Sacral agenesis: why is it so frequently misdiagnosed?

A Case Report of a Colorectal and Caudal Duplication Syndrome Associated with Caudal Regression Syndrome

We describe an uncommon clinical presentation of caudal duplication syndrome and features of caudal regression syndrome in a female infant with complex urogenital and colorectal duplication associated with lipomyleomeningocele and left lower limb hypoplasia. A staged surgical treatment plan was carried out to maintain fecal and urine continence, potential fertility, and cosmetic appearance.

Neurogenic Bowel Dysfunction in Children and Adolescents

Neurogenic/neuropathic bowel dysfunction (NBD) is common in children who are affected by congenital and acquired neurological disease, and negatively impacts quality of life. In the past, NBD received less attention than neurogenic bladder, generally being considered only in spina bifida (the most common cause of pediatric NBD). Many methods of conservative and medical management of NBD are reported, including relatively recently Transanal Irrigation (TAI). Based on the literature and personal experience, an expert group (pediatric urologists/surgeons/gastroenterologists with specific experience in NBD) focused on NBD in children and adolescents. A statement document was created using a modified Delphi method. The range of causes of pediatric NBD are discussed in this paper. The various therapeutic approaches are presented to improve clinical management. The population of children and adolescents with NBD is increasing, due both to the higher survival rate and better diagnosis. While NBD is relatively predictable in producing either constipation or fecal incontinence, or both, its various effects on each patient will depend on a wide range of underlying causes and accompanying comorbidities. For this reason, management of NBD should be tailored individually with a combined multidisciplinary therapy appropriate for the status of the affected child and caregivers.

Sacral agenesis and fecal incontinence: how to increase the index of suspicion

PURPOSE

Sacral abnormalities range from missing the coccyx, a few sacral vertebrae, or hemi-sacrum, to complete absence with fused iliac bones. The purpose of this study was to review the association between sacral agenesis and fecal incontinence to help inform patient prognosis.

METHODS

A retrospective review was performed of patients who presented for bowel management due to sacral agenesis at a tertiary care children's hospital between 2016 and 2017 (n = 10). Data collection included: gender, time of diagnosis, sacral ratio, and associated anomalies. Patients with anorectal malformation and sacrococcygeal teratomas were excluded.

RESULTS

Four patients were female. Seven patients had a delayed diagnosis ranging from 22 months of age to 9 years. Most common symptoms included failure of age-appropriate toilet training and severe diaper rash. The sacral ratio was zero (6), 0.3 and 0.4 (2), and hemi-sacrum (2). Associated anomalies were present in five patients.

CONCLUSION

Sacral abnormalities should be suspected in patients who present with early severe diaper rash and those who fail to toilet train. An abdominal radiograph can evaluate the sacrum, when the sacral ratio is 0.4 or less, parents should be counseled regarding fecal incontinence and neurogenic bladder.

Cloning and characterization of an inversion breakpoint at 6q23.3 suggests a role for Map7 in sacral dysgenesis

Here we report on a male patient with sacral dysgenesis (SD) and constitutional pericentric inversion of chromosome 6 (p11.2;q23.3). SD is a heterogeneous group of congenital anomalies with complex genetic etiology. Previously, a patient with sacral abnormalities and an interstitial deletion of 6q23-->q25 region has been described. We speculated that a susceptibility gene for SD lies in 6q23.3 region (disrupted in both patients), and therefore, cloning of the breakpoint in our patient would lead to the identification of the disrupted gene. We performed FISH analysis followed by Southern blot analysis and inverse PCR to clone the breakpoint. The 6p11.2 breakpoint mapped very close to the centromere, and the 6q23.3 breakpoint localized in the ninth intron of the MAP7 gene. We then evaluated the involvement of MAP7 in SD by further screening of the gene in several patients with a similar phenotype. Two nucleotide changes causing Ile257Asn and Glu571Ala substitutions in the protein, both affecting amino acid residues conserved in the mouse homolog, were identified in two patients. Both changes are either very rare polymorphisms or true mutations, since they were not detected in 167 normal individuals nor found in the SNP database. Therefore, our study suggests MAP7 as a candidate gene for SD. However, we were unable to detect any sacral defects in the MAP7 knockout mice.

Urinary incontinence and vesicourethral dysfunction in pediatric surgical conditions

The most common cause for urinary incontinence in children with pediatric surgical conditions of the pelvic region and perineum is lower urinary tract dysfunction caused by concomitant sacral agenesis, especially in children with anorectal malformations. Another common cause is iatrogenic pelvic nerve damage secondary to reconstructive surgery. Moreover, an intrinsically altered pelvic floor anatomy as seen in some cases of complex cloacas, or disruption of pelvic floor muscles with consecutive loss of supportive structures, as in sacrococcygeal teratoma, should also be taken into consideration. It is important to understand that the causes of urinary incontinence in these children are not isolated problems concerning only the urinary tract. They may have the same negative impact on anorectal function as they have on the bladder and urethral sphincter. Therefore, children with pediatric surgical conditions of the pelvic and perineal region often will present with a combination of both fecal incontinence caused by anorectal dysfunction and urinary incontinence caused by vesicourethral dysfunction. The additional morbidity caused by urinary incontinence may have an enormous impact on the patient's life and well being, not only with regard to physical disability, but also in terms of emotional problems, social handicap, and socioeconomic burden. It is obvious that a patient's quality of life will be significantly reduced if he or she suffers from both fecal and urinary incontinence. Therefore, an integrated approach to the management of both vesicourethral and anorectal dysfunction should be developed to achieve the optimum care for these children.

Sacral agenesis in siblings

Sacral agenesis is a rare congenital abnormality of the lower vertebral column which is frequently associated with neurological, orthopedic as well as urological malformations. With regard to the incidence of the anomaly, although approximately 200 cases have been reported previously, the occurrence of sacral agenesis in siblings has only rarely been found. To date only two pairs of siblings have been reported. Herein we present 2 siblings with partial sacral agenesis and emphasize the need for a careful family investigation, early diagnosis and appropriate treatment.

Case reports of malformations associated with maternal diabetes: history and critique

Several malformations and malformation complexes have been alleged to be associated with maternal type 1 diabetes mellitus: in particular, sacral dysplasia, caudal regression/sirenomelia, femoral dysplasia, and holoprosencephaly. For some of the malformations the claim rests on case material, and for others on theoretical considerations. The history and evolution of these ideas are presented.

Diagnosis and treatment of neurogenic bladder due to partial sacral agenesis

Fifteen patients with partial sacral agenesis were treated over a mean period of 68 months. Partial unilateral agenesis was present in 7 and bilateral sacral agenesis was present in 8. Three important diagnostic features are emphasised: symptoms referable to neurogenic bladder without an obvious neurogenic lesion (all 15 patients); skin or hair abnormalities in the lumbosacral region (9/15) and paraesthesia or other neurological disorders of the lower extremities (8/15). The definitive diagnosis can be made by careful inspection of a plain film of the lumbosacrum. Detrusor contractility was absent in 13 patients but preserved in 2; 11 patients were managed by clean intermittent catheterisation, 2 voided using detrusor contractility and 2 voided by means of the Valsalva/Credé manoeuvre. In 5 patients surgery in the intradural space preserved sexual function and prevented further deterioration in function of the lower extremities but could not restore bladder function that had already deteriorated. Complete continence was achieved in 11 patients and socially acceptable continence in 4. Early diagnosis and conservative treatment with clean intermittent catheterisation are extremely important in management. Should functional deterioration of the bladder and/or sensomotor function of the lower limbs occur, neurosurgery should be performed promptly.