Penile Agenesis Associated with Anorectal Malformation and Bilateral Renal Agenesis: A Case Report and a Review of the Literature

ABSTRACT

Penile agenesis is complete absence of the penis in an otherwise normal phenotypic and genotypic male at birth that results from failure of development of the genital tubercle. It is an extremely rare anomaly that may be associated with anomalies in other organ systems, the extent and severity of which may affect the prognosis. The management is challenging and may have far reaching implications for the individual and family. While gender reassignment with bilateral orchidectomy and feminising genitoplasty has been carried out for most patients, significant psychosexual and social issues related to the male identity may occur due to foetal or postnatal sex steroid imprinting. We report a neonate with penile agenesis with bilateral renal agenesis and anorectal malformation.

Congenital Urethrocutaneous Fistula

ABSTRACT

Male congenital urethrocutaneous fistula is an extremely rare anomaly that is commonly associated with chordee or anorectal malformations. It is characterised by an abnormal urethral opening on the ventral aspect of the penis with well-formed distal urethra and meatus at the tip of the glans. The treatment is individualised according to the site of the fistula, associated anomalies and condition of the distal urethra. The principles of hypospadias surgery should be strictly followed.

Rectal biopsy: is it really necessary in anorectal malformations?

AIM OF THE STUDY

The coexistence of Hirschsprung's disease (HD) with anorectal malformation (ARM) is rare but many surgeons still ask pathologists to look for ganglia in the terminal rectum or fistula. In this study, we aimed to highlight the rarity of this association and question the necessity of histological evaluation.

METHODS

After obtaining board review approval, rectal specimens of ARM patients who underwent corrective surgery in the last 8 years were re-analyzed by two blinded pathologists for the presence and structure of ganglia. Clinical and radiological data of patients retrieved from center records and correlated with histopathologic findings.

MAIN RESULTS

67 patients with ARM were identified, distal rectal specimen was obtained in 47. The median age at the time of surgery was 11 months (2 days-59 months). A normal pattern of ganglia was present in 51.1% (24/47), 29.7% (14/47) had aganglionosis and 19.1% (9/47) were inconclusive due to insufficient material. None of the aganglionic specimens showed other histological findings of HD. Patients were followed up regularly in the outpatient colorectal clinic for a median of 87 months (42-117 m). Only 6 experienced severe constipation (3 ganglionic, 2 no biopsy, 1 aganglionic), all of whom responded to a bowel management program, and none developed other manifestations of HD (abdominal distension, failure to thrive or enterocolitis) or required additional surgery.

CONCLUSIONS

Our results strongly suggest that the association of ARM and HD is extremely rare and the practice of searching for ganglia in the distal rectum or fistula of ARM patients should be discouraged to avoid potential misdiagnosis and overtreatment.

Missed or delayed diagnosis of anorectal malformations: a review of the literature, current training and practice in the UK in relation to detection via the NIPE programme

Anorectal malformations (ARMs) are a spectrum of congenital anomalies where there is abnormal development of the anus and rectum. With an incidence of 1:5000 live births and affecting both males and females, these anomalies vary in their appearance and presentation, lack features enabling antenatal detection and should be detected at birth by the examining midwife or within 72 hours through the newborn and infant physical examination (NIPE) screening programme. However, it is recognised that the diagnosis of ARMs can be missed or delayed leading to morbidity and mortality. In the UK, despite the existence of the NIPE screening programme and NICE guidelines, published literature shows that nearly a quarter of ARMs are not diagnosed at birth. This review takes a critical look at the frequency of missed/delayed diagnosis of ARMs at birth, the implications of delayed diagnosis, and the possible reasons for this related to education and training of healthcare professionals involved in newborn examination, focusing on the UK national screening programme for NIPE. We propose a strategy for enhancing detection of ARMs in a timely manner through the existing framework of the NIPE screening programme.

The Importance of Screening for Additional Anomalies in Patients with Anorectal Malformations: A Retrospective Cohort Study

BACKGROUND

In children with anorectal malformations (ARM), additional anomalies can occur within the VACTERL-association. Routine screening is of great importance for early identification and potential treatment. However, uniformity in screening protocols is lacking and only small cohorts have been described in literature. The aim of this study was to assess and describe a unique large cohort of ARM patients who underwent VACTERL screening in the neonatal period.

