The Pediatric Penile Perception Score: An Instrument for Patient

Self-Assessment and Surgeon Evaluation After Hypospadias Repair

Daniel M. Weber,*,† Verena B. Schönbucher, Markus A. Landolt and Rita Gobet
From the Division of Pediatric Urology, Department of Pediatric Surgery and Department of Psychology (MAL), University Children’s
Hospital, Zurich, Switzerland

Purpose: The aim of this study was to develop and evaluate an instrument that allows assessment and comparison of penile
perception of patients, parents and surgeons.
Materials and Methods: A total of 77 boys 6 to 17 years old who had undergone hypospadias repair were interviewed by
a psychologist with a standardized questionnaire concerning penile self-perception with regard to meatus, glans, skin and
general appearance. The Pediatric Penile Perception Score was derived from the sum of these 4 items. The results were
compared with a control group of age matched boys following inguinal hernia repair. Parents were asked via questionnaire
to report the penile appearance of their son using the Pediatric Penile Perception Score. A total of 56 patients accepted
standardized photographic documentation, and their pictures were sent for evaluation with the Pediatric Penile Perception
Score to 6 blinded urologists.
Results: The Pediatric Penile Perception Score allowed us to assess perception of the genitalia by patients, parents and
urologists. Statistical analysis of the Pediatric Penile Perception Score assigned by the urologist revealed good interrater
reliability (interclass correlation 0.75 to 0.88) and stability (r ⫽ 0.59 to 0.83). Intercorrelation of the items “meatus,” “glans”
and “skin” with “general appearance” was good among the boys, parents and urologists. Patients with hypospadias expressed
high satisfaction with the penile appearance, which did not differ significantly from age matched controls. However, parents
and urologists were less satisfied with the penile appearance than were the patients themselves.
Conclusions: The Pediatric Penile Perception Score is a reliable instrument to assess penile self-perception in children after
hypospadias repair, and for appraisal of the surgical result by parents and uninvolved urologists.

Key Words: child, hypospadias, outcome assessment (health care), surgery

ecent progress in hypospadias surgery allows us to Attempts to compare patient appraisal and surgeon as-

R achieve good cosmetic results, unimpaired sexual

function and normal voiding even for patients with
proximal hypospadias. Yet there is no perfect result, and
patients have to cope with minor cosmetic issues such as
scars.
Previous publications suggest that psychosexual function
and quality of life may be impaired in patients with distal
hypospadias.1,2 However, it is not clear which factors influ-
ence this outcome and to what extent the surgical result
contributes to it. Most likely, the perception of the genitalia
by the patient himself is more important for psychosexual
development and quality of life than is the perception of the
urologist. The attitude of the parents toward the genital
appearance of their child may also potentially influence pa-
tient genital perception and development.3 Therefore, in-
struments should be available to assess the penile percep-
tion of patients, parents and surgeons.
Submitted for publication December 31, 2007.
Study received institutional ethical committee approval.
* Correspondence: Division of Pediatric Urology, University Chil-
dren’s Hospital, Steinwiesstr. 75, CH-8032 Zurich, Switzerland (tele-
phone: 41-44-266-73-37; FAX: 41-44-266-81-21; e-mail: Daniel.
Weber@kispi.uzh.ch).
† Financial interest and/or other relationship with Foundation
Mercator Ltd., Switzerland.
See Editorial on page 808.
sessment of the results of hypospadias surgery were first
made by Schwobel et al.4 In that study the urologists them-
selves asked the patients for their evaluation of the surgical
result, and all patients reported a satisfactory or excellent
result.
Mureau et al improved on the concept by developing a
standard questionnaire consisting of 8 items regarding dif-
ferent aspects of the genitals.5 The items were rated by the
patients and compared to the rating given by a pediatric
urologist who was unaffiliated with the treating team. It was
found that patients were much less satisfied with the penile
appearance than was the surgeon.
This standard assessment of single items by the patients
was a big step forward in the evaluation of results after
hypospadias repair. However, questions arise regarding
whether assessment of the outcome by a single urologist is
objective. Baskin introduced photographs seeking to ap-
praise cosmetic outcome after hypospadias repair.6 With a
dual score he evaluated whether the criteria of overall ap-
pearance, mucosal collar, meatal location and configuration
appeared as in a normal penis. This was the first known
attempt at systematically documenting the postoperative
outcome based on penile appearance. However, the photo-
graphs were evaluated by only 1 reviewer, and the outcome
was not measured by a person uninvolved in the treatment
of the patient.

