
Diagnosis starts with a thorough physical examination by a urologist, who visually inspects the penis for the location of the urethral opening and the presence of any accompanying penile curvature. Specialists look for evidence of scarring, tissue deficiency, or the telltale glans cleavage indicative of catheter-induced injury. The meatus position is measured to determine the severity and complexity of the defect.
Specialized imaging is necessary to map the extent of the damage to the deeper urethral structures. A retrograde urethrogram, where contrast dye is injected into the urethra, can reveal strictures, diverticula, or fistulas that are not visible externally. Urethroscopy, which involves inserting a small, flexible camera, provides a direct view of the scar tissue and the precise length of the damaged segment, informing the reconstructive plan.
Corrective Surgery and Long-Term Outlook
The repair of iatrogenic hypospadias is significantly more challenging than the primary repair of a congenital defect because the surgeon must work with scarred, poorly vascularized tissue. This corrective procedure, known as secondary urethroplasty, aims to straighten the penis, reconstruct the urethra, and position the meatus at the glans tip. The complexity often dictates the need for a staged repair, which involves multiple operations separated by several months.
The first stage focuses on excising the scarred, unhealthy tissue and inlaying a graft to form a new urethral plate. Tissue grafts are frequently harvested from sites like the inner cheek lining, or buccal mucosa, because this tissue is wet, robust, and readily available. This graft is allowed several months to fully integrate and heal before the second stage of the repair.
The second stage involves tubularizing the newly formed urethral plate over a catheter to complete the urethra and close the penile skin. The long-term outlook for these complex repairs is complicated by the fact that each successive operation increases the odds of complications by approximately 1.5-fold. Despite high success rates in specialized centers, the potential for complications like strictures, fistulas, or persistent curvature remains elevated, necessitating long-term follow-up and the potential for additional minor procedures.