Alternative Names
Anorectal malformation; Anal atresia Definition of Imperforate anus:
Imperforate anus is congenital (present from birth) defect in which the opening to the anus is missing or blocked. The anus is the opening to the rectum through which stools leave l eave the body. Causes, incidence, and risk factors:
Imperforate anus may occur in several forms. The rectum may end in a blind pouch that does not connect with the colon. Or, it may have openings to the urethra, bladder, base of penis or scrotum in boys, or vagina in girls. A condition of stenosis (narrowing) of the anus or absence of the anus may be present. The problem is caused by abnormal development of the fetus, and many forms of imperforate anus are associated with other birth defects. It is a relatively common condition that occurs in about 1 out of 5,000 infants.
Imperforate anus
Symptoms: y
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Anal opening very near the vaginal opening in girls Missing or misplaced opening to the anus No passage of first stool within 24 - 48 hours after birth
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Stool
passes out of the vagina, base of penis, scrotum, or urethra Swollen belly area
Signs and tests:
A doctor can diagnose this condition during a physical exam. Imaging tests may be recommended.
Imperforate anus
Treatment:
The infant should be checked for other problems, especially those affecting the genitals, urinary tract, and spine. Surgical
reconstruction of the anus is needed. If the rectum connects with other organs, repair of these organs will also be necessary. A temporary colostomy is often required. Expectations (prognosis):
With treatment, the outcome is usually good. However, it depends on the exact problem. Some infants may never develop adequate bowel control. Complications: y
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Bowel
incontinence Constipation Intestinal blockage
Calling your health care provider:
This disorder is usually discovered when the newborn infant is first examined. Call your health care provider if a child that was treated for imperforate anus has abdominal pain or fails to develop any bowel control by the age of 3. what is an imperforate anus? An imperforate anus is a defect (something which is abnormal) that happens to an unborn baby while it is still growing inside its mother. The baby develops this defect or abnormality during the fifth to seventh weeks of the mother·s pregnancy. With these defects, the anus (opening at the end of the large intestine where stool passes) and the rectum (area of the large intestine just above the anus) do not develop properly. Imperforate Anus Incidence Imperforate anus affects 1 in 5,000 babies and is a little more common in males. No
one knows the exact reason some baby·s have imperforate anus. The exact cause of imperforate anus is unknown. In some cases, environmental factors or drug use during pregnancy may play a role, but no one is completely sure. During a bowel movement, stool passes from the large intestine to the rectum and then to the anus. Nerves in the anus help us feel the need for a bowel movement and start muscle activity. Muscles in this area help control when we have a bowel movement. With an imperforate anus, any of the following can happen:
The anal opening may be narrow or misplaced in front of where it should be located
A membrane (covering) may be present over the anal opening The rectum may not connect to the anus The rectum may connect to part of the urinary tract or the reproductive system though an opening called a fistula, and an anal opening is not present Return to top Why worry about an imperforate anus? A number of problems can happen depending on the type and how severe the imperforate anus is.
When the anal opening is narrow or misplaced in front of the correct location, a child may have a hard time passing a bowel movement, causing constipation and discomfort. If there is a membrane covering the anal opening, the baby may be unable to have a bowel movement until the membrane is opened with surgery. If the rectum is not connected to the anus and no fistula (abnormal connection between the rectum and urinary tract or vagina) is present, there is no way for stool to leave the intestine. The baby will be unable to have a bowel movement. This will cause a bowel obstruction (stool becomes trapped inside the baby). When the rectum is not connected to the anus but a fistula is present, stool may pass through the fistula instead of the anus. This can cause urinary tract infections. Return to top Who is at risk for developing an imperforate anus? Although most babies who have imperforate anus are the only ones in their family to have it, there are some cases where other family members have had it as well.
Are other disorders associated with imperforate anus? Almost 50% of babies with imperforate anus have other abnormal defects along with the imperforate anus. These commonly include:
abnormalities, such as hemivertebra, absent vertebra and tethered spinal cord Kidney and urinary tract malformations, such as horseshoe kidney and duplication of parts of the urinary tract Congenital heart defects Tracheal and esophageal defects and disorders Limb (particularly forearm) defects Down syndrome, Hirschsprung's disease and duodenal atresia can also happen with an imperforate anus. Return to top How is imperforate anus diagnosed? When a baby is born, the doctor will check the baby for any problems. While the doctor is checking the baby, he or she will check to make sure the baby·s anus is open and in the correct position. If an imperforate anus is found, a number of tests may be done to better understand the problem and to see if any other problems are present.
