Hypospadias & Epispadias
Hypospadias is a congenital anomaly in which the urethral meatus opens proximally on the ventral surface of the penis, often with ventral curvature, deficient ventral penile skin, and a dorsally hooded foreskin.[1][2] Epispadias is a much rarer congenital malformation in which the urethral plate fails to tubularize dorsally, leaving the meatus on the dorsal penis and often placing the patient within the exstrophy-epispadias complex.[3][4]
For the adult reconstructive urologist, these are not pediatric diagnoses left behind in childhood. Adults present with uncorrected distal anomalies, failed childhood repair, urethral stricture, urethrocutaneous fistula, chordee, sexual dysfunction, infertility concerns, urinary incontinence, catheterizable channels, bladder augmentation, and renal surveillance needs. The operation is rarely just "move the meatus"; it is a problem of scarred genital skin, urethral substitution, continence reconstruction, and transition from pediatric to adult lifelong care.
Definition and Terminology
| Condition | Core defect | Typical curvature | Reconstructive implication |
|---|---|---|---|
| Hypospadias | Ventral ectopic meatus with incomplete ventral urethral development | Ventral chordee | Adult redo surgery often means penile urethral stricture repair, fistula closure, chordee correction, and genital skin substitution |
| Epispadias | Dorsal urethral plate defect with dorsal ectopic meatus | Dorsal chordee | Adult care often centers on continence, bladder neck reconstruction, sexual function, and exstrophy-related renal surveillance |
| Bladder exstrophy-epispadias complex (BEEC / EEC) | Spectrum of failed lower abdominal wall, bladder, pelvic-ring, and urethral closure | Variable | Requires lifelong surveillance after staged reconstruction, augmentation, bladder neck surgery, or catheterizable channel creation |
Hypospadias and epispadias are usually diagnosed and repaired in childhood, but adult presentations are common in reconstructive practice because childhood repairs can fail late and uncorrected variants may remain functionally acceptable until urinary or sexual expectations change.
Hypospadias in Adults
Classification
Hypospadias is usually classified by the final meatal location after release of chordee. This matters because a meatus that appears distal before degloving may become more proximal once tethering is released.
| Type | Meatal location | Approximate frequency | Adult surgical relevance |
|---|---|---|---|
| Distal / mild | Glanular, coronal, subcoronal | ~70% | May be asymptomatic if uncorrected; late problems include spraying, meatal stenosis, cosmetic concern, or failed childhood repair |
| Middle | Distal penile, mid-penile | ~10% | More likely to require urethral substitution if scarred from prior surgery |
| Proximal / severe | Proximal penile, penoscrotal, scrotal, perineal | ~20% | Highest risk of chordee, multiple operations, psychosexual concerns, fertility impairment, and complex adult revision |
The Cleveland Clinic adult presentation framework is useful for reconstructive triage:[5]
| Category | Adult presentation | Frequency in the Cleveland Clinic series |
|---|---|---|
| Category I | Continuous multiple surgeries with significant scarring and tissue loss | 58.2% |
| Category II | Delayed complications after initially successful childhood repair | 29.1% |
| Category III | No previous repair | 12.7% |
Epidemiology
Hypospadias is one of the most common congenital anomalies in males, with an estimated incidence of 1 in 200-300 live male births.[1] Reported incidence has increased in some populations over recent decades, although ascertainment, registry methods, environmental exposures, and diagnostic threshold all complicate interpretation.[1]
Adults presenting to reconstructive practices are typically in early to middle adulthood. Contemporary adult series report mean presentation ages around 34-37 years, often decades after childhood reconstruction.[5][6]
Etiology and Developmental Biology
Hypospadias is multifactorial. Normal urethral development requires coordinated androgen signaling, urethral-fold fusion, glanular urethral canalization, corporal development, and ventral penile skin formation.[1][2]
Important contributors include:
- Genetic factors - familial clustering is recognized; variants in androgen metabolism and genital tubercle development pathways are implicated.