0022-5347/08/1803-1080/0 1080 Vol. 180, 1080-1084, September 2008

THE JOURNAL OF UROLOGY® Printed in U.S.A.
Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/j.juro.2008.05.060
 PEDIATRIC PENILE PERCEPTION SCORE AFTER HYPOSPADIAS REPAIR
Ververidis et al have assessed cosmesis after hypospadias
surgery with a scoring system based on photographic docu-
mentation presented to a panel of 5 independent health
professionals.7 Although the instrument was used success-
fully to demonstrate a different outcome between 2 surgical
techniques, the quality of the instrument itself was not
evaluated.
Because no known comprehensive reliable scoring system
for penile perception has been published, we decided to
develop such an instrument and to evaluate it in a cross-
sectional study. This tool incorporates some of the previous
concepts to assess and compare penile perception by pa-
tients, parents and surgeons.
MATERIALS AND METHODS
Patients
A total of 147 males 6 to 17 years old who had undergone
hypospadias repair at our institution between 1991 and
2005 were eligible for this cross-sectional study. Exclusion
criteria were genital surgery less than 12 months before the
onset of the study, further planned operations for hypospa-
dias, chronic disease and other signs of disorders of sex
development besides hypospadias. A total of 102 patients
fulfilled the recruitment criteria, and 77 families (75%)
agreed to participate and were interviewed by a psycholo-
gist.
A physical examination and photographic documentation
by a urologist were available in 56 patients. The number of
patients with interviews was higher than the number with
photographic documentation because some parents and ad-
olescents refused photographs. A total of 48 patients had
distal hypospadias, 26 had penile hypospadias and 3 had
penoscrotal hypospadias. After 2000 most patients were op-
erated on using the tubularized incised plate method,
whereas earlier meatal advancement and glanuloplasty and
Mathieu repairs were the most popular approaches for distal
hypospadias. Two-stage Bracka repairs, onlay and tubular-
ized flaps were used for proximal hypospadias. Of the 77
patients 48 (62%) underwent 1 procedure, while 29 (38%)
underwent 2-stage repair or reoperation for complications.
A control group of healthy boys operated on for inguinal
hernias at our institution was recruited. A total of 131 fam-
ilies had to be contacted to recruit 77 boys matched for
current age and age at surgery with the study patients.
Control subjects did not significantly differ from the hypo-
spadias group with regard to mean age at first operation
(study patients 3.01 ⫾ 2.37, controls 2.81 ⫾ 2.77 years),
current age (11.03 ⫾ 3.31 vs 11.34 ⫾ 3.32 years), nationality
or socioeconomic status. However, the controls had under-
gone fewer operations and were hospitalized for fewer days.
Also, few patients in the control group were circumcised,
since circumcision is not a tradition for the majority of Swiss
males.
Methods
All patients and controls were interviewed by a psychologist
concerning penile appearance with regard to configuration
and position of the meatus; configuration and appearance of
the glans; appearance of the shaft skin, mucosal collar and
penile axis; and general penile appearance. Patients could
express their satisfaction for every single item according to
a 4-point Likert scale, which included the ratings of very
