After the Pull-Through: Urologic Concerns in Anorectal Malformations  ::  Nationwide Children's Hospital

After the Pull-Through: Urologic Concerns in Anorectal Malformations

After the pull-through procedure and colostomy closure, many parents feel that the stress is now behind them. But they must realize that the new focus should then move to the treatment of constipation and urologic management. The bowels are ideally managed with diet, fiber, a Senna-based laxative, or in some cases, enemas at an early age. Urologic care at this point is vital to ensuring good renal health. There are a few things you should keep in mind as your child with ARM ages.

Growth and Development

Contrary to popular belief, there is no evidence to suggest that patients with ARM should be small or have delayed growth. However, for children with ARM, growth curves must be carefully monitored. Constipation, bowel irritation, multiple surgeries, anatomic bowel problems and kidney and bladder issues can all impact growth and development.  It is never too early for a nutritional evaluation. 

Ideally, parents should know in what percentile their child falls for height and weight. Endocrinology and nephrology evaluations may be necessary when growth is not progressing as expected. 

Urologic Monitoring

The Center for Colorectal and Pelvic Reconstruction has devised a urologic monitoring plan for patients with ARM. Children with a cloacal malformation are somewhat different and will have a different testing plan. Your surgeon will be able to tell you the location of the fistula and the type of ARM your child has which guides the evaluation and correlates with the incidence of associated urologic issues. 

Males with rectoperineal fistula or rectoprostatic fistula and females with rectoperineal fistula or rectovestibular fistula (with or without vaginal atresia) can expect the following urologic examinations: 

  • A kidney and bladder ultrasound at birth, three months after colorectal repair and at the time of toilet training
  • voiding cystourethrogram (VCUG) 
  • If there is any swelling of the kidney on the ultrasound or a urinary tract infection (UTI), a VCUG is particularly important 
  • Renal lab tests to assess kidney function after birth and after colorectal repair
  • Possible long-term urology follow-up or yearly evaluations 

Males with a rectobladder neck fistula can expect the following urologic monitoring: 

  • Ultrasound of the kidneys and bladder at birth and before and after colorectal repair
  • A VCUG at the time of the rectobladder neck fistula diagnosis and after colostomy closure
  • Baseline renal labs at birth and blood tests after 18 months of age
  • Long-term urology management and follow-up

Males and females with a tethered cord can expect the following: 

  • Blood tests and kidney and bladder ultrasounds at birth and prior to colorectal repair
  • Urodynamic study at one year of age to assess bladder function, repeated as necessary
  • Yearly follow-up with the urologist through toilet training 

Toilet Training

Many people are under the mistaken impression that toilet training is delayed in a child with ARM. While bowel management with enemas is sometimes necessary to allow the child to be clean and not require diapers, the control of the bladder should not be delayed. For more information about toilet training with ARM, click here

Urodynamics

There has been much discussion and debate as to when and why to obtain urodynamics. The purpose of urodynamic studies is to find out whether a child has a neurogenic bladder.  For more information on urodynamics, click here

Urinary Tract Reconstruction

There are several conditions that require urinary tract reconstruction. You should investigate a surgeon's experience specifically with children with ARM, as urinary tract reconstruction in children with ARM is very different from a standard reimplant surgery or even a reconstruction in a child with spina bifida. For the types of urinary tract reconstruction, click here

Conclusions

The careful monitoring of children with ARM for potential urologic complications is necessary during infancy and early childhood. Collaborative efforts among related specialty physicians can ensure a holistic approach to diagnosis and treatment of children with ARM. 

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At Nationwide Children’s, every child diagnosed with a colorectal condition is handled with an individualized treatment plan. For more information or to request an appointment, please contact us.

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