 avoid it after the pull-through procedure. The patients must be followed regularly, and laxatives and dietary manipulations are begun at the first sign of constipation.
Occasionally constipation becomes so severe that patients develop chronic fecal impaction and constant soiling. Patients like this are often referred with "fecal incontinence." However, if the patient has a good prognosis type of anorectal anomaly, often this incontinence is actually overflow pseudoincontinence. Once the constipation is managed, they become continent.
Less frequently than constipation, some patients may experience soiling. While in a patient with a good prognosis, this may be overflow incontinence, it may also represent true fecal incontinence in cases of very high imperforate anus or poor muscles and an abnormal sacrum. A contrast enema is helpful in differentiating these two groups of patients. Patients with real incontinence require a bowel management program, which involves cleaning of the child's colon once a day by the use of a suppository, an enema or a colonic irrigation .
Giving the enema after the main meal of the day allows a more efficient cleansing of the bowel by taking advantage of the gastrocolic reflex. Antegrade enema procedures, whereby enema is introduced in a conduit via appendicocecostomy, has been devised to help the patient clean its bowel [30, 31]. The artificial bowel sphincter and electrically stimulated gracilis neosphincter are two relatively new techniques that have been used for the treatment of patients with severe refractory fecal incontinence.
Patients who have undergone abdominoperineal operations for imperforate anus that included resection of the rectum suffer from a tendency to have diarrhea due to a lack of a rectal reservoir. These patients' incontinence is much harder to manage because they pass stool constantly.
Bowel movement pattern prior to potty-training may give an important clue as to the child's potential for continence. For example, a one-year-old child who has undergone a pull-through for imperforate anus and has one to three bowel movements per day with no soiling in between has a great potential for future fecal continence. The child shows signs that he is "feeling" while having a bowel movement as he pushes. On the other end of the spectrum, a child who suffers from fecal incontinence passes stool constantly without any evidence of pushing or feeling. A child with a normal bowel movement pattern is trainable, whereas a child with the second pattern will likely need a bowel management program. For that child, one should not expect him to achieve voluntary bowel control.
When evaluating the results of the treatment of anorectal defects, we feel that one cannot group patients according to the traditional nomenclature into "high," "intermediate," and "low" defects, as malformations classified in a same group can have different treatments and different prognoses. For instance, rectoprostatic fistula and bladderneck fistula, both considered as "high" defects are actually very different. We believe that an anatomic classification would have more clinical value. The functional results of the repair of anorectal anomalies seem to have significantly improved since the advent of the posterior sagittal approach. However, the results of this approach are difficult to compare with those of other methods because terminology and classification are not consistent [32, 33].
Fecal continence depends on three main factors: Voluntary sphincter muscles, anal canal sensation, and colonic motility.
Voluntary muscle structures
In the normal patient, the voluntary muscle structures are represented by the levators, muscle complex, and external sphincter. Normally, they are used only for brief periods, when the rectal fecal mass reaches the anorectal area, pushed by the involuntary peristaltic contraction of the rectosigmoid motility. This voluntary contraction occurs only in the minutes prior to defecation, and these muscles are used only occasionally during the rest of the day and night.
Patients with anorecta