Hypospadias is characterized by an abnormality in location and configuration of the urethral meatus and surrounding urethral spongiosum (Fig. 98.1). The urethral meatus may be ventrally placed just below a blind dimple at the normal meatal opening on the glans or so far back in the perineum that it appears as a “vaginal” hypospadias. Most patients present with the urethral meatus on the glans penis, coronal margin, or distal aspect of the glans. The configuration of the meatus may vary in form, diameter, elasticity, and rigidity. It can be fissured in both transverse and longitudinal directions or can be covered with delicate skin secondary to associated atresia of the supporting urethral spongiosum. In the case of the megameatus intact prepuce, the distal urethra is enlarged, tapering to a normal caliber in the penile shaft. Often, there is an orifice of a periurethral duct located along the urethral plate distal to the meatus that courses dorsal to the urethral channel for a short distance. It is blind ending and does not communicate in any way with the urinary stream. The periurethral duct corresponds with Guérin sinus or Morgagni lacunae. Unless these ducts are inadvertently closed, leading to a blind ending epithelial pouch, they are of no clinical consequence.

The skin of the penis is changed as a result of the disturbance in the formation of the urethra. Prepuce formation is aborted distal to the abnormal meatus with excess dorsal foreskin. Proximal to the meatus, there is often a paucity of ventral skin, which may contribute to penile curvature. The frenulum is
always absent in hypospadias. Vestiges of a frenulum are sometimes found inserting on either side of the open navicular fossa.

The skin proximal to the urethral meatus may be extremely thin, so much so that a catheter or probe passed proximally is readily apparent through a tissue paper thickness of skin.

The urethral plate defined as a rectangular segment of tissue from the abortive hypospadias urethral meatus to the glandular groove is often well developed. Even with a meatus quite proximal on the shaft, this normal urethral plate is quite elastic and typically nontethering. After degloving the penile shaft skin, artificial erection demonstrates no ventral curvature in these situations. A normal urethral plate may be incorporated into the surgical repair. However, in the rare severe case of hypospadias if the urethral plate is underdeveloped, it will act as a tethering fibrous band that bends the penis ventrally during artificial erection. When this fibrous chordee tissue is divided, the penile curvature will frequently improve.

Normally, the penis should develop in a cranial position above the two genital swellings. The penis may be caught between the two scrotal halves and become engulfed with fusion of the penoscrotal area resulting in penile scrotal transposition.

The curvature of the penis is caused by deficiency of the normal structures, most commonly on the ventral side of the penis. It has been labeled chordee; however, this term implies a strand of connective tissue stretched like a cord between the meatus and glans, which is rarely found in practice. Penile curvature can be from skin deficiency, a true fibrous chordee with tethering of the ventral shaft, or deficiency of the corpora cavernosa on the concave side of the penis (3).

There are occasional reports of other penile anomalies that represent variations of the embryologic defect causing hypospadias. They can be characterized as a defect in the course of the urethra such as congenital urethral fistula and a group characterized by curvature of the penis without hypospadias or so-called chordee without hypospadias.