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Pediatr Surg Int. 2019 Nov 20. doi: 10.1007/s00383-019-04600-3. [Epub ahead of print]

Increased hand digit length ratio (2D:4D) is associated with increased severity of hypospadias in pre-pubertal boys.

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Division of Urology, The Hospital for Sick Children, Toronto, ON, M5G1X8, Canada.
Division of Urology, The Hospital for Sick Children, Toronto, ON, M5G1X8, Canada.



Hypospadias is a common congenital male disorder, with much research focusing on prenatal androgen exposure as a causative factor. Whilst digit length ratios were apparent in sexual dimorphism since the nineteenth century, their role in hypospadias remains unknown. The objective of our study was to determine the correlation between digit length (2D:4D) ratio, hypospadias severity, and anogenital distance.


Pre-pubertal boys (<3 years old) seen intra/postoperatively following hypospadias repair (June 2018-January 2019 inc.) were included. These were age-matched to non-hypospadias controls. Anthropomorphic measurements of digit lengths, penile/glans width, and anogenital distance were measured using digital calipers.


Data measurements were collected for 105 boys with hypospadias (60 distal; 45 proximal) and 55 controls. There were significant differences in 2D:4D ratios in each hand (p < 0.001), as well as individual digits (p < 0.001), and a reduced anogenital distance (p < 0.001), when comparing the proximal group with distal or control groups. There were no significant differences in glans width, or between term- and preterm births.


This study is the first to demonstrate increased 2D:4D ratios with proximal hypospadias, which also correlate with a shortened anogenital distance. This may provide a non-invasive, potentially antenatal, anthropomorphic measurement, as an indirect indicator of aberrant urogenital development.


2D: 4D ratio; Anogenital distance (AGD); Endocrine disruptor; Hypospadias; Male programming window (MPW); Penile width; Testicular dysgenesis syndrome (TDS)


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