Colorectal Quizzes: Episode 39 – Mullerian Anomalies in Patients with ARM
With Dr. Marc Levitt & Dr. Jason Frischer & Dr. Leslie Breach & Dr. Veronica Gomez-Lobo · hosted by Dr. Lisa Bokova
This podcast is for verified healthcare professionals.Sign in to watch — the rest of this page is open.Sign in
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Video
ARMs in Female Patients: Pediatric Colorectal Controversies 2014
55 min · Published Apr 2012
Video
Surgical Management Of Female Anorectal Malformation Patients Including...
57 min · Published Nov 2018
Video
Anorectal Malformation Management of Female Patients Part II: Pediatric...
28 min · Published Apr 2012
Podcast
Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison
43 min · Published Dec 2016
Podcast
Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula
19 min · Published Feb 2022
Podcast
Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison
43 min · Published Dec 2016
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
Colorectal and Pelvic Reconstruction Techniques with Dr. Marc Levitt
Marc Levitt · Published Jul 2026
Video
Connecting Surgeons and Nurses: Collaborative Care in Pediatric Surgery
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
Video
The value and weakness of Medical Mission Work in ARM
Marc Levitt · Published Jul 2026
What the experts said
During vaginoscopy, the vagina does not have a sphincter, so you need to squeeze the labia around the scope so that the vagina fills up with water.
Before performing vaginoscopy, you should grab the labia and pull them out so the vagina opens up to ensure there isn't a septum that goes all the way out, because sometimes you can put the scope into one vagina and never realize there's a second vagina.
If you see a cervix in the midline during vaginoscopy, usually there might be just one uterine structure, but you can still have a second vagina that you might be missing.
If you see two cervixes during vaginoscopy, then you know the anatomy: there are two uteruses with two vaginas and two cervixes.
If you see one cervix and one vagina during vaginoscopy, you don't really know what the anatomy is—duplication may still be present.
Anytime a baby with an anorectal malformation is under anesthesia, she should be evaluated for Mullerian anatomy.
The majority of cloaca patients will have duplication of Mullerian structures.
Just because you see one cervix, don't be satisfied—be thinking, is there another, and how can I best assess for that?
Saline perturbation (test menstruation) can be performed either retrograde (from the cervix) or antegrade (from the distal fallopian tube) to assess patency of the system.
A gentle perturbation carries relatively low risk.
Hysteroscopy can be performed using small cystoscopy equipment to go into the cervix and look at the uterine cavity, which shows whether there are one or two ostia (fallopian tube openings).
Cloaca patients have the highest association of Mullerian anomalies, followed by rectal vestibular fistula, then perineal fistula (which is still slightly above the general population).
The closer the vagina and rectum are together, the higher the chances of a Mullerian anomaly.
When babies are first born, they are under the influence of mother's hormones, and then they go through a mini-puberty. That is a great time to look at Mullerian structures because they get really small after that, once the hormones are gone.
The reason Mullerian anomalies declare themselves at puberty is because the hormones kick in again.
An ultrasound after birth is very valuable because the Mullerian structures are more visible under maternal hormonal influence.
Do not diagnose an absent uterus when a child is 7 years old—many girls told they don't have a uterus at age 7 then get a period at age 13.
Ultrasound is extremely good for assessing Mullerian structures in the neonatal period, and MRI is extremely bad in prepubertal children because the structures are very tiny.
All you really want to know in prepubertal imaging is whether anything is dilated, and at that age there is nothing really dilated except in the very early stage when they are still under maternal hormonal effects.
If a patient has symptoms and is 12 years old, then MRI is an awesome modality to see what is dilated.
When performing hysteroscopy in a patient with a unicornuate uterus and non-communicating horn, you will see only one ostium opening into the fallopian tube, which tells you the two uterine bodies are not communicating into that one cervix.
If there is endometrium within a non-communicating uterine horn, that is a problem because menstrual blood has no way out.
Non-communicating uterine horns cause severe pain—much worse than other obstructive anomalies—and because these can be very small, sometimes people have a hard time identifying them.
Removing the fallopian tube not only prevents ectopic pregnancies but also prevents ovarian cancer, because what was previously thought to be ovarian cancer (serous cystadenocarcinoma) is actually coming from the tube.
The main blood supply to the ovary is the ovarian vessels, so you want to protect those at all costs when removing a fallopian tube and uterine horn.
To remove a fallopian tube while preserving the ovary, stay close to the fallopian tube itself in the mesosalpinx, but the ovarian vessels are the highest priority to protect.
In patients with renal anomalies on the side of the Mullerian anomaly, ureteral stents can be placed to help protect the ureter, which can be in the admixture near the ovarian vessels going down into the pelvis.
Mullerian remnants and anomalies are often found on the side of a pelvic kidney or absent kidney.
Patients with a unicornuate uterus should have normal reproductive potential if the fallopian tube is not damaged by previous surgery, but there is a higher rate of premature deliveries.
10% of vestibular fistulas have an absent vagina.
Approximately 5% of vestibular fistulas have a vaginal septum, and approximately 1% (which might be high) have distal vaginal atresia.
Vaginal septa and distal vaginal atresia can occur in perineal fistulas, but are much more uncommon than in vestibular fistulas.
You lose the opportunity for good imaging after the neonatal period until puberty, where MRI is a little more helpful but requires sedation.
Reproductive endocrinology colleagues remind us to be very gentle and careful with the fallopian tubes during laparoscopy, to avoid causing trauma that could be subsequently associated with hydrosalpinx or scarring of the tube.