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Journal of Pediatric Urology (2013) xx, 1e6

The GMS hypospadias score: Assessment of inter-

observer reliability and correlation with post-
operative complications
Laura S. Merriman, Angela M. Arlen, Bruce H. Broecker, Edwin A. Smith,
Andrew J. Kirsch, James M. Elmore*

Department of Urology, Children’s Healthcare of Atlanta, Emory University School of Medicine, Georgia Pediatric Urology,
Atlanta, GA, USA

Received 22 January 2013; accepted 8 April 2013

KEYWORDS Abstract Objective: An agreed upon method for describing the severity of hypospadias has
Hypospadias; not been established. Herein we assess the inter-observer reliability of the GMS hypospadias
Chordee; score and correlate it with the risk of a post-operative complication.
Score; Methods: A 3-component method for grading the severity of hypospadias was developed
Grade; (GMS). Eighty-five consecutive patients presenting for hypospadias repair were graded inde-
Complications; pendently by at least 2 surgeons using the GMS criteria. Scores were compared statistically
Children to determine agreement between the observers. The outcomes of these patients were then
reviewed to determine how the GMS score correlates to the risk of a surgical complication.
Results: The G, M, and S scores had excellent agreement between observers. The GMS total
score was exactly the same or differed by one point in 79/85 (93%) of patients. The complica-
tion rate was 5.6% for patients with a GMS score of 6 or less, but was 25.0% for patients with a
GMS score greater than 6.
Conclusions: The GMS score provides a concise method for describing the severity of hypospa-
dias and appears to have high inter-observer reliability. The GMS score also appears to corre-
late with the risk of a surgical complication.
ª 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Introduction exists along a continuum. Some cases are only a minor

cosmetic concern, while other cases may be severe and
Hypospadias is one of the most common congenital anom- effect urinary and/or reproductive function. Given this
alies in boys. The severity of the anomaly varies widely and widely variable presentation, as well as anatomical nuances

* Corresponding author. Emory University School of Medicine, Georgia Pediatric Urology, 5545 Meridian Mark Rd, Suite 420, Atlanta, GA
303042, USA. Tel.: þ1 404 252 5206; fax: þ1 404 252 8604.
E-mail address: jmelmoremd@gmail.com (J.M. Elmore).

1477-5131/$36 ª 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jpurol.2013.04.006

Please cite this article in press as: Merriman LS, et al., The GMS hypospadias score: Assessment of inter-observer reliability and corre-
lation with post-operative complications, Journal of Pediatric Urology (2013), http://dx.doi.org/10.1016/j.jpurol.2013.04.006
 + MODEL
2 L.S. Merriman et al.
that make every case unique, hypospadias is difficult to
describe in a concise and standardized manner.
The position of the urethral meatus is the most common
way to classify the severity of hypospadias, however meatal
position is only one of several possible anatomic factors
that effect outcomes. Other features of the anomaly, such
as the quality of the urethral plate, size of the glans, and
the severity of chordee, may impact the success of surgery
as much as meatal location. These factors are not typically
or precisely reported in most outcomes studies. Hence, a
confounding problem of many hypospadias outcomes
studies is a common one e how is “mild”, “moderate” or
“severe” defined?
In an effort to address the need for standardized criteria
to classify the severity of hypospadias, the GMS hypospa-
dias scale was developed (Fig. 1). This scale was developed
as a means to qualitatively score the severity of hypospa-
dias based on easily observable features of the glans (G),
meatus (M), and penile shaft (S). Each of the three com-
ponents is scored numerically on a scale of 1e4 with more
unfavorable characteristics being assigned higher values.
These values are then summed to determine the GMS total
score. The lowest possible GMS score, therefore, is 3 (very
mild hypospadias) and the highest score is 12 (severe
hypospadias). Representative photographs of patients
categorized using the GMS criteria are shown in Fig. 2. Note
that certain qualities are difficult to demonstrate photo-
graphically and that there is some subjectivity to the scale.
It is also important to point out that the G score is used to
assess both glans size and the quality of the urethral plate.
In Fig. 2, the photographs shown were taken to emphasize
differences in urethral plate quality and not necessarily
glans size.
The purpose of the current study is two-fold: 1) to
determine if the GMS score is reproducible between ob-
servers and 2) to determine if and how the GMS score cor-
relates to the risk of a surgical complication.
Materials and methods
Following IRB approval, a group of consecutive patients
having primary hypospadias repair at our inpatient hospitals
were scored using the GMS criteria. Patients were assessed
while under anesthesia and immediately prior to any sur-
gical manipulation by at least 2 surgeons in a blinded
Glans (G) Score:
1. Glans good size; healthy urethral plate, deeply grooved
2. Glans adequate size; adequate urethral plate, grooved
3. Glans small in size; urethral plate narrow, some fibrosis or flat
4. Glans very small; urethral plate indistinct, very narrow or flat
Meatus (M) Score:
1. Glanular
2. Coronal Sulcus
3. Mid or Distal Shaft
4. Proximal shaft, penoscrotal
Shaft (S) Score:
1. No chordee
2. Mild (< 30°) chordee
3. Moderate (30 - 60°) chordee
4. Severe (> 60°) chordee
Figure 1 GMS scoring criteria.
Please cite this article in press as: Merriman LS, et al., The GMS hypospadias score: Assessment of inter-observer reliability and corre-
lation with post-operative complications, Journal of Pediatric Urology (2013), http://dx.doi.org/10.1016/j.jpurol.2013.04.006
fashion. The G score was based on assessment of the glans
and urethral plate. In cases where there was a discrepancy
between glans size and urethral plate quality, the higher
score was used. The S score was assessed in a standardized
fashion by gently pushing downward on the peno-pubic
junction from above while simultaneously gently pushing
downward on the peno-scrotal junction from below. No
rulers or other measuring devices were utilized. The highest
M score was 4 and included scrotal and perineal hypospa-
dias if encountered.
In total, 7 attending pediatric urologists participated in
this study along with 2 pediatric urology fellows and 4
urology residents. New surgeon scorers were oriented to
the GMS scale by a review of the criteria. The standardized
method for simulating an erection to assess chordee was
also described. Aside from this no special training, photo-
graphs, or demonstrations were utilized. After patients
were scored, the surgeons were permitted to discuss the
scores and any discrepancies. Verbal and non-verbal cues,
however, were prohibited during scoring and no scores
could be changed once finalized. Patients who had surgery
at our ambulatory surgery centers were not included in this
study since more than one surgeon was not available for
scoring. Individual G, M, and S scores as well as total GMS
scores were then compared statistically to determine
agreement between the raters.
Statistical analyses were performed using SAS 9.2 (Cary,
NC). Statistical significance was assessed using a 0.05 level
of statistical significance. Descriptive statistics (e.g.,
means and standard deviations or frequencies and per-
centages) were calculated for each component of the GMS
score as well as the total score. The Wilcoxon rank sum test
was used to compare median GMS scores (and each
component score) to assess whether differences existed
between the patients being scored; specifically, for patient
differences related to the severity of the condition.
Agreement between raters was assessed using the Intra-
class Correlation Coefficient (ICC).
A chart review of those patients scored by GMS criteria
was then conducted 6 months following repair and perti-
nent data was collected. The data collected included the
GMS component and total scores, age, type of repair, and
any surgical complication. The GMS score was then corre-
lated to the risk of a post surgical complication.
Results
Eighty-five patients with a mean age of 8.8 months (range 3
monthse8.6 years) were scored using the GMS method. The
distribution of scores is shown in Fig. 3. The average total
GMS score was 6.2 (range 3e12) and the average G, M, and S
scores were 2.0, 2.1, and 2.1 respectively. The rating sur-
geons had complete agreement on component scores 78%,
79%, and 85% of the time for the G, M, and S scores
respectively. In only 1 case did a component score differ by
more than one (Table 1). The GMS total score was the same
in 50 of the 85 (58.8%) cases and differed by 1 in another 29
(34.1%). Therefore, the total GMS score was the same or
differed by one in 79 of 85 (93.0%) cases. Statistical analysis
showed the G, M, and S scores to have very good to
excellent agreement between observers. The ICC ranged
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The GMS hypospadias score 3

Figure 2 Representative photographs of the GMS scoring criteria. Note that for the G scores, the examples shown are to
emphasize differences in urethral plate quality rather than glans size.