Spinal
of the stomach will give the doctor a picture showing the general location of the imperforate anus. X-rays also let doctors know if there are problems with the spine and sacrum (a triangleshaped bone just below the lumbar vertebrae). Abdominal ultrasound and spinal ultrasound -- These tests are used to look at the urinary tract and spinal column. They also help doctors decide if a tethered spinal cord (an abnormality where the end of the spinal cord is abnormally anchored) is present. A tethered spinal cord may cause neurological problems, such as incontinence (toileting without control) and leg weakness as the child grows.
X-rays
Echocardiogram
-- This test is done to find heart defects. Magnetic resonance imaging / MRI --Magnetic resonance imaging / MRI -- In some cases, this test is needed to make a definite diagnosis of tethered cord or other spinal problems.
How
is imperforate anus treated or repaired? Treatment recommendations will depend on the type of imperforate anus, the presence and type of associated abnormalities and the child's overall health. However, most infants with an imperforate anus will need surgery Rectoperineal Malformation Infants with a rectoperineal malformation will need an operation called an anoplasty, which involves moving the anus to an appropriate place within the muscles that control continence (controlled toileting, in this case bowel movements)
Return to top Colostomy for Infants with Imperforate Anus Without a Fistula Newborn boys and girls who have an imperforate anus without a fistula will need one or more operations to correct it. An operation to make a colostomy is usually done early. With a colostomy, the large intestine is divided into two sections, and the ends of intestine are brought through small openings in the abdominal wall (small opening will be on your child·s belly). The upper section allows stool to pass through the opening, called a stoma, and into a collection bag. Mucus from the intestine exits through the opening of the lower section of intestine. B y
performing this surgery, digestion will not be harmed and growth can continue to happen before the next operation is needed. B y changing the original route of the stool, the risk of infection will be smaller when the next operation is done. Nurses
and other health care workers who work with your child's doctor will help you learn how to take care of the colostomy, and they
will help you, as you prepare to take care of your child at home. Local and national support groups may also be very helpful during this time. The next operation creates a connection between the rectum and the newly created anal opening. This procedure is usually performed from the child·s bottom. In some cases where the rectum ends within the abdomen (high lesions), laparoscopic surgery (surgery through small holes, usually without an incision) or traditional open surgery (surgery with an incision or cut opening) can be used to bring the rectum down to the anal opening. After the rectum is brought down to the anal opening the colostomy will stay in place for six to eight weeks. Stool will continue to leave the body through the colostomy until it is closed with surgery. The colostomy will have to stay in place to let the new anal opening heal without being infected by stool and let the child undergo the dilation process (schedule that includes slowly stretching the anus to the correct size for the child·s age). Return to top Anal Dilatation After Surgery to Repair Imperforate Anus A few weeks after surgery, parents are taught to perform anal dilatations to make sure the anal opening is large enough to allow normal passage of stool. The colostomy is closed in another operation at least six to eight weeks later. Several days after surgery, the child will begin passing stools through the rectum (anal opening). Shortly after surgery, stools may be loose and happen more often than usual. Diaper rash and skin irritation can also be a problem. Your doctor and nurse will help you with the care needed to keep the diaper area healthy.
Within a few weeks after surgery, stools will happen less often and become firmer. Anal dilatations should continue for several weeks or months. Some
infants may become constipated. To avoid this, we encourage following a high-fiber diet. Laxatives may be required prior to the age of potty training. In cases of severe constipation, a bowel management program may be developed according to the specific needs of the child. The program may include child and parent education in the use of laxatives, stool softeners, enemas, bowel training techniques. Return to top What should be done about toilet training kids who've had an imperforate anus? Toilet training should be started at the usual age, usually when the child is around 3 years old. Children who have had imperforate anus generally gain bowel control more slowly, and depending on the type of malformation and the operations done to repair it, some children may not be able to gain good bowel control. Each child·s situation will be slightly different and will be determined with the help of your doctor. What
is the long-term outlook for children with imperforate anus? Children who have had an imperforate anus that have a rectoperineal fistula are usually able to gain good control over their bowel movements after surgical repair.
