Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
Content of this collection
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High-Yield Summaries
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The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula
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Pediatric colorectal surgeons Dr. Marc Levitt and Dr. Jason Frischer discuss a case of a new born with a low anorectal malformation. Listen as they take you through the workup, diagnosis, and treatment of an ARM with an ending that you migh
podcast15:45 · Jan 2021
Anorectal Malformations with Dr. Andrea Bischoff
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Discussion with Dr Andrea Bischoff and Dr Todd Ponsky regarding anorectal malformations.Evaluation of the male baby with possible anorectal malformation (01:19) Dr. Ponsky: Let’s get into it Andrea. I want to give you a case and tell me how
podcast47:46 · Dec 2020
In-depth Review
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Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison
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Marc Levitt, MD discusses Cloaca with Todd Ponsky, MD and Aaron Garrison, MDEdited by Ian C Glenn, MD and Sophia Abdulhai, MDDr. Levitt is surgical director of the Center for Colorectal and Pelvic Reconstruction as well as program director
podcast43:47 · Dec 2020
Colorectal Quiz Episode 33: Cloaca Extrophy
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Dr. Payam Saadai joins Dr. Marc Levitt and Dr. Jason Frischer to discuss the management of cloacal exstrophy covering traditional, and newer techniques.
podcast · Aug 2022
Complications of Anorectal Malformations with Dr. Marc Levitt
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Dr Marc Levitt discusses ARM Complications with Dr Todd Ponsky
Edited by Nicholas Bruns, MD and Ian C. Glenn, MD
In this episode, Dr. Marc Levitt from Nationwide Children’s Hospital discusses complications of anorectal malformations. This e
podcast48:09 · Dec 2020
Colorectal Quiz episode 12 Newborn ARM Part 1
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Surgeons, neonatologists, pediatricians, and anyone who cares for the newborn child needs to understand how to evaluate anorectal malformations. To clear things up, Dr. Marc Levitt and Dr. Jason Frischer explain how to make sense of various
video11:28 · Jul 2023
Colorectal Quiz Episode 13 Newborn ARM Part 2
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Surgeons, neonatologists, pediatricians, and anyone who cares for the newborn child needs to understand how to evaluate anorectal malformations. To clear things up, Dr. Marc Levitt and Dr. Jason Frischer explain how to make sense of various
video15:48 · Jul 2023
Colorectal Quiz Episode 14: ARM Newborn Part 3
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Surgeons, neonatologists, pediatricians, and anyone who cares for the newborn child needs to understand how to evaluate anorectal malformations. To clear things up, Dr. Marc Levitt and Dr. Jason Frischer explain how to make sense of various
podcast10:03 · Jun 2021
Colorectal Quiz Episode 2: When to redo a PSARP
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In the second installment of the Colorectal quiz, Dr. Jason Frischer and Dr. Marc Levitt discuss a topic of debate - when is the right time to redo an anorectoplasty? Listen as they walk you through their thought process on 2 different case
podcast18:15 · Jan 2021
Colorectal Quiz Episode 17: Cloaca Part 1
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The treatment for cloacal malformations are a great example of collaboration between pediatric colorectal surgery, gynecology, and urology. In today's episode, Dr. Marc Levitt and Dr. Jason Frischer talk to Dr. Richard Wood about the initia
podcast27:29 · Jul 2021
Colorectal Quiz Episode 18: Cloaca Part 2
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The treatment for cloacal malformations are a great example of collaboration between pediatric colorectal surgery, gynecology, and urology. In today's episode, Dr. Marc Levitt and Dr. Jason Frischer talk to Dr. Richard Wood about the operat
podcast23:10 · Jul 2021
Colorectal Quiz Episode 24: Cloaca Part 3
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The treatment for cloacal malformations are a great example of collaboration between pediatric colorectal surgery, gynecology, and urology. In today's episode, Dr. Marc Levitt and Dr. Jason Frischer talk to Dr. Richard Wood about the operat
podcast · Dec 2021
Work-up and Treatment