- Androgen signaling disruption - inadequate androgen production, conversion, receptor signaling, or local tissue response can impair urethral-fold fusion.
- SRD5A2 variants - mutations in 5-alpha-reductase type 2 have been identified in a substantial proportion of posterior hypospadias cohorts.[7]
- Environmental factors - endocrine disruptors have been proposed, but causal attribution in individual patients is usually impossible.[1]
- Associated anomalies - proximal hypospadias with cryptorchidism, bifid scrotum, micropenis, or atypical genitalia should prompt consideration of a disorder/difference of sex development pathway.
Adult Presentation
Adults fall into two practical groups: uncorrected hypospadias and complications of prior repair.
Uncorrected Hypospadias
Many adults with uncorrected distal hypospadias are asymptomatic or well adapted. In one survey, 32% were unaware they had a congenital anomaly, only 5% expressed dissatisfaction with appearance, and 36% reported angulation or spraying, although only 5% sat to void.[8]
That older reassurance should be balanced against newer adult-centered observations: men with uncorrected hypospadias can be more bothered by genital difference, urinary spraying, sexual function, or penile appearance than early surgical series suggested.[9] Adult repair should therefore be driven by symptoms, anatomy, expectations, and tissue quality rather than by meatal position alone.
Complications of Childhood Repair
Adults after childhood repair most often present with voiding dysfunction, urethral stricture, fistula, recurrent infection, chordee, or dissatisfaction with genital appearance.[5][6]
| Presenting problem | Reported frequency / pattern | Reconstructive concern |
|---|---|---|
| Lower urinary tract symptoms | 49-82% | Often reflects stricture, diverticulum, hair-bearing neourethra, or bladder dysfunction |
| Spraying / split stream | ~24% | Meatal stenosis, glans dehiscence, irregular neomeatus, or distal stricture |
| Urethrocutaneous fistula | ~18% | Requires stricture exclusion before closure |
| Recurrent UTI | 15-19% | Look for obstruction, diverticulum, stones, hair, post-void residual, or catheterizable-channel issues |
| Residual chordee | ~14% | Requires erection assessment; may need staged straightening before urethral reconstruction |
| Cosmetic dissatisfaction | 4-16% | Must be separated from functional goals and realistic tissue constraints |
| Urethral stricture | 11-47% | Most common adult indication for hypospadias-related urethroplasty |
Childhood surgery changes the adult disease phenotype. Compared with unrepaired adults, previously operated patients have higher rates of urethral stricture, recurrent UTI, and LUTS, and their strictures are significantly longer in some series (5.5 cm vs 3.0 cm).[6] Lichen sclerosus / balanitis xerotica obliterans is also over-represented in adults with hypospadias who were not previously repaired in the Cleveland Clinic cohort.[5]
Adult Evaluation
Adult evaluation should document the current anatomy and the childhood operative history, but the exact childhood repair is often unknown. Ask specifically about number of operations, stents/catheters, fistula repairs, chordee repair, skin grafts/flaps, infections, urinary retention, and prior dilation or urethrotomy.
Core assessment:
- Penile examination - meatal location, glans configuration, skin quality, lichen sclerosus, hair-bearing skin, fistulae, scars, prior flap territories, ventral skin shortage, and penile length.
- Erection-time curvature - patient photographs, induced erection, or intracavernosal injection when operative correction is considered.
- Uroflowmetry and PVR - low plateau flow or elevated residual suggests obstruction.
- RUG / VCUG - defines stricture length, diverticulum, fistula, and proximal urethra.
- Cystourethroscopy - evaluates distal meatus, hair, stones, diverticulum, stricture caliber, and proximal urethra.
- Sonourethrography - useful when the extent of spongiofibrosis may exceed the fluoroscopic lumen, especially in post-hypospadias penile strictures.
- Urine culture - treat infection before reconstruction.