from 0.82 to 0.90. There was no statistically significant
change or improvement in agreement over time for any of
the unique observer pairs or over the study period.
For statistical purposes, the two observers compared
were the primary surgeon and the pediatric urology fellow
in 27 of 85 (32%) cases or an upper level urology resident in
58 of 85 cases (68%). There were no statistical differences
in agreement between the pediatric urology fellow and
resident but a trend toward matched agreement for the
attending-fellow group was noted. Eighteen of the patients
were also scored by two attending pediatric urologists. A
trend toward better agreement was noted, however this
was not found to be statistically significant.
The surgical technique chosen for hypospadias repair
was left up to the attending surgeon. In general TIP or
Thiersch Duplay repairs were used for mild to severe
hypospadias. The urethral plate was incised at the sur-
geon’s discretion to allow for tension-free tubularization.
GAP and MAGPI repairs were utilized for glanular hypospa-
dias. Hypospadias repair types included: TIP in 51 (60%),
Thiersch-Duplay in 19 (22%), GAP in 6 (7%), MAGPI in 4 (5%),
a 2-stage repair in 4 (5%) and 1 patient had a flip-flap repair.
Eleven patients (13%) had a post-operative complication,

Table 1 Frequency of agreement between raters and

measures of inter-rater reliability.a
Variable Complete Differ by 1 Differ by 2 ICC
agreement
G 66 (78%) 18 (21%) 1 (1) 0.82
M 67 (79%) 18 (21%) 0 (0) 0.84
S 72 (85%) 13 (15%) 0 (0) 0.90
a
All measures of agreement were statistically significant
Figure 3 Distribution of G, M, and S scores of the study
(p < 0.05).
cohort.

