title: Appraisal of adult genitalia after hypospadias repair: Do laypersons mind the difference?
abstract: BACKGROUND
  Men with corrected hypospadias often suffer from sexual inhibition and fear of being ridiculed by others because of their penile appearance. However, no investigation has thus far been made of the perception of hypospadias-affected surgically repaired genitals by laypersons unacquainted with hypospadias. Therefore, the aim of this study was to find out whether laypersons notice a difference between genitals of men with corrected hypospadias in comparison with circumcised genitals. Furthermore, the most relevant predictors of laypersons' perception of hypospadias-affected genitals were examined.
  
  
  METHODS
  A cross-sectional study was performed in which a questionnaire with 10 standardized photographs of non-erect hypospadias-affected genitals and 10 circumcised genitals was presented to laypersons unacquainted with hypospadias to measure how they rated these genitals. Laypersons were 105 women and 70 men of three different age groups (age ranges 16-20, 25-30, and 40-45 years). Furthermore, laypersons were asked about demographic characteristics, their sexuality and their genital self-perception.
  
  
  RESULTS
  The results showed that genitals with distal forms of hypospadias were rated similarly to circumcised genitals. In contrast, genitals with more proximal types were perceived as significantly less positive than circumcised genitals. However, the effect size was small. Higher age, being in an intimate relationship, higher socio-economic status, and a higher sexual interest predicted a better layperson's perception of hypospadias-affected genitals.
  
  
  CONCLUSIONS
  These findings do not support the fear of some men with corrected hypospadias of being ridiculed by others because of their penile appearance. The results indicate that laypersons do not notice a difference between corrected distal types of hypospadias (which represent the majority of hypospadias) and circumcised genitals. Although the findings showed that laypersons perceive more proximal forms of hypospadias less positively than circumcised genitals, the difference does not appear to be clinically relevant as the effect size was small. A major strength of this study is its comprehensive study design. However, the low response rate of hypospadias patients and control individuals for photo documentation and of laypersons who rated these photosets is a limitation of the study. Therefore, generalization from the results must be made carefully.
  
  
  CONCLUSIONS
  The results are relevant for patient counseling. Knowing that the penile appearance would not trouble laypersons may prevent the development of a negative genital self-perception and feelings of shame. The findings also suggest that hypospadias-affected genitals seem to be rated more positively when laypersons know more about the "normal" variation of penile appearance (e.g. with increasing sexual experience at a higher age).
authors.affiliation: Division of Pediatric Urology, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland. Electronic address: Norma.Ruppen@kispi.uzh.ch.
authors.forename: Norma K
authors.initials: NK
authors.lastname: Ruppen-Greeff
authors.affiliation: Department of Psychosomatics and Psychiatry, University Children's Hospital Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; Department of Psychology, University of Zurich, Zurich, Switzerland.
authors.forename: Markus A
authors.initials: MA
authors.lastname: Landolt
authors.affiliation: Division of Pediatric Urology, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.
authors.forename: Rita
authors.initials: R
authors.lastname: Gobet
authors.affiliation: Division of Pediatric Urology, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Weber
mesh_terms: D000293:Adolescent; D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007021:Hypospadias / Q000523:psychology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D010413:Penis / Q000033:anatomy & histology*; D010465:Perception; D012649:Self Concept; D012725:Sexual Behavior; D019529:Sexuality / Q000523:psychology*; D011795:Surveys and Questionnaires; D055815:Young Adult
keywords: Genital appearance; Genital perception; Hypospadias; Patient outcome assessment; Sexuality