- Semen and endocrine assessment - appropriate in severe/proximal hypospadias, infertility concern, cryptorchidism history, or pubertal endocrine concerns.[10][11]
Urethral Stricture Management
Urethral stricture is the most common adult surgical indication after hypospadias repair. The AUA urethral stricture guideline emphasizes that penile urethral strictures have high recurrence after endoscopic treatment and that urethroplasty should be offered rather than repeated dilation or urethrotomy. Simple dilation or meatotomy for meatal/fossa disease is inappropriate when the narrowing is associated with prior hypospadias repair, lichen sclerosus, prior failed endoscopic manipulation, or prior urethroplasty.[12]
| Approach | Typical role | Reported outcome pattern |
|---|---|---|
| Two-stage urethroplasty | Complex redo hypospadias, long penile strictures, poor urethral plate, dense fibrosis, LS, hair-bearing neourethra, multiple prior operations | Commonly preferred; success ~76-90% in selected series, with failures increasing over longer follow-up[13][14][15] |
| One-stage substitution urethroplasty | Shorter, healthier strictures with usable plate and adequate vascularized coverage | Can be successful in selected patients, but patient selection is decisive[14][15] |
| Buccal mucosa graft | Preferred graft for staged or substitution repair | Lower recurrence than genital skin in many complex settings; avoids hair-bearing skin[13][16] |
| Perineal urethrostomy | Elderly patients, severe scarring, multiple failures, patient preference, or desire to avoid multistage penile reconstruction | Durable and rational salvage option, particularly when sexual/cosmetic goals do not justify repeated penile reconstruction[16] |
Key operative principles:
- Do not close a fistula until distal obstruction and stricture are excluded.
- Avoid anastomotic excision-and-primary-anastomosis for most penile post-hypospadias strictures; penile shortening, chordee, and recurrence risk are high, with poor outcomes reported in failed-hypospadias cohorts.[14]
- Remove hair-bearing urethra, stones, diverticula, and diseased plate when they drive infection or obstruction.
- Correct chordee before committing to urethral tubularization.
- Use well-vascularized coverage over suture lines: dartos, tunica vaginalis, local fascia, or staged open graft bed as anatomy allows.
- Counsel that "success" may require several operations and long follow-up.
Adult hypospadias repair can achieve outcomes comparable to pediatric repair when performed in experienced hands, but reoperation, proximal anatomy, and severe scarring increase complication risk.[17][18]
Sexual Function and Psychosexual Outcomes
Adult outcomes are heterogeneous because severity, number of operations, chordee, penile size, cosmesis, and partner experience all vary. Reported erectile dysfunction rates range widely, and sexual dissatisfaction is more common in proximal or multiply operated patients.[19][20][21][22]
| Domain | Pattern |
|---|---|
| Erections | Most men can have penetrative sex, but ED rates vary by series and severity |
| Ejaculation | Ejaculatory problems occur in a minority; spraying, dribbling, or altered force can be bothersome |
| Penile length / appearance | Proximal hypospadias is associated with greater concern about penile length and appearance |
| Physical contact | Some adolescents and adults with proximal hypospadias report uncertainty or avoidance around genital contact |
| Satisfaction with repair | Many men are satisfied with childhood repair, especially after uncomplicated surgery; multiple surgeries predict poorer psychosexual outcomes |
The practical adult consultation should address urinary goals, sexual goals, appearance goals, and the patient's own language for distress. Reconstructive options can improve obstruction and fistula, but they may not normalize penile size, glans shape, sensation, or lifelong body image.
