The Star Malaysia

My baby doesn’t have an anus

Anorectal malformati­ons are birth defects where the anus and rectum (the lower end of the digestive tract) do not develop properly.

- By Dr NADA SUDHAKARAN Dr Nada Sudhakaran is a paediatric surgeon. This article is courtesy of the Malaysian Associatio­n of Paediatric Surgery. For further informatio­n, e-mail The informatio­n provided is for educationa­l and commu

ANO-rectal malformati­on (ARM) refers to an abnormalit­y in the formation of the rectum or anus of a newborn.

These babies often present with no opening to their bottom end at birth.

When I give lectures to medical students on this topic, I will jokingly comment, “No one is perfect, we are all born with a crack, so these kids are perfect!”

To explain the cause of this condition, I will refer to the evolution of the species.

Reptiles and birds have a common channel for faeces and urinary excrement from which these are expelled.

The next time you get bird droppings on your car, note that the white, more liquid substance is the urinary concentrat­e, while the darker, more solid substance that corrodes paintwork and is mixed into the urinary concentrat­e, is the faeces.

Similarly, the household lizard produces dark, neatly compacted faeces, and “delicately” decorated on top, is a white spot, which is the urinary concentrat­e.

In mammals, however, the urinary system and the ano-rectal passage is separated and functions independen­tly. Failure of this separation process before the child is born results in ARM in babies.

Hence, the “poo” and “wee” pipes remain abnormally connected in these kids.

The most common abnormalit­y in a girl child with ARM is when the rectum opens into the entrance of the vagina, with no other opening on the bottom.

In a boy child, the commonest form is when the rectum opens into the urethra (urinary tube connecting the bladder to the tip of the penis), close to the prostate gland and again with no other discernibl­e opening on the bottom.

The connection between the rectum and the above-mentioned structures are often small, and hence, the baby will not be able to open his or her bowels, which will subsequent­ly be obstructed.

It is imperative that a paediatric surgeon create a stoma (bowel opening into a bag on the abdomen) to prevent bowel obstructio­n.

Once a stoma is formed, the child can feed and grow until definitive surgery can be planned to construct a new opening for the anus, usually after a few months.

Smelly people don’t make many friends, so most of us try to remain socially continent of faeces, unless a mishap occurs after eating dodgy food at the mamak stall the night before.

Our mechanism of continence is a voluntary control of our anal sphincter, which is shut tightly most of the time until one relaxes it when safely positioned over the toilet bowl, ready to defecate.

In a child with ARM, these sphincter muscles surround the anal canal and are usually still present in the correct place despite the rectum connecting to other structures.

The definitive surgery would involve disconnect­ing the rectum from whatever it’s attached to, and “re-plumb” it through the sphincter muscle.

The surgery would hope to achieve a good calibre new anus, which is centrally placed within the sphincter muscle and can function to maintain faecal continence.

As you can imagine, the surgery itself is a delicate process of trying to preserve the precious sphincter muscles and carefully placing the new anus in the precise location.

A paediatric surgeon should perform this complex surgery, as it is crucial that surgery is done correctly the first time round.

Once the reconstruc­tive work is done, the stoma can then be closed, so that the “new bottom” can then be used.

The surgery may involve a larger incision near where the new anus is to be located, and some surgeons offer keyhole surgery for boys, which means smaller incisions.

Most children do well in the long term. However, some may be constipate­d, requiring long term use of laxatives to help them with their bowel opening.

Some children may have the opposite problem of incontinen­ce, often dirtying their underpants.

This may become a social hindrance. However there are bowel management programmes, which are successful in maintainin­g social continence, so that these kids are not rejected by society.

The key point is that this condition requires specialise­d treatment.

Paediatric surgery is a highly specialise­d field. The outcomes for such conditions are better if treated appropriat­ely at the right time, the right place and by the right person.

 ??  ?? The incidence of anorectal malformati­ons is reported as 2.0–2.5 per 10,000 live births. — AFP
The incidence of anorectal malformati­ons is reported as 2.0–2.5 per 10,000 live births. — AFP

Newspapers in English

Newspapers from Malaysia