eMedicine Specialties > Pediatrics: Surgery > General Surgery

Imperforate Anus: Surgical Perspective: Workup

Author: Marc A Levitt, MD, Assistant Professor of Surgery and Pediatrics, University of Cincinnati; Associate Director, Colorectal Center for Children, Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center
Coauthor(s): Alberto Pena, MD, Consulting Surgeon, Colorectal Center for Children, Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center
Contributor Information and Disclosures

Updated: Aug 10, 2007

Workup

Imaging Studies

  • Imaging studies performed in the newborn period include the following:
    • The radiologic evaluation of a newborn with imperforate anus includes abdominal ultrasonography to evaluate for urologic anomalies. In patients with persistent cloaca, a distended vagina (hydrocolpos) may be identified.
    • Plain radiography of the spine may reveal spinal anomalies, such as spina bifida and spinal hemivertebrae.
    • Plain radiography of the sacrum in the anterior-posterior and lateral projections may demonstrate sacral anomalies, such as a hemisacrum and sacral hemivertebrae. In addition, the degree of sacral hypodevelopment may be assessed, and a sacral ratio can be calculated by measuring the distances between key bony structures (see Image 8).
    • Spinal ultrasonography in the newborn period and up to age 3 months (when the sacrum ossifies) may be performed to find evidence of a tethered spinal cord and other spinal anomalies.
    • Cross-table lateral radiography may help demonstrate the air column in the distal rectum in the small percentage of patients in whom clinical evidence does not delineate the likely anorectal anomaly in 16-24 hours.
  • Imaging studies performed after the newborn period include the following:
    • High-pressure distal colostography is performed on an outpatient basis, after the colostomy has been created.
      • Hydrosoluble contrast material is injected into the distal stoma to demonstrate the precise location of the distal rectum and its likely urinary communication.
      • Hydrostatic pressure under fluoroscopic control is required. A Foley catheter is placed in the mucous fistula, and the 3-cm3 balloon is inflated and pulled back to occlude the stoma during contrast injection.
      • The hydrostatic pressure must be high enough (manual syringe injection) to overcome the muscle tone of the striated muscle mechanism that surrounds the rectum and keeps it collapsed. This is the best way to demonstrate a rectourinary communication and determine the rectum's true height.
      • The contrast material usually fills the proximal urethra and bladder through the fistula.
      • The injection is continued until the child voids, and pictures are taken during micturition to reveal, in a single picture, the sacrum, rectum height, perineum, fistula location, bladder, vesicoureteral reflux (if present), and urethra.
      • When colostography is performed correctly, voiding cystography and cystoscopy are not necessary.
      • Colostography is vital in determining the anatomy to plan definitive repair. In 10% of patients, the fistula is at the level of the bladder neck; in these instances, during the main repair, the surgeon knows that the rectum can be found only through the abdomen, and a combined posterior sagittal and abdominal or laparoscopic approach is used.
      • The anorectal defect of imperforate anus without fistula may also be demonstrated with this radiologic evaluation. Occurring in approximately 5% of patients, imperforate anus without fistula has a good functional prognosis and is common in individuals with Down syndrome.
    • In most newborn girls with anorectal malformations (except for those with persistent cloaca), distal colostography is not necessary because the fistula is clinically evident.
  • If the spine was not evaluated with ultrasonography in the newborn period, MRI is necessary after age 3 months to exclude the presence of tethered cord and other spinal anomalies.

More on Imperforate Anus: Surgical Perspective

Overview: Imperforate Anus: Surgical Perspective
Workup: Imperforate Anus: Surgical Perspective
Treatment: Imperforate Anus: Surgical Perspective
Follow-up: Imperforate Anus: Surgical Perspective
Multimedia: Imperforate Anus: Surgical Perspective
References
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References

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Further Reading

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Keywords

imperforate anus, anorectal malformations, anorectal anomaly, persistent cloaca, rectoperineal fistula, bucket-handle malformation, recto–bladder neck fistula, rectobladder neck fistula, bowel control, anoplasty, colostomy, rectobulbar urethral fistula, rectoprostatic urethral fistula, rectovesical fistula, imperforate anus without fistula, rectal atresia, rectovestibular fistula, rectovaginal fistula, urinary fistula, urinary tract malformation, colostography, rectovesical defect, rectoperineal, tethered cord, sacral defect, spinal defect, descending colostomy with separated stomas, fecal diversion, megarectum, posterior sagittal approach, constipation, megasigmoid

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Contributor Information and Disclosures

Author

Marc A Levitt, MD, Assistant Professor of Surgery and Pediatrics, University of Cincinnati; Associate Director, Colorectal Center for Children, Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center
Marc A Levitt, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Alberto Pena, MD, Consulting Surgeon, Colorectal Center for Children, Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Robert Kelly, MD, Chairman, Department of Surgery, Departments of Surgery and Pediatrics, Children's Hospital of the King's Daughters; Associate Professor, Eastern Virginia Medical School
Robert Kelly, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society of Abdominal Surgeons, Medical Society of Virginia, Norfolk Academy of Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Deborah F Billmire, MD, Associate Professor, Department of Surgery, Indiana University Medical Center
Deborah F Billmire, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Phi Beta Kappa, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

H Biemann Othersen Jr, MD, Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina
H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American Thoracic Society, British Association of Paediatric Surgeons, Pediatric Oncology Group, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

Chief Editor

Marleta Reynolds, MD, Professor of Surgery, Feinberg School of Medicine, Northwestern University; Interim Head, Division of Pediatric Surgery, Department of Surgery, Children's Memorial Hospital of Chicago
Marleta Reynolds, MD is a member of the following medical societies: American Pediatric Surgical Association
Disclosure: Nothing to disclose.

 
 
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