Fertility and Endocrine Outcomes
Hypospadias can be part of a broader testicular dysgenesis phenotype. In a young adult cohort of nonsyndromic hypospadias, oligozoospermia or azoospermia occurred in 18.6%, with higher rates in complex hypospadias and in men born small for gestational age.[10] Population-level linkage studies also show reduced paternity among men born with genital anomalies, including hypospadias.[23]
Mechanisms may include impaired spermatogenesis, cryptorchidism, altered Leydig cell function, ejaculatory dysfunction, genital self-image, or reduced sexual opportunity. Young adults with severe hypospadias, cryptorchidism, or infertility concern should be offered semen analysis and endocrine evaluation rather than reassurance based only on successful childhood voiding reconstruction.[10][11]
Epispadias in Adults
Classification and Spectrum
Epispadias exists on a spectrum within the exstrophy-epispadias complex.[3][4][24]
| Condition | Severity | Approximate prevalence | Adult reconstructive burden |
|---|---|---|---|
| Isolated epispadias | Mildest | ~1 in 117,000 | Dorsal urethral reconstruction, chordee correction, and continence assessment |
| Classic bladder exstrophy | Intermediate | ~1 in 30,000 | Bladder closure, epispadias repair, bladder neck reconstruction, augmentation, catheterizable channel, renal surveillance |
| Cloacal exstrophy | Most severe | ~1 in 200,000 | Multisystem reconstruction involving GU, GI, abdominal wall, pelvic ring, and continence pathways |
Male epispadias is classified by the dorsal meatal location:[3][25]
- Glanular epispadias - meatus on the dorsal glans; mildest.
- Penile epispadias - meatus on the dorsal penile shaft.
- Penopubic / complete epispadias - entire dorsal urethra open to the pubic symphysis; highest continence burden.
Female epispadias is characterized by a bifid clitoris and patulous urethra; incontinence is common when the bladder neck and sphincteric mechanism are involved.[4]
Concealed epispadias is a rare variant with intact prepuce, later diagnosis, and generally milder anatomy than complete penopubic epispadias.[26]
Clinical Features
| Feature | Epispadias pattern | Adult implication |
|---|---|---|
| Meatus | Dorsal ectopic opening | Determines reconstruction type and continence risk |
| Curvature | Dorsal chordee | Can impair penetrative intercourse and require straightening |
| Penile morphology | Short, broad penis with dorsal urethral plate defect | Cosmetic and sexual goals should be discussed explicitly |
| Pelvis | Pubic diastasis in exstrophy spectrum | Affects continence mechanics and pelvic floor support |
| Bladder neck | Underdeveloped or surgically reconstructed | Drives continence, catheterization, and outlet obstruction risk |
| Female genitalia | Bifid clitoris and patulous urethra | Continence and sexual pain/function are central adult concerns |
Incontinence severity correlates with the degree of dorsal meatal displacement. Glanular and some penile epispadias patients may be continent or minimally incontinent, whereas penopubic epispadias has the highest risk because the sphincteric outlet is underdeveloped.[25][26][27]
Adult Evaluation
Adult epispadias and exstrophy evaluation should not stop at the genital exam. The reconstructive surgeon should establish the patient's complete urinary drainage anatomy, renal status, continence pathway, sexual function, and prior operations.
Core assessment:
- Operative history - bladder closure, pelvic osteotomy, epispadias repair, bladder neck reconstruction, augmentation cystoplasty, bladder neck closure, continent catheterizable channel, ureteral reimplant, stones, revisions.
- Voiding / catheterization pattern - urethral voiding, clean intermittent catheterization, Mitrofanoff/Monti use, stomal leakage, channel stenosis, recurrent UTI, mucus, stones.
- Continence phenotype - daytime, nocturnal, stress-related, urgency-related, overflow, or stomal leakage.
- Renal surveillance - serum creatinine/eGFR, renal ultrasound, hydronephrosis, recurrent pyelonephritis, stones.
- Urodynamics - capacity, compliance, detrusor overactivity, outlet resistance, leak point, and safety of storage pressures.
- Sexual and fertility history - erections, curvature, ejaculation, vaginal/introitus pain, pregnancy goals, assisted reproduction history.
