Normal Anus Research Articles

Ovarian Cysts in Premenarchal Children

A 20-month-old child with vaginal pain of 3 weeks duration presented to clinic. There was no change in urinary or bowel pattern. She complained of intermittent pain with no relation to time of day. The pain lasts only a few minutes and the patient is distractible. She denied any skin changes pruritus or vaginal discharge and was still in diaper (Pampers). She washes her hair in bath water with Johnson & Johnson soap. Upon physical examination she appeared well and very active alert and happy. Her thyroid was normal. Breasts were at Tanner stage 1 and her abdomen was soft without mass and there was no hepatosplenomegaly. Her perineum was Tanner stage 1 with no erythema. Examination in the frog-legged position revealed no discharge normal hymen normal lower vagina and normal anus. (excerpt)

Surgical repair of rectovestibular fistula with normal anus

Purpose : The aim of this study was to evaluate the authors' surgical approach and technique in patients with congenital rectovestibular fistula with a normal anus (CRF). Methods : During the period between 1981 and 1995, 19 girls from 2 months to 13 years of age were treated surgically for CRF by a primary perineal approach. After appropriate bowel preparation, the patient was placed in a lithotomy position. A probing catheter was placed in the fistula. A perineal transverse skin incision was made on the midpoint between the posterior commissure and the anus, and the underlying tissue was dissected. The fistula was divided, and the both ends were closed by interrupted sutures. The external sphincter muscle was mobilized to interpose between the vestibular and rectal stumps of the fistula. Postoperative feeding was begun on day 6. Results : A protecting colostomy was created in the early 4 patients. Fifteen patients underwent a primary fistula division without colostomy. In thos without colostomy, 1 patient had a reopening of the fistula 6 days after the primary repair. In this patient, colostomy was created, and the fistula was divided 6 months later by the same approach. After a follow-up of 3 to 17 years, all patients have normal bowel habit. Conclusion : A primary perineal approach is appropriate for the treatment of CRF.

Anal Endoscophic Features of Normal Anus in Children

Anal Endoscophic Features of Normal Anus in Children

Rectal atresia: pathogenesis and operative treatment

Rectal atresia (RA) with a normal anus is a rare anomaly mostly described as part of a series of anorectal malformations. Most authors believe it to be an acquired lesion with a vascular genesis. One of the arguments quoted is the lack of other congenital anomalies. Several operative procedures are recommended for this lesion. We describe four patients with RA who had other significant congenital anomalies; two other cases were found in the literature. A lack of other congenital anomalies in patients with RA does not seem to be a strong argument for an acquired lesion. All four patients were treated by a posterior sagittal approach with good functional results.

Anal canal duplication in childhood

Anal canal duplication is an extremely rare abnormality. Two cases in children are reported; in both cases, the orifice of the duplicate tubular structure was located just behind the normal anus and ran along the posterior side of the anal canal without communication with the anorectum. Complete removal of the duplication was performed through a perineal approach. Histology revealed a squamous lining with a smooth-muscle component around the cavity, with mucus-secreting transitional epithelium. Anal ducts with apocrine secretion and lymphocyte infiltration were also observed. The postoperative clinical courses were uneventful with satisfactory anal function. We collected nine similar cases from the literature. The term "anal canal duplication" is proposed based on common clinical features and pathology.

The principles of normal and abnormal hindgut development

In the past, several theories have been proposed to explain the occurrence of anorectal malformations. Most investigators believe that these malformations are the result of an impaired process of septation. However, in 1986 vd Putte challenged all theories that tried to explain anorectal malformations by a faulty fusion of lateral ridges of the cloaca. To elucidate the principles of normal and abnormal cloacal development, the authors studied the morphology of this region in normal embryos of rats and abnormal embryos of SD mice, which often have abnormal cloacas. Using scanning electron microscopy (SEM), 245 normal rat embryos and 80 abnormal SD-mice embryos were observed. The results were as follows. (1) In normal embryos the region of the future anal opening can be identified soon after the establishment of the cloacal membrane. This part is a fixed point in cloacal development. (2) In abnormal embryos the cloacal membrane is too short. The region of the future anal opening is missing. (3) In abnormal embryos a spectrum of malformed cloacas can be observed. This is in accordance with the spectrum of anorectal malformations clinically observed in humans. (4) The authors' observations support recent findings that the “fistula” in anorectal malformations resembles a normal anus at an ectopic position.

Rectal membranous atresia: sutureless endoscopic repair

Rectal atresia with a normal anus is rare, and the choice of the surgical procedure employed for its correction is controversial. A male infant with supralevator-type rectal membranous atresia who had presented with perforation of the sigmoid colon at 2 days of age and subsequently had a sigmoid colostomy for decompression underwent resection of the atretic lesion with the aid of the colonofiberscope at 1 month of age. Bougienage was employed for 6 months after the operation. No functional deficits have been observed, and the infant remains continent.

