This study is a cross-sectional investigation that randomly enrolled children aged 3–17 with hypospadias, conducting interviews and scale assessments with the children and their families to demonstrate the current status of behavioral issues in hypospadias patients and explore influencing factors.

From May to October 2024, a convenience sampling method was employed to select pediatric patients with congenital hypospadias and their family members from the Urology Department of a public tertiary-grade children’s hospital in Chongqing, China, as the survey subjects. Inclusion criteria: ① Diagnosed with congenital hypospadias; ② 3–17 years old; ③ The children and their families have normal communication abilities. Exclusion criteria: ① Have severe organic diseases; ② Have speech, hearing, intellectual, or cognitive functional impairments. Elimination criteria: The children or their families request to terminate the investigation. According to the sample size calculation formula (17):

The number of dimensions of the Conners scale is 6, and the calculated sample size should be 69–108 cases. In total, 143 children with hypospadias were investigated. All participants gave informed consent and voluntarily participated in this investigation. Among them, children under 8 years of age only require parental consent, while those over 8 years of age require both parental and child consent. This study was approved by the hospital ethics committee (initial review 2023), and the review number for research was (360).

The questionnaire survey was conducted by a postgraduate student with 9 years of experience in pediatric nursing, under the guidance of a chief nurse who holds a National Level II Psychological Counselor qualification certificate. The primary survey method involved on-site interviews and distribution of paper PSQ questionnaires, with interviews taking place in the urology departments office. Researcher 1 was responsible for study introduction, answering questions, obtaining consent forms, and using standardized instructions and neutral explanatory language to guide participants in completing the questionnaires. The interview duration for each participant was approximately 30–55 min. Objective medical record data, such as the number of surgeries, disease classification, and urination status, were obtained from electronic medical records with the informed consent of the children’s parents. A total of 150 questionnaires were distributed. Among them, 7 questionnaires were excluded due to missing data or because the parents refused to complete them midway. Consequently, 143 valid questionnaires were included in the analysis, yielding an effective questionnaire recovery rate of 95.3%. Researcher 2 was responsible for entering all the participants information and questionnaire data, while Researcher 1 conducted a secondary verification of the data.

Data analysis was conducted using SPSS 21.0. Following normality testing, continuous variables not conforming to a normal distribution were reported as median (quartile), with between-group comparisons performed using the Mann–Whitney U test. Categorical variables were expressed as frequencies (n) or percentages (%), and chi-square tests were applied for group comparisons. Logistic regression analysis was utilized to identify factors influencing behavioral problems. Statistical significance was defined as p < 0.05.

A total of 143 children with congenital hypospadias were included in this study. The general information is shown in Table 1.

Among the 143 children with hypospadias included in the study, 34 exhibited abnormal behavioral manifestations, yielding an incidence rate of 23.8%. A comparative analysis was conducted between the groups of children with negative and positive behavioral findings. No statistically significant differences were observed between the two groups in terms of age grouping, other surgical history, Combining chronic diseases, duration of indwelling urethral catheter, living environment, or main caregiver (p > 0.05). However, statistically significant differences were identified between the two groups regarding number of surgeries, disease classification and urination status (p < 0.05), as shown in Table 1.

The results revealed the following scores for various behavioral dimensions: conduct problems scored 9 (5.5, 12) points, learning problems scored 4 (2, 6) points, psychosomatic problems scored 0 (0, 1) point, impulsivity-hyperactivity scored 1 (0, 3) points, anxiety scored 2 (2, 4) points, and the hyperactivity index scored 7 (5, 10) points.

Among the 143 children with congenital hypospadias, 24 (16.8%) exhibited positive in only one behavioral dimension, 6 (4.2%) in two dimensions, 3 (2.1%) in three dimensions, and 1 (0.7%) in four dimensions. Specifically, 7 children (4.9%) tested positive for conduct problems, 9 (6.3%) for learning problems, 1 (0.7%) for psychosomatic problems, 1 (0.7%) for impulsivity-hyperactivity, 27 (18.9%) for anxiety, and 4 (2.8%) showed abnormal hyperactivity index scores.

All observed indicators were included in a Univariate logistic regression analysis. The results indicated that the number of surgeries, disease classification, and urination status were significant factors influencing the positive rate of behavioral problems in the children (p < 0.05), as shown in Table 2.

Variables that demonstrated statistical significance in the univariate analysis were selected as independent variables. Based on the scores from the Conners Parent Rating Scale, behavioral problem status (negative = 1, positive = 0) was used as the dependent variable for binary logistic regression analysis. The assignment of independent variables is detailed as follows:

Number of surgeries (times): 1 time = 1; 2 times = 2; 3 times = 3; >3 times = 4.

