Anorectal malformations refer to a range of congenital anomalies that involve the anus, rectum, and sometimes the urinary and genital organs. They result from abnormal development during the embryonic stage, leading to incomplete or absent formation of the rectum, anus, or both.

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ANORECTAL
MALFORMATIONS
Mr. Pradeep Abothu, M.Sc (N), PhD Scholar,
Associate Professor, Dept. of Child Health(N)
ASRAM College Of Nursing

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DEFINITION
 Anorectal malformations refer to a range of congenital anomalies that involve
the anus, rectum, and sometimes the urinary and genital organs. They result
from abnormal development during the embryonic stage, leading to incomplete
or absent formation of the rectum, anus, or both.

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INCIDENCE
 The incidence of anorectal malformations is approximately 1 in every 5,000
live births.
 The condition is more commonly found in males than females, with a male-
to-female ratio of 3:1.

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ETIOLOGY
 The exact cause of anorectal malformations is not fully understood.
However, several factors may contribute to their development,
including genetic and environmental factors.
 Some genetic syndromes, such as Down syndrome, VACTERL
association, and CHARGE syndrome, are associated with an
increased risk of anorectal malformations.

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TYPES
There are basically 4 types of Anorectal anomalies:
i. Anal stenosis :
 In this type, there is a stricture 1-4 cm above the anus or the stricture extends
through the entire length of anus.

6. ii. Anal membrane Atresia :
• In this type, a persistent anal membrane produces obstruction, behind
which meconium can be seen.

7. iii. Rectal Atresia :
• In this type, a normal anus is present but rectum ends as a blind pouch in
the hollow of the sacrum.

8. iv. Anal agenesis or imperforate anus:
• In this type, there is an imperforate anus possibly seen as a dimple with
rectum ending as a blind pouch some distance above the anus.
• In this type, fistula may also be present between the rectum and
urogenital tract.

9. There are 3 types of anal agencies:
• Low Imperforate Anus: The anus is absent, but there is a normal rectum
that ends in a blind pouch.
• Intermediate Imperforate Anus: The anus is absent, and the rectum is
located higher in the pelvis.
• High Imperforate Anus: The anus is absent, and the rectum may be
connected to the urinary tract or other structures.

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PATHOPHYSIOLOGY
The Anorectal and genitourinary tract originate from the embryonic structure called cloaca.
By seventh week of gestation the membrane that separates the rectum from anus breaks to
form a continuous canal, the outlet of which is anus.
If the membrane that was separating the anus and rectum is not absorbed, union of anus and
rectum does not occur, resulting in an Anorectal anomaly.
Both the rectum and urinary structures are also completely separated during the same
gestational age.
Any abnormality in the development of these systems results in Anorectal and genitourinary
malformations.

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CLINICAL MANIFESTATIONS
The clinical presentation of anorectal malformations can vary depending on the type
and severity of the malformation. Common signs and symptoms include:
 Absence or abnormal position of the anus.
 Failure to pass meconium within 24 to 48 hours after birth
 Abdominal distension
 Urinary tract anomalies
 Genital anomalies

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DIAGNOSTIC EVALUATION TESTS
Several diagnostic tests and procedures are used to evaluate and diagnose anorectal
malformations, including:
 Physical examination: Inspection of the perineal area to assess the position and
patency of the anus.
 Imaging studies: X-rays, ultrasound, and MRI can provide detailed
information about the anatomy and associated anomalies.
 Anorectal manometry: Measures the pressure within the rectum and helps
determine the functional status of the anal sphincter muscles.

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TREATMENT
Initial management of anorectal malformations often involves initial stabilization and
addressing associated complications. It may include:
 Colostomy or ileostomy: Temporary diversion of the fecal stream to allow the
affected area to heal before surgical repair.
 Bowel management program: Establishing regular bowel habits and preventing
constipation or fecal incontinence.
 Treatment of associated anomalies: Addressing any additional congenital
abnormalities, such as urinary or genital malformations.

15. z SURGICAL MANAGEMENT
The surgical procedure done depends on the type of anomaly.
For Anal Stenosis, manual dilatation is done by using Hegar's dilators of
increasing thickness. Repeated regular dilatation is done in the hospital and
showed to the parents so that they can do it at home.

16. z SURGICAL MANAGEMENT
 Anal Membrane Atresia: For anal membrane atresia, the membrane is
incised.
 Anal Agenesis: For anal agenesis, the Pull-Through Procedure is
preformed, it involves excising the affected portion of the rectum and
connecting the healthy bowel to the anus.
 The affected portion of the rectum is excised, and the healthy bowel is
connected to the anus. The approach may vary based on the type of
malformation:

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 Low Anorectal Malformations: Generally, allow for direct repair and
immediate connection to the anus.
 High Anorectal Malformations: May require staged surgeries,
starting with a temporary colostomy to divert stool away from the
malformation, followed by posterior sagittal anorectoplasty after 6
months, once the infant is stabilized. If there are associated fistulas,
they are ligated. The colostomy is closed after 12 weeks, followed by
surgery.

19. NURSING
MANAGEMENT

20. Preoperative care:
• Assess and monitor vital signs, including temperature, heart rate, and
respiratory rate.
• Ensure the infant is kept NPO (nothing by mouth) for a specified period
before surgery.
• Administer prescribed medications, such as antibiotics or bowel
preparations.
• Provide emotional support and education to parents about the surgical
procedure and postoperative care.

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Postoperative care:
 Monitor vital signs, including temperature, heart rate, respiratory
rate, and blood pressure.
 Assess the surgical site for signs of infection, bleeding, or
dehiscence.
 Administer prescribed analgesics to manage pain.
 Provide wound care and maintain a clean, dry, and sterile
dressing.
 Promote bowel regularity and bowel function through dietary
interventions, stool softeners, and laxatives as needed.

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NURSING DIAGNOSIS
 Common nursing diagnoses related to anorectal malformations may
include:
 Impaired bowel elimination related to anatomical defect and surgical
interventions.
 Risk for infection related to surgical site and altered bowel function.
 Acute pain related to surgical procedure and wound healing.
 Anxiety related to the child’s condition, surgical intervention, and
potential long-term outcomes.