METHODS

A retrospective mono-center cohort study was performed. Included were all neonates born between January 2000 and December 2020 who were diagnosed with ARM and screened for additional anomalies. Full screening consisted of x-ray and ultrasound of the spine, cardiac and renal ultrasound, and physical examination for limb deformities, esophageal atresia, and ARM. Criteria for VACTERL-classification were predefined according to the EUROCAT-definitions.

RESULTS

In total, 216 patients were included, of whom 167 (77.3%) underwent full VACTERL-screening (66% in 2000-2006 vs. 82% in 2007-2013 vs. 86% in 2014-2020). Median age at follow-up was 7.0 years (IQR 3.0-12.8). In 103/167 patients (61.7%), additional anomalies were identified. Some 35/216 patients (16.2%) fulfilled the criteria of a form of VACTERL-association. In 37/216 patients (17.1%), a genetic cause or syndrome was found.

CONCLUSIONS

The majority of ARM patients underwent full screening to detect additional anomalies (77%), which improved over time to 86%. Yet, approximately a quarter of patients was not screened, with the potential of missing important additional anomalies that might have severe consequences in the future. Forms of VACTERL-association or genetic causes were found in 16% and 17% respectively. This study emphasizes the importance of routine screening.

LEVEL OF EVIDENCE

III.

High molecular diagnostic yields and novel phenotypic expansions involving syndromic anorectal malformations

Evidence suggests that genetic factors contribute to the development of anorectal malformations (ARMs). However, the etiology of the majority of ARMs cases remains unclear. Exome sequencing (ES) may be underutilized in the diagnostic workup of ARMs due to uncertainty regarding its diagnostic yield. In a clinical database of ~17,000 individuals referred for ES, we identified 130 individuals with syndromic ARMs. A definitive or probable diagnosis was made in 45 of these individuals for a diagnostic yield of 34.6% (45/130). The molecular diagnostic yield of individuals who initially met criteria for VACTERL association was lower than those who did not (26.8% vs 44.1%; p = 0.0437), suggesting that non-genetic factors may play an important role in this subset of syndromic ARM cases. Within this cohort, we identified two individuals who carried de novo pathogenic frameshift variants in ADNP, two individuals who were homozygous for pathogenic variants in BBS1, and single individuals who carried pathogenic or likely pathogenic variants in CREBBP, EP300, FANCC, KDM6A, SETD2, and SMARCA4. The association of these genes with ARMs was supported by previously published cases, and their similarity to known ARM genes as demonstrated using a machine learning algorithm. These data suggest that ES should be considered for all individuals with syndromic ARMs in whom a molecular diagnosis has not been made, and that ARMs represent a low penetrance phenotype associated with Helsmoortel-van der Aa syndrome, Bardet-Biedl syndrome 1, Rubinstein-Taybi syndromes 1 and 2, Fanconi anemia group C, Kabuki syndrome 2, SETD2-related disorders, and Coffin-Siris syndrome 4.

Atrésie rectale membraneuse: présentation tardive à propos d’un cas

L´atrésie rectale et la sténose rectale sont des formes rares de malformations anorectales représentant seulement un à deux pourcent des cas vus. Nous rapportons un cas d´atrésie rectale. Il s´est agi d´un nouveau-né de sexe féminin accouché à terme par voie basse pesant 3600g à la naissance qui était admis à J6 de vie pour absence d´émission de méconium, ballonnement abdominal et fièvre. L´examen avait permis de noter une température à 39^ºC, un abdomen distendu, un anus normalement situé et perméable, laissant prolabée une masse bien rosée, sans signe de nécrose. L´introduction d´un stylet entre la masse et la muqueuse rectale butait à environ 3cm de la marge anale. La radiographie de l´abdomen sans préparation montrait des anses distendues et des niveaux hydro-aériques sans signe de perforation d´organes creux. Devant la suspicion d´une atrésie rectale membraneuse complète, une ponction avec un cathéter 16 gauge à travers la membrane avait ramené le méconium dont l´aspiration d´une quantité abondante de méconium avait permis un affaissement considérable de l´abdomen. Nous avons ensuite réalisé une exérèse chirurgicale de la membrane. Les suites opératoires immédiates ont été simples et le nouveau-né était sorti à J3 post opératoire de l´hôpital. Des dilatations anales ont été faites pour traiter une sténose anale. Avec un recul de 6 mois, le résultat est excellent. L´atrésie rectale présentée sous forme d´absence d´émission de méconium associée à une masse prolabée par l´anus ne semble pas encore décrite. La ponction à travers la membrane rectale atrésique a permis de confirmer le diagnostic. La résection de la membrane donne de bons résultats.

