Once the diagnosis of hypospadias has been given, this is usually the first question that comes to mind. Is my son's case a severe one?
The short answer is that it is not decided by where the opening lies. Here is why, and what is actually looked at instead.
The usual categories
Cases are normally grouped by where the opening sits: distal if it is near the glans, midshaft if it is along the shaft, proximal if it is back toward the scrotum. It is true that the more proximal it is, the larger the operation.
Even so, the European paediatric urology guideline states that meatal position alone does not always determine severity. Two distal cases can differ considerably in how difficult the repair is and how it must be planned.
Three things are actually assessed
First, how much the penis is bent. This matters most. The degree of bending decides whether the repair is done in one operation or two, and by which method the penis is straightened.
Second, the tissue available to build the urethra. A shallow groove runs from the opening to the tip of the glans, and whether it is wide and healthy or narrow and flat changes the surgical approach.
Third, the size and shape of the glans. A small, flat glans makes the reconstruction more demanding.
The position of the opening is then added to these. In other words, position is only one of four.
The item shown to be associated with complications after surgery was the degree of bending. The position of the opening did not retain an independent association once the other factors were taken into account. And the bend is also the one problem that can persist into adulthood.
The accurate judgement happens during surgery
This is the part parents find frustrating. The degree of bending cannot be established accurately by looking before the operation. A child's penis is small, and in the ordinary state a bend often does not show.
So during the operation an erection is produced artificially and the angle is checked. Releasing the skin alone straightens a good deal of the milder bending, so the final plan is only settled after this check.
If you were told before surgery that "we will know exactly once we are in there," that is not evasion — it is simply how it is.
Severe does not mean the result will be poor
Severity is a guide to how complex the operation will be and whether it needs to be staged, not a prediction of the result. Many boys with proximal hypospadias do well when the plan is set out properly and the repair carried through.
Conversely, a case that looks mild can cause trouble years later if the bend was not dealt with. What matters is not the grade but what was corrected, and how.
Worth asking in the consulting room
"Is my son's penis bent? How much?"
"How will that bend be corrected in this operation?"
"Will it be done in one operation or two? If two, why?"
These are more useful than asking for a grade or a score, because they bring out what the problem actually is for your son and how it will be handled.
What hypospadias surgery is correcting, and what is worth knowing before it, is set out in the main hypospadias guide.
The evidence behind severity assessment, the GMS score, and the problem of outcome reporting are covered for clinicians.
Part 3 — "Is my son's case severe?" Matching severity
Part 1 — What are we aiming at?
Part 2 — What counts as a good result?
Written for clinicians.
References
- EAU Guidelines on Paediatric Urology. Hypospadias. European Association of Urology, 2026.
- Arlen AM, Kirsch AJ, Leong T, Broecker BH, Smith EA, Elmore JM. Further analysis of the Glans-Urethral Meatus-Shaft (GMS) hypospadias score: correlation with postoperative complications. J Pediatr Urol. 2015;11(2):71.e1-71.e5.