In males, an imperforate anus with a fistula from the rectum to the urethra may contact the latter proximally - prostatic urethra - or more distally - bulbar urethra. A large percentage of these patients have a poorly developed sacrum and perineal muscles. A common presenting sign is meconium in the urine. A protective colostomy is constructed first before a definitive correction.
Treatment is by posