Colostomy versus anoplasty
The decision to perform an anoplasty during the early newborn period or to delay the repair and perform a colostomy is based on physical examination findings in the newborn, the appearance of the perineum, and changes that occur during the first 24-36 hours of life.
Operating earlier and in a single stage is potentially beneficial to the patient, but this should be decided carefully, based on the specific circumstances of the newborn and the experience of the surgeon. A more conservative approach is warranted in neonates with low birth weight and associated cardiac or respiratory conditions.
The indications for colostomy versus anoplasty for newborn boys are as follows:
Anoplasty - Rectoperineal fistula
Colostomy - Rectobulbar urethral fistula, rectoprostatic urethral fistula, rectobladderneck fistula, imperforate anus without fistula, rectal atresia
The indications for colostomy versus anoplasty for newborn girls are as follows:
Anoplasty - Rectoperineal fistula, rectovestibular fistula
Colostomy - Imperforate anus without fistula, persistent cloaca, rectal atresia, rectovaginal fistula
Decision-making in newborn boys with anorectal anomalies
In 80-90% of newborn boys, clinical evaluation and urinalysis provide enough information for the surgeon to decide whether a colostomy is required.
After birth, an intravenous line is placed for fluids and antibiotics. A nasogastric tube is inserted to keep the stomach decompressed to avoid the risk of vomiting and aspiration.
Meconium is not usually observed at the perineum in a newborn with rectoperineal fistula until at least 16-24 hours of life. Abdominal distension does not develop during the first few hours of life but is required to force meconium through a rectoperineal fistula, as well as through a urinary fistula. This is because the most distal part of the rectum in these children is surrounded by a funnel-like voluntary muscle structure that keeps part of the rectum collapsed and empty. The intra-abdominal pressure must be high enough to overcome the tone of the muscles that surround the rectum to force meconium through the fistula. Therefore, the decision to perform a colostomy or an anoplasty must be delayed for 16-24 hours while the surgeon evaluates for clinical evidence of the newborn’s anorectal anomaly.
Clinical inspection of the buttocks is important. A flat bottom or flat perineum, as evidenced by the lack of a midline gluteal fold and the absence of an anal dimple, indicates that the patient has poor muscles in the perineum. These findings are associated with a high malformation; therefore, a colostomy should be performed.
Perineal signs found in patients with low malformations include the presence of meconium at the perineum, a bucket-handle malformation (ie, a prominent skin tag located at the anal dimple, below which an instrument can be passed), and an anal membrane (through which meconium is visible).
Newborn boys with rectoperineal fistula do not require a colostomy. They can undergo a posterior sagittal anoplasty.
Newborn boys with evidence of a rectourinary tract communication should undergo fecal diversion with a colostomy.
If none of the clinical signs to reveal the location of the anorectal anomaly are evident by 24 hours, obtaining radiographs can help. This situation is necessary in only approximately 10% of patients. Obtain cross-table lateral radiographs with the newborn prone, with the pelvis elevated, and with a radiopaque marker placed on the perineum (see the image below). Rarely, radiography reveals the column of air in the distal rectum to be within 1 cm of the perineum; in these instances, treatment is similar to that for rectoperineal fistula, and a newborn perineal operation may be performed. If the air column is more than 1 cm from the perineum, a colostomy is indicated.
Cross-table lateral radiograph of a patient in which the air column in the distal rectum can be observed close to the perineal skin.
A definitive repair in the newborn period avoids a colostomy; however, because the surgeon does not know the precise anorectal defect, the urinary tract is at considerable risk. To definitively determine the patient's anorectal defect, perform distal colostography, which requires the presence of a colostomy. Without this information, an operation in the newborn period is, essentially, a blind perineal exploration. The surgeon may not be able to locate the rectum and may find and damage other unexpected structures (eg, posterior urethra, seminal vesicles, vas deferens, ectopic ureters) during the search for the rectum. Finally, without fecal diversion, the risk of dehiscence and infection exists. These complications may compromise the chance of achieving bowel function.
The rare exception occurs when the cross-table lateral radiograph obtained at 16-24 hours reveals that the rectum is located below the coccyx. In this case, the rectum may be reliably reached from the posterior sagittal approach.
Obtain urinalysis and place gauze over the penis to reveal the presence of fecal matter in the urine, which is considered evidence of a rectourinary fistula.
