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Journal of Indian Association of Pediatric Surgeons
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Year : 2022  |  Volume : 27  |  Issue : 5  |  Page : 585-587

Correlation between glans, meatus, shaft score, and penile perception after hypospadias repair

Department of Surgery, Division of Pediatric Surgery, Faculty of Medicine, Padjadjaran University, RSUP Dr. Hasan Sadikin, Bandung, Indonesia

Date of Submission24-Nov-2021
Date of Acceptance26-Nov-2021
Date of Web Publication09-Sep-2022

Correspondence Address:
Patricia Oktaviani Alimoeddin
RSUP Dr. Hasan Sadikin, Jl. Pasteur No. 38, Bandung 40161
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaps.jiaps_231_21

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Aims: The aim is to analyze the correlation between the degree of hypospadias based on the Glans-Urethral Meatus-Shaft (GMS) score and penile perception after hypospadias repair using pediatric penile perception score (PPPS).
Settings and Design: Analytic observational study with a cross-sectional design.
Subjects and Methods: Thirty-two children with hypospadias were included in this study. The severity of hypospadias was assessed using GMS score. Postoperatively, PPPS was rated by two external pediatric surgeons.
Statistical Analysis Used: Correlation between GMS score and PPPS were analyzed using the Spearman test, P ≤ 0.05: Significant.
Results: Mean-GMS was 8.69 ± 2.303 (mean-G 2.67 ± 0.858, mean-M 3.27 ± 0.942, mean-S 2.75 ± 1.055). Mean-PPPS was 10.19 ± 1.287. GMS score and PPPS had a very weak correlation (r = −0.227; P > 0.05).
Conclusions: There was no correlation between GMS score and penile perception according to PPPS after hypospadias repair.

Keywords: Glans, meatus, shaft score, hypospadias, pediatric penile perception score, penile perception

How to cite this article:
Indriasari V, Alimoeddin PO, Pamungkas KO. Correlation between glans, meatus, shaft score, and penile perception after hypospadias repair. J Indian Assoc Pediatr Surg 2022;27:585-7

How to cite this URL:
Indriasari V, Alimoeddin PO, Pamungkas KO. Correlation between glans, meatus, shaft score, and penile perception after hypospadias repair. J Indian Assoc Pediatr Surg [serial online] 2022 [cited 2022 Oct 3];27:585-7. Available from: https://www.jiaps.com/text.asp?2022/27/5/585/355793

   Introduction Top

Hypospadias is a common congenital disorder with a prevalence of 1 in 200–300 male births.[1] Despite many improvements in hypospadias repair, low self-esteem and negative genital perception are still major issues felt by patients.[2] The severity of hypospadias is thought to be one of the factors that affect penile perception.[3],[4]

To date, there is no universal definition of severe hypospadias. Location of the urethral meatus, degree of curvature, and urethral plate quality are among determinants.[5],[6],[7] Merriman developed Glans-Urethral Meatus-Shaft (GMS) score to assess hypospadias degree based on the quality of glans, meatus, and penile shaft.[6],[7] Pediatric penile perception score (PPPS) is an objective scoring system focussed on evaluating penile perception after hypospadias repair.[1]

The aim of this study is to analyze the correlation between GMS score and postoperative penile perception according to PPPS in children with hypospadias.

   Subjects and Methods Top

Ethical approval for this study was obtained from Medical Research Ethics Committee Dr. Hasan Sadikin General Hospital. All patients who completed their hypospadias repair for more than 6 months were included in this study. Preoperative GMS scores were recorded from the medical record. It consists of glans size and urethral plate quality (G), meatal location (M), and degree of curvature (S). Each of the three components is scored from one until four, with more unfavorable characteristics being assigned higher values with the lowest score of three and the highest of 12.

During the COVID-19 pandemic, routine long-term follow-up was done online by short messages and video calls. Standardized penile photographs (oblique, lateral, anteroposterior with the penis held against the abdominal wall and anteroposterior with the penis held up straight positions) were taken. The penile perception was evaluated by two external pediatric surgeons using the PPPS based on those photos. PPPS consist of four questions including meatal position and shape, the shape of glans, shape of penile skin, and general cosmetic appearance. The perception was rated into four scales from very dissatisfied (one), dissatisfied (two), satisfied (three), and very satisfied (four), with four being the lowest (most dissatisfied) and 16 the highest (most satisfied).

Correlation of GMS score and PPPS were analyzed using spearman test, P ≤ 0.05 considered significant.

   Results Top

Thirty-two children with hypospadias were included in this study. The mean age at surgery was 5.06 ± 3.350 years (range 1–14 years). The mean GMS score of the patient was 8.69 ± 2.303 (G, M, S scores were 2.67 ± 0.858, 3.27 ± 0.942, 2.75 ± 1.055, respectively). The mean PPPS of the patients assessed by both surgeons was 10.19 ± 1.287.

The correlation between GMS score and PPPS is described in [Table 1], which shows no correlation either between the mean GMS score and PPPS, as well as the G, M, S individual components and the PPPS.
Table 1: Correlation between glans, meatus, shaft score, and pediatric penile perception score

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   Discussion Top

Hypospadias patients in this study had older age compared to other studies which were usually aged 6–15 months at the surgery.[6],[8] The late presentation was maybe caused by socioeconomic problems, access difficulties to our provincial referral hospital which cover wide geographic region, and health insurance problems. However, Weber et al. in their study showed that there was no difference in penile perception between patients who underwent repair before 18 months old and older.[9]

GMS score is a concise method for describing the severity of hypospadias. The mean GMS score in this study was high (8.69 ± 2.303), as well as the three aspects of the score (Glans-Urethral Meatus-Shaft quality). This indicates the severe form of hypospadias in our patients. Our patients also had higher degree of hypospadias according to GMS score compared to Meriman et al. and Arlen et al. studies (mean GMS scores were 6.2 and 7 ± 2.5).

To our knowledge, this is the first study to analyze the possible correlation between GMS score and postoperative penile perception. However, prior studies found that proximal hypospadias was associated with poor penile perception due to less successful cosmetic results compared to distal ones.[10] Patients with severe hypospadias also tend to have smaller glans diameters. Bush and Snodgrass in their study found that glans width <14 mm was associated with postoperative complications.[11] Indeed, reoperative surgery will be associated with poor penile perception. Patients with proximal hypospadias also tend to have shorter penis and more severe curvature.[12],[13] Incomplete penile straightening and residual curvature will cause severe psychological problems.[10],[14]

Weber et al. developed PPPS, an instrument to evaluate the penile perception of patients, parents, and surgeons.[1] The evaluation usually was conducted at the clinic through a questionnaire filling and direct interview with parents and patients. However, regular long-term follows up after hypospadias repair is still a problems, especially during the COVID-19 pandemic. We developed an online follow-up through short messages and video calls to obtain the evaluation. In this study, the PPPS was rated by the pediatric surgeons to assess penile perception from surgeons' sight, as they mastered the anatomical anomaly of hypospadias and had certain expectations of postoperative features after hypospadias correction.

In this study, we found no correlation between the mean GMS score and mean PPPS. This finding was not in accordance with prior studies mentioned before in which the degree of hypospadias (based on meatal location) was associated with penile perception. Rynja et al. also found that patients with severe hypospadias had a worse penile perception than the control group.[15] However, Webber et al. in their study found that there was no significant correlation between PPPS and the severity of hypospadias.

In this study, the glans and urethral plate aspect (G) of the GMS score was not correlated with the mean PPPS. It was in accordance with Ke et al. study which showed that the size of the urethral plate did not affect the cosmetic outcome of hypospadias patients.[16] Da Silva also found that penile shape and the quality and size of the urethral plate did not affect the postoperative outcome of hypospadias.[17]

The meatus aspect (M) was also not correlated with mean PPPS. This result was in contrast to Liu et al., who concluded that the severity of hypospadias was associated with PPPS based on the location of the preoperative meatus.[18] Keays et al. stated that most patients whose surgery was successful had a preoperative condition that was categorized as distal hypospadias.[19] However, the study of Arlen et al. stated that meatus location alone was not statistically significant in relation to postoperative outcome.[20] Rynja et al. also stated that patients with distal and proximal hypospadias had the same level of satisfaction measured using PPPS.[15]

Insignificant correlation also found between the shaft aspect of the GMS score (S) and mean PPPS. Arlen et al. stated that shaft is the only aspect that has a statistical effect on the output, so it can be concluded that the greater the penis curvature will increase the risk of complications.[20] Menon in his journal also said that men with a penile curvature of at least 20°, experienced dissatisfaction with the appearance of their penis.[21] In this study, although the shaft score was poor, the PPPS was not poor. This was probably because one of the goals of hypospadias management, which is to form a straight penis was already achieved. The penile straightening and lengthening were completed so that recurrent curvature could be prevented.

Although our patients had severe hypospadias according to GMS score, but the mean PPPS was moderate. This shows that in these patients, postoperative penile perception is not always poor, and genital satisfaction may be achieved by implementing good technical and perioperative care.

This study has some limitations. The patients and parents PPPS had not been assessed. Clinical pictures were taken online, although they meet the standards for assessment, some had poor quality. The correlation of the GMS score and the six specific aspects of PPPS also had not been assessed individually. In conclusion, there was no correlation between GMS score and postoperative penile perception according to PPPS in children with hypospadias.