However, those with more difficult types of anorectal malformation may need to participate in a bowel management program to help them achieve control over their bowel movements and prevent constipation.
Nurses
and other health care professionals who work with your child's doctors can outline a program made for your child's individual needs.
mperforate anus From Wikipedia, the free encyclopedia rate anus
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An imperforate anus or anal atresia is a birth defect in the rectum is malformed. Its cause is unknown.
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1 Diagnosis 2 Treatment 3 Features 4 Prognosis 5 Epidemiology 6 Associated anomalies 7 References 8 External links [edit]Diagnosis When an infant is born with an anorectal malformation, it is usually detected quickly as it is a very obvious defect. Doctors will then determine the type of birth defect the child was born with and whether or not there are any associated malformations. It is important to determine the presence of any associated defects during the newborn period in order to treat them early and avoid further sequelae. There are two main categories of anorectal malformations: those that require a protective colostomy and those that do not. The decision to open a colostomy is usually taken within the first 24 hours of birth. [edit]Treatment Imperforate anus usually requires immediate surgery to open a passage for faeces. Depending on the severity of the imperforate, it is treated either with a perineal anoplasty[1] or with a colostomy. [edit]Features There are several forms of imperforate anus:
A low lesion, in which the colon remains close to the skin. In this case, there may be a stenosis (narrowing) of the anus, or the anus may be missing altogether, with the rectum ending in a blind pouch. A high lesion, in which the colon is higher up in the pelvis and there is a fistula connecting the rectum and the bladder, urethra or the vagina. A persistent cloaca (from the term cloaca, an analogous orifice in reptiles and amphibians), in which the rectum, vagina and urinary tract are joined into a single channel.
Imperforate anus is usually present along with other birth defects³ spinal problems, heart problems, tracheoesophageal fistula, esophageal atresia, renal anomalies, and limb anomalies are among the possibilities.[2] Sonography
can be used to determine the type of imperforate anus. [3]
[edit]Prognosis ection does not cite any references or sources . elp improve this article by adding citations to reliable . Unsourced material may enged and removed. (February 2010) With a high lesion, many children have problems controlling bowel function and most also become constipated. With a low lesion, children generally have good bowel control, but they may still become constipated. For children who have a poor outcome for continence and constipation from the initial surgery, further surgery to better establish the angle between the anus and the rectum may improve continence and, for those with a large rectum, surgery to remove that dilated segment may significantly improve the bowel control for the patient. An antegrade enema mechanism can be established by joining the appendix to the
skin (Malone stoma); however, establishing more normal anatomy is the priority. [edit]Epidemiology Imperforate anus has an estimated incidence of 1 in 5000 births.[4][5] It affects boys and girls with similar frequency. [6] However, imperforate anus will present as the low version 90% of the time in females and 50% of the time in males. Imperforate anus is an occasional complication of sacrococcygeal teratoma.[7] [edit]Associated anomalies Imperforate anus is associated with an increased incidence of some other specific anomalies as well, together being called the VACT ERL association:
V - Vertebral anomalies A - Anal atresia C - Cardiovascular anomalies T - Tracheoesophageal fistula E - Esophageal atresia R - Renal (Kidney) and/or radial anomalies L - Limb defects
mperforate anus: Introduction Imperforate anus: A congenital disorder where the anus is missing or located in the wrong position. More detailed information about the symptoms, causes, and treatments of Imperforate anus is available below. Symptoms of Imperforate anus Click to Check
Abnormal anus Absent anus Rectal opening into vagina Rectal opening near scrotum more symptoms...» Read more about symptoms of Imperforate anus y
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Home
Diagnostic Testing
Home medical testing related to Imperforate anus: y
Food
Allergies & Intolerances: Home Testing: Home Food Allergy Tests Home Food Intolerance Testing Home Water Testing more...»
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Wrongly
Diagnosed with Imperforate anus? y
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Misdiagnosis
of Imperforate anus Hidden causes of Imperforate anus (possibly wrongly diagnosed)
Surya Mega: Colostomy Operation Surya Mega,
the sixth child of a widow from an impoverished village in Lombok, was born with an imperforate anus and survived for three years, when a colostomy operation was performed. In July 2003, at 7 years of age, she was brought to the Foundation for assistance and underwent an operation in Bali to restore her bowel function to normal. Surya Mega
with her family in
Lombok.