Abdominal ultrasonography must be performed to evaluate for the presence of an obstructive uropathy. At the same time, spinal ultrasonography may be performed to evaluate for spinal anomalies, including the presence of a tethered cord.
Methods to reveal the location of the distal rectum before 16 hours of life are flawed because of the contracted state of the rectum within the funnel-like sphincter mechanism. Typically, the funnel-shaped muscle structure is contracted unless overcome with a distending force. Tests such as MRI, ultrasonography, CT scanning, or injection of contrast through the perineum locate the distal rectum as falsely high in the pelvis.
Distal colostography (typically obtained 1 mo after colostomy opening) must have adequate pressure to demonstrate a fistula from the rectum to the urinary tract. If pressure is inadequate, this method also falsely locates the distal rectum as high in the pelvis.
Once the patient recovers from colostomy and demonstrates good growth and development, the definitive operation can be planned for 4-12 weeks later.
Decision-making in newborn girls with anorectal anomalies
The decision to perform a colostomy is less complicated in newborn girls. In 90% of patients, a meticulous perineal inspection demonstrates the anorectal defect. Waiting 16-24 hours for enough abdominal distension to demonstrate the presence of a rectoperineal fistula or rectovestibular fistula also applies to newborn females.
The most common anomaly in newborn girls is a rectovestibular fistula. Perineal inspection reveals a typical urethra, typical vagina, and another orifice, which is the rectal fistula in the vestibule.
In newborns with clinical evidence of a rectovestibular fistula, a diverting colostomy is the safest option for surgeons without extensive experience in anorectal anomalies. Colostomy prior to the main repair avoids the complications of infection and dehiscence. Definitive repair of this anomaly in the newborn period should be reserved for surgeons who have significant experience repairing these defects. Once this anomaly is repaired, patients have an excellent prognosis; therefore, complications that may affect continence must be avoided.
Patients with rectovestibular fistulas in whom primary repair failed in the newborn period are the most common referrals for re-operations to tertiary centers that care for anorectal anomalies. Occasionally, the fistulas are large enough to decompress the gastrointestinal tract. They may be dilated to facilitate fecal drainage until the baby is older and a definitive repair is performed. Definitive repair involves a posterior sagittal approach. The most delicate part of this operation is the separation of the rectum and vagina, which share a common wall.
As in boys, newborn girls may also have a rectoperineal fistula, which requires an anoplasty procedure in the newborn period.
Similar to boys, the rectum location is not clinically evident in less than 5% of newborn girls after 24 hours. They may have imperforate anus with no fistula. Cross-table lateral radiography should be performed, which helps determine the need for a colostomy.
The presence of a single perineal orifice in a patient is clinical evidence of a persistent cloaca (see the image below). See for details regarding treatment of a persistent cloaca. In patients with a persistent cloaca, abdominal examination may reveal a mass that likely represents a distended vagina (hydrocolpos), which is present in 50% of patients with persistent cloaca. Abdominal ultrasonography is helpful to reveal the presence of an obstructive uropathy and hydrocolpos.
Perineum of a newborn with persistent cloaca. Note the single perineal orifice.
During the perineal inspection, newborn girls are commonly given an incorrect diagnosis of imperforate anus with rectovaginal fistula; however, all 3 structures (ie, urinary tract, vagina, rectum) actually meet in a common channel, and the baby has persistent cloaca. This misconception carries important therapeutic implications.
Making the correct determination is vital, because 90% of newborns with persistent cloaca have an associated urologic problem and 50% have hydrocolpos. The urinary tract and distended vagina both may require treatment in the newborn period to avoid serious complications.
Missing the diagnosis of persistent cloaca commonly means that an obstructive uropathy is overlooked. The patient may then receive only a colostomy, resulting in subsequent sepsis, acidosis, and, occasionally, death.
The other implication of missing the diagnosis of persistent cloaca involves repairing only the rectal component of the anomaly, leaving the patient with a persistent urogenital sinus.
Types of urinary tract malformations are as follows:
Renal agenesis
Vesicoureteral reflux
Neurogenic bladder
Renal dysplasia
Megaureter
Hydronephrosis
Ectopic ureter
Imaging Studies in Newborn Period
The radiologic evaluation of a newborn with imperforate anus includes abdominal ultrasonography to evaluate for urologic anomalies. In patients with persistent cloaca, a distended vagina (hydrocolpos) may be identified.