Long-Term Urological Outcomes
Adult EEC outcomes are diverse because childhood surgical strategies vary. Continence may be achieved through urethral voiding, bladder neck reconstruction, augmentation, or bladder neck closure with a catheterizable channel.
| Reconstruction pathway | Continence pattern |
|---|---|
| Bladder neck reconstruction alone | Social continence in many series, but durability and catheterization needs vary[27][28] |
| BNR + augmentation cystoplasty | Used when capacity/compliance is inadequate; increases need for mucus/stone/channel surveillance[28] |
| Bladder neck closure + continent catheterizable stoma | High continence rates in selected patients but creates lifelong channel and reservoir management needs[29] |
| Isolated glanular/penile epispadias without bladder neck surgery | Many achieve daytime continence, sometimes with pelvic floor therapy rather than bladder neck surgery[30] |
In contemporary adult classic bladder exstrophy cohorts, only a minority void spontaneously per urethra without catheterization, and many adults perform clean intermittent self-catheterization.[29][31] Continence can continue to improve during puberty; one series found that 46% of previously incontinent patients became continent after age 10 without major additional surgery.[32]
Lower urinary tract symptoms are common and often underrecognized without questionnaires. In one adult EEC cohort, 80% reported moderate or severe LUTS, involving both storage and voiding domains.[33]
Renal surveillance is essential. Adults with EEC presenting to adult urology clinics have substantial rates of CKD stage II or higher, hydronephrosis, and poor or intermediate bladder compliance on urodynamics.[34]
Sexual Function and Fertility
Adults with complete male epispadias can often achieve satisfactory sexual intercourse, but abnormal ejaculation, diminished sensation, erectile-maintenance difficulty, penile curvature, and body-image concerns are common enough to require direct questioning.[35][36]
| Domain | Reported pattern |
|---|---|
| Satisfactory intercourse | Approximately 79-80% in complete male epispadias series |
| Sexual activity | High among pubertal/post-pubertal men; lower but substantial among women in EEC cohorts |
| Ejaculation | Abnormal ejaculation reported in roughly one-third to one-half of men |
| Erectile function | Some men report diminished sensation or difficulty maintaining erections |
| Fertility | A meaningful proportion of men father children; some require assisted reproduction |
| Women with EEC | Fertility is achievable; pregnancy requires coordinated adult reconstructive, obstetric, and pelvic floor care |
Quality-of-life scores in adult EEC cohorts can be comparable to the general population despite high surgical burden, although sexual pain domains in women and urinary symptom burden remain important.[37]
Surgical Management in Adults
Epispadias repair aims to place the meatus in an anatomic position, correct dorsal curvature, reconstruct functional genitalia, and preserve or improve continence. The two classic male epispadias repair families are the modified Cantwell-Ransley and Mitchell-Bagli approaches.[3]
Adult operations are usually individualized salvage or completion procedures:
- Residual dorsal chordee correction - straightening before urethral or sexual reconstruction.
- Redo urethral reconstruction - repair of dehiscence, stenosis, fistula, or unsatisfactory meatal position.
- Bladder neck reconstruction - when continence can reasonably be achieved through the urethra.
- Augmentation cystoplasty - when capacity or compliance is unsafe or inadequate.
- Bladder neck closure with continent catheterizable channel - when outlet continence cannot be salvaged or urethral voiding is not realistic.
- Channel revision - stenosis, false passage, leakage, stones, or catheterization difficulty.
- Introitoplasty / genital reconstruction - selected women with obstructive introitus, sexual pain, or genital functional concerns.
