ANORECTAL MALFORMATION

ANORECTAL
MALFORMATION
VIJI VS
LECTURER
KIMS COLLEGE OF NURSING
INTRODUCTION
• Anorectal malformations are wide spectrum of developmental deformities

involving distal anus and rectum as well as genital tract.
• This condition affects both boys and girls
• The incidence is 1 in 5000 live births.
DEFINITION
• Anorectal malformations refer to anomalies of the rectum and distal anus,

the urinary tract and the genital tract.
ETIOLOGY
• The exact causes is unknown
• It associated with many other conditions such as downs syndrome,

undescended testis, congenital heart disease, oesophageal atresia and neural
tube defect.
PATHOPHYSIOLOGY
• During 8th week of embryonic period, the membrane which separates the
endodermal hindgut from the anal dimple perforates and a canal is formed.
• The outlet of the canal is anus.

• If the membrane is not absorbed and canal is not formed, anorectal
anomalies occur.
• There may be fistula formed between the rectum and vagina or perineum in
female and between rectum and the urinary tract, scrotum or perinium in
male.
CLASSIFICATION
• Anomalies were classified as per their location into three categories such as
high, intermediate and low
• High- the terminal end of the bowel remaining above the levator ani
muscle(pelvic floor).
• Intermediate- the terminal end of the bowel remaining within the levator
ani muscle(pelvic floor).
• Low- the terminal end of the bowel remaining below the levator ani
muscle(pelvic floor).
• Anal stenosis- refers to the presence of strictures at the anus, at 1-4cm

above the anus or extend the entire length of the anus.
• Anal atresia—obstruction caused by persistent anal membrane.
• Rectal atresia- normal anus and anal pouch with the rectal pouch ending
blindly in the hollow of rectum.
• Anal agenesis- imperforated anus-a dimple with a rectal pouch ending

blindly above the anus and fistula between rectum and another area.
• Rectoperineal fistula- abnormal connection between rectum and perineum
• Rectovaginal fistula- abnormal connection between rectum and vagina

where stool passes through vagina
• Cloaca- a common channel of rectum, urethra and vagina that opens into
perineum via usual urethral site.
Anal atresia Rectal Atresia

CLINICAL FEATURES
• No obvious anal opening found on examination
• Absence of meconium
• A gloved finger or thermometer cannot be inserted into infants rectum
• Progressive abdominal distension
• Passage of stools through fistula
• Association of other anomalies like cardiac, tracheoesophageal, vertebral,-

• -radial, renal and limb anomalies.
• History of difficult defecation, abdominal distension and ribbon like stool in

older child in case of anal stenosis
DIAGNOSTIC TESTS
• Physical examination-no anal opening, a gloved finger or thermometer

cannot be inserted into the child’s rectum
• No history of passage of meconium
• Presence of abdominal distension

• Presence of meconium in urine, indicating rectovaginal fistula
• Abdominal Ultrasound scan to locate the rectal pouch and to detect

associated urinary tract anomalies.
• Invertogram-a type of abdominal x-ray which is used to find the extent of

anal or rectal atresia
• Micturating cystourethrogram- a scan that shows how well your child’s

bladder works
• Intravenous pyelogram-to exclude vesicoureteral reflux

MANAGEMENT
• Surgical management is the primary treatment
• Reconstructive surgery is done to correct or repair of congenital

malformations.
• It depends upon the type of anomaly and sex of the infants
• In case of low ARMs, where there is less than 1.5cm distance between the
anal dimple and the rectal pouch, rectal cut back anoplasty or y-v anoplasty is
done for male infants and dilatation of fistula with definitive repair or perineal
anoplasty is performed for female infants.
• An anoplasty is used to repair minor anal defects (a perineal fistula) in both
male and female patients.
• In both male and female patients, the goal of the procedure is to move the
anal orifice back and place it within the bounds of the external sphincter
which is the lowest part of the funnel-like sphincter mechanism.
• This procedure consists of making a deep cut in the posterior wall and the
sphincter and suturing rectal wall to the skin.
• In case of high or intermediate ARMs, where there is more than 1.5cm
distance between the anal dimple and the rectal pouch, initial colostomy is
done in the neonatal period followed by definitive reconstructive surgery as
posterior sagittal anorectoplasty (Pena’s procedure)at the age of 10-
12months or when the infant is having 7 to 9 kg body weight.
• In this PSARP procedure the rectum is pulled down and opened at normal
anatomic site.
• After 2 weeks post operatively, anal calibration is performed followed by a

program of anal dilatations.
• The anus is dilated twice daily and every week, the size of dilator is
increased, depending upon the age of patient.
• The dilatations will help to prevent the scar tissue from closing the newly
created anus.
• Once the desired anus is formed and healed, the colostomy is closed.
• Colostomy closure is done after 10 to 12 weeks of successful definitive

surgery.
PSARP
• In case of anal membrane atresia, the membrane is perforated with a blunt
instrument.
• Repeated dilatation might be necessary to prevent scar formation.
• In case of anal stenosis, repeated dilatation is done using Hegar’s dilator

every 4 to 6 months.
• In case of fistulas, colon can be brought down through the anal by an

abdomino-perineal procedure.
• The anus is positioned in the area of external sphincter and the fistula is
removed.
NURSING MANAGEMENT
Nursing assessment: Pre-operative
• Examining the anal opening, site of fistula
• Check for any signs of intestinal obstruction(abdominal distention)
• Monitor hydration and nutritional status
Pre-operative management
• Gastric suction should be done.

