Urological Assessment of ARM Patients

How do we assess a child who comes to us with anorectal malformation? We do a lot of um questions, you know, so in the intake process, there's a lot of questions that we ask the parents, even before you come in for that first visit, so we can get a gauge of where your child is and what tests do we want to bring to bear for your child. We obviously want to avoid over testing your child or duplicating tests that your child may have already had. And we get a lot of information with a simple voiding diary, which is a documentation of how often your child's going to the bathroom. Sometimes if you can get really specific, we can have you measure how much urine they're emptying every time they do go to the bathroom. And then is there any leakage of urine in between? We can do a renal bladder ultrasound that is a non-invasive test that allows us a look at the child's kidneys and bladder, and again it can be coupled with the child going to the bathroom and we can see how well they're emptying their bladder, and almost every single hospital around the country, around the world has access to an ultrasound machine, so that's one of the tests that we do most frequently. It is important for us to know what the renal function of your child is and and monitor that in a progressive manner so that if we see deterioration of renal function, we're going to sit up and take notice of that and say, why is this happening? Is this a function of your child growing and their lack of renal reserve, or is there something that should be prevented going on here that we should be assessing? We can also do a non-invasive urodynamic study, which is a very helpful study. It's also called a uroflow study where we have your child urinate into a machine that tells us how their bladder is emptying and is there the appropriate coordination between the bladder and the sphincter muscle. When indicated, we will escalate the level of testing that becomes more invasive, a little bit more uncomfortable for your child, but very necessary when we do order it. And one of those tests is a VCUG, which is a bladder X-ray, allows us to look at the anatomic appearance of the bladder, the urethra tells us if there's a condition called reflux where urine is backing up from the bladder into the kidneys, and if that's present, then that obviously escalates the interventions that we're going to be undertaking. And that first VCUG is an X-ray VCG, so it also tells us what's going on with your child's spinal column. Are they someone that we would suspect having a tethered cord? What's going on with their bowels? Are they constipated? So that first VCUG, when we do it, gives us a lot of information. Sometimes we have to go to more sophisticated testing like a CT scan or an MRI, and one thing we are very cognizant about is the radiation safety. We know that some of these tests expose your children to radiation, and so we try to do non-ionizing radiation tests like ultrasounds as much as possible and reserve these X-rays, tests like a VCG or a CT scan only when indicated. Urodynamic testing is a test that involves the use of catheters in the bladder where we're actually measuring how the bladder responds to changing volume and what sort of pressures are being generated. This is one of the ways that we're being very proactive in protecting your children's kidneys from harm. In the past we used to monitor kidney function and when we saw some changes happening we're like, OK, maybe our current strategy is not working well and we need to rethink this. But by the time we made that decision, there had already been some demonstrable harm to the kidneys. With the urodynamic testing now, we can actually proactively assess how well a bladder is working to store urine, to empty urine, and is it doing so in a safe manner for the upper tracts, which are the kidneys and the ureter. If we see any changes happening in the urodynamics, we can proactively intervene before, before that harm happens to your child's kidneys. And every once in a while, in order to get a better understanding of your child's anatomy, we will in a coordinated manner along with our colorectal surgeons and for the girls, gynecologists, take your child to the operating room so we can do an exam under anesthesia and do an endoscopic assessment of their urethra and their bladders.