9-Month-Old Male Patient with Anorectal Malformation without Fistula

Case Summary

• 9-mo-old male presents for evaluation. He was diagnosed with anorectal malformation without fistula and underwent a colostomy at birth.
• Family sent a photo of the colostomy and of the perineum. Purulent secretions were visible and draining from the perineum. The family cleansed the perineum and then took a photo of the anatomy to send to the physician.
• On physical exam, the scrotum showed evidence of a meconium tract.
• Parents observed increased drainage in the perineum, fever, and pain. A hole was visible in the perineum with surrounding infection.
• Cystourethrogram and distal colostogram were performed.
• Based on the studies, there was concern for recto-urethral fistula then the contrast exits through the perineum.
• Irrigations through the distal stoma and oral antibiotics were initiated and the symptoms improved.
• Since the symptoms improved, the parents discontinued the irrigations. His symptoms returned with pain, fever, and purulent discharge. Daily irrigations through the distal stoma and oral antibiotics were restarted in preparation for surgery.
• Posterior sagittal approach was used for surgery. Rectum and a perineal abscess were visible. A subcutaneous tract into the pelvic fat was visible through the sphincter. This tract was formed by the perineal abscess.
• Dissection of the subcutaneous tract caused partial damage to the skin. The hole was repaired with interrupted vicryl sutures.
• Perineal body was opened to resect a perineal fistula tract near the scrotum.

Takeaways

• In patients without anorectal malformation, when a distal stoma study and voiding cystourethrogram (VCUG) are performed it is important to remember it can give the impression that there is a rectal urinary fistula. It can appear this way because the rectum and the urethra share a common fascia.
• Almost all the patients born with anorectal malformation can be diagnosed by examining the perineum. In female patients, vestibular fistula, cloaca, and perineal fistula are diagnosed by physical exam.
• This patient was born with a perineal fistula.
• Even when a mucous fistula is present, the bowel is not sterile, produces mucous, and contains bacteria.
• This patient did not have any history of urinary tract infection.
• It is important to treat the local infection prior to performing the posterior sagittal anorectoplasty.
• Sometimes rectogram is performed through the perineal fistula to determine if the rectum is dilated.