Cloaca - Case Presentations
With Dr. Belinda Breech & Dr. Dr. Langer & Dr. Dr. Pena & Dr. Richard Wood · hosted by Dr. Em Gootee · StayCurrentMD
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Cloaca 25 items
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Podcast
Colorectal Quiz Episode 17: Cloaca Part 1
27 min · Published Jul 2021
Video
Collaborative work: Complex Pediatric Anorectal Malformations 2017
Dr. Todd Ponsky · 23 min · Published Jun 2017
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Cloaca - Workup & Evaluation
20 min · Published Nov 2018
Podcast
Colorectal Quiz Episode 17: Cloaca Part 1
Marc Levitt · 27 min · Published Jul 2021
Podcast
Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison
43 min · Published Dec 2016
Podcast
Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison
43 min · Published Dec 2016
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What the experts said
Approximately 28% of female patients with cloaca have hydrocolpos, with the majority having bilateral hemivaginas
More than half of patients with hydrocolpos did not receive timely diagnosis and treatment, leading to sequelae including infection, sepsis, recurrent UTIs, and rupture
69.4% of patients with hydrocolpos had common channel length greater than 3 centimeters
When duplicated vaginas are present, the cervices are typically at the same level, requiring careful identification to avoid trauma during septum division
Interventional radiology drainage of hydrocolpos may traverse the uterus or come close to the cervix, potentially compromising future fertility
Intermittent catheterization may work for hydrocolpos in short common channel cases or when the catheter preferentially enters the vagina
Whatever drainage method is used for hydrocolpos, ultrasound follow-up is essential to confirm decompression and prevent reaccumulation
Children with hydrocolpos generally need colostomy within 24-48 hours, making concurrent drainage at colostomy the most sensible and safest approach
The choice between tube vaginostomy and formal vaginostomy depends on whether the vagina reaches the abdominal wall
In duplicated vaginas with hydrocolpos, draining one side may decompress both, but some cases require drainage of both or hybrid approach with intermittent catheterization of the second side
Hydrocolpos can reaccumulate and become infected even with a catheter in place, requiring monitoring and sometimes gentamicin irrigation of the vaginas
Open vaginostomy allows division of vaginal septum to ensure 100% drainage of both hemivaginas versus tube placement which may require waiting to assess drainage
Approximately 3 centimeters is the cutoff for confidently approaching cloaca from posterior sagittal versus needing to discuss potential abdominal approach
Common channel length alone is insufficient for surgical planning; urethral length, urethral takeoff location, and rectal fistula position also determine approach
For very short common channels (less than 1 cm), the urethra can be left in place with acceptable female hypospadias, mobilizing only vagina and rectum
Sufficient female hypospadias must be accepted to allow catheterization if needed, with the meatus identifiable by patient or physician
There is no explanation for why patients develop hydrocolpos under tension, as no obstruction or atresia is found at surgery
The rectal fistula is usually located in the posterior aspect of the vaginal septum, sometimes as a tiny orifice requiring intentional search
In some cloacas, the rectal orifice is located immediately behind the urethra with the vagina posterior to the rectum
Total urogenital mobilization requires sufficient urethral length (at least 1-2 cm) to avoid bringing the bladder neck to the perineum, which would cause urinary incontinence
In congenital adrenal hyperplasia patients with urogenital sinus, the majority have urethral length of approximately 1.5 to 2 centimeters
Endoscopic assessment of bladder neck competency is unreliable due to hydrostatic pressure from the endoscope
Common channel length is definitively important for prognosis, but no studies compare the prognostic value of common channel length versus urethral length
Long common channel typically means shorter distance between bladder neck and vaginal confluence
Total urogenital mobilization on very long common channels sacrifices blood supply to the common channel, causing bladder neck closure and loss of the urethra
For common channels of 5 centimeters or longer, it is better to go directly to abdominal approach without attempting total urogenital mobilization
When vaginas attach to the bladder neck or trigone, separation may result in loss of bladder neck function
The 3-5 centimeter common channel range represents the most difficult decision-making, particularly with large vaginas and wide common wall between vaginas and trigone containing ureters
Surgical decision-making in borderline cases requires intraoperative 'feeling' - judgment that cannot be found in evidence-based literature
To leave the common channel as urethra, there must be a straight catheterization path to the bladder; if catheterization is impossible even when fully exposed, it will not work as future urethra
When separating vagina from urinary tract, a completely normal wall of one structure must face the suture line of the other; never place suture line opposite suture line to prevent fistula
Vaginal septum resection does not contribute to fistula formation
In cloacal malformations requiring extensive surgery, vaginal septum should be divided during primary repair for patient comfort with menstruation and sexual function, as it does not extend the procedure or increase fistula risk
Dr. Wilcox published data on intermittent catheterization of the common channel for hydrocolpos management without increased pyelonephritis or infectious complications in approximately 25 patients
External drainage tubes may provide tethering to the vagina that could interfere with total urogenital mobilization or complicate pulling the vagina to the perineum