1081
dissatisfied (0 points), dissatisfied (1), satisfied (2) and very
satisfied (3, Appendix 1). The PPPS was calculated by add-
ing the scores of the items meatus, glans, shaft skin and
general appearance.
Parents were not present during the patient interviews.
However, a parent was asked to fill out a questionnaire
evaluating the appearance of the penis, which included the
same items and same scale as the patient form (Appendix 2).
After the interview boys with hypospadias were exam-
ined by a pediatric urologist who obtained photographs of
the penis in 4 standardized views, namely oblique, lateral,
anteroposterior with the penis held against the abdominal
wall and anteroposterior with the penis held up straight
(Appendix 3). No urological examination or photographic
documentation was performed for boys in the control group.
The photographic charts were sent to and evaluated by 6
blinded urologists (2 American, 2 British, 2 Swiss), of whom
4 were not affiliated with our hospital. In the set of 56 charts
10 were included twice without forehand information to
assess the stability of the instrument. The urologists were
asked to rate the photographs according to the same criteria
and with the same scale as the patients.
Statistical Analyses
Intercorrelation of single items to general appearance as
well as associations between the PPPS and medical charac-
teristics were calculated using Spearman’s rank correlation
coefficients. For the urologist evaluation the stability of the
PPPS items and the PPPS total score were also calculated
using Spearman’s rank correlation coefficients. Interrater
reliability was calculated using interclass correlation coeffi-
cients. The results of the urologists were averaged to obtain
an objective outcome measurement. Mann-Whitney U tests
were used to test agreement in penile perception between
the patients, parents and surgeons.
RESULTS
Patients who had undergone hypospadias repair expressed a
high satisfaction for every single item of the penile percep-
tion scale, with mean values between 2 (satisfied) and 3
(very satisfied). Statistical evaluation to assess the internal
consistency with interclass correlation showed a good inter-
correlation of the items meatus (r ⫽ 0.45, p ⫽ 0.00), glans (r
⫽ 0.6, p ⫽ 0.00) and shaft skin (r ⫽ 0.59, p ⫽ 0.00) with the
general appearance. Patient satisfaction for the single items
of penile perception and the PPPS overall exhibited no sta-
tistically relevant difference compared to the control group
(table 1).
Parent satisfaction with the appearance of the genitals
after hypospadias repair was relatively high, with a mean
value slightly greater than 2 (satisfied) for each item of the
PPPS. However, comparison with the parents of the control
group revealed that parents of the patients with hypospa-
dias were less satisfied (table 2).
Urologists were most dissatisfied with the results
achieved when evaluating the photographic charts, since
their mean results for all of the items were less than 2.
Statistical evaluation of the instrument demonstrated a
high interrater reliability between urologists when tested
with the interclass correlation coefficient and a high stabil-
ity of the instrument. Intercorrelation of the items meatus,
glans and shaft skin with general appearance was good.
1082 PEDIATRIC PENILE PERCEPTION SCORE AFTER HYPOSPADIAS REPAIR