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Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula
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Join Dr. Kathy van Leeuwen and Dr. Christine Velazco at Phoenix Children’s as they discuss a specific case of a perineal fistula that leads to further discussion with Dr. Marc Levitt and Dr. Jason Frischer on the different potential finding
podcast19:59 · Feb 2022
Colorectal Quiz Episode 29: Female ARM-Post Op Management
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Join Dr. Kathy van Leeuwen and Dr. Cristine Velazco at Phoenix Children’s as they discuss the nuances of post-operative anorectal malformation management following the PSARP procedure with Dr. Marc Levitt and Dr. Jason FrischerHosted by Ama
podcast25:09 · Mar 2022
Articles and Infographics
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Comparing 30-day outcomes between early versus delayed repair of anorectal malformations with perineal or rectovestibular fistulas: An analysis of the ACS NSQIP-Pediatric database
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AbstractBackgroundAnorectal malformations (ARMs) have a wide spectrum of presentation ranging from mild defects with perineal fistulas to more severe defects requiring complex management. A primary repair of ARMs with perineal or rectovesti
article · Oct 2020
Anatomy of the Rectourethral Fistula in ARM
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Recto-urethral fistulae are the most common finding in males born with an anorectal malformation (ARM). A high pressure distal colostogram is an important tool in visualizing the fistula, although the precise level at which the fistula comm
article · Sep 2019
Technique Videos
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Descending Colostomy for Anorectal Malformations Dr. Tamer Ashraf Wafa
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In this video, a creation of a descending colostomy is demonstrated in a newborn with ano-rectal malformation.The video shows the surgeon's point of view (POV). And the surgeon is standing on the patient’s left side. This video is intended
video5:09 · May 2021
Laparoscopic pull-through for Hirschsprung disease updated 2024
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Pediatric Colorectal & Pelvic Reconstruction | Children's National Hospital (childrensnational.org)
video7:49 · Jul 2024
Technique: Female PSARP
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Female Posterior Sagital AnoRectoPlasty technique by Dr. Marc Levitt.
video · Nov 2018
Technique: PSARP in female with no fistula
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Posterior Sagital AnoRectoPlasty in a female patient with no fistula by Dr. Marc Levitt.
video · Jan 2019
Technique: PSARP in Male with Rectobulbar Fistula
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Posterior Sagital AnoRectoPlasty in a male patient with rectobulbar fistula by Dr. Marc Levitt.
video · Jan 2019
Summaries and takeaways+ Show
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Featured picks for families are being prepared — the summaries above are written for you.
Takeaways+ Show
Anorectal malformations (ARM) encompass a spectrum from perineal fistulas to complex cloacas, each requiring tailored surgical planning. Diagnosis begins with meticulous perineal examination—a single orifice below the clitoris defines cloaca, while three distinct openings (often misidentified as cloaca) indicate vestibular fistula . Cross-table lateral films at 24 hours guide initial management: air column near the sphincter suggests low lesions amenable to primary repair, while high air columns mandate colostomy and distal colostography [e4155-c3,e4155-c4]. Cloaca management prioritizes hydrocolpos decompression—modern practice favors clean intermittent catheterization over routine vaginostomy, as hydrocolpos compresses the trigone causing hydronephrosis [e299-c15,e4322-c14,e4322-c15]. Vesicostomy is rarely needed . Definitive repair timing and approach depend on anatomy: urogenital mobilization suits common channels ≤3 cm with urethral length ≥1.5 cm; shorter urethras require urogenital separation to preserve continence [e4336-c18,e4336-c20,e4336-c21]. 3D cloacography outperforms endoscopy for measuring the curved common channel [e4336-c8,e4336-c10]. Continence prediction integrates malformation type, sacral ratio (≥0.7 favorable), and spine status [e3527-c7,e304-c30]. Perineal body dehiscence—the most common complication—is minimized by complete anterior rectal mobilization and restricted early feeding [e304-c25,e304-c26,e5181-c4].