Through donations, the
Foundation is also assisting the family so that the three school-aged children can continue in school. Abdominal and Digestive Conditions / Diagnoses Early Diagnosis of Anorectal Malformations / Imperforate Anus Related
Services Colorectal Center Early diagnosis and prompt treatment can help change the outcome for children born with anorectal malformations / imperforate anus.
An emerging area of interest is the prenatal diagnosis of anorectal malformations. Much is being learned in this area as technology improves, and perinatologists are learning to recognize certain clues of the prenatal ultrasound. Immediate Postnatal Diagnosis Certainly the vast majority of anorectal malformations diagnoses are made in the delivery room on examination of the infant after birth or in the newborn nursery when the nurse attempts to take a rectal temperature and no anus is visible.
Inspection of the perineum, the area surrounding the external genitals and where the anus would normally be located, should be performed on all newborns and may result in an immediate postnatal diagnosis of an anorectal malformation / imperforate anus. An infant who is diagnosed with an anorectal malformation / imperforate anus requires a more comprehensive examination that may include evaluation of the following conditions:
Does the abdomen appear distended (enlarged or stretched out)? Is the infant vomiting?
Does the infant display a voiding (urination) pattern that would indicate involvement of the urinary tract? Is meconium present in the perineum of a male infant or in the genitalia of a female infant? Meconium, a greenish mass of cells that accumulate in the bowel of the fetus, is usually discharged after birth. Is meconium present in the urine of a male baby? Meconium can be detected by filtering the urine through a gauze pad placed at the tip of the penis or by laboratory examination of the urine (urinalysis). Infant Care Following Anorectal Malformation / Imperforate Anus Diagnosis Once the infant has been diagnosed with an anorectal malformation / imperforate anus, the goals of care are:
Determining whether the infant needs a temporary colostomy (explained below) or whether the defect can be treated primarily without a colostomy Evaluating other defects or medical problems that require immediate attention Providing information and emotional support to the parents and other family members Providing general medical support to the child Decision to Perform a Colostomy Versus an Anoplasty Some anorectal malformations / imperforate anus can be treated with a one-stage surgical repair. In infants with more extensive defects, however, a colostomy is needed to surgically create an alternate route for feces to exit the infant's body while the infant awaits more extensive surgery to correct the anorectal malformation.
A colostomy decompresses the bowel, diverting feces outside the body. It also helps prevent infection during the reconstructive surgery to
correct the anorectal malformation / imperforate anus. The decision to perform a colostomy is generally made after 24 hours of observation. Associated Defects Requiring Immediate Attention The most frequently associated defects of anorectal malformations / imperforate anus that require immediate attention are those of the urinary tract.
Infants with anorectal malformations require an ultrasound examination of the abdomen to detect a urinary obstruction. If the ultrasound examination is abnormal, a more detailed urologic evaluation is indicated. Associated defects of the digestive tract include an obstruction of the esophagus (tube that carries food and liquids from the throat to the stomach). Known
as esophageal atresia, this condition can also cause leakage from the digestive tract into the lungs, and requires surgical correction so the child can eat. Children
born with anorectal malformations / imperforate anus may also have abnormalities in the bones, particularly the sacrum bone and the lumbosacral spine, and heart. All infants diagnosed with an anorectal malformation should have a thorough cardiac evaluation with an echocardiogrambefore undergoing surgery. An ultrasound of the spine will help to rule out the presence of a condition called tethered cord, which includes the final outcome. Care of the Infant Awaiting Treatment Once an infant has been diagnosed with an anorectal malformations and is being evaluated for treatment, several steps are recommended:
Intravenous nourishment while taking nothing by mouth ( NPO) Inserting a nasogastric ( NG) tube to avoid vomiting and risk of aspiration Intravenous fluids Antibiotics Vitamin K to correct clotting deficiencies of a newborn prior to surgery Strict monitoring of intake and output We believe that it is now possible to establish an accurate early diagnosis, which allows us to tell the parents what the future of their child is going to be in terms of bowel control.