Functional constipation or redundancy of the colon?

OBJECTIVES

Constipation is a common problem in children, and most of the time, the cause is defined as functional. Our hypothesis is that children with functional refractory constipation had anatomic alterations of the colon.

METHODS

All children with chronic refractory constipation who visited our centre underwent accurate clinical examination, contrast enema (CE), anorectal manometry (ARM) and rectal suction biopsies (RSB). In case of functional constipation, three operators measured the size of the colon using radiograms and calculated the ratio based on the width of the second lumbar vertebra. The measurements carried out were compared with those reported in the literature on patients of the same age without constipation.

RESULTS

Over a period of 24 months, 69 patients with chronic refractory constipation, aged between 1 and 14 years, visited our department. A CE was performed on 67, and 2 were excluded because of anal stenosis. Sixty-five underwent anorectal manometry. Rectal suction biopsies were needed in 14 children, and 2 of them were found to have colonic aganglionosis. After a complete evaluation, 57 (82.61%) patients were diagnosed having functional constipation. By comparing the data of the patients with those of normal children reported by the other authors, we found that none of the measurements was statistically significant except for the rectosigmoid length: the mean value in one-year-old patients was 19.03 vs. 9.75, and in older children, it was 19.46 vs. 9.59.

CONCLUSIONS

Recognizing an anatomic anomaly in patients suffering from functional constipation is important for specific treatment, especially when the ratio (rectosigmoid length/L2) is higher than 15.

No-fistula vs. fistula type anorectal malformation: Outcome comparative study

INTRODUCTION

Anorectal malformation (ARM) is a congenital defect that exists in varying presentations and no-fistula type (NFT) ARM is a rare high-type category. We aim to report our experience with management of this anomaly and its outcome, compared to the more common fistula-type (FT) ARM.

METHODS

A retrospective review of medical records of patients diagnosed with high ARM and 3years and older, for the period between September 2000 and January 2015 was conducted. Demographic, anatomic, and outcome data were obtained for each group and compared. Quality of life data were collected using the Krickenbeck classification and assessed as documented at clinic visits as well as phone interviews.

RESULTS

There were 100 patients managed for ARM during that period and were 3years or older. Sixteen of them were NFT (16%). For comparison purposes each NFT patient was matched with 3 FT patients. We have analyzed data on 44 patients with FT (44 males), and 16 with NFT (12 males and 4 females). The occurrence of Down syndrome in NFT patients was 56.2% compared to 0% in the FT patients (p=<0.0001). Quality of Life data showed no significant differences between the two groups with p-values of 0.39, 1.0, and 1.0 for Voluntary Bowel Movement, Soiling, and Constipation respectively.

CONCLUSION

NFT ARM represents a significant number at our population (16%). There is a strong association between NFT ARM and Down syndrome. NFT ARM has similar outcomes compared to the FT ARM.

TYPE OF STUDY

Clinical research paper.

LEVEL OF EVIDENCE

Level III.

Underdiagnosis of Mild Congenital Anorectal Malformations

OBJECTIVE

To determine whether the frequency and severity of congenital anorectal malformations (CARMs) differs by sex.

STUDY DESIGN

We included 129 patients (0-319 weeks old) diagnosed with CARMs, who had been referred to our Department of Pediatric Surgery between 2004 and 2013. Rectoperineal and rectovestibular fistulas were classified as mild CARMs, all others as severe. If a patient was diagnosed with CARM within 48 hours after birth, this was considered an early diagnosis, all others as late.