TABLE 1. Comparison of study patients and control group for self-perception and parent perception regarding appearance of genitals
Self-Perception Score Parent Perception Score
(mean ⫾ SD) (mean ⫾ SD)
p Value p Value
Pts Controls (Mann-Whitney U test) Pts Controls (Mann-Whitney U test)

Meatus 2.50 ⫾ 0.64 2.44 ⫾ 0.58 0.454 2.19 ⫾ 0.70 2.45 ⫾ 0.50 0.068
Glans 2.44 ⫾ 0.61 2.44 ⫾ 0.61 0.995 2.26 ⫾ 0.54 2.48 ⫾ 0.50 0.051
Shaft skin 2.44 ⫾ 0.57 2.40 ⫾ 0.65 0.822 1.98 ⫾ 0.80 2.47 ⫾ 0.54 0.001
General appearance 2.37 ⫾ 0.74 2.49 ⫾ 0.70 0.337 2.13 ⫾ 0.66 2.47 ⫾ 0.54 0.010
Overall PPPS 9.75 ⫾ 1.95 9.77 ⫾ 1.97 0.935 8.54 ⫾ 2.33 9.86 ⫾ 1.93 0.004

Comparison of patient self-perception, perception of the
parents and perception of the urologists showed striking
differences. While parent perception was only slightly but
statistically significantly inferior to patient self-perception,
the urologists considered the results much poorer than did
the patients or parents (tables 1 and 2).
In the interview of the patients and the control group the
item perception of the penile axis was included as well.
However, when the results were controlled with Spearman’s
rho test the item had a poor intercorrelation with the gen-
eral appearance for the patients (r ⫽ 0.28, p ⫽ 0.02). Penile
axis may be an important item after hypospadias repair.
However, due to the conflicting self-reported results and the
inability to judge the axis by an independent urologist on a
photograph of the flaccid penis, we decided to omit the item
from further evaluations.
No significant correlation between the severity of hypo-
spadias and the PPPS, either in the patient self-assessment
(r ⫽ 0.15, p ⫽ 0.41), urologist evaluation (r ⫽ 0.16, p ⫽ 0.23)
or parent evaluation (r ⫽ 0.154, p ⫽ 0.23), could be found.
The number of operations and the PPPS did not correlate for
patient self-assessment (r ⫽ 0.04, p ⫽ 0.73) or parent as-
sessment (r ⫽ 0.00, p ⫽ 0.99). However, a correlation was
found with the urologist PPPS (r ⫽ 0.34, p ⫽ 0.01). Further-
more, patients and controls were asked about their satisfac-
tion with penile size, and a similar correlation of satisfaction
with penile size and PPPS was found for patients (r ⫽ 0.55,
p ⫽ 0.00) and controls (r ⫽ 0.52, p ⫽ 0.00).
DISCUSSION
Patient penile self-perception could be reliably assessed
with the PPPS. The instrument proved to be practical to use,
and the good internal consistency is an indication of its
reliability. However, the high patient satisfaction, similar to
the control group, was not anticipated, and contradicts some
of the studies available.5,8 Nevertheless, nonparticipating
patients (25%) may be particularly embarrassed by their
condition and their penile self-perception may be less favor-
able, so that the patients included in the study may possibly
give an overly optimistic view. The good self-perception
could reflect the improvement of surgical results achieved
with recent techniques. However, with regard to the parent
and urologist evaluation it seems to be unlikely that this is
the sole reason, and other causes must be considered.
Mureau et al published an extensive survey on patient
satisfaction after hypospadias repair with a similar study
design, and found that the patients were less satisfied with
the penile appearance than were the treating surgeons.5 In
that questionnaire 3 of 8 items were related to penile size
and 1 to the appearance of the scrotum and testes, so that
comparison to our results is difficult. Furthermore, Mureau
et al included older patients (range 9 to 18 years, mean
13.3).
Despite an overall high satisfaction reported by our pa-
tients, young age is associated with a higher PPPS. This
finding suggests a higher expectation of patients regarding
their penile appearance in adolescence, and confirms results
of other studies.8,9 Therefore, we assume that satisfaction
with genital self-perception by our patients will decrease
with advancing age. It would be interesting to assess the
self-perception of patients younger than 6 years, who were
excluded from our study. However, we do not believe that a
child that young is able to understand the various items that
were measured, or to judge the appearance of the penis.
Nevertheless, satisfaction with the penile appearance dur-
ing childhood is relevant, since it is one of the potential
factors that may influence the psychosexual development of
boys and can potentially interfere with health related qual-
ity of life even beyond childhood.10,11
Parents of boys with hypospadias were less satisfied with
the appearance of the genitals than were the patients them-
selves or the parents of the control group. This finding not
only may reflect parental assessment of the penile appear-
ance, but also may be influenced by fear or feelings of guilt
regarding the penile malformation. Furthermore, parents
have other penises to compare to, and know where their son
started and had expectations regarding what the final result
would look like. This negative appraisal of the result may be

TABLE 2. Evaluation of patients by 6 blinded urologists

Intercorrelation to
Score (mean ⫾ SD) Interclass Correlation Stability General Appearance