Treatment Medical Care Newborns
with imperforate anus should not be fed and should receive intravenous hydration. Life-threatening comorbidities take precedence and must be treated first. If a urinary fistula is suspected, broad-spectrum antibiotics can be administered, although anaerobic coverage is unnecessary within the first 48 hours of life. Any cardiac murmurs identified upon physical examination should be evaluated using echocardiography prior to surgical intervention. The remainder of treatment includes diagnostics and surgical evaluation and management. Surgical Care
The decision-making process aims to determine which children should undergo primary repair in the neonatal period and which children require colostomy and definitive repair in a staged fashion. Children with anorectal malformations may undergo one or several of the following surgical procedures based on the child's presentation, physical examination findings, and imaging study findings.
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Neonatal
colostomy A colostomy is performed in children who are not amenable to primary pull-through either because of malformation complexity (any urinary fistula in boys, vestibular fistula and cloaca in girls, no fistula in either sex >1 cm from perineal skin) or associated comorbidity. The colostomy is usually fashioned through a left lower quadrant incision. The colon is divided at the point where the descending colon meets the sigmoid colon, and both ends are brought to the abdominal wall. B y fashioning the colostomy at this location, the entire sigmoid colon is kept in place; thus, when the pull-through is eventually performed, a large portion of the colon is available for the surgeon to bring down to the perineal skin. The mucous fistula (the downstream segment) should be very small, flush with the skin, and far enough from the proximal end to be outside the colostomy appliance (or under the flange) to avoid continued urinary soiling with feces. During this operation, the distal segment of the colon must be exhaustively irrigated to clean out the impacted meconium, which is always significant. This prevents postdiversion urinary sepsis and allows for effective distal colostography. Primary neonatal pull-through without colostomy Many pediatric surgeons opt for primary pull-through in children with perineal fistulas (or no fistulas) and close (<1 cm) rectal pouches on 24-hour lateral pelvic radiography. Some pediatric surgeons who specialize in colorectal problems often offer the same procedure for girls with vestibular fistulas. C ystoscopy is usually performed to rule out associated malformation. This is performed immediately prior to the o
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pull-through operation. A Foley catheter is inserted following the cystoscopy. The preferred surgical approach is the posterior sagittal approach developed by Peña et al. The child is placed in the prone position with generous padding under the face and chest and a large bolster under the hips to elevate the area of interest. A muscle stimulator is used to show the precise position of the rectal muscle complex to enable exact division at the midline. The midline for this operation is defined by the line that precisely divides the muscle complex in half. Dissection proceeds until the rectal pouch is identified. The pouch is then mobilized until adequate length is obtained and the rectum is fully separated from its attachment to the genitourinary tract. Even if the structures do not communicate, they remain intimately associated until fully mobilized. This step ensures that the surgeon does not miss a fistula that was missed on urinalysis findings. Once the rectum has been mobilized, the muscle stimulator is used to mark the anterior and posterior limits of the muscle complex. The perineal body is then reconstructed, and the rectum is tacked down in the middle of the muscle complex. The posterior wound is closed and anoplasty is performed. Posterior sagittal pull-through with colostomy This approach is used in boys with rectourinary fistula (bulbar, prostatic, or bladder-neck fistula), in girls with cloaca or vestibular fistula, and in patients of either sex who do not have a fistula when the rectal pouch is further than 1 cm on 24-hour lateral prone abdominal radiography. o
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The approach is also used in children who may have malformations that were amenable to primary neonatal pullthrough but were unable to undergo such a procedure because of extreme prematurity or other comorbidity. Colostomy is performed after 24 hours (or immediately if one of the above diagnoses is made based on either physical examination findings or meconium in the urine). Several weeks following colostomy, distal colostography is performed, and the specifics of the malformation are clarified. C ystoscopy is usually performed to clarify anatomy and to rule out associated malformation. This is performed immediately prior to the pull-through operation. A Foley catheter is inserted following the cystoscopy, except in girls with cloaca. The reconstructive procedure varies based on the malformation, but the essential concepts include identifying and separating the rectum from other structures, dividing and ligating any fistulas, and fully reconstructing the pelvic anatomy with placement of the rectum within the confines of the muscle complex. Procedures for specific malformations are as follows: Vestibular fistulas are directly visible but have the longest common wall between the rectum and vagina and require significant delicate mobilization to avoid holes in either structure. The posterior sagittal approach is used in boys with bulbar or prostatic urethral fistulas. The rectum is isolated and opened, and the fistula is identified through progressive distal opening. Once the fistula is identified, the rectum proximal to it may be mobilized, and the fistula is then ligated. Reconstruction then
proceeds with primary pull-through, as described above. Abdominal (open or laparoscopic) and posterior sagittal approaches are best in boys with bladder-neck fistulas because the fistula is best identified in the abdomen. Cloaca procedures are complex. A short ² commonchannel cloaca can be repaired using total urogenital mobilization. The posterior sagittal wound is opened into the cloaca, which is then further proximally opened until the urethral orifice is identified and catheterized. The rectum is then sought. In girls with 2 hemivaginas (50%), the rectum opens in the vaginal septum, although significant asymmetry may be present. After identification, the rectum is separated from the urogenital tract and completely mobilized. The urogenital tract is then mobilized as a solitary structure until the urethral orifice reaches the perineum. This is then reconstructed, and the muscle is marked to enable creation of an adequate vaginal opening and perineal body without impinging on rectal space. A long ² common-channel cloaca repair often necessitates formal separation of the bladder and vagina, which requires laparotomy and ureteral catheterization. Vaginal replacement is sometimes necessary if the vaginal length is insufficient for reconstruction. Colostomy closure: Once the wound has completely healed and postoperative dilations have achieved their goal (ie, the neoanus is at the desired size), the colostomy may be closed in traditional surgical fashion.
