Anorectal Malformations Complications
With Dr. Mark Levitt · hosted by Dr. Todd Ponsky · Marc Levitt
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Podcast
Anorectal Malformations Complications
Marc Levitt · 48 min · Published Feb 2016
Podcast
Complications of Anorectal Malformations with Dr. Marc Levitt
48 min · Published Jan 2017
Podcast
Complications of Anorectal Malformations with Dr. Marc Levitt
48 min · Published Jan 2017
Podcast
Anorectal Malformations Complications
Marc Levitt · 48 min · Published Feb 2016
Video
Problematic Anorectal Malformation Cases: Pediatric Colorectal Controversies...
13 min · Published Apr 2012
Podcast
Colorectal Quiz Episode 29: Female ARM
Marc Levitt · 25 min · Published Mar 2022
Podcast
(500) Days of Summer (classic Movie Review: Zooey Deschanel, Joseph Gordon-Levitt, Marc Webb) by The Cory Baker Show
Marc Levitt · Published Aug 2026
Video
Meeting with Marc Levitt: Clinical Discussion with Ivon Martinez
Marc Levitt · Published Jul 2026
Video
Introducing Dr. Marc Levitt: Pediatric Colorectal Surgeon Profile
Marc Levitt · Published Jul 2026
Video
Integrated Care Concept in Pediatric Colorectal Surgery by Marc Levitt
Marc Levitt · Published Jul 2026
Video
Patient Outreach and Communication in Pediatric Colorectal Surgery
Marc Levitt · Published Jul 2026
Video
Keynote Address on Pediatric Colorectal Surgery by Dr. Marc Levitt
Marc Levitt · Published Jul 2026
Podcast
Colorectal Quiz: Episode 49 - Collaborating for Kids: Colorectal & Pelvic Solutions (with a Little Help from AI)
Marc Levitt · 40 min · Published Jul 2025
Podcast
Colorectal Quiz: Episode 49 – Collaborating for Kids: Colorectal & Pelvic Solutions (with a Little Help from AI)
40 min · Published Jul 2025
Podcast
Colorectal Quiz: Episode 46
Marc Levitt · 29 min · Published Apr 2025
Podcast
Colorectal Quiz: Episode 46
Marc Levitt · 29 min · Published Apr 2025
Podcast
Colorectal Quiz: Episode 43
Marc Levitt · 23 min · Published Jan 2025
Podcast
Colorectal Quiz: Episode 43
Marc Levitt · 23 min · Published Jan 2025
Video
Andrea Kesar Discusses Marc Levitt's Contributions to Pediatric Colorectal Surgery
Marc Levitt · Published Jul 2026
Video
Dr. Marc Levitt on the CTO Mission in Pediatric Colorectal Surgery
Marc Levitt · Published Jul 2026
Podcast
Hirschsprung's Disease with Dr. Marc Levitt
Marc Levitt · 22 min · Published Jul 2026
Video
Introduction to Dr. Marc Levitt's Pediatric Colorectal Surgery Practice
Marc Levitt · Published Jul 2026
Video
Addressing Ministers of Health: Pediatric Colorectal Surgery Advocacy and Global Healthcare Priorities
Marc Levitt · Published Jul 2026
Video
The History of International Colorectal Surgery Team Development
Marc Levitt · Published Jul 2026
What the experts said
Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period.
Male infants with perineal fistula may pass meconium and present in the first year of life with severe constipation when the fistula is missed.
In missed perineal fistula, the rectum and sigmoid dilate because stool passes through a very tiny fistulous orifice which is not normal anal or rectal mucosa.
Missed anorectal malformation can lead to perforation if stool doesn't pass satisfactorily.
The current standard is to check temperature on forehead or ear rather than rectally, which means the anus may not be examined.
Relocating perineal fistula into sphincters does not completely fix constipation, though it improves anatomy.
Patients with uncorrected perineal fistula can have some continence with formed stool but will soil with loose stool or athletic activity because they cannot completely close the hole when squeezing sphincters.
A newborn anus should accept a size 12 Hagar dilator, and a one-year-old should accept size 15.
In perineal fistula, the anal opening is in the anterior portion of the pinkish ellipse (sphincter) or completely anterior to it.
A bucket handle skin tag is consistent with perineal fistula; a probe can be passed underneath it, and the fistula lies beneath.
Beads of meconium (black) or mucus (white) along the scrotal raphae are consistent with perineal fistula.
Diagnostic criteria for female perineal fistula: hole too close to vagina (inadequate perineal body), inadequate hole size, and hole not centered in sphincter.
If the anal hole is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, no surgery is needed; the perineal body will lengthen with growth.
Examination under anesthesia with stimulation can confirm whether the anal opening is properly centered in the sphincter when diagnosis is uncertain.
An anesthesia nerve stimulator ($150) with appropriate needle probes works as well as a dedicated Pena stimulator ($15,000).
The vast majority of male ARM patients have rectourethral fistula.
Rectourethral fistula should not be approached primarily because the rectum location is unknown; it could be at bladder neck, prostatic, or bulbar level.
If posterior sagittal incision is made without knowing rectal location, a midline white shiny structure will be found that might be urinary tract, not rectum.
With laparoscopy for rectourethral fistula, all cases go slightly below peritoneal reflection, making it impossible to distinguish bladder neck, prostatic, or bulbar fistula.