• Withhold oral feeds
• Start IV fluids
• Measurement of abdominal girth to detect abdominal distension
• Maintain intake-output chart
• Get the consent from parents
• Administer pre operative medications

Nursing assessment: Post-operative
• Assess the integrity of the skin covering the texture, colour, skin
temperature.
• Observe for any signs of infection
• Observe the patterns of elimination
• Monitor the general condition of the patient
Post-operative management
• Scrupulous perineal care

• Change perineal dressings whenever soiled
• Apply protective ointments such as zinc oxide to decrease irritation
• Position the baby in side-lying or supine position with the legs suspended at
a 90 degree angle to the trunk to prevent pressure on perineal sutures.
• Continue IV fluids till the wound heals or until peristalsis appear.
• Prevention of constipation by exclusive breastfeeding and proper weaning

with stool softeners or fibres.
• Bowel habit training

• Daily enemas until controls have achieved if necessary.
• Do not use diaper in in case of anoplasty
• Colostomy care by changing the collection bag and meticulous skin care
• Administer medications as per doctors order
• Family psychological support and teaching home care after discharge.
• Explain the techniques of anal dilatation at home if prescribed.

COMPLICATIONS
• Urinary tract infections
• Intestinal obstructions
• Fecal impaction
• Anal stenosis, Recurrence of fistula
• Poor bowel control
• Constipation
• Colostomy related problems

NURSING DIAGNOSIS
Pre-operative
• Impaired bowel elimination r/t structural defect of rectum
Nursing Interventions
• Withhold oral feeds
• Do gastric compression with NG tube
• Start IV fluids
• Carryout pre-operative orders

• Fluid volume deficit r/t restriction of oral feeds
• Administer IV fluids
• Observe vital signs regularly
• Maintain intake out put chart
Post Operative
• Acute pain related to surgical incision

• Administer analgesics as per doctors order
• Do not spread the legs or place in supine position to avoid strain in the
suture site
• Keep the legs suspended at 90 degree angle to the trunk
• Prevent constipation by restarting breastfeeding when peristalsis appears
• Risk for infection r/t tissue injury at surgery
• Follow strict aseptic techniques while handling the baby
• Keep the sutured site clean
• Apply zinc oxide ointment to prevent skin irritation
• Monitor for signs of infection
• Do not use diaper
• Change the dressing often
• Administer antibiotics if prescribed
• Change colostomy bag soon as it soiled

OTHER NURSING DIAGNOSIS
• Impaired skin integrity r/t presence of colostomy
• Delayed growth and development r/t physical defect
• Impaired family process r/t care of the child with surgical repair
• Imbalanced nutritional status less than body requirement r/t inadequate

intake secondary to anorectal defect

ANORECTAL MALFORMATION

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ANORECTAL

• Anorectal malformations are wide spectrum of developmental deformities

• This condition affects both boys and girls

• The incidence is 1 in 5000 live births.

• Anorectal malformations refer to anomalies of the rectum and distal anus,

• The exact causes is unknown

• It associated with many other conditions such as downs syndrome,

• The outlet of the canal is anus.

• Anal stenosis- refers to the presence of strictures at the anus, at 1-4cm

• Anal agenesis- imperforated anus-a dimple with a rectal pouch ending

• Rectoperineal fistula- abnormal connection between rectum and perineum

• Rectovaginal fistula- abnormal connection between rectum and vagina

Anal atresia Rectal Atresia

• No obvious anal opening found on examination

• A gloved finger or thermometer cannot be inserted into infants rectum

• Progressive abdominal distension

• Passage of stools through fistula

• Association of other anomalies like cardiac, tracheoesophageal, vertebral,-

• History of difficult defecation, abdominal distension and ribbon like stool in

• Physical examination-no anal opening, a gloved finger or thermometer

• No history of passage of meconium

• Presence of abdominal distension

• Abdominal Ultrasound scan to locate the rectal pouch and to detect

• Invertogram-a type of abdominal x-ray which is used to find the extent of

• Micturating cystourethrogram- a scan that shows how well your child’s

• Intravenous pyelogram-to exclude vesicoureteral reflux

• Surgical management is the primary treatment

• Reconstructive surgery is done to correct or repair of congenital

• It depends upon the type of anomaly and sex of the infants

• After 2 weeks post operatively, anal calibration is performed followed by a

• Colostomy closure is done after 10 to 12 weeks of successful definitive

• Repeated dilatation might be necessary to prevent scar formation.

• In case of anal stenosis, repeated dilatation is done using Hegar’s dilator

• In case of fistulas, colon can be brought down through the anal by an

• Examining the anal opening, site of fistula

• Check for any signs of intestinal obstruction(abdominal distention)

• Monitor hydration and nutritional status

• Gastric suction should be done.

• Measurement of abdominal girth to detect abdominal distension

• Maintain intake-output chart

• Get the consent from parents

• Administer pre operative medications

• Observe for any signs of infection

• Observe the patterns of elimination

• Monitor the general condition of the patient

• Scrupulous perineal care

• Apply protective ointments such as zinc oxide to decrease irritation

• Continue IV fluids till the wound heals or until peristalsis appear.

• Prevention of constipation by exclusive breastfeeding and proper weaning

• Bowel habit training

• Do not use diaper in in case of anoplasty

• Administer medications as per doctors order

• Family psychological support and teaching home care after discharge.

• Explain the techniques of anal dilatation at home if prescribed.

• Urinary tract infections

• Anal stenosis, Recurrence of fistula

• Poor bowel control

• Colostomy related problems

• Impaired bowel elimination r/t structural defect of rectum

• Withhold oral feeds