Combined bladder neck reconstruction and epispadias repair has been used in selected patients to reduce staged operative burden, with complete continence reported in a majority in early series.[38]
Hypospadias vs Epispadias
| Feature | Hypospadias | Epispadias |
|---|---|---|
| Urethral opening | Ventral / undersurface | Dorsal / upper surface |
| Penile curvature | Ventral chordee | Dorsal chordee |
| Foreskin / skin pattern | Dorsally hooded foreskin, ventral skin deficiency | Ventral preputial deficiency or dorsal urethral plate defect |
| Incidence | Common: ~1 in 200-300 live male births | Rare: isolated epispadias ~1 in 117,000 |
| Incontinence | Rare unless obstruction/repair complication | Common in penopubic epispadias and exstrophy spectrum |
| Associated anomalies | Cryptorchidism, DSD concern in severe proximal cases | Bladder exstrophy, pubic diastasis, pelvic-floor and bladder-neck abnormalities |
| Adult reconstructive problem | Stricture, fistula, chordee, hair-bearing neourethra, sexual/fertility concerns | Incontinence, catheterizable-channel issues, renal dysfunction, sexual/fertility concerns |
Key Recommendations for Adult Management
Hypospadias
- Follow patients with significant childhood hypospadias repair into adulthood; late stricture, fistula, chordee, LUTS, and sexual concerns may present decades later.[6]
- Treat post-hypospadias penile strictures as reconstructive problems, not as dilation problems.[12]
- Prefer buccal mucosa grafting and staged reconstruction when tissue quality, stricture length, lichen sclerosus, hair, diverticulum, or multiple prior operations make one-stage repair unsafe.[13][14][16]
- Discuss perineal urethrostomy early in patients with severe scarring, multiple failures, older age, or preference to avoid prolonged multistage penile reconstruction.
- Offer semen analysis and endocrine evaluation for severe/proximal hypospadias, cryptorchidism history, infertility concern, or pubertal endocrine abnormalities.[10][11]
Epispadias / Exstrophy
- Transition to adult urology should include urinary, sexual, fertility, renal, catheterization, and psychosocial review, not just a genital examination.
- Monitor renal function and upper tracts long term; CKD, hydronephrosis, stones, and poor compliance are common adult issues.[34]
- Define the continence pathway anatomically: urethral voiding, BNR, augmentation, bladder neck closure, catheterizable channel, or urinary diversion.
- Use urodynamics liberally when continence, upper-tract dilation, recurrent UTI, catheterization difficulty, or augmentation safety is unclear.
- Ask directly about sexual function and fertility; many adults have functional sexual lives, but ejaculation, sensation, curvature, pain, and reproductive assistance may matter more than spontaneous reporting suggests.[35][36]
References
1. van der Horst HJ, de Wall LL. "Hypospadias, All There Is to Know." Eur J Pediatr. 2017;176(4):435-441. doi:10.1007/s00431-017-2864-5
2. Upasani A, Desai D, Mushtaq I, et al. "Penis and Urethra and Prostate Congenital Anomalies." In: Pediatric Urology; Chapter 30.
3. Frimberger D. "Diagnosis and Management of Epispadias." Semin Pediatr Surg. 2011;20(2):85-90. doi:10.1053/j.sempedsurg.2011.01.003
4. Ebert AK, Reutter H, Ludwig M, Rosch WH. "The Exstrophy-Epispadias Complex." Orphanet J Rare Dis. 2009;4:23. doi:10.1186/1750-1172-4-23
5. Ching CB, Wood HM, Ross JH, Gao T, Angermeier KW. "The Cleveland Clinic Experience With Adult Hypospadias Patients Undergoing Repair: Their Presentation and a New Classification System." BJU Int. 2011;107(7):1142-1146. doi:10.1111/j.1464-410X.2010.09693.x
6. Hoy NY, Rourke KF. "Better Defining the Spectrum of Adult Hypospadias: Examining the Effect of Childhood Surgery on Adult Presentation." Urology. 2017;99:281-286. doi:10.1016/j.urology.2016.07.057
7. Yuan S, Meng L, Zhang Y, et al. "Genotype-Phenotype Correlation and Identification of Two Novel SRD5A2 Mutations in 33 Chinese Patients With Hypospadias." Steroids. 2017;125:61-66. doi:10.1016/j.steroids.2017.06.010