Disease classification: Balanic type = 1; Coronal type = 2; Penile type = 3; Penoscrotal type = 4; Scrotal type = 5; Perineal type = 6.

Urination status: standing urination without dribbling = 0; standing urination with dribbling = 1; Squatting urination = 2.

The results revealed that the number of surgeries and urination status were significant influencing factors for positive behavioral problem status in children (p < 0.05). Specifically, both the number of surgeries and urination status were identified as risk factors for positive behavioral problem status (OR > 1, p < 0.05). As shown in the Table 3.

In this study, the incidence rate of positive behavioral problems among children with congenital hypospadias was 23.8%, aligning with the range (15%–65%) reported by Schönbucher et al. (19). As a congenital urological condition, our research found that behavioral issues in children with hypospadias become more pronounced after reaching school age. This is primarily attributed to the psychological development characteristics of children, who initially lack a distinct sense of gender identity. Upon entering school, they gradually recognize their differences from typically developing male peers, leading to the emergence of various emotional and behavioral problems. Specifically, 40% of school-aged children with hypospadias exhibit emotional symptoms such as anxiety, depression, low mood, and diminished interest (9). Behaviorally, they may demonstrate hyperactivity, aggression, heightened reactivity, and easy distractibility (20), with some displaying marked cross-gender behaviors (21). Compared to their peers, children with congenital hypospadias tend to encounter greater difficulties in behavior and social interaction after school age (22). Standing urination with dribbling and frequent incidents of wetting pants may prompt these children to intentionally withhold urination or avoid drinking water to reduce bathroom visits, fearing ridicule from peers. Such self-image challenges can hinder the development of their social competencies, including peer relationships and participation in social organizations (23, 24), and also low self-esteem (25). Additionally, multiple medical visits and treatments for hypospadias during childhood and adolescence can influence the development of coping strategies (emotional, behavioral, and cognitive responses to stressful situations), making them more prone to adopting avoidant coping mechanisms compared to healthy children (26). The behavioral manifestations observed across different age groups may stem from traditional, reserved Chinese parenting styles. Parents rarely initiate discussions on sexual and reproductive health, and children are often hesitant to communicate their disease-related distress. When children struggle to control urine flow and wet their pants, they may deliberately conceal their situation, while parents may choose to feign ignorance to protect their child’s self-esteem. On the other hand, some parents, feeling guilty due to the congenital nature of hypospadias, may be more inclined to tolerate and indulge their child’s negative emotions, potentially contributing to the high incidence of behavioral problems. Therefore, we recommend establishing support groups for families affected by hypospadias to foster mutual support and experience sharing, encouraging parents to prioritize their child’s psychological development. Additionally, hospitals could offer cognitive-behavioral therapy programs to guide parents and children in correctly understanding the disease, encourage parents to adopt positive approaches in assisting their children to overcome psychological stress, actively cooperate with treatment, reinforce positive thinking, reduce disease-related stigma, and rebuild self-confidence.

This study indicates that among children with hypospadias, behavioral problems are most notably manifested in three dimensions: anxiety, learning difficulties, and conduct disorders. The incidence rate of anxiety in children with hypospadias is 18.9%, predominantly characterized by “fear of new environments and strangers” and “shyness.” This may be associated with feelings of inferiority and a lack of self-acceptance stemming from experiences of frequently wetting pants or being ridiculed by peers for squatting urination after reaching school age. In this study, we surveyed children aged 3 to 17 years. Given that children aged 3 to 5 years have limited gender awareness, the psychological impact of wetting pants or squatting urination is relatively minor. However, among school-aged children and adolescents, the proportion of positive cases in the anxiety dimension is significantly higher. In terms of learning problems, children with hypospadias often exhibit “learning difficulties,” “inattention,” and “a tendency to start tasks but not complete them.” This may be related to psychological stress induced by disease symptoms, which hinders their ability to concentrate. This is also a major concern for parents of affected children. Regarding conduct disorders, the most frequently reported behaviors include “being rude to adults,” “disobedience or reluctant compliance,” and “pouting or sulking.” This may be attributed to parents’ increased leniency and tolerance due to empathy for their child’s suffering from the disease and undergoing multiple surgeries. As a result, children may develop indulged or spoiled personalities during their growing process. It is suggested that parents can learn the knowledge of the impact of negative psychology on behavioral problems, strengthen the attention and communication with children, understand the psychological status of children, timely guide children to correctly relieve the psychological pressure brought by the disease, and do not indulge children’s inappropriate behavior because of the disease.