e 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.
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