Please cite this article in press as: Merriman LS, et al., The GMS hypospadias score: Assessment of inter-observer reliability and corre-
lation with post-operative complications, Journal of Pediatric Urology (2013), http://dx.doi.org/10.1016/j.jpurol.2013.04.006
 + MODEL
4 L.S. Merriman et al.
including glans dehiscence in 2, urethral fistula in 7, and
meatal stenosis in 3. One patient developed both meatal
stenosis and a urethral fistula.
The complication rate was 5.6% (3/53) for patients with
a GMS score of 6 or less versus 25.0% (8/32) for patients
with a GMS score of greater than 6. Fig. 4 shows the dis-
tribution of GMS scores for the study cohort as well as the
number with each score who developed a complication.
The average total GMS score for those patients with post-
operative complications was 7.7 (range 5e12, median 7.0)
and differed significantly from the average total GMS score
of 5.9 (range 3e12, median 5.0) for those patients who did
not have a complication (p Z 0.017, 95% CI 3.08 to
0.32). The average component and total GMS scores for
those patients who developed a complication, according to
complication type, are shown in Table 2. There was no
statistical difference in complication rate based on repair
type, but 2 of 4 patients requiring a 2-stage repair devel-
oped a complication.
Discussion
Describing hypospadias based on the position of the ure-
thral opening has been suggested as the most reliable and
reproducible way to classify the anomaly [1]. Indeed, in
most outcomes studies, patients are grouped according to
meatal position (i.e. distal, proximal) [2e5]. However,
given that hypospadias exists as a complex, other factors
may have as much impact on surgical outcomes as the po-
sition of the urethral meatus. To our knowledge there is no
universally accepted method for classifying the severity of
the hypospadias complex in a standardized fashion. If one
assumes that the severity of chordee, size of the glans, and
the quality of the urethral plate impact surgical outcome,
then it becomes difficult to compare one study to another
using only meatal position for stratifying patients.
Castagnetti and El-Ghoneimi emphasized the need for
shared criteria for patient stratification in their 20-year
review of the management of severe hypospadias [2]. They
point out that a clear definition of severe hypospadias is
Figure 4 GMS scores of the study cohort. Note that patients
who had a complication are represented by the red portion of
the bar. (For interpretation of the references to color in this
figure legend, the reader is referred to the web version of this
article.)
Please cite this article in press as: Merriman LS, et al., The GMS hypospadias score: Assessment of inter-observer reliability and corre-
lation with post-operative complications, Journal of Pediatric Urology (2013), http://dx.doi.org/10.1016/j.jpurol.2013.04.006
Table 2 Average G, M, S and GMS total scores for patients
who developed a complication, categorized by complication
type.
Complication type G M S GMS total
Fistula (n Z 7) 2.1 2.4 2.1 6.6
Meatal stenosis (n Z 3) 3.0 3.3 2.7 9.0
Dehiscence (n Z 2) 3.5 2.0 3.5 9.0
lacking and highlight the difficulties encountered when
trying to compare one study to another without a stan-
dardized classification scheme. Giannantoni, in a recent
editorial regarding hypospadias, also comments on the
need for use of a “same language” and points out the need
for a better definition of moderate and severe with regards
to chordee [6]. Indeed, inconsistency with descriptive
terms for hypospadias and the lack of a standardized
method to assess severity of the entire complex limits the
comparison of outcomes studies. Indirectly, this may
impede our ability as a specialty to identify surgical re-
finements that could potentially reduce complication rates
and improve outcomes.
The concept that factors other than meatal position may
impact surgical outcomes is not new and others have made
efforts to investigate their surgical relevance. Sarhan and
colleagues evaluated the effect of specific urethral plate
characteristics on surgical outcomes in a study involving 80
boys [7]. Although they did not standardize their observa-
tions according to surgical technique, of the factors eval-
uated, a urethral plate width of less than 8 mm was the
only one that correlated to the risk of a surgical compli-
cation. Along the same lines, Holland et al. found a shallow
urethral groove depth to be associated with meatal stenosis
while a narrow urethral plate was associated with fistula
formation [8]. In contrast, Nguyen et al. found no correla-
tion between urethral plate characteristics and risk of post-
surgical complications [9]. Ziada et al. prospectively stud-
ied the surgical outcomes of 3 different age groups under-
going surgery for mid-shaft and distal hypospadias [10]. In
addition to age and meatal position they also collected data
regarding urethral plate width, urethral wall thickness, and
the severity of chordee. Analysis to determine how these
factors impacted surgical outcomes was not included in
their study, but it highlights the sentiment that features of
the hypospadias complex other than meatal position are of
importance.
In response to the need for a uniformly accepted clas-
sification system for hypospadias, we developed the GMS
hypospadias score. Our goal was to develop a standardized
method for scoring the severity of the hypospadias com-
plex, which includes, but is not limited to, meatal position.
The criteria chosen were based on the anatomic features of
hypospadias felt most likely to impact complication rates as
well as the cosmetic and functional outcomes of surgical
repair. This classification scheme was developed with the
intent that it would be easy to use, reproducible, as
objective as possible, and directly reflect the risk of a
surgical complication. The results of our study suggest that
the GMS scoring method has high inter-observer reliability
and also appears to correlate with the risk of a surgical
complication. The average GMS score was significantly
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The GMS hypospadias score
higher for those who developed a complication when
compared to those who did not. Furthermore, an increased
risk of a surgical complication was noted when the total
GMS score was greater than 6. Although a more detailed
and comprehensive grading system might be more prog-
nostic, it would have the potential disadvantage of being
overly cumbersome and not practical for use in an office
setting.
One criticism of the GMS method is that the G score re-
mains subjective and actually evaluates two features of the
