ema. The program, although simplistic, is implemented by trial and error over a period of one week. The patient is seen each day and an x-ray film of the abdomen is taken so that they can be monitored on a daily basis for the amount and location of any stool left in the colon, as well as the presence of stool in the underwear. The decision as to whether the type and/or quality of the enemas should be modified as well as changes in their diet and/or medication can be made daily .
Approximately 75% of all patients with anorectal malformations have voluntary bowel movements . About 50% of them have voluntary bowel movements, but soil their underwear occasionally. Episodes of soiling are usually related to constipation, and when constipation is treated properly, the soiling frequently disappears. Approximately 40% of the group have voluntary bowel movements and never soil, thus making them totally continent. 25% of patients suffer from fecal incontinence and must receive a bowel management regimen to artificially keep them clean.
Once the diagnosis of the specific defect is established, the functional prognosis can be rapidly predicted, which is vital in order to avoid raising false expectations in the parents. Factors such as the status of the spine, sacrum, and perineal musculature affect the counseling of the parents. Patients with a hypodeveloped sacrum are much more likely to be incontinent and a hypodeveloped sacrum is also a good predictor of associated spinal problems such as tethered cord. If the patient's defect is of the type pointing to a good prognosis such as vestibular fistula, perineal fistula, rectal atresia, rectourethral bulbar fistula, or imperforate anus without fistula, one should expect that that child will have voluntary bowel movements by the age of 3. Such children need supervision to avoid fecal impaction, constipation, and soiling. If a patient's defect points to a poor prognosis, such as a high cloaca (common channel greater than 3 cm) or a recto-bladder neck fistula, the parents should be informed of the likelihood that that child will need a bowel management program to remain clean, which should be implemented at the age of 3 or 4. Patients with rectoprostatic fistulas have almost equal chance of having voluntary bowel movements or being incontinent. Toilet training should be attempted at age 3, and if unsuccessful, a bowel management program should be initiated. Each year, during summer vacation, an attempt should be made to try to achieve bowel control, and if unsuccessful, the bowel management should be restarted. As the child grows older and more cooperative, the likelihood of achieving bowel control will improve.
Urinary incontinence occurs in male patients with anorectal malformations only when they have an extremely defective or absent sacrum, or when the basic principles of surgical repair are not followed and important nerves are damaged during the operation. The overwhelming majority of male patients have urinary control. This is also true for female patients, not including the cloaca group.
For patients with cloaca, functional prognosis with regard to achieving fecal continence depends on the complexity of the defect and the status of the spine and sacrum. Urinary control varies based on the length of the common channel. 69% of patients with cloaca with a common channel greater than 3 cm require intermittent catheterization, as compared to 20% in the group with a common channel less than 3 cm. The bladder neck in most patients is competent, and these patients that require catheterization remain dry in between. If catherization is not performed, overflow incontinence occurs. Occasionally, the bladder neck is not competent or is non-existent, and in these cases, urinary diversion such as a Mitrofanoff procedure is considered.
Careful, regular follow-up is necessary in these patients to accurately reassess their prognosis and to avoid problems, which can dramatically impact on their ultimate functional result.
Pena A, Devries PA: Posterior sagittal anorectoplasty: important technical co