Journal of Pediatric Urology (2021) 17, 670.e1e670.

e5

Ano-Scrotal Distance (ASD) : Is it a

marker for the severity of chordee?

Johannes Wirmer, Michael Sennert, Ahmed T. Hadidi *

Hypospadias Centre,
Department of Pediatric
Surgery, Emma and Sana
Klinikum Offenbach Hospitals,
Germany
* Correspondence to: Ahmed T
Hadidi, Max-Planck Str. 2,
Seligenstadt, D - 63500,
Germany, Tel.: þ49 174 205
6905; fax: þ49 6182 843 0293
Prof.Hadidi@hypospadiezen-
trum.de, ahmedthadidi@
yahoo.de (A.T. Hadidi)
Keywords
Penis; Ano-scrotal distance
urologic surgical procedures;
Chordee; Hypospadias; Ure-
thra; Male
Received 15 January 2021
Revised 16 April 2021
Accepted 4 June 2021
Available online 12 June 2021
Summary
Objective
To evaluate the relation between ASD and the
severity of chordee and hypospadias in a referral
center.
Methods
The distance between the anal verge and proximal
scrotal edge (ASD) was measured in hypospadias pa-
tients between 6 and 18 months between 2016 and
2020 in the operating room under anaesthesia. Pa-
tients older than 36 months and younger than 6
months were excluded. The patients were classified
according to meatus into: Grade I (glandular or chor-
dee without hypospadias), II (distal), III (proximal)
and IV (perineal). Chordee was assessed by erection
test and classified into 2 groups; Group I: no chordee
or mild chordee <30 and Group II: with severe chor-
dee >30. Short ASD was defined as  2.0 cm.
Results
817 boys were included. The patients were classified
according to the hypospadias grades I (180 pt), II
(415 pt), III (120 pt) and IV (102 pt). The median ASD
for group I was 3.07 cm (range 1.0e5.5), for group II
3.10 cm (range 1.5-5.0), for group III 2.40 cm (range
1.5e54.5) and for group IV 2.10 cm (range 1.0e3.5).
The average ASD of the patients in Grade III and
IV (2.26 cm) was significantly shorter than the
average ASD of the patients in Grade I and II
(3.09 cm) (p < 0.05). 184 patients had an ASD
2.0 cm. 38% of patients with glanular hypospadias
(grade I) with ASD  2.0 cm had severe chordee.
Conclusion
This study shows that short ASD is a helpful marker
of the severity of chordee and hypospadias. Patients
with glanular hypospadias and short ASD have 38%
chance of having severe chordee.

https://doi.org/10.1016/j.jpurol.2021.06.010
1477-5131/ª 2021 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

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Ano-Scrotal Distance 670.e2

Introduction the severity of chordee. However, it is difficult to assess the

The standard classifications of hypospadias according to the
meatus location do not consider the severity of chordee.
The severity of chordee influences the surgical technique
and the incidence of complications.
The Ano-Genital and Ano-Scrotal Distance (AGD and ASD)
has been identified as a marker for androgen exposure in
utero in numerous animal studies, with a short distance
reflecting decreased androgen exposure [1]. A study
examining the ASD in 371 male newborns found an average
ASD of 2.47 mm [2].
Hypospadias on the other hand, is second commonest
congenital malformations in boys after undescended testis
with a rising prevalence [3e5]. However, many coherences
in this common congenital anomaly remain unclear [6e8].
These clinical classifications lack international stan-
dardization [6, 9]. However, the classification of hypospa-
dias into four grades (glanular, distal, proximal and
perineal) seems to become more popular [10]. Meanwhile,
more than 300 surgical techniques have been described for
correction [10]. In our center, we use 4 surgical techniques
for the different grades of hypospadias [10e16].
To choose the appropriate surgical technique, the sur-
geon needs to identify the grade of hypospadias as well as
severity of chordee during the outpatient examination
without erection especially when the baby is crying and
moving. While it is expected to encounter severe chordee
in severe forms of hypospadias, it is also encountered in
some mild forms, leading to unpleasant surprises during
surgery.
Recent studies suggest an association of hypospadias in
general with short AGD and ASD [9, 17, 18]. However, the
ASD in patients with hypospadias has so far only been
examined on a small patient series [9]. An association be-
tween the ASD and severity of chordee has not been
reported.
This study was designed to assess the relationship of ASD
with the severity of chordee and the severity of hypospa-
dias in a large referral center.
Methods
In a prospective study, boys between 6 and 18 months un-
dergoing hypospadias surgery in the center between
January 2016 and December 2020 were included in the
study. Patients older than 36 months or younger than 6
months were excluded. The study obtained the approval of
the institutional ethics committee.