- Hydrocolpos in cloaca causes hydronephrosis by compressing the trigone; modern management uses clean intermittent catheterization rather than routine vaginostomy, with vesicostomy rarely needed.
- Urogenital mobilization is appropriate only when common channel ≤3 cm AND urethral length ≥1.5 cm; inadequate urethral length mandates urogenital separation to avoid incontinence.
- 3D cloacography significantly outperforms cystoscopy for measuring common channel and urethral length because endoscopy cannot account for the curve behind the pubis.
- Continence prognosis integrates malformation type, sacral ratio (≥0.7 favorable), and spine status; bulbar fistula with normal sacrum predicts 85% control, bladder neck fistula only 20%.
- Perineal body dehiscence—the most common redo indication—is prevented by complete anterior rectal mobilization to eliminate tension and restricted feeding (clear liquids 5–7 days) until healing confirmed.
For patients & families
Anorectal malformations are birth defects where the opening for bowel movements is missing or in the wrong place. Doctors sometimes miss these at birth, especially if the baby passes stool through a small opening near the genitals. The first step is usually a temporary colostomy—a surgical opening in the belly that lets stool pass into a bag while doctors plan the main repair. Between two and six months old, your child will have imaging tests (special X-rays and a camera exam) to see exactly where the rectum is and how to fix it. The repair surgery moves the rectum to the correct spot inside the muscle that controls bowel movements. Doctors look at three things to predict how well your child will control their bowels later: the type of malformation, the shape of the tailbone, and whether the spinal cord is normal. Many children with good anatomy will learn to use the toilet normally; others may need help with a bowel program (scheduled enemas) to stay clean and dry.
Anorectal malformations are birth defects where the opening for bowel movements is missing or in the wrong place. Doctors sometimes miss these at birth, especially if the baby passes stool through a small opening near the genitals. The first step is usually a temporary colostomy—a surgical opening in the belly that lets stool pass into a bag while doctors plan the main repair. Between two and six months old, your child will have imaging tests (special X-rays and a camera exam) to see exactly where the rectum is and how to fix it. The repair surgery moves the rectum to the correct spot inside the muscle that controls bowel movements. Doctors look at three things to predict how well your child will control their bowels later: the type of malformation, the shape of the tailbone, and whether the spinal cord is normal. Many children with good anatomy will learn to use the toilet normally; others may need help with a bowel program (scheduled enemas) to stay clean and dry.
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Every expert statement below comes from the recorded discussions, with its speaker and moment.
Complications of Anorectal Malformations with Dr. Marc Levitt
Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period.
clinicalMarc Levitt2:57 ↗
Male babies with perineal fistula may pass meconium and no one notices anything wrong with their anorectal anatomy, typically presenting in the first year of life with severe constipation.
clinicalMarc Levitt3:06 ↗
A newborn anus should accept a size 12 Hagar dilator and a 1-year-old should accept a size 15.
clinicalMarc Levitt6:13 ↗
Relocating a perineal fistula into the sphincters improves anatomy but does not completely fix constipation; patients will inherently have some constipation requiring aggressive treatment.
clinicalMarc Levitt4:54 ↗
If a perineal fistula is not centered in the sphincter, patients with loose stool will soil, and athletic activity will cause soiling because sphincter squeeze cannot completely close the hole.
clinicalMarc Levitt5:38 ↗
In females, diagnostic criteria for perineal fistula are: hole too close to vagina (inadequate perineal body), inadequate hole size by Hagar dilators, and hole not centered in sphincter.
clinicalMarc Levitt8:02 ↗
If a female's anal opening 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.
clinicalMarc Levitt8:47 ↗
The standard practice of checking temperature on forehead or ear rather than rectally makes it easier to miss anorectal malformations in newborns.
opinionMarc Levitt4:25 ↗
An anesthesia nerve stimulator costing $150 with appropriate needle probes works as well as commercial $15,000 stimulators for identifying sphincter muscles.