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Consultations
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Pediatric surgeon: Early consultation with a pediatric surgeon experienced with these anomalies is essential. Ill-conceived procedures during the newborn period may have lifelong consequences for the patient. Neurosurgeon: Consultation with a neurosurgeon is warranted if a tethered spinal cord is present (25% of all cases). Urologist: The need for consultation with a urologist depends on the malformation and the individual pediatric surgeon.
Diet y
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After the obstruction is relieved using colostomy, primary pullthrough, or dilation, children do not require special diet. The most common complication of imperforate anus repair is constipation or anal incontinence; therefore, diet can be a crucial part of management. Many patients may require laxatives, enemas, or other medications or irrigations in addition to dietary manipulations.3 Children should avoid constipating foods, such as those included in the bananas, rice, applesauce, and toast ( BRAT) diet. High-fiber and laxative foods (whole-grain foods and breads, dairy, fruits, vegetables, greasy foods, spicy foods) should be encouraged. Unfortunately, dietary manipulation is often of limited effectiveness because of the fussy nature of most children regarding diets. Fiber supplements and laxatives can be critically important in avoiding constipation, which can significantly affect prognosis.
Activity y
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Children
with anorectal malformations are often otherwise
healthy. Activity limitations are usually related only to the period around their surgical procedures.
Medication y
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Many
children with anorectal malformations require medications for various reasons. Beyond perioperative medications, maintenance medications often include urinary antibiotic prophylaxis or treatment and/or laxatives. Urinary prophylaxis is used to mitigate the risk of urinary infection and urosepsis in children with risk factors for urinary infection such as urinary fistula, vesicoureteral reflux, or continent diversion. Common agents include oral amoxicillin, oral trimethoprim/sulfamethoxazole, and gentamicin bladder irrigations. Comprehensive information on all these medications and others is available in the e Medicine pediatric topicUrinary Tract Infection. Common laxatives include senna products, milk of magnesia, and propylene glycol solutions (eg, MiraLax, GlycoLax).
Multimedia
ile 1: Distal colostogram, posteroanterior view. The initial augmented-pressure distal colostography aims to determine e colostomy was placed in the colon and how much colon is for pull-through, without taking down the colostomy.
Image)
ile 2: Distal colostogram, lateral view. This image shows the hase of distal colostography, in which the patient is placed in ral position. A radio-opaque marker is clearly visible in the ht side of the image, marking the muscle complex on the skin. ge shows that the rectal pouch joins the urinary tract at the he bulbar urethra, a relatively common malformation in boys.
Image) le 3: Bucket-handle malformation. The appearance of a skin overlying the sphincteric muscle complex is a sign in a child born with imperforate anus and perineal
Image) le 4: String-of-pearls malformation. This image shows white material within a perineal fistula. The fistula frequently anteriorly up the scrotum's median raphe.
Image)
le 5: Cloaca. This is the classic appearance of a girl with malformation with a single perineal orifice. The genitals uite short, which is a finding consistent with cloaca.
Image) ile 6: Fourchette fistula. This malformation is somewhere between perineal fistula and vestibular fistula. The fistula et vestibular mucosal lining on its anterior half, but the r half is
Image)
