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 .