ARMs in Female Patients: Pediatric Colorectal Controversies 2014
hosted by Dr. Marc Levitt · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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
Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison
43 min · Published Dec 2016
Video
Collaborative work: Complex Pediatric Anorectal Malformations 2017
Dr. Todd Ponsky · 23 min · Published Jun 2017
Video
Pediatric Colorectal Contraversies Part I: Pediatric Colorectal Contraversies...
Dr. Todd Ponsky · 25 min · Published Aug 2017
Video
Pediatric Surgical Oncology Research Collaborative (PSORC): Studying Rare Pediatric Tumors
56 s · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Pooling Patients to Study Rare Pediatric Tumors: An Introduction to PSORC
56 s · Published May 2026
Video
The fetal frontier: A review of current and emerging fetal therapies for genetic diseases
44 s · Published May 2026
Video
Indocyanine green assists with sentinel lymph node mapping in pediatric and adolescent patients
1 min · Published May 2026
What the experts said
Perineal fistula is diagnosed when the fistula opening is at or anterior to the fourchette, with normal urethra and vagina visible
Vestibular fistula is diagnosed when the fistula opens posterior to the fourchette within the vestibule
For perineal fistula mobilization, the goal is to mobilize just enough to reach perineal skin with a little bit of tension
Complete separation from vagina is preferred because incomplete mobilization may lead to retraction and wound problems
In every redo of a female ARM, areolar tissue is found that had never been dissected by the original surgeon
Inadequate anterior rectal wall mobilization can lead to perineal body disruption as the anterior wall pulls back
Many newborn female vestibular fistula redos were done without a colostomy
The rectal blood supply is intramural, so injuring the rectal wall hurts its blood supply
Starting laterally before attempting anterior separation is key to avoiding injury when separating rectum from vagina
Coming in from lateral to anterior and starting more proximally makes separation easier than starting at the perineum
Primary vestibular repair without colostomy can be done in newborn or within 3-4 months depending on child's condition
Waiting until perineal body is healed (day 6-7) before feeding allows intervention if dehiscence is developing
10% dextrose can be used for NPO periods up to 7 days in well-nourished children, avoiding need for hyperalimentation
Systematic review shows early enteral nutrition appears better than later nutrition in ARM patients, but all studies are retrospective and poor quality
About 2-5% of vestibular fistulas have a vaginal septum
The ideal time to remove a vaginal septum is when the rectum is being mobilized and the perineal body is open
Women with longitudinal vaginal septum often learn to work around it for intercourse but have problems with tampon use
Vaginal septum resection in adolescents is not a difficult operation and can be done with electrocautery
True vaginal fistula (within introitus) is rare and requires slightly more rectal mobilization than vestibular fistula
Sigmoid colon can be used as neovagina in vestibular fistula with absent vagina
Using rectum as vagina and mobilizing proximal bowel as neo-rectum should only be done if patient unlikely to be continent (spinal anomaly, absent sacrum)
In vestibular fistula with absent vagina, 75% have urologic problems including neurogenic bladder
Of patients with vestibular fistula and absent vagina, 50% have CKD stage 3 or greater
Rectum separates from urethra more easily than from vagina in absent vagina cases, with thick fibrous tissue rather than adherent common wall
Neovagina is technically easier in younger children because the pedicle reaches more easily in a shorter pelvis
There are two types of cloacas: lower ones (common channel ≤3 cm) and complicated ones (>3 cm)
Hydrocolpos in cloaca may obstruct distal ureters and cause bilateral hydronephrosis
About 50% of cloacas have a duplicated gynecologic system
For newborn cloaca with hydrocolpos, open divided colostomy with pigtail catheter decompression of vagina is preferred over formal vaginostomy
Attempting cystoscopy at time of colostomy creation in cloaca makes the colostomy very difficult
Laparoscopic approach for cloaca colostomy allows visualization of pelvic structures and percutaneous vaginostomy tube placement
Curled tube is preferred over straight tube for vaginostomy because straight tubes fall out at 2 months when inflammation resolves
Much of hydrocolpos fluid is urine refluxing up, not just vaginal secretions
Intermittent catheterization of cloaca 2-3 times daily can drain urine and avoid need for vaginostomy tube in many cases
Catheterization teaching should be done under ultrasound guidance because tube can go into right vagina, left vagina, bladder, or rectum
Once hydrocolpos is drained, the bladder can fill, demonstrating that hydrocolpos compresses ureters and prevents bladder filling