Figure 1 Ano-Scrotal Distance (ASD). a. glanular hypospadias with 5 cm ASD. b. Distal hypospadias with 3 cm ASD. c. Mid-penile
hypospadias with the ASD Z 3 cm. Notice that 3 cm is about 2 finger breadth. d. Proximal hypospadias with 2 cm ASD. e. Perineal
hypospadias with 1.5 cm ASD. Observe in (c) that 3 cm is about 2 fingers ‘breadth. This is helpful to have a rough estimation of ASD
in the outpatient clinic especially if the child is moving.

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670.e3 J. Wirmer et al.

Figure 2 A 12 months old child with glanular hypospadias and severe chordee. a. Examination under anaesthesia showed that the
penis was curved and the ASD was short (1 cm). b. Close up showing that ASD was 1 cm. c. Close up showing the glanular hypo-
spadias. d. Notice the extensive dissection including excision of the outer Longitudinal layer of Tunica Albuginea around the
urethra. However, the urethra was not completely mobilized to maintain its blood supply. Also observe how the sub-coronal incision
retracted down from the sub-coronal level to the proximal penis. e. Erection test confirmed that the penis was straight. f. The final
appearance after glans and skin closure.

Patients were classified according to the location of the
meatus into 4 grades: Grade I (glanular or chordee without
hypospadias), Grade II (distal to the mid penis), Grade III
(proximal, from mid penis to penoscrotal junction) and
Grade IV (proximal to penoscrotal junction).
The Ano-Scrotal Distance (ASD) was measured amongst
other anatomical landmarks under general anaesthesia.
Anoscrotal distance was defined as the distance between
the anterior anal verge and proximal edge of the scrotum
where the perineal skin changes from smooth to corrugated
as described by Sathyanarayana et al. in the infant devel-
opment and the environment study (TIDES) [2] and
measured with a flexible ruler by midline or symmetry
(Fig. 1).
Short ASD was defined as equal or smaller than 2.0 cm
and the severity of chordee was assessed intra-operatively.
Chordee was assessed under anaesthesia by erection test
(Fig. 2) using a goniometer and was classified into 2 groups:
no chordee or mild chordee, less than 30 corrected by
degloving and severe chordee (more than 30 ) requiring
additional procedures for chordee correction other than
degloving. These include division of the urethral plate,
excision of the outer layer of tunica albuginea and (when
indicated) incision of the inner layer of tunica albuginea
and placing a flap or graft. The mean ASD and the per-
centage of severe chordee for every hypospadias grade
were documented.
Furthermore, the average ASD of patients with a mild
form of hypospadias (Grade I and II) was compared to the
average ASD of patients with more severe form of hypo-
spadias (Grade III and IV) and a two-sample t-test with
assumed unequal variance was used to determine signifi-
cance of difference along the two unpaired groups.
Patients with grade I hypospadias and severe chordee
required more aggressive approach than simple degloving
(Fig. 2). This may include aggressive excision of fascia,

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Ano-Scrotal Distance 670.e4

Table 1 ASD and severe chordee to severity of hypospadias total number of patients Z 817 patients.
Grade I II III IV
Total 180 415 120 102
Mean ASD (cm) 3.07 3.10 2.40 2.10
Range(cm) 1.0e5.5 1.5e5.0 1.0e4.5 1.0e3.5
No. Pt. with ASD  2,0 cm 21 51 50 62
% Pt. with ASD  2,0 cm 11.67% 12.29% 41.67% 60.78%
No. Pt. with severe chordee 24 9 25 102
% of Pt. severe chordee 13.33% 2.17% 20.83% 100%