Plain radiography of the spine may reveal spinal anomalies, such as spina bifida and spinal hemivertebrae.
Plain radiography of the sacrum in the anterior-posterior and lateral projections may demonstrate sacral anomalies, such as a hemisacrum and sacral hemivertebrae. In addition, the degree of sacral hypodevelopment may be assessed, and a sacral ratio can be calculated by measuring the distances between key bony structures (see the image below).
Calculation of the sacral ratio.
Spinal ultrasonography in the newborn period and up to age 3 months (at which point the sacrum ossifies) may be performed to find evidence of a tethered spinal cord and other spinal anomalies.
Cross-table lateral radiography may help demonstrate the air column in the distal rectum in the small percentage of patients in whom clinical evidence does not delineate the likely anorectal anomaly in 16-24 hours.
Imaging Studies After Newborn Period
High-pressure distal colostography is performed on an outpatient basis, after the colostomy has been created. Hydrosoluble contrast material is injected into the distal stoma to demonstrate the precise location of the distal rectum and its likely urinary communication.
Hydrostatic pressure under fluoroscopic control is required. A Foley catheter is placed in the mucous fistula, and the 3-cm3 balloon is inflated and pulled back to occlude the stoma during contrast injection. The hydrostatic pressure must be high enough (manual syringe injection) to overcome the muscle tone of the striated muscle mechanism that surrounds the rectum and keeps it collapsed. This is the best way to demonstrate a rectourinary communication and determine the rectum's true height.
The contrast material usually fills the proximal urethra and bladder through the fistula. The injection is continued until the child voids, and pictures are taken during micturition to reveal, in a single picture, the sacrum, rectum height, perineum, fistula location, bladder, vesicoureteral reflux (if present), and urethra. When colostography is performed correctly, voiding cystography and cystoscopy are not necessary.
Colostography is vital in determining the anatomy to plan definitive repair. In 10% of patients, the fistula is at the level of the bladder neck; in these instances, during the main repair, the surgeon knows that the rectum can be found only through the abdomen, and a combined posterior sagittal and abdominal or laparoscopic approach is used.
The anorectal defect of imperforate anus without fistula may also be demonstrated with this radiologic evaluation. Occurring in approximately 5% of patients, imperforate anus without fistula has a good functional prognosis and is common in individuals with Down syndrome.
In most newborn girls with anorectal malformations (except for those with persistent cloaca), distal colostography is not necessary because the fistula is clinically evident.
If the spine was not evaluated with ultrasonography in the newborn period, magnetic resonance imaging is necessary after age 3 months to exclude the presence of tethered cord and other spinal anomalies.
Approach Considerations
Indications for surgical treatment (colostomy vs anoplasty) are discussed more fully elsewhere (see
Presentation). No absolute contraindications to surgery exist. The presence of associated malformations, such as prematurity and congenital cardiac disease, often postpones definitive colorectal reconstruction.
Potential methods of evaluation for anorectal malformations, including prenatal diagnosis and genetic karyotyping to reveal familial disposition, are areas of rapid advance.
Medical Therapy
Associated malformations must be addressed.
Genitourinary defects
Approximately 50% of all patients with anorectal malformations have an associated urogenital anomaly, which commonly varies with the type of anorectal defect.
A list of anorectal defects and the percentages of patients with associated urogenital anomalies is as follows:
Persistent cloaca - 90%
Rectobladderneck fistula - 84%
Rectoprostatic urethral fistula - 63%
Rectovestibular fistula - 47%
Rectobulbar urethral fistula - 46%
Rectoperineal fistula - 26%
Imperforate anus without fistula - 31%
All patients must be examined at birth for these defects; the most valuable screening test is abdominal and pelvic ultrasonography. Urologic evaluation prior to colostomy provides the surgeon the necessary information to address the urologic problem if needed.
Tethered cord
A tethered spinal cord refers to the intravertebral fixation of the phylum terminale. Tethered cord has a known association with anorectal malformation; approximately 25% of patients with anorectal malformation have a tethered spinal cord. The prevalence of this anomaly increases with increasing height and complexity of the anorectal anomaly. In addition, patients with a hypodeveloped sacrum and associated urologic problems are more likely to have tethered cord. Motor and sensory disturbances of the lower extremities may result.
Patients with anorectal malformations and tethered cord have a poorer prognosis for bowel and urinary function; they also have higher anorectal defects, less-developed sacra, other spinal problems, and less-developed perineal musculature. The actual impact of tethered cord alone on functional prognosis remains unclear.
