Anorectal Atresia with Rectoscrotal Fistula : A Rare Anorectal Malformation

A full-term male baby was referred at birth with small midline opening in the mid-scrotum covered by a thin membrane which was perforated by passing a fine infant feeding tube (Fig. 1). The tube seemed to pass upwards and obliquely, indicating that this was not a low type of ARM. The bowel was decompressed by giving rectal washouts twice daily through the fistula, thus avoiding emergency colostomy. A contrast study through fistula confirmed the diagnosis of an intermediate type of ARM with a long recto-scrotal fistula in close proximity to the urethra (Fig. 2).


DEAR SIR
A full-term male baby was referred at birth with small midline opening in the mid-scrotum covered by a thin membrane which was perforated by passing a fine infant feeding tube (Fig. 1).The tube seemed to pass upwards and obliquely, indicating that this was not a low type of ARM.The bowel was decompressed by giving rectal washouts twice daily through the fistula, thus avoiding emergency colostomy.A contrast study through fistula confirmed the diagnosis of an intermediate type of ARM with a long recto-scrotal fistula in close proximity to the urethra (Fig. 2).The baby was managed with rectal washouts for 4 weeks, when a laparoscopy assisted anorectoplasty (LAARP) was planned after ruling out other anomalies.Under a general anesthetic, the center of the external sphincter was mapped out with a muscle stimulator for the proposed site of the neo-anus.
The bladder was catheterized with an 8F Foley catheter, and the rectum was catheterized with a 10F infant feeding tube through the fistula.The fistula opening was incised circumferentially with aid of stay sutures and dissected to reach the rectum and mobilize a sufficient length of bowel through the scrotal incision and was then transposed to the site of the neo-anus anchoring to the external sphincter and the skin.The perineal body were reconstituted in the midline.The urethra was visible throughout sharing a common wall with the fistula.The post-operative period was uneventful and the urethral catheter was removed 9 days after surgery.The baby had a small amount of leakage of urine through the scrotal incision next day.Continuous bladder drainage by a Foley catheter through the urethra for 10 days healed the leak.The baby is seventeen months old now passing stools three times a day and is completely free of

LETTER TO THE EDITOR
soiling or leakage of stools.The anus looks normal except for minimal mucosal prolapse.
In the majority of intermediate level of anorectal malformations (ARM) in males, the hindgut terminates as a fistula into the lower urinary tract, but less commonly without a fistula, or with a fistula terminating externally in the perineum.[1] A rectoscrotal fistulas have been also described rarely.[1][2][3][4][5] This entity could be easily mistaken for a low type of ARM, and could lead to an inappropriate perineal surgical procedure.Hence, one should suspect an intermediate ARM when the catheter passes obliquely and cranially, rather than backwards; this should be further confirmed by a contrast study.If the bowel can be adequately decompressed through the fistula, a diverting colostomy can be avoided and one-stage elective surgical correction could be done.Anal transposition has been described before for this anomaly in a much older individual.[5] We performed the procedure at the age of four weeks and achieved the placement of the bowel within the continence mechanism, in the midline, without extensive division of the sphincter muscle complex.Initial indicators of continence are encouraging in the infant.

Figure 2 :
Figure 2: Contrast study showing rectoscrotal fistula, intermediate level of ARM and close proximity with the urethral catheter.