clinicalMarc Levitt11:06 ↗
The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through by the location of the colostomy or mucous fistula.
clinicalMarc Levitt17:18 ↗
Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections.
clinicalMarc Levitt17:45 ↗
With transverse colostomy and large rectourethral fistula, the left colon absorbs urine which doesn't exit the mucous fistula, potentially causing acidosis from urine absorption.
clinicalMarc Levitt18:38 ↗
Prolapse risk depends on colostomy location: mid-transverse allows bilateral prolapse, hepatic flexure allows only distal prolapse, proximal sigmoid allows only distal prolapse because left colon is fixed to retroperitoneum.
clinicalMarc Levitt19:58 ↗
Marking the sphincter ellipse on skin surface before making any incision prevents confusion from muscle stimulation after dissection is open, avoiding misplaced anoplasty.
clinicalMarc Levitt21:30 ↗
A distal colostogram showing flattening of the rectum corresponding to the pubococcygeal line indicates insufficient contrast or pressure; more pressure is needed to overcome the sphincters and reveal the true rectal position and fistula.
clinicalMarc Levitt24:26 ↗
Fistula level is determined by viewing the urethra as 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.
clinicalMarc Levitt25:23 ↗
Bulbous rectum on colostogram may be reachable posterior sagittally and difficult laparoscopically; tapered rectum is better approached laparoscopically.
clinicalMarc Levitt25:55 ↗
Opening posterior sagittally without knowing exact rectal location risks finding and potentially mobilizing bladder neck instead of rectum.
clinicalMarc Levitt27:00 ↗
Bulbar and low prostatic fistulas with bulbous rectum are best approached posterior sagittally; high prostatic with tapered rectum and bladder neck fistulas are best approached laparoscopically.
clinicalMarc Levitt30:09 ↗
Attempting laparoscopy for bulging rectum below peritoneal reflection at low prostatic or bulbar level risks leaving behind a remnant of the original fistula (roof) if the surgeon is timid.
clinicalMarc Levitt30:43 ↗
Laparoscopy replaces laparotomy, not PSARP; a mini-PSARP during laparoscopy allows safe entry through peritoneal reflection and tacking rectum to posterior muscle complex to prevent prolapse.
opinionMarc Levitt31:48 ↗
Rectal prolapse occurs in about 3% of cases, particularly in patients without great muscles.
epidemiologicalMarc Levitt33:35 ↗
Rectal prolapse more than 3 millimeters should be treated because it causes bleeding, mucus, and can inhibit bowel control in patients with good muscle potential.
clinicalMarc Levitt34:14 ↗
Circumferential prolapse can be trimmed in two separate ambulatory sessions (half circumference each), avoiding hospitalization and eliminating need for dilation since half the circumference remains untouched.
clinicalMarc Levitt34:48 ↗
Perineal body dehiscence is the most common cause of reoperation in female ARM repairs.
clinicalMarc Levitt36:03 ↗
Complete anterior rectal wall mobilization to the areolar plane between rectum and vagina is essential to avoid tension on the anoplasty that can lead to perineal body dehiscence.
clinicalMarc Levitt35:41 ↗
Clear liquids only for one week postoperatively prevents hard stool formation while allowing more stool volume, showing good perineal body healing results without traditional 7-day NPO period.
clinicalMarc Levitt36:45 ↗
If perineal body dehiscence is recognized on days 5-8, taking the patient back to OR to re-suture can salvage the repair; by 3-4 weeks the entire perineal body is dehisced and unsalvageable.
clinicalMarc Levitt37:48 ↗
During laparoscopic approach for high rectums, the IMA must be preserved because prior colostomy may have disrupted collaterals down the left colic, making the rectum completely dependent on IMA blood supply.
clinicalMarc Levitt39:33 ↗
Continence potential in ARM patients is predicted by three factors: original malformation type, sacral ratio, and spine quality (ARM continence index). Three A's predicts continence, three C's predicts incontinence.
clinicalMarc Levitt42:14 ↗
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