The neurosurgical literature indicates that untethering the cord avoids motor and sensory problems. No evidence suggests that this operation affects the functional prognosis of patients with anorectal malformation, but may improve bladder emptying capacity.
Spinal ultrasonography in the first 3 months of life and magnetic resonance imaging (MRI) thereafter are useful radiologic modalities to establish the diagnosis.
Sacral and spinal defects
The sacrum is the most commonly affected bony structure. Traditionally, the number of sacral vertebral bodies was counted to evaluate the degree of sacral deficiency. A more objective assessment of the sacrum may be obtained by calculating a sacral ratio. The sacrum is measured and its length is compared with bony parameters of the pelvis (see the image below). The lateral view is more accurate than the anteroposterior view because its calculation is not affected by pelvic tilt.
Calculation of the sacral ratio.
Assessment of sacral hypodevelopment correlates with the patient's functional prognosis. Normal sacra have a calculated sacral ratio greater than 0.7. Bowel control has rarely been observed in patients with calculated sacral ratios of less than 0.3. Hemisacrum is almost always associated with a presacral mass (teratomas or anterior meningoceles). Hemivertebrae may also affect the lumbar and thoracic spine, predisposing to scoliosis.
Patients may have spinal anomalies other than tethered cord, such as syringomyelia and myelomeningocele.
Surgical Therapy
As discussed previously, the surgeon must decide in the newborn period whether the child requires fecal diversion with a colostomy or if a primary procedure is possible.
Colostomy
A descending colostomy with separated stomas is recommended. The advantages of this type of colostomy include the following:
Only a small portion of distal colon is defunctionalized, but with an adequate amount of rectosigmoid for the future pullthrough
Washing and cleaning the portion of the colon distal to the colostomy is relatively easy
Distal colostography is easy to perform
The separated stomas prevent spillage of stool from proximal to distal bowel, which avoids impacted distal stool and urinary tract infections
Prolapse with this technique is uncommon; proximal stoma prolapse in a normally rotated colon should not occur with this technique, because the colon is well fixed to the retroperitoneum just before the colostomy rises to skin level; because the distal stoma is in a mobile portion of the colon, it may prolapse; the distal stoma must intentionally be made small, both to avoid prolapse and because it is used only for irrigations and radiologic studies
When performing a colostomy in the newborn, the distal bowel should be irrigated to remove all the meconium. This prevents formation of a megasigmoid, which may lead to constipation after the colostomy ultimately gets closed.
Colostomy errors include the following:
Too-distal sigmoidostomy - In this most common error, the colostomy is placed too distal and interferes with the pullthrough procedure
Right upper sigmoidostomy - Instances of inadvertent sigmoid colostomy placed in the right upper quadrant during an attempt to perform a transverse colostomy have occurred. Inadvertent anchoring of the sigmoid in the right upper quadrant interferes with the pullthrough procedure
Incomplete diversion of stool - A loop colostomy does not divert the stool completely and allows for distal stool impaction and urinary tract infections
Megarectum - Transverse colostomies may produce megarectum, due to passage and accumulation of mucus
Definitive repair
Repair of an anorectal malformation requires a meticulous, delicate technique and a surgeon with experience in treating these defects. The posterior sagittal approach is ideal for defining and repairing anorectal anomalies.
Anorectal abnormalities in 90% of newborn boys may be repaired solely with a posterior sagittal approach, whereas 10% require an additional abdominal component (with laparotomy or laparoscopy) to mobilize a very high rectum. All anorectal malformations in newborn girls may be repaired with the posterior sagittal approach, with the exception of approximately 30% of instances of persistent cloaca. In this 30%, the rectum or vagina is high enough to also require an abdominal approach.
A Foley catheter is placed first; then, patients are placed in the prone position with the pelvis elevated.
The posterior sagittal incision length varies depending on the anorectal defect. Perineal fistulas are repaired with a minimal posterior sagittal incision that is large enough to divide the external sphincter and to mobilize the anus back to the center of the sphincter complex. The sphincter mechanism is always located posterior to the fistula site. This operation may be performed in the neonatal period without a protective colostomy.
The posterior sagittal approach is based on the fact that nerves do not cross the midline. Remaining exactly in the midline, the surgeon preserves the innervation of all the important pelvic structures.
