Case Summary
Case Overview, Part 1
- 2-year-old male presents for evaluation due to constipation. Mother sent a photo of the perineal anatomy to be evaluated by the pediatric colorectal surgeon.
- Anorectal malformation with perineal fistula was suspected based on physical exam.
- Studies to obtain for workup for his anorectal malformation included abdominal radiograph, contrast enema, renal ultrasound.
- Anus accommodated a size 15 Hegar dilator.
- Patient was offered bowel management and no surgical intervention.
- He has been successful with enemas of 300 mL normal saline, 20 mL glycerin and 10 ml Castile soap.
Case Overview, Part 2
- 9-month-old presents for evaluation for constipation.
- Anus accommodated a size 14 dilator, and the patient was identified to have a perineal fistula.
- Studies that should be completed as part of the workup include abdominal radiograph, contrast enema, renal ultrasound, voiding cystourethrogram and spinal MRI.
Takeaways
Recto-perineal fistula with or without surgery will continue to have constipation throughout life.
Surgery for perineal fistula will not prevent future constipation.
With an anus that accommodates the appropriate size of hegar dilator size, surgical intervention is not mandatory.
On physical exam, the reddish discoloration of the skin shows the limits of the sphincter.
Patients with perineal fistula may be managed with laxatives as they typically have good prognosis for bowel control. The exception to this is if the patient has a technically deficient surgery or the presence of a presacral mass.
An anterior anus is defined as within the sphincter but anterior. This is not a common malformation.
Surgery for perineal fistula is indicated if the anal orifice is narrow as determined by calibrating with a hegar dilator.
Patient Case Discussion