RESULTS

Seventy-five (58%) girls and 54 (42%) boys were diagnosed with different forms of CARM. More patients had mild rather than severe forms of CARM (67% and 33%, respectively, P <.001). We found that 89% of girls had a mild form of CARM, whereas 65% of boys had severe forms (P <.001). All severe forms were diagnosed early, whereas 54% mild forms were diagnosed early and 46% were diagnosed late.

CONCLUSIONS

Girls more often have mild forms of CARM, whereas boys more often have severe forms. Overall, the distribution across the sexes is equal. Because chronic constipation can be the only symptom of mild CARMs, it often requires more time to diagnose than severe forms. Many women are, therefore, diagnosed with CARMs at an older age, or they may go undiagnosed altogether. Subsequently, these women have a greater risk of full rupture during vaginal delivery.

Anorectal malformation with rectobladder neck fistula: A distinct and challenging malformation

BACKGROUND

Rectobladder neck fistula is the highest and most complex anorectal malformation in boys and the only one that requires an abdominal approach, open or laparoscopic, for repair. The aim of this study was to describe the unique characteristics of rectobladder neck fistulas that warrant special attention and to describe the associated anatomic variants in the genitourinary tract.

METHODS

The database of a tertiary medical center was retrospectively reviewed for all patients treated for rectobladder neck fistula, by our team in 1980-2011. Data on surgical history, associated and functional defects, treatment and outcome were collected by chart review.

RESULTS

The study group included 111 patients. The most common anatomic urologic defect was a single kidney in 37 patients (33.3%) and the most common functional urologic defect was vesicoureteral reflux in 40 patients (36%), including 11/37 patients with a single kidney (29.7%). Of the 40 patients who underwent cystoscopy, 16 (40%) had a higher than normal location of the verumontanum. Follow-up ranged from 2 to 290months (median 59). Urinary continence was achieved in 40 of the 61 patients (65.5%) for whom data were available, and fecal continence was achieved in 9 of the 69 patients (13%) for whom data were available. A sacral ratio of 0.4 or less was associated with lower rates of urinary control (23%) and fecal control (0%), relative to higher ratios. Twenty stomas (18%) were found to be located too distally, limiting the availability of the bowel for a pull through.

CONCLUSIONS

Rectobladder neck fistula carries a poor prognosis for bowel control and is associated with a high rate of urinary malformations that require long-term care. Pediatric surgeons need to be aware of these complications in order to provide proper treatment and parental counseling. Intra-vesical verumontanum is found in a surprisingly high percentage of patients. The combination of a single kidney with vesicoureteral reflux is common and should be closely followed to avoid renal deterioration. Special attention should be given to colostomy construction to avoid complications and unnecessary procedures. A sacral ratio of 0.4 or less is an indicator of poor fecal and urinary control.

Anorectal emergencies

Anorectal emergencies refer to anorectal disorders presenting with some alarming symptoms such as acute anal pain and bleeding which might require an immediate management. This article deals with the diagnosis and management of common anorectal emergencies such as acutely thrombosed external hemorrhoid, thrombosed or strangulated internal hemorrhoid, bleeding hemorrhoid, bleeding anorectal varices, anal fissure, irreducible or strangulated rectal prolapse, anorectal abscess, perineal necrotizing fasciitis (Fournier gangrene), retained anorectal foreign bodies and obstructing rectal cancer. Sexually transmitted diseases as anorectal non-surgical emergencies and some anorectal emergencies in neonates are also discussed. The last part of this review dedicates to the management of early complications following common anorectal procedures that may present as an emergency including acute urinary retention, bleeding, fecal impaction and anorectal sepsis. Although many of anorectal disorders presenting in an emergency setting are not life-threatening and may be successfully treated in an outpatient clinic, an accurate diagnosis and proper management remains a challenging problem for clinicians. A detailed history taking and a careful physical examination, including digital rectal examination and anoscopy, is essential for correct diagnosis and plan of treatment. In some cases, some imaging examinations, such as endoanal ultrasonography and computerized tomography scan of whole abdomen, are required. If in doubt, the attending physicians should not hesitate to consult an expert e.g., colorectal surgeon about the diagnosis, proper management and appropriate follow-up.