hypospadias complex, the glans and urethral plate. In
retrospect it may more be more practical to consider the
glans and urethral plate separately (i.e. GUMS). Currently,
data regarding glans size and a U component to the scale are
being collected to determine if and how this additional in-
formation relates to surgical outcomes. Despite the sub-
jective nature of the G score, we feel that features of the
glans and urethral plate which can be observed but not easily
measured, are of critical importance. Such features include
the apparent thickness, elasticity, and quality of the
epithelium of the urethral plate. One could also foresee
scenarios where measurements might actually be
misleading. For example, a 6-month-old and 3-year-old with
the same urethral plate width may have different risks for a
complication. The same issues could be encountered for
patients of different weights or who have different penile
sizes. Furthermore, assessment becomes increasingly com-
plex as measurements are obtained. For example, should the
urethral plate be measured where it is widest, narrowest, or
should an average be used? How is the concavity or convexity
of the urethral plate taken into consideration? Similarly,
should the glans be measured at its base, at the mid-glans, or
should a ratio be used? Again, the GMS classification system is
designed to be easy to use even in the office setting and it
may prove to be as informative as a similar scale that in-
cludes objective measurements. Other grading systems
including The International Reflux Study Committee system
for grading urinary reflux and the Bosniak classification sys-
tem for grading renal cysts are also partially subjective and
do not include measurements, yet have proven very useful
clinically. Indeed, we were impressed that a group of 7 pe-
diatric urologists with different training and backgrounds,
and blinded to one another’s assessment, had very high
agreement on what was a favorable, adequate, marginal,
and unfavorable G score. This is a case where a trained eye
may be able to better assess, or at least categorize, features
and proportions that are difficult to concisely measure.
Certainly refinements maybe necessary over time and with
further investigation, but the current GMS classification
system provides a starting point for studies related to
developing a standardized instrument for scoring the
severity of hypospadias. Indeed, we have become accus-
tomed to using a patient’s G, M, and S scores as a rapid
reference point for assessing cosmetic and functional out-
comes following surgery.
Limitations of the GMS method include the fact that
associated scrotal anomalies, such as peno-scrotal trans-
position, are not evaluated. Whether and how this should
be included in a standardized scoring method is a subject of
debate. We have also encountered patients with severe
urethral hypoplasia such that the surgical meatus is found
to be significantly proximal to the anatomic meatus. In
Please cite this article in press as: Merriman LS, et al., The GMS hypospadias score: Assessment of inter-observer reliability and corre-
lation with post-operative complications, Journal of Pediatric Urology (2013), http://dx.doi.org/10.1016/j.jpurol.2013.04.006
5
most instances this was apparent on exam and taken into
consideration by the rating surgeons. We also make a no-
tation for the mega-meatus intact prepuce (MIP) variant of
hypospadias since repair in these patients may pose unique
challenges.
Finally, our study was conducted at a single institution
by a relatively small group of surgeons who were familiar
with the grading scale. However, we noted a very high
degree of inter-observer agreement even initially and with
new observer pairs, suggesting broader application of the
scale is feasible. While care was taken to avoid observer
bias, the possibility of this exists and external validation of
the GMS scale will therefore be necessary. Conflicting
operating room schedules also made it impractical for every
patient to be evaluated by two attending urologists, which
would otherwise be ideal.
Conclusions
A standardized method for describing the severity of the
hypospadias complex would be useful for our discipline.
Although refinements or additions may be necessary, the
GMS score provides a concise and reproducible way to
describe the severity of hypospadias and correlates to the
risk of a surgical complication. This or a similar method may
prove useful for academic discussion, hypospadias
research, and parental counseling. Ongoing study with a
larger number of patients, a longer follow-up period, and
more detailed statistical analysis may enable the identifi-
cation specific characteristics that correlate to the risk of a
surgical complication.
Conflict of interest
None.
Funding
None.
References
[1] Snodgrass W, Macedo A, Hoebeke P, Mouriquand PD. Hypo-
spadias dilemmas: a round table. J Pediatr Urol 2011;7:
145e57.
[2] Castagnetti M, El-Ghoneimi A. Surgical management of pri-
mary severe hypospadias in children: systematic 20-year re-
view. J Urol 2010;184:1469e74.
[3] Rynja SP, Wouters GA, Van Schaijk M, Kok ET, De Jong TP, De
Kort LM. Long-term followup of hypospadias: functional and
cosmetic results. J Urol 2009;182:1736e43.
[4] Snodgrass W, Bush N, Cost N. Tubularized incised plate
hypospadias repair for distal hypospadias. J Pediatr Urol 2010;
6(4):408e13.
[5] Frimberger D, Campbell J, Kropp BP. Hypospadias outcome in
the first 3 years after completing a pediatric urology fellow-
ship. J Pediatr Urol 2008;4(4):270e4.
[6] Giannantoni A. Hypospadias classification and repair: the riddle
of the sphinx. Eur Urol 2011;60:1190e1 [discussion 1e2].
[7] Sarhan O, Saad M, Helmy T, Hafez A. Effect of suturing
technique and urethral plate characteristics on
 + MODEL
6 L.S. Merriman et al.

complication rate following hypospadias repair: a pro-
spective randomized study. J Urol 2009;182:682e5 [dis-
cussion 5e6].
[8] Holland AJ, Smith GH. Effect of the depth and width of the
urethral plate on tubularized incised plate urethroplasty. J
Urol 2000;164:489e91.
[9] Nguyen MT, Snodgrass WT, Zaontz MR. Effect of urethral plate
characteristics on tubularized incised plate urethroplasty. J
Urol 2004;171:1260e2 [discussion 2].
[10] Ziada A, Hamza A, Abdel-Rassoul M, Habib E, Mohamed A,
Daw M. Outcomes of hypospadias repair in older children: a
prospective study. J Urol 2011;185:2483e5.

Please cite this article in press as: Merriman LS, et al., The GMS hypospadias score: Assessment of inter-observer reliability and corre-
lation with post-operative complications, Journal of Pediatric Urology (2013), http://dx.doi.org/10.1016/j.jpurol.2013.04.006