We thank all staff members for their assistance during the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Weber DM, Schönbucher VB, Landolt MA, Gobet R. The Pediatric Penile Perception Score: An instrument for patient self-assessment and surgeon evaluation after hypospadias repair. J Urol 2008;180:1080-4.  Back to cited text no. 1
Hoag CC, Gotto GT, Morrison KB, Coleman GU, Macneily AE. Long-term functional outcome and satisfaction of patients with hypospadias repaired in childhood. Can Urol Assoc J 2008;2:23-31.  Back to cited text no. 2
Mouriquand PD, Gorduza DB, Noché ME, Targnion A. Long-term outcome of hypospadias surgery: Current dilemmas. Curr Opin Urol 2011;21:465-9.  Back to cited text no. 3
Jiao C, Wu R, Xu X, Yu Q. Long-term outcome of penile appearance and sexual function after hypospadias repairs: Situation and relation. Int Urol Nephrol 2011;43:47-54.  Back to cited text no. 4
Snodgrass W, Macedo A, Hoebeke P, Mouriquand PD. Hypospadias dilemmas: A round table. J Pediatr Urol 2011;7:145-57.  Back to cited text no. 5
Hadidi AT. Classification of hypospadias. In: Hadidi AT, Azmy AF, editors. Hypospadias Surgery – An Illustrated Guide. 1st ed. New York: Springer; 2004. p. 79-82.  Back to cited text no. 6
Merriman LS, Arlen AM, Broecker BH, Smith EA, Kirsch AJ, Elmore JM. The GMS hypospadias score: Assessment of inter-observer reliability and correlation with post-operative complications. J Pediatr Urol 2013;9:707-12.  Back to cited text no. 7
Long CJ, Zaontz MR, Canning DA. Hypospadias. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, editors. Campbell-Walsh-Wein Urology. 12th ed. Philadelphia: Elsevier; 2021. p. 4042.  Back to cited text no. 8
Weber DM, Schonbucher VB, Gobet R, Gerber A, Landolt MA. Is there an ideal age for hypospadias repair? A pilot study. J Pediatr Urol 2009;5:345-50.  Back to cited text no. 9
Long CJ, Canning DA. Hypospadias: Are we as good as we think when we correct proximal hypospadias? J Pediatr Urol 2016;12:196.e1-5.  Back to cited text no. 10
Bush NC, Villanueva C, Snodgrass W. Glans size is an independent risk factor for urethroplasty complications after hypospadias repair. J Pediatr Urol 2015;11:355.e1-5.  Back to cited text no. 11
Mureau MA, Slijper FM, van der Meulen JC, Verhulst FC, Slob AK. Psychosexual adjustment of men who underwent hypospadias repair: A norm-related study. J Urol 1995;154:1351-5.  Back to cited text no. 12
Berg R, Svensson J, Aström G. Social and sexual adjustment of men operated for hypospadias during childhood: A controlled study. J Urol 1981;125:313-7.  Back to cited text no. 13
Stojanovic B, Bizic M, Majstorovic M, Kojovic V, Djordjevic M. Penile curvature incidence in hypospadias: Can it be determined? Adv Urol 2011;2011:813205.  Back to cited text no. 14
Rynja SP, de Jong TP, Bosch JL, de Kort LM. Functional, cosmetic and psychosexual results in adult men who underwent hypospadias correction in childhood. J Pediatr Urol 2011;7:504-15.  Back to cited text no. 15
Chukwubuike KE, Obianyo NE, Ekenze SO, Ezomike UO. Assessment of the effect of urethral plate width on outcome of hypospadias repair. J Pediatr Urol 2019;15:627.e1-6.  Back to cited text no. 16
da Silva EA, Lobountchenko T, Marun MN, Rondon A, Damião R. Role of penile biometric characteristics on surgical outcome of hypospadias repair. Pediatr Surg Int 2014;30:339-44.  Back to cited text no. 17
Liu MM, Holland AJ, Cass DT. Assessment of postoperative outcomes of hypospadias repair with validated questionnaires. J Pediatr Surg 2015;50:2071-4.  Back to cited text no. 18
Keays MA, Starke N, Lee SC, Bernstein I, Snodgrass WT, Bush NC. Patient reported outcomes in preoperative and postoperative patients with hypospadias. J Urol 2016;195:1215-20.  Back to cited text no. 19
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;11:71.e1-5.  Back to cited text no. 20
Menon V, Breyer B, Copp HL, Baskin L, Disandro M, Schlomer BJ. Do adult men with untreated ventral penile curvature have adverse outcomes? J Pediatr Urol 2016;12:31.e1-7.  Back to cited text no. 21


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