An electrical stimulator helps reveal the location of the sphincteric mechanism. The parasagittal fibers, the muscle complex, and the levators are identified during the dissection. The external sphincter is represented by muscle fibers that run parallel to the midline in a parasagittal fashion. A muscle structure termed the levator mechanism lies medial to these fibers and represents the lower end of the funnel-like voluntary muscle.
The levator mechanism extends in continuum down to the skin, but this was not known prior to the use of the posterior sagittal approach. Electrically stimulated, the parasagittal fibers elicit a contraction that results in shortening of the same fibers. The rectum pushes forward toward the pubic bone when the upper portion of the levators are stimulated. Stimulating the lower part of the funnel-like muscle structure elevates the anal dimple. This group of muscle fibers, termed the muscle complex, extends from the levator mechanism down to the skin and is located immediately medial to the parasagittal fibers.
The surgeon opens posterior sagittally. The skin and subcutaneous tissue are divided, and the parasagittal fibers below are divided in the midline, as is the muscle complex. The levator muscle is then opened, and the rectum is found, except in patients with a true supralevator malformation (10% of cases), in whom the surgeon will instead find a genitourinary structure with this approach.
When the rectum is located, its posterior wall is opened in the midline to demonstrate the presence of a fistula. This posterior incision in the rectum is carried down to the fistula site. The rectum and urethra share a common wall. Meticulous dissection is required to separate the distal rectum from the urethra. A submucosal dissection must be performed in the first 5 mm above the fistula site.
The rectum is separated from the urinary tract. This dissection is facilitated through placing multiple 6-0 silk sutures in the rectal mucosa to exert uniform traction. The opening in the urethra is then closed with absorbable suture.
Once the rectum is separated, it is then mobilized down to reach the perineum by circumferentially dividing the bands and vessels that hold the rectum up in the pelvis. The intramural blood supply of the rectum is excellent; therefore, the rectum remains viable. Because the newborn depends on this intramural blood supply, preventing damage to the rectal wall is vital.
Once the rectum is fully mobilized, the size of the rectum and the available space must be assessed. The rectum occasionally requires tapering to fit the limits of the sphincteric mechanism. The tapering should take place on the posterior wall so that the suture lines of the tapered rectum and the closed urethral fistula do not lie next to each other.
The rectum is placed in the limits of the sphincter mechanism, which is reconstructed around it in the midline. The rectum is sutured to the perineal skin (anoplasty).
In 10% of newborn boys with this defect, the rectum enters the urinary tract at the bladderneck level. The repair of this malformation involves a posterior sagittal incision and an abdominal component. The distal rectum is separated from the urinary tract, mobilized, and pulled through to lay within the sphincteric funnel. The pathway is just under the coccyx and sacrum in the area of the pelvic retroperitoneum.
To mobilize the rectum off of the bladderneck, an abdominal component is required via laparoscopy or laparotomy. The fistula is ligated with great care to avoid injuring the ureters and vas deferens: the plane of dissection must be made close to the bowel wall of the rectosigmoid, 2-3 cm above the peritoneal reflection. The rectum is then mobilized for adequate length to reach the perineum without tension.
The fistula is divided and sutured with absorbable material. The rectum is passed through to the posterior sagittal incision and an anoplasty is performed. This part can be done with legs lifted up, remaining in supine position.
In patients with imperforate anus without fistula, the same meticulous dissection is required to separate the distal rectum from the urinary tract as in patients with rectourinary fistulae, because the rectum and urethra still share a common wall.
In patients with rectovestibular fistula, the posterior sagittal incision may be shorter than in newborn boys with rectourethral fistulae. Often, the entire levator mechanism does not need to be divided; only the external sphincter, muscle complex, and part of the lower portion of the levator mechanism require division. The rectum and posterior vagina share a common wall; this separation is the most difficult part of the operation. Once the rectum is completely mobilized, the perineal body is constructed, and the rectum is placed within the limits of the sphincter mechanism.
A rare malformation, rectal atresia, occurs in 1% of patients. The anal canal is normal, and, externally, the anus appears typical. However, a blockage exists 1-2 cm from the anal skin and is usually found when the nurse tries to pass a thermometer. These babies should undergo colostomy at birth; definitive repair involves a posterior sagittal approach and an anastomosis between the posterior rectum and the anal canal. This defect is particularly associated with a presacral mass, which must be sought.
Postoperative Details
Postoperative management
The posterior sagittal incision is relatively painless.
