a 60-year - old man was presented to an orthopedician in the operating theatre as a case of difficult urinary catheterization .
the patient was going for a lengthy orthopedic operation that required a drained urinary bladder beforehand .
the urologist was called and he found the patient anesthetized , having circumcised penis and a pin - hole external urethral meatus ( eum ) at the corona penis level .
the tight meatus was negotiated first with a lubricated 4-french ( fr ) bougie urethral dilator followed by subsequent sized dilators up to 14- fr caliber when a proper foley catheter was introduced easily into the bladder .
the patient was carefully interviewed to reveal that circumcision was performed neontally as a religious rite , and he has no history of urologic diseases or trouble voiding , as this was the first time for him to meet a urologist . the patient , who is unaware of his condition , is a father of 12 children and never underwent urinary catheterization .
hypospadias is a highly prevalent congenital anomaly of the male genitalia . in comprehensive review , sorensen ( 1953 ) credited rennes in 1831 with reporting a prevalence of hypospadias of 1 in 300  recruits  and also reported the same figure for live male births in denmark .
there is a plethora of hypospadias cases of different degrees of severity repaired in childhood that resulted in different psychological , social , and sexual outcomes .
psychosexual effects of hypospadias repair are endured in adulthood although affected men maintain satisfaction in their sexual life .
it is unusual in the sense that the elderly man should have had his hypospadias deformity repaired decades ago in order to pass urine freely and to impregnate his spouse with a wider , and properly located meatus .
the tight meatus in this case was severe , hardly admitting a lubricated 4-fr bougie dilator .
litvak et al . , reported that the meatus in children younger than one year accepts a lubricated 5-fr feeding tube .
they also reported that , in children aging 1 - 6 years , an 8-fr feeding tube could pass without difficulty .
the social and sexual life of adults operated for hypospadias during childhood has been studied by a few authors .
a few publications reported patient and partner dissatisfaction with the appearance of genitalia , as sexual dissatisfaction is often attributed to penile size and curvature .
noted that self - reported strength of libido was slightly better for controls compared to patients with hypospadias , but without a statistically significant difference .
noted that only about 10% of both patients and controls reported that their libido was low .
problems reported include weak or dribbling ejaculation , having to milk out ejaculate after orgasm , quantity of semen passing after intercourse , anejaculation with or without orgasm .
liu et al . observed that the rates of ejaculation problems in the distal and proximal groups were 19.5% ( 8/41 ) and 48.6% ( 17/30 ) , respectively [ 5 , 6 ] .
the erectile problems in repaired hypospadias may be attributed to surgically correctable and non - correctable causes .
more commonly encountered correctable causes include persistent chordee , penile torsion , fistula formation , acquired meatal stenosis , and inadequate cosmetic outcome .
similarly , in unrepaired cases , as the eum is distal enough to deposit the seminal fluid high in the posterior vagina with no difficulty , fertility is supposed to be preserved . furthermore , aho et al . found that men who had hypospadias during childhood were less likely to live with a partner , and that they had fewer children ( 0.8 vs. 1.1 ) .
figure 1 
  extremely tight external meatus in a fairly asymptomatic 60 yrs , old man with distal hypospadias .
the literature is scant about the urinary , social , sexual , and fertility aspects of unrepaired hypospadias cases .
to our knowledge , no other case has been reported for a circumcised uncorrected hypospadias with extremely tight eum in a 
the finding in this treatise supports the previously published data surrounding the unaffected sexual and fertility aspects of patients having distal hypospadias , and limits repair to cosmetic reasons .
 hypospadias is a highly prevalent congenital anomaly . 
 english articles , indexed in pubmed , published the long - term sexual and reproductive outcome following hypospadias repair . 
 almost all repairable cases of hypospadias are operated in childhood . 
 although distal hypospadias does not interfere with fertility , it is worthy reporting a case of an elderly man , who fathers 12 children and has no urologic complaint , presented with unrepaired coronal hypospadias and severely tight external urethral meatus . 
CASE REPORT
DISCUSSION
CONCLUSIONS