Meatus 1.65 ⫾ 0.68 0.88 0.74 0.45

Glans 1.84 ⫾ 0.50 0.75 0.59 0.60
Shaft skin 1.63 ⫾ 0.57 0.78 0.69 0.59
General appearance 1.64 ⫾ 0.57 0.84 0.83
Overall PPPS 6.76 ⫾ 2.04 0.81 0.71
Interrater reliability was calculated with interclass correlation coefficients, stability and intercorrelation to general appearance, using Spearman’s rho
correlation.
 PEDIATRIC PENILE PERCEPTION SCORE AFTER HYPOSPADIAS REPAIR 1083

relevant for the patients because the parental attitude to- interviews, and found a positive correlation of penile size
ward a malformation may be another factor that could pos- and PPPS in the patients and controls.
sibly interact with the psychosexual development of the
child.3
The evaluation by 6 blinded urologists, of whom 4 were CONCLUSIONS
not affiliated with our hospital, allowed us a sobering view of
our results, because a mean of 2 (“satisfied”) was not We evaluated the PPPS to assess penile self-perception in
achieved for any of the 4 items on the questionnaire. How- children after hypospadias repair, and to appraise the sur-
ever, the instrument proved to be reliable, with a satisfac- gical result by parents and uninvolved urologists. Its reli-
tory interrater reliability, stability and intercorrelation to ability and ease of use are 2 prerequisites that may qualify
general appearance. Therefore, we assume that the opinions the PPPS as a possible standard instrument for cosmetic
of the urologists can be considered an objective evaluation. assessment after hypospadias repair. For future studies of
Compared to the low satisfaction with penile appearance hypospadias we strongly suggest assessment of the results
expressed by the urologists, patient self-perception was by uninvolved urologists, since their appraisal of the surgi-
clearly superior. This finding contradicts previous series in cal result may diverge considerably from that of patients
which urologists were more satisfied than patients.5,8 It is and parents.
possible that our results following hypospadias surgery are
inferior to those of other centers. However, as Bracka has
indicated, the treating surgeon is always biased when judg- ACKNOWLEDGMENTS
ing his or her own work, and current surgical fashion may
influence judgment once one is committed to a particular Marc A. M. Mureau and F. Van der Thoorn assisted with the
method of treatment.8 A urologist who is not associated with development of the questionnaire and PPPS. Drs. E.
the treating team does not include his or her expectations in Figueroa, R. Gonzalez, M. Gundeti, M. Horst and F. Murphy
relation to the severity of the hypospadias in his or her scored the photographic documentations of the study pa-
judgment, but instead compares the outcome with a normal tients according to the PPPS.
penis.
For future studies we strongly encourage urologists to APPENDIX 1
ask colleagues who were not involved in the treatment of the
patients to evaluate the results after hypospadias repair. Interview child
“Nonbelievers” in a preferred technique tend to be more We will talk about several aspects of your penis. Please tell me how
satisfied you are with these. There are four possible answers: Very satis-
objective than colleagues who follow the same treatment fied, satisfied, dissatisfied, very dissatisfied. Please tell me which one is the
strategies. Standardized photographic documentation is the most appropriate for you.
key to an objective outcome measurement.
The present study provides an instrument to assess the very very
satisfied satisfied dissatisfied dissatisfied
outcome after hypospadias repair that is easy to use, has
good reproducibility and is of clinical usefulness— elements a Length of your penis □(3) □(2) □(1) □(0)
b Position and shape □(3) □(2) □(1) □(0)
that are critical for a scoring system.11 Because it is an of your urethral
instrument to measure perception, the functional outcome is opening
c Shape of your glans □(3) □(2) □(1) □(0)
not included. However, measurement of urinary flow could d Shape of your penile □(3) □(2) □(1) □(0)
be added as an objective functional parameter to supplement skin
the PPPS. Another element that is important for sexual e Penile axis □(3) □(2) □(1) □(0)
(straightness upon
function and appearance is penile straightness. This factor erection)
clearly needs to be examined intraoperatively with an arti- f General appearance □(3) □(2) □(1) □(0)
of your penis
ficial erection test. However, later evaluation by an indepen-
dent urologist is difficult.
Penile axis cannot be determined in a flaccid penis, be it
during examination or on photographic documentation. APPENDIX 2
However, few pediatric patients are willing or able to dem-
Questionnaire parent
onstrate an erection for photographic documentation. In our
The chart below shows various aspects about your son’s penis. There are
study the self-reported perception of the penile axis by pa- four possible answers: Very satisfied, satisfied, dissatisfied, very dissatis-
tients and the control group yielded conflicting results, and fied. Please mark with a cross the box that corresponds best.
the intercorrelation with general appearance was poor.
Hence, we have decided to omit this item from the PPPS. very very
Nevertheless, we assume that penile axis could be incorpo- satisfied satisfied dissatisfied dissatisfied