In patients with a rectourethral fistula, the Foley catheter usually stays in place for approximately 5-7 days.
If the colostomy is untouched during the operation and laparotomy or laparoscopy was not necessary, oral feedings may be started immediately postoperatively. If a laparotomy or laparoscopy was necessary, the patient may require a period of fasting and nasogastric decompression.
At 2 weeks after surgery, anal calibration is performed, followed by a program of anal dilatations. The anus must be dilated twice daily, and the size of the dilator is increased every week. The final size to be reached depends on the patient’s age. Once the desired size is reached, the colostomy may be closed. Dilatations are continued afterward according to a prescribed protocol. Dilatations are a vital part of postoperative treatment to avoid an anoplasty stricture.
After colostomy closure, severe diaper rash is common, because the perineal skin has never before been exposed to stool.
Postoperative functional disorders
Constipation is the most common problem encountered after treatment for imperforate anus. It is the most important problem to avoid after definitive repair in newborn girls with rectovestibular or rectoperineal fistula and in newborn boys with rectobulbar urethral fistula, imperforate anus without fistula, and rectoperineal fistula. Failure to avoid constipation may result in megarectum and megasigmoid and can lead to fecal impaction and overflow incontinence. See
Bowel Management for further discussion.
The origin of the constipation problem is unknown. Originally, the perirectal dissection was believed to cause a degree of denervation that resulted in constipation. However, on careful review of the largest patient series, those with the most benign defects (ie, the least amount of perirectal dissection) experienced the worst constipation.
The presence of a megarectum prior to the pull-through procedure correlates with postoperative constipation. Megarectum is more common in patients who underwent a transverse or loop colostomy during the newborn period.
Constipation appears to be a hypomotility disorder secondary to chronic bowel dilatation; alternatively, the hypomotility may cause the dilatation. Dilatation causes constipation, creating a vicious cycle. Patients who have undergone an older operation, an abdominoperineal operation for imperforate anus that included rectum resection, are prone to develop diarrhea because of lack of a rectal reservoir. Incontinence in these patients is much more difficult to treat because stool constantly passes (see
Bowel Management).
Occasionally, constipation becomes so severe that patients develop chronic fecal impaction and constant soiling. These patients are often referred to as having fecal incontinence. However, if the patient has a type of anorectal anomaly with a good prognosis, this incontinence is often overflow pseudoincontinence. Once the constipation is treated, the patient regains continence.
When constipation is severe and the patient has a megasigmoid (and the patient is fecally continent), resection of the sigmoid has been found to dramatically reduce the patient's laxative requirements. The descending colon with normal caliber and motility is anastomosed to the rectum at the peritoneal reflection. This procedure is useful for the select group of patients who require enormous amounts of daily laxatives to keep their colons clean. The rectal reservoir should be preserved to avoid the problem of diarrhea-related incontinence.
Complications
Complications of surgery include dehiscence and infection, which may be avoided with colostomy before the main repair. These complications may compromise the chance of achieving typical bowel function.
With inadequate preoperative anatomic information, the urinary tract is at considerable risk because the surgeon does not know the precise anorectal defect and if the surgeon approaches a low rectum transabdominally, they risk leaving behind the very distal rectum, which becomes a posterior urethral diverticulum.
Long-Term Monitoring
The key in these patients is to treat constipation proactively and, if possible, avoid it after the pull-through procedure altogether. Patients must be regularly monitored, and laxatives and dietary manipulations are begun at the first sign of constipation.
Patients may experience soiling. This may represent fecal incontinence in patients with very high imperforate anus or in those with poor muscles and an abnormal sacrum. These patients require a bowel management program (see
Bowel Management). However, in a patient with a good prognosis, soiling may represent overflow incontinence, and constipation must be treated.
The child’s bowel movement pattern before toilet-training may provide important information concerning the potential for continence. For example, a 1-year-old child who has undergone a pullthrough procedure for imperforate anus and has one to three discrete bowel movements per day has good potential for future fecal continence. Signs of feeling are demonstrated while the child is pushing during a bowel movement.
On the other end of the spectrum, a child who has fecal incontinence passes stool constantly without evidence of pushing or feeling. Whereas a child with a typical bowel movement pattern is trainable, a child with the pattern of fecal incontinence likely requires a bowel management program with a daily enema. The child with true fecal incontinence should not be expected to achieve voluntary bowel control.