division of the tunica albuginea longitudinally as it bi-
furcates to enclose the urethra and excision of the outer
layer of tunica albuginea deep to the urethra. In 3 patients
with chordee without hypospadias, the authors had to
incise the tunica albuginea and put dermal graft.
Results
The grade of hypospadias and ASD measurements were
documented in 817 Patients between 6 and 36 months.
There were 180 cases of hypospadias Grade I, 415 Grade II,
120 Grade III and 102 Grade IV.
The median ASD overall was 2.86 cm. The median ASD for
group I was 3.07 cm (range 1.0e5.5), for group II 3.10 cm
(range 1.5-5.0), for group III 2.40 cm (range 1.5e4.5) and for
group IV 2.10 cm (range 1.0e3.5) (Table 1). The average ASD
of the patients in group I and II (3.09 cm) was significantly
longer than the average ASD of the patients in group III and IV
(2.26 cm) (p < 0.05) (Table 2).
45% of the 184 Patients with short ASD (2.0 cm) had
severe chordee (see Table 2). All patients with perineal
hypospadias and short ASD had severe chordee (>30 ) that
necessitated division of the urethral plate. Interestingly,
more than 1/3 of patients (38%) in Grade I had severe
chordee that could not be corrected by simple degloving.
This is different from patients with Grade II or III Hypo-
spadias with short ASD (only 5% had severe chordee)
(Table 3).
Discussion
In this study, the ASD was measured in 817 children with
hypospadias between 6 and 36 months. We excluded all
younger and older children, since other studies have shown
that ASD and Ano-Genital Distance (AGD) are expected to
increase rapidly during the Mini Puberty Period (first 6
months) and plateau after one year of age [19].
Table 2 The mean ASD group I þ II vs group III þ IV
total Z 817.
Grade I-II III-IV
Total 595 222
Mean ASD (cm) 3.09 2.26
Range(cm) 1.0e5.5 1.0e4.5
p < 0.05
As the TIDES study described a mean ASD of 2.47 cm in
371 male newborns [2], we defined a short ASD as equal or
smaller than 2.0 cm, considering the expected increase of
the ASD during the first 3 month of birth.
The results of the study on 817 patients with hypospa-
dias showed a direct relation of short ASD with the severity
of hypospadias. The majority (95%) of patients with distal
and proximal (Grade II & III) hypospadias had a normal ASD.
Cox et (2017) demonstrated that, patients with hypospadias
in general have a shorter ASD compared to a healthy pop-
ulation in a small sample size without differentiation of the
hypospadias grade [9].
To our knowledge, this is probably the first report in
literature that shows the relation between short ASD and
the severity of chordee.
This is perhaps of particular importance in patients with
glanular hypospadias or chordee without hypospadias. Ac-
cording to the study, if the surgeon finds that the ASD is less
than 2 finger width (2 cm), there is a 38% chance that the
child has severe chordee not correctable by simple
degloving. This is of great importance when informing the
parents of success rate, possible complications and perhaps
hospital stay.
Management of Grade I or glanular hypospadias may not
as easy as one may expect with mild hypospadias especially
if there is associated severe chordee. This may be sus-
pected in the outpatient clinic if the ASD is shorter than
2 cm as was the case with this child. This is of importance
for the less experienced surgeon to choose the simple cases
and refer cases with severe chordee to a more specialized
center.
One limitation of the study is that the measurement can
be operator dependent. However, the 3 authors have
noticed that difference of measurement is about 2e3 mm
among them. The second limitation is that using a flexible
ruler does not provided 100% accurate measurements.
Table 3 Incidence of short ASD (2.0 cm) and severe
Chordee total Z 184.
Grade I II III IV
No. of patients with 21 51 50 62
ASD 2.0 cm
No. of patients with 8 4 8 62
severe chordee
Percentage of patients 38% 4.8% 4.91% 100%
with severe chordee

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670.e5
It must be pointed out that some patients with severe
forms of hypospadias and severe chordee may still have
normal ASD. However, all patients with perineal hypospa-
dias and short ASD had severe chordee.
Conclusion
The study suggests that ASD is a helpful marker to identify
the severity of hypospadias and the severity of chordee.
This may help the surgeon to identify patients with severe
chordee, plan the appropriate technique and to give the
parents a more reliable information during outpatient
examination.
Conflict of interest
None.
Funding
This research did not receive any specific grant from
funding agencies in the public, commercial, nor not-for-
profit sectors.
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