Health-Related Quality of Life and Psychological Adjustment of Children and Adolescents with Hypospadias VERENA B. SCHÖNBUCHER, MSC,MARKUS A. LANDOLT,PHD, RITA GOBET, MD, AND DANIEL M. WEBER, MD Objective To assess health-related quality of life (HRQoL) and psychological adjustment of children and adolescents after hypospadias repair and to identify sociodemographic, medical, and psychosocial predictors of outcome. Study design 77 boys (7-17 years old) who underwent surgery for hypospadias were investigated in a cross-sectional study. Child- and mother-rated HRQoL was evaluated by the TNO-AZL Child Quality of Life Questionnaire, psychological adjustment by the Child Behavior Checklist. Scores were compared with an age-matched control group consisting of 77 boys after hernia repair. Results Compared with the control subjects, self-reported HRQoL of patients with hypospadias was lower in most dimen- sions. In contrast, mother-reported HRQoL and psychological adjustment did not differ in the 2 groups. Higher age and “being less ashamed of penile appearance” predicted better self-reported HRQoL, whereas positive penile self-perception, the patient’s experience of not having been teased about his penis, and more severe hypospadias contributed to better mother- reported HRQoL. Psychological adjustment was predicted by higher age, Swiss nationality, more severe hypospadias, and the patient’s experience of not having been teased about his penis. Conclusions In contrast to psychological adjustment, self-reported HRQoL of boys with hypospadias can be diminished. Psychosocial factors are more important predictors than medical variables. (J Pediatr 2008;152:865-72) H ypospadias is the most common malformation of the penis, with a reported incidence ranging as high as 3 per 1000 male births. 1 It is manifested by an abnormal position of the urethral opening, which lies anywhere between the glans and the scrotum. In most hypospadias, the prepuce is split, and severe forms are associated with a curvature of the penis (chordee). 2 The goal of hypospadias repair is to achieve a normal-looking penis, to allow micturition in the standing position, and to enable full sexual functions. 2 Although it is commonly assumed that both genital surgery and residual cosmetic or functional deficits may cause psychological stress to the patients, 3,4 only a few studies report on the patients’ psychological adjustment during childhood and adolescence. 5 Furthermore, findings are inconsistent. In older and methodologically less sound studies, children with hypospadias showed increased rates of psychological maladjustment, 6,7 whereas outcome is better in more recent, methodologically sound studies. 4,8,9 Earlier findings on the significance of medical factors for psychological adjustment are also inconsistent. However, most authors suggest that medical characteristics such as severity of hypospadias, number of operations, and age at first and final surgery bear a minimal influence on the patient’s psychological adjustment. 4,6,8-10 Despite these weak associations between medical factors and psychological adjustment, psy- chosocial risk factors have hardly been examined. 5 No studies on health-related quality of life (HRQoL) of boys with hypospadias have been published. This is striking, because it is known from children with other deformities such as bladder extrophies or anorectal malformations that their quality of life can be impaired. 11,12 The multidimensional concept of HRQoL is defined as the patient’s subjective evaluation of his or her physical, cognitive, social, and emotional functioning. It has recently become established as one of the most important approaches in assessing significant consequences of the patients’ state of health. 13 This study aimed at a comprehensive, cross-sectional investigation of both HRQoL and psychological adjustment, comparing a large sample of boys who underwent surgery for hypospadias and a healthy control group. We hypothesized that boys with hypospadias CBCL Child Behavior Check List HRQoL Health-related quality of life PPPS Pediatric Penile Perception Scale SES Socioeconomic status TACQOL-CF/PF TNO-AZL Child Quality of Life Questionnaire Child/Parent Form From University Children’s Hospital, Pedi- atric Urology, Zurich, Switzerland (V.S., R.G., D.M.); and Department of Psychoso- matics and Psychiatry, University Children’s Hospital, Zurich, Switzerland (M.L.). Supported by the Foundation Mercator Switzerland. The sponsor had no influence on the study design, the collection, analyses, and interpretation of data, the writing of the report, or the decision to submit the paper for publication. Submitted for publication Aug 16, 2007; last revision received Oct 3, 2007; accepted Nov 27, 2007. Reprint requests: Verena B. Schönbucher, MSc, University Childrens’s Hospital, Pe- diatric Urology, Steinwiesstrasse 75, CH- 8032 Zurich, Switzerland. E-mail: verena. schoenbucher@kispi.uzh.ch. 0022-3476/$ - see front matter Copyright © 2008 Mosby Inc. All rights reserved. 10.1016/j.jpeds.2007.11.036 865