Kiss A, Sulya B, Szász AM, Romics I, Kelemen Z, Tóth J, Merksz M, Kemény S, Nyírády P. J Sex Med. 2011 May; 8(5):1529-39

DOI: 10.1111/j.1743-6109.2010.02120.x

Abstract  

INTRODUCTION: Hypospadias is the most common penis malformation, and there exist a variety of surgical approaches used to correct the abnormal position of the meatus. Although the long-term outcomes of surgery are considered important for psychosexual development, only a few attempts have been made to evaluate patient satisfaction.

AIM: The aim of our study was to evaluate surgical results and psychosocial adaptations in a homogeneous group of subjects with severe penile hypospadias who underwent the same types of surgical repairs during childhood and compare the results to data obtained from age-matched healthy controls.

METHODS: In this cross-sectional study, 104 men (between 24 and 42 years old) who underwent an uncomplicated two-stage hypospadias repair in their childhood and 63 age-matched healthy men without genital malformations completed the questionnaire.

MAIN OUTCOME MEASURES:   Difference in self-perception assessed by a 15-item questionnaire regarding psychosexual well-being and penile appearance between subjects with corrected hypospadias and healthy participants.

RESULTS: On average, subjects with a hypospadias repair were less satisfied with their genital appearance; however, they were more satisfied with their sex lives compared to healthy controls. The meatus distance was approximately 1.5 cm from the tip of the penis after surgical correction. None of the postoperative surgical results correlated with patient satisfaction. Furthermore, the small percentage of patients (11%) who were very unsatisfied with their surgical outcomes had no significant differences in surgical outcomes compared to satisfied patients. However, there was a significant difference between the two groups in almost all psychological outcome measures.

CONCLUSIONS: In adults who underwent an uncomplicated ventral repair of a severe penile hypospadias 20-30 years earlier, healthy psychosexual development was achieved despite the lack of a glanular meatus. Early identification of unsatisfied patients is important for appropriate long-term follow-up and counseling.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Summary 

This article is a must read for the clinician or researcher interested in associations between physical appearance or function and psychological outcomes measures. This study, and others, brings into question the assumption that our perceptions match objective measurements. We are apparently faced with the paradox that the quality of surgical outcomes for hypospadias repair in childhood does not foretell adult patient satisfaction or psychosexual experiences.

The study compared the sexual satisfaction, satisfaction with genital appearance, body image, and functional outcomes of 104 men with midshaft or proximal hypospadias who had undergone a Denis-Brown procedure between ages 3 and 7 years and who, at the time of follow-up, were >/=21 years old (mean=31.6 ± 6.0 years) to an age-matched healthy comparison group. Only patients with ‘uncomplicated’ two-stage repairs were asked to participate.

The study was conducted as a cross-sectional postal survey. A high percentage of cases were lost to follow-up (167/400; 42%). In contrast, all control group participants targeted (n=150) had valid addresses. Of those with valid addresses, participation rates were 104 out of 233 (45%) for the cases and 63 out of 150 (42%) for controls. The average distance between the meatus and tip of the penis was 1.39 ± 0.06cm. Micturition without force was achieved in 90% of hypospadias cases but 79% experienced some degree of deviation in urine flow. The absence of curvature with an erection was reported by 63% of cases and 5% reported major curvature.

In comparison to healthy controls, participants with a history of hypospadias and repair expressed lower satisfaction with genital appearance. There were no differences detected between the groups in body image, the proportion who masturbated, age at first kiss or first sexual intercourse. Although there was not a difference between the groups in the proportions expressing sexual satisfaction (dichotomous item: yes/no), the hypospadias group expressed significantly higher sexual satisfaction when this variable was measured on a continuous (1-10) scale. The groups did not differ in the proportion experiencing regular sexual relations or having a child.

Using a cut-point of <5 on a 1-10 scale for satisfaction with the surgical outcome, 12/104 (12%) former patients fell below the cut-off (median=3, range: 2-3) whereas the remainder (88%) fell above it (median=8, range: 6-9) (p<0.0001). Lower satisfaction with the surgical outcome was associated with more negative ratings on virtually all psychological and psychosexual outcomes. All dissatisfied former patients desired additional surgery, although there were no differences between satisfied and dissatisfied former patients with regard to surgical outcomes (meatal distance from penis tip, force required during micturition or penis curvature during erection).

The authors concluded that close to 90% of surgically treated patients were statistically indistinguishable from control group participants in terms of important psychological and psychosexual variables, even though they expressed less satisfaction with their genital appearance than the comparison group.

The limitations in the design of the study are clearly outlined in the paper, including potential selection bias in study participants, use of a questionnaire without previously established psychometric properties, self-report of meatal distance from tip of penis, and lack of information about demographic factors that could confound interpretation of the results.

Should these findings be viewed as anomalous? After all, considerable effort is expended in ‘normalizing’ the appearance of the hypospadic penis. Accordingly, the Denis-Brown technique has been substituted by procedures that achieve a better cosmetic result. Intuitively, a better cosmetic result would be expected to yield greater patient satisfaction, a more positive body image, and a psychosexual development less or unencumbered by inhibitions stemming from physical differences. However, studies from other clinical areas (short stature [see reference {1}, on which I am an author] and facial differences {2}) suggest that subjective self-assessments are more closely related to psychosocial adaptation than objective measures of appearance. An interesting question concerns the 12% of the hypospadias sample expressing dissatisfaction with the surgical results and who were reporting poorer psychological adjustment. Should we expect that additional surgery (as requested by this subgroup) will improve subjective experiences or should other psychological interventions that potentially mediate satisfaction and resilience be explored?

References   

1. Hunt et al. Horm Res 2000, 53:129-38. PMID: 11044793

2. Feragen et al. Body Image 2010, 7:271-9. PMID: 20541483

Recommendation Citation 

Sandberg D and Rolston A: F1000Prime Recommendation of [Kiss A et al., J Sex Med 2011, 8(5):1529-39]. In F1000Prime, 17 Jan 2012; DOI: 10.3410/f.13476971.14857074. F1000Prime.com/13476971#eval14857074