Rectourethral fistula patients should receive colostomy with distal colostogram.
Exceedingly rarely, a cross-table lateral film at 20 hours showing very low rectum may allow safe primary posterior sagittal approach.
Cloaca can be missed in the newborn period; a recent case presented at six months with constipation.
Newborn examination should be standardized to include conscious visual inspection of the anus and confirmation of adequate size and location.
Ambiguous genitalia with clitoromegaly and normal anus represents urogenital sinus with virilization, an endocrine problem.
Cloaca patients have no anus, a urogenital sinus, large clitoris (not from endocrine stimulation), and two completely normal ovaries with no endocrine problem.
The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through.
Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections.
Separated stomas prevent any chance of stool crossing to the distal segment.
Transverse colostomies can prolapse and, with large rectourethral fistula, cause the left colon to absorb urine, leading to acidosis.
Distal colostogram through transverse colostomy is difficult, requires high pressure, and leaves meconium in the entire distal segment for months.
Proximal sigmoid colostomy leaves the entire sigmoid loop for pull-through and should be performed laparoscopically with separated stomas.
Mid-transverse colostomy: both sides can prolapse. Hepatic flexure colostomy: only distal side prolapses. Proximal sigmoid colostomy: only distal (mucous fistula) can prolapse if not made tiny and flat.
Ileostomies prolapse frequently because they are free-floating unless tacked to anterior abdominal wall.
Anoplasty location should be marked on the skin surface before making any incision by drawing a circle around the pinkish ellipse where it stimulates.
Surgeons can choose the wrong anoplasty location when they see muscles jumping with stimulator after opening the incision, because they lack a reference landmark.
Really good surgeons have put anuses in wrong locations because everything is disrupted once the incision is open and they lack a sense of center.
Distal colostogram is an absolutely vital study; many mistakes result from poorly done studies and misinterpretation.
The distal colostogram must answer: where is the rectum, how low is it, is it reachable posterior sagittally or better approached laparoscopically, and what is its relationship to the urinary tract.
Common colostogram error: insufficient contrast and pressure, giving false impression that rectum is high or that there is no fistula.
If the distal rectum shows a straight line flattening corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure.
The PC line is where the sphincters compress the distal rectum; more pressure is needed to overcome this and show the bulging rectum and fistula.
Rectourethral fistula can be at bladder neck, prostatic level, or bulbar level. The urethra looks like a reverse C or elbow: fistula at or below the elbow is bulbar; above the elbow is prostatic; at bladder neck is bladder neck fistula.
Colostogram should show whether the rectum is bulbous or tapered. Bulbous rectum may be reachable posterior sagittally but hard laparoscopically due to girth. Tapered rectum is better approached laparoscopically.
Opening posterior sagittal incision without knowing rectal location will reveal a whitish shiny midline structure that may be bladder neck, not rectum.
Proper distal colostogram tells the surgeon exactly where to look for the rectum: right under the coccyx for prostatic fistula, distal to coccyx for bulbar, or not reachable posterior sagittally for bladder neck.
Bulbous prostatic fistulas can be found right under the coccyx and are preferably done posterior sagittally.
Bulbar fistulas are nearly at the perineal skin and should definitely be done posterior sagittally, not laparoscopically, because transabdominal approach requires more work.
If uncertain whether a structure is rectum, place stitches on either side and open in midline; if wrong, close it. Staying perfectly midline allows safe closure if urinary tract is opened.
Never go to the operating room without knowing exactly what anatomy to expect. The key question is: where is the rectum and is it the most posterior structure?
Bulbar or low prostatic fistula with bulging rectum: approach posterior sagittally. High prostatic with tapered rectum or bladder neck fistula: approach laparoscopically.
Attempting laparoscopy for bulging rectum below peritoneal reflection (low prostatic or bulbar) requires unnecessary extra work and risks leaving behind a remnant of the original fistula (roof).
Attempting posterior sagittal approach for high rectum is very difficult to mobilize and risks urinary tract injury.
Laparoscopy replaces laparotomy, not PSARP. A mini-PSARP incision (3-4 cm) allows safe entry hugging the sacral hollow and permits rectal fixation to posterior muscle complex to prevent prolapse.
Prolapse is very common if the rectum is not fixed; some hitch to pelvis, but Dr. Levitt prefers fixation to muscle complex through posterior sagittal incision.
Prolapse prevention: proper anoplasty location, adequate levator closure, posterior wall fixation to muscle complex (3-4 stitches), and minimal rectal dissection so rectum lands where anus should be without excessive trimming.
Prolapse occurs in about 3% of cases, particularly in patients without great muscles.
Rectal prolapse causes bleeding, mucus discharge, and in patients with good continence potential, inhibits bowel control because they cannot close the opening with prolapsed tissue through it.
Dr. Levitt trims prolapse greater than about 3 millimeters. Ectropium versus prolapse distinction is not critical; both are extra reddish tissue, usually circumferential but can be unilateral.
For circumferential prolapse, Dr. Levitt trims half the circumference in two different ambulatory settings, which families prefer to hospitalization and eliminates need for dilation because half the circumference is untouched.
Perineal body dehiscence is the most common cause of reoperation Dr. Levitt performs.