Congenital urethral fistula with normal anus: A report of two cases

Congenital rectourethral or anourethral fistulae without imperforate anus in males are rare, representing less than 1% of anorectal malformations. We report our experience with two males with “N type” urethral fistulae. One, a 5-year-old boy, presented with recurrent urinary tract infections (UTIs) and passage of urine per anus. Investigations included a voiding cystourethrogram (VCUG), which demonstrated a fistula from the urethra to the anus. On physical examination, a small perianal opening was noted just outside the anus, which drained a small amount of urine after voiding. The fistula was excised via a perineal approach. The second patient is a 5-year-old boy with a long history of recurrent UTI requiring multiple hospitalizations since the newborn period. Chronic renal failure developed as a complication of repeated urinary tract infections. Investigations showed a single hydronephrotic pelvic kidney and a small bladder. He underwent numerous diagnostic and reconstructive procedures including cystoscopy and augmentation cystoplasty. Recurrent infections continued and an N type anourethral fistula was eventually diagnosed. The fistula was located between the anal canal and the membranous urethra. An anterior perineal approach was also used. Both fistulae were easily located, and reconstructive surgery of the urethra was not required. Postoperative VCUGs in both patients were normal. They have been free of infection with normal urinary continence since resection of the fistula. Congenital N type anourethral fistulae are rare, but should be considered in cases of recurrent urinary tract infections. The diagnosis may be missed by endoscopic procedures, but VCUG should demonstrate the fistulous tract.

Anteriorly displaced anus: an under-recognized cause of chronic constipation

Anterior displacement of a normal anus is recognized as a cause of severe constipation in some children. We have reviewed our experience with 13 children treated for this disorder over the past 8 years at the University of Virginia Health Sciences Center. Twelve of the patients were female and the age at the time of operation ranged between 12 months and 9 years. In all patients constipation began in the first 3 to 6 months of life. Symptoms were characterized by marked straining upon passage of stool, often accompanied by perineal pain. All patients had been unsuccessfully treated with agressive use of stool softeners and cathartics. The anus had a normal appearance, although it was located anterior to its normal position in every case. There was no evidence of anal stenosis on digital examination; in each case a large posterior rectal cul-de-sac could be palpated. A barium enema examination disclosed a prominent posterior shelf of the rectum, often with enormous dilation of the colon posteriorly. All patients underwent surgical treatment using a posterior anoplasty with advancement of the posterior rectal wall. In 10 patients a posterior rectal myomectomy was added to the procedure. Pathologic evaluation of the rectal muscle was normal in each instance. Complete relief of constipation was achieved in all patients, with follow-up extending for as long as 6 years. One patient continues to require occasional use of stool softeners. Anterior displacement of the anus is a frequently overlooked, although easily corrected, cause of severe constipation in childhood.

Determination of the normal position of the anus (with reference to idiopathic constipation).

The position of the normal anus was numerically defined by the ano-genital index, which is the distance from the anus to the vagina or scrotum divided by the distance between the vagina or scrotum and the coccyx. In idiopathic constipation, one must look for an anterior displacement of the anus, which might be the cause of the constipation.

Determination of the Normal Position of the Anus (with Reference to Idiopathic Constipation)

SummaryThe position of the normal anus was numerically defined by the ano‐genital index, which is the distance from the anus to the vagina or scrotum divided by the distance between the vagina or scrotum and the coccyx. In idiopathic constipation, one must look for an anterior displacement of the anus, which might be the cause of the constipation.

The perineal groove and canal in males and females--a third look.

We present 5 uncommon cases: One case of perineal canal in a female; two cases of perineal groove in females, one with normal anus and another with ectopic perineal anus. Two cases of perineal canal in males. The canal is deep in the perineum, runs forward above the root of scrotum, close to the floor of the urethra (which is normal), and opens on the undersurface of the penis. One of them is associated with covered anus incomplete with anocutaneous fistula as well opening on the scrotal raphe. In all 5 cases the perineal canal or gutter opens posteriorly in the ectodermal anal canal, immediately below the line of anal valves. A third look to the origin of these conditions will be discussed versus the 1st and 2nd looks of Stephens and Chatterjee. Embryological and histopathological studies will support our point of view.

Rectal atresia: Treatment through a single sacral approach

Rectal atresia (with a normal anus) is a rare abnormality. A boy was operated upon successfully by using a single stage sacral approach, when he was 1 yr old. In the neonatal period he had a colostomy done for decompression. This colostomy was later useful in demonstrating the distance between the two blind pouches of the anal canal and the rectosigmoid segment. He is now perfectly continent without stenosis, 3 yr after the operation. If this procedure could be done in the neonatal period before the colon becomes very dilated, a long term colostomy might be obviated.

Anterior ectopic anus: A common cause of constipation in children

Anterior ectopic anus is increasingly being recognized as a cause of constipation in infancy. Experience is reported with surgical treatment of 20 patients with anterior ectopic anus. This form of anal ectopia is associated with a syndrome of constipation that begins at birth, straining on defecation, and anterior displacement of an otherwise normal anus and sphincter. It is seen almost exclusively in females. Posterior anoplasty with sphincterotomy is curative.

N-type anorectal malformations

Three cases of N-type anorectal malformations have been encountered. Two girls with anorectal-vestibular fistulas (one with a normal anus and the other with mild stenosis) were typical of 15 other such cases in the literature. A boy with an anorectal-urethral fistula and covered anus had a lesser variant than most of the other 8 males in the literature. The frequently accompanying esophageal, renal, and skeletal anomalies were not present, nor did he have anterior urethral hypoplasia. The constellation of other major associated anomalies in the boys, but not in the girls, follows the pattern of other types of anorectal malformations and suggests an earlier and/or more severe teratogenic insult in the boys. Anterior perineal resection of the fistula is appropriate for girls with N-type fistulas and for those boys with normal anterior urethras. An additional urethroplasty is necessary for boys with anterior urethral hypoplasia. Our experience and that from the literature suggest that N-type anorectal malformations constitute a rare but real entity, akin to N-type tracheoesophageal fistulas. A plea is made that they be included in classifications of anorectal anomalies.

Congenital rectovestibular fistula with the normal anus: K. Sai, J. Uchino and Y. Kasai. J Jap Soc Pediatr Surg 11:521–527 (October), 1975

Congenital rectovestibular fistula with the normal anus: K. Sai, J. Uchino and Y. Kasai. J Jap Soc Pediatr Surg 11:521–527 (October), 1975

Position of rectal fistula in relation to the hymen in 46 girls with imperforate anus

Forty-six records of infant girls with so-called imperforate anus have been reviewed to determine the position of the rectal opening in relation to the hymen.Eight of these children proved to have the cloacal deformity, in which the rectum enters high into a single tube and just behind the opening of a double or septate vagina, with the urethra entering anteriorly at the same level. No normal hymen was visible in these eight children.Seventeen patients had a normal-appearing hymen, and no rectal opening on the perineum. In each of these 17 children the rectal opening was found above the tissue flap overlying the posterior vestibule.In the remaining 21 patients, the hymen was visible and appeared normal, and there was a rectal opening somewhere on the perineum between the vestibule and the normal position for the external sphincters.These findings suggest that in the presence of a normal-appearing hymen, and in the absence of a normal anus, the rectal opening will be either in the posterior part of the vestibule or on the perineum. Where no hymen was visible, we have found in a limited experience that the rectal opening was high in the pelvis in some degree of the so-called cloacal deformity.

Anal sphincter-preserving operation for congenital low rectovaginal or rectoperineal fistula

A slight modification of a technic, originally described by Stone, is advocated for correction of low rectovaginal or rectoperineal congenital anomalies in which the external sphincter is preserved. Excellent functional results were obtained in four patients operated upon with this method; and in the fifth patient, operated upon too recently to evaluate the final result, an entirely satisfactory immediate result has been obtained. The advantages of this procedure over that of Rizzoli are that it does not necessitate severance of the perineal body and external sphincter, and the functional and cosmetic appearances approach those of the normal anus.

CONGENITAL ANORECTAL ATRESIA

THE CONGENITAL malformation wherein a normal anus is separated from a blind rectal pouch is classified by Ladd and Gross1as type 4 (fig. 1). It constitutes a small percentage of anorectal anomalies but is reported to bear a high mortality. The following discussion, which concerns only the type 4 anomaly without urogenital fistula, raises the question whether a discarded surgical procedure, transabdominal repair of the defect, may be performed without increased hazard and with satisfactory result. With the risk of deemphasis of the fundamental problem of the structural fault in cases of this malformation, brief mention will be given of the embryologic developments involved (fig. 2). As the cloaca is divided into separate urogenital and intestinal systems at about the seventh week by the urorectal septum, the perineum is formed. The proctodeum develops from the ectoderm, and an external opening is formed by rupture of the anal membrane

Some complications of a colostomy

To fulfill its purpose, a colostomy must function without distress or discomfort and with a minimum amount of attention. There should be no mental hazard associated with an artificial intestinal opening, as otherwise a large proportion of the benefit is lost. Many complications that arise as the result of the operative work or in the care of the colostomy, should be avoided by careful planning of the operative technique and a clear understanding of what is to be expected of the abdominal anus. It is necessary to avoid or lessen the possibility of subsequent accidents if we expect to offer the colostomy as a substitute for a normal anus. A colostomy should be so devised and constructed, and its after-care such that its presence will be only a minor handicap.