rated into a questionnaire on penile self-perception in a Penile length □(3) □(2) □(1) □(0)
adults. b Position and shape of □(3) □(2) □(1) □(0)
the urethral opening
The last point that needs to be addressed is penile size. c Shape of the glans □(3) □(2) □(1) □(0)
We have decided to exclude this item from the PPPS because d Shape of the penile skin □(3) □(2) □(1) □(0)
e Penile axis □(3) □(2) □(1) □(0)
it is not a factor that is amenable to hypospadias repair. This (straightness upon
omission may partly account for the more favorable self- erection)
appraisal of our patients and controls compared to other f General appearance of □(3) □(2) □(1) □(0)
the penis
studies. However, we assessed penile size in the patient
1084 PEDIATRIC PENILE PERCEPTION SCORE AFTER HYPOSPADIAS REPAIR

APPENDIX 3 children and adolescents after different types of hypo-

spadias surgery: a norm-related study. J Urol 1995; 154:
1902.
2. Schonbucher VB, Weber DM and Landolt MA: Psychosocial
adjustment, health-related quality of life, and psychosexual
development of boys with hypospadias: a systematic review.
J Pediatr Psychol 2008; 33: 520.
3. Schultz JR, Klykylo WM and Wacksman J: Timing of elective
hypospadias repair in children. Pediatrics 1983; 71: 342.
4. Schwobel MG, Sacher P and Stauffer UG: Denis-Browne cor-
rective surgery of hypospadias: long-term results. Z Kinder-
chir 1987; 42: 157.
5. Mureau MA, Slijper FM, Slob AK, Verhulst FC and Nijman
RJ: Satisfaction with penile appearance after hypospa-
dias surgery: the patient and surgeon view. J Urol 1996;
155: 703.
6. Baskin L: Hypospadias: a critical analysis of cosmetic out-
comes using photography. BJU Int 2001; 87: 534.
7. Ververidis M, Dickson AP and Gough DC: An objective assess-
ment of the results of hypospadias surgery. BJU Int 2005;
96: 135.
8. Bracka A: Sexuality after hypospadias repair. BJU Int, suppl.,
1999; 83: 29.
9. Mureau MA, Slijper FM, van der Meulen JC, Verhulst FC and
Slob AK: Psychosexual adjustment of men who underwent
hypospadias repair: a norm-related study. J Urol 1995; 154:
1351.
10. Schonbucher VB, Landolt MA, Gobet R and Weber DM:
Health-related quality of life and psychological adjustment
of children and adolescents with hypospadias. J Pediatr
2008; 152: 865.
11. Holland AJ, Smith GH, Ross FI and Cass DT: HOSE: an
objective scoring system for evaluating the results of hypo-
spadias surgery. BJU Int 2001; 88: 255.

EDITORIAL COMMENT
very very
satisfied satisfied dissatisfied dissatisfied
Here is a “classic” study that clearly shows that “beauty is in
the eyes of the beholder,” which in this instance is the
Meatal position and shape □ □ □ □
Shape of the glans □ □ □ □ patient himself. I am not surprised that independent urolo-
Shape of the penile skin □ □ □ □ gists would be less impressed with the cosmetic results,
General cosmetic appearance □ □ □ □
since every one of us thinks that we are the best and that the
work of others pales in comparison. That attitude in and of
itself may be a built-in bias toward the negative. Overall,
Abbreviations and Acronyms this study is a brave attempt to assess objectively penile
appearance following hypospadias repair, and to a large
PPPS ⫽ Pediatric Penile Perception Score degree it succeeds.

REFERENCES Mark R. Zaontz

Department of Urology
1. Mureau MA, Slijper FM, Nijman RJ, van der Meulen JC, Temple University School of Medicine
Verhulst FC and Slob AK: Psychosexual adjustment of Philadelphia, Pennsylvania