8. Dodds PR, Batter SJ, Shield DE, et al. "Adaptation of Adults to Uncorrected Hypospadias." Urology. 2008;71(4):682-685. doi:10.1016/j.urology.2007.07.078
9. Snodgrass W, Bush N. "What Adults Teach Urologists About Hypospadias." Urol Clin North Am. 2023;50(3):447-453. doi:10.1016/j.ucl.2023.04.005
10. Tack LJW, Spinoit AF, Hoebeke P, et al. "Endocrine Outcome and Seminal Parameters in Young Adult Men Born With Hypospadias: A Cross-Sectional Cohort Study." EBioMedicine. 2022;81:104119. doi:10.1016/j.ebiom.2022.104119
11. Moriya K, Mitsui T, Tanaka H, Nakamura M, Nonomura K. "Long-Term Outcome of Pituitary-Gonadal Axis and Gonadal Growth in Patients With Hypospadias at Puberty." J Urol. 2010;184(4 Suppl):1610-1614. doi:10.1016/j.juro.2010.04.022
12. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. "Urethral Stricture Disease Guideline Amendment (2023)." J Urol. 2023;210(1):64-71. doi:10.1097/JU.0000000000003482
13. Morrison CD, Cina DP, Gonzalez CM, Hofer MD. "Surgical Approaches and Long-Term Outcomes in Adults With Complex Reoperative Hypospadias Repair." J Urol. 2018;199(5):1296-1301. doi:10.1016/j.juro.2017.11.078
14. Verla W, Van Nieuwenhuyse F, Hoebeke P, et al. "Urethroplasty for Failed Hypospadias Repair Related Strictures in Adults: A Retrospective Analysis With Long-Term Follow-Up." Urology. 2020;143:248-254. doi:10.1016/j.urology.2020.05.070
15. Horiguchi A, Asanuma H, Shinchi M, et al. "Efficacy of Urethral Reconstruction for Urethral Stricture Associated With Hypospadias Surgery in Adults." Int J Urol. 2022;29(12):1470-1475. doi:10.1111/iju.15015
16. Snodgrass WT, Bush NC. "Management of Urethral Strictures After Hypospadias Repair." Urol Clin North Am. 2017;44(1):105-111. doi:10.1016/j.ucl.2016.08.014
17. Snodgrass W, Villanueva C, Bush N. "Primary and Reoperative Hypospadias Repair in Adults--Are Results Different Than in Children?" J Urol. 2014;192(6):1730-1733. doi:10.1016/j.juro.2014.07.012
18. Aldamanhori RB, Osman NI, Inman RD, Chapple CR. "Contemporary Outcomes of Hypospadias Retrieval Surgery in Adults." BJU Int. 2018;122(4):673-679. doi:10.1111/bju.14355
19. Effendi R, Situmorang GR, Wahyudi I, et al. "Adult Sexual Function Following Hypospadias Repair in Childhood: A Systematic Review and Meta-Analysis of Long-Term Patient Outcomes." Urology. 2025;S0090-4295(25)00471-6. doi:10.1016/j.urology.2025.05.015
20. Andersson M, Sjostrom S, Wangqvist M, et al. "Psychosocial and Sexual Outcomes in Adolescents Following Surgery for Proximal Hypospadias in Childhood." J Urol. 2018;200(6):1362-1370. doi:10.1016/j.juro.2018.06.032
21. Tack LJW, Springer A, Riedl S, et al. "Psychosexual Outcome, Sexual Function, and Long-Term Satisfaction of Adolescent and Young Adult Men After Childhood Hypospadias Repair." J Sex Med. 2020;17(9):1665-1675. doi:10.1016/j.jsxm.2020.04.002
22. Chertin B, Natsheh A, Ben-Zion I, et al. "Objective and Subjective Sexual Outcomes in Adult Patients After Hypospadias Repair Performed in Childhood." J Urol. 2013;190(4 Suppl):1556-1560. doi:10.1016/j.juro.2012.12.104
23. Schneuer FJ, Milne E, Jamieson SE, et al. "Association Between Male Genital Anomalies and Adult Male Reproductive Disorders: A Population-Based Data Linkage Study Spanning More Than 40 Years." Lancet Child Adolesc Health. 2018;2(10):736-743. doi:10.1016/S2352-4642(18)30254-2
24. Lee T, Borer J. "Exstrophy-Epispadias Complex." Urol Clin North Am. 2023;50(3):403-414. doi:10.1016/j.ucl.2023.04.004
25. Spinoit AF, Claeys T, Bruneel E, et al. "Isolated Male Epispadias: Anatomic Functional Restoration Is the Primary Goal." Biomed Res Int. 2016;2016:6983109. doi:10.1155/2016/6983109
26. Li JY, Yu B, Yang MC, et al. "Comparative Analysis of Isolated Male Epispadias: Concealed Versus Nonconcealed Cases in a Chinese Tertiary Hospital." Asian J Androl. 2025;27(4):502-507. doi:10.4103/aja2024114
27. McMahon DR, Cain MP, Husmann DA, Kramer SA. "Vesical Neck Reconstruction in Patients With the Exstrophy-Epispadias Complex." J Urol. 1996;155(4):1411-1413.
28. Maruf M, Manyevitch R, Michaud J, et al. "Urinary Continence Outcomes in Classic Bladder Exstrophy: A Long-Term Perspective." J Urol. 2020;203(1):200-205. doi:10.1097/JU.0000000000000505
29. Abdellaoui S, Cazzorla F, Morel-Journel N, et al. "Long-Term Urinary Outcomes in Classic Bladder Exstrophy: Results of an Extensive Follow-Up." BJU Int. 2025;135(6):1018-1024. doi:10.1111/bju.16680
30. Mariotto A, Keene DJ, Alshafei AR, et al. "Bladder Neck Surgery Is Not Routinely Needed to Achieve Urinary Continence in Patients With Primary Epispadias." J Pediatr Surg. 2024;59(6):1182-1185. doi:10.1016/j.jpedsurg.2023.12.017
31. Zhu X, Klijn AJ, de Kort LMO. "Urological, Sexual, and Quality of Life Evaluation of Adult Patients With Exstrophy-Epispadias Complex: Long-Term Results From a Dutch Cohort." Urology. 2020;136:272-277. doi:10.1016/j.urology.2019.10.011
32. Taskinen S, Suominen J, Makela E. "Development of Late Continence in Bladder Exstrophy and Epispadias Patients." Urology. 2020;144:194-197. doi:10.1016/j.urology.2020.06.034
33. Taskinen S, Suominen JS. "Lower Urinary Tract Symptoms (LUTS) in Patients in Adulthood With Bladder Exstrophy and Epispadias." BJU Int. 2013;111(7):1124-1129. doi:10.1111/j.1464-410X.2012.11756.x
34. Handa N, Bowen DK, Guo J, Chu DI, Kielb SJ. "Long-Term Kidney Outcomes in Exstrophy-Epispadias Complex: How Patients Present as Adults." Urology. 2021;154:333-337. doi:10.1016/j.urology.2021.01.033
35. Reddy SS, Inouye BM, Anele UA, et al. "Sexual Health Outcomes in Adults With Complete Male Epispadias." J Urol. 2015;194(4):1091-1095. doi:10.1016/j.juro.2015.04.082
36. Sinatti C, Waterschoot M, Roth J, et al. "Long-Term Sexual Outcomes in Patients With Exstrophy-Epispadias Complex." Int J Impot Res. 2021;33(2):164-169. doi:10.1038/s41443-020-0248-2
37. Spinoit AF, Waterschoot M, Sinatti C, et al. "Fertility and Sexuality Issues in Congenital Lifelong Urology Patients: Male Aspects." World J Urol. 2021;39(4):1013-1019. doi:10.1007/s00345-020-03121-2
38. Surer I, Baker LA, Jeffs RD, Gearhart JP. "Combined Bladder Neck Reconstruction and Epispadias Repair for Exstrophy-Epispadias Complex." J Urol. 2001;165(6 Pt 2):2425-2427. doi:10.1016/S0022-5347(05)66220-9