ISSN - 0973-0958

Pediatric Oncall Journal

Anorectal malformations: beyond the imperforate anus 07/03/2023 00:00:00

Anorectal malformations: beyond the imperforate anus

Beatriz Vieira1, Joana Pinho2, Vilma Lopes2, Marina Amaral3, Céu Rosinha3, Pinho de Sousa3, Vinhas da Silva4, Joana Pereira3, Andreia Teles4.
1Pediatric Department, Centro Hospitalar Póvoa de Varzim/Vila do Conde, Póvoa de Varzim, Portugal,
2Pediatric Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal,
3Pediatric Surgery Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal,
4Neonatology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.

Beatriz Vieira, Serviço de Pediatria, Centro Hospitalar da Póvoa de Varzim/Vila do Conde, Póvoa de Varzim. Largo da Misericórdia, 4490-421 Póvoa de Varzim, Portugal.
Anorectal malformation, Colonic atresia, Imperforate anus, VACTERL association
Anorectal malformations (ARMs) constitute a significant portion of congenital anomalies in pediatric surgery (1/2000-5000 live births).1,2,3
ARMs encompass a broad range of defects1,4, varying from relatively minor ones, which can be easily treated and carry an excellent functional prognosis, to complex cases that are challenging to manage and often accompanied by other anomalies, resulting in a less optimistic prognosis.4
In 50% of children with ARMs, associated anomalies have been reported: genitourinary anomalies (40-50%), cardiac anomalies (30-35%), spinal anomalies (25-30%), gastrointestinal problems (5-10%) and VACTERL anomalies (4-9%).1,5,6,7
A retrospective descriptive study was performed, involving the review of clinical files of neonates with ARMs admitted to a Neonatal Intensive Care Unit of a portuguese level II hospital over a 5-year period (January 31, 2017 to January 31, 2022).
7 neonates were diagnosed with ARMs accounting for 0.09% of all births (1/1163 live births), a higher incidence than reported in the literature.1,2,3 We found a predominance in females (4), contrary to what was reported.2,3,5
As described8, we also reported that vestibular fistula (2) was the most frequent ARM in female patients. We encountered one case of a complex cloaca spectrum malformation, which was previously deemed rare but now ranks as the third most common defect in females.2 In our sample we had 2 newborns with colonic atresia (CA), a rare entity and the least common type among cases of intestinal atresia.9,10 In fact, only 9 cases of CA associated to ARM were described in literature. Additionally, one of our cases presented a combination of CA and VACTERL with ARM, an exceedingly rare incidence, with only a single similar case described. Furthermore, we identified 3 cases of VACTERL association, an exceptionally rare condition.11
As expected, since it remains infrequent and occurs in merely up to 16% of cases12, none of our cases had a confirmed prenatal diagnosis of ARM. However we had some findings on prenatal ultrasound (hydramnios, hydronephrosis and intestinal distention) that should leave us alert to that possibility.
As described, in most of our cases (6/7), the anus remains unperforated and the lower intestinal segment may terminate blindly or form a connection via a fistula with the urinary or genital tract or perineum.11
Regarding associated anomalies, our incidence (87.7%) was higher than what is typically reported. The genitourinary and cardiac anomalies were, as expected, the most common.
A multi-step approach was performed with a protective colostomy in the early postnatal, followed by a delayed repair (5 to 19 months later) using a posterior sagittal anorectoplasty, which provided in most cases a good functional result. The less favorable outcomes resulted mainly from the other associated anomalies and not exactly from the ARM/surgical repair.
We are aware that children with an ARM face the potential for gross motor function issues, particularly when accompanied by major comorbidities1,13, but we only detect that in one case.
Given that our study reports only the cases in the last 5 years, we still do not have the ideal follow-up time to realize all the outcomes that may arise.
Compliance with Ethical Standards
Funding None
Conflict of Interest None
  1. Gangopadhyay AN, Pandey V. Anorectal malformations. J Indian Assoc Pediatr Surg. 2015;20(1):10-15. DOI:10.4103/0971-9261.145438.  [CrossRef]  [PubMed]  [PMC free article]
  2. Wood RJ, Levitt MA. Anorectal Malformations. Clin Colon Rectal Surg. 2018 Mar;31(2):61-70. DOI: 10.1055/s-0037-1609020.  [CrossRef]  [PubMed]  [PMC free article]
  3. Kapapa M, Becker N, Serra A. Risk factors for anorectal and associated malformations in German children: A 10-year analysis. Pediatr Neonatol. 2021 Jan;62(1):97-105. DOI: 10.1016/j.pedneo.2020.09.008.  [CrossRef]  [PubMed]
  4. Levitt MA, Peña A. Anorectal malformations. Orphanet J Rare Dis. 2007 Jul 26;2:33. DOI: 10.1186/1750-1172-2-33.  [CrossRef]  [PubMed]  [PMC free article]
  5. Zwink N, Jenetzky E, Brenner H. Parental risk factors and anorectal malformations: systematic review and meta-analysis. Orphanet J Rare Dis. 2011 May;6:25. DOI:10.1186/1750-1172-6-25.  [CrossRef]  [PubMed]  [PMC free article]
  6. DeMeo SD, Izatt S, Goldberg RN. A Newborn with an Anorectal Malformation. J Pediatr 2013;163:1220-1. DOI: 10.1016/j.jpeds.2013.05.016.  [CrossRef]  [PubMed]
  7. Sood MR. Functional constipation in infants, children, and adolescents: clinical features and diagnosis. UpToDate 2021. Accessed March 2022. Available at:
  8. Bischoff A, Bealer J, Peña A. Controversies in anorectal malformations. Lancet Child Adolesc Health. 2017 Dec;1(4):323-330. doi: 10.1016/S2352-4642(17)30026-3.  [CrossRef]  [PubMed]
  9. Cabrera Valerio C, Díaz Z, Alcántara E, et al. Colonic atresia: a rare entity in the newborn. A six-case report and a bibliographic review. Cir Pediatr. 2021 Apr 1;34(2):74-78. English, Spanish. PMID: 33826259.
  10. El-Asmar KM, Abdel-Latif M, El-Kassaby AA, et al. Colonic Atresia: Association with Other Anomalies. J Neonatal Surg. 2016;5(4):47. DOI:10.21699/jns.v5i4.422.  [CrossRef]  [PubMed]  [PMC free article]
  11. Alamo L, Meyrat BJ, Meuwly JY, et al. Anorectal Malformations: Finding the Pathway out of the Labyrinth. Radiographics. 2013 Mar-Apr;33(2):491-512. DOI: 10.1148/rg.332125046.  [CrossRef]  [PubMed]
  12. Bischoff A, Levitt MA, Lim FY, et al. Prenatal diagnosis of cloacal malformations. Pediatr Surg Int. 2010 Nov;26(11):1071-5. DOI: 10.1007/s00383-010-2685-3.  [CrossRef]  [PubMed]
  13. van den Hondel D, Sloots CE, Gischler SJ, et al. Prospective long-term follow up of children with anorectal malformation: growth and development until 5years of age. J Pediatr Surg. 2013 Apr;48(4):818-25. DOI: 10.1016/j.jpedsurg.2012.09.068.  [CrossRef]  [PubMed]


Cite this article as:
Vieira B, Pinho J, Lopes V, Amaral M, Rosinha C, Sousa P d, Silva V d, Pereira J, Teles A. Anorectal malformations: beyond the imperforate anus. Pediatr Oncall J. 2024;21. doi: 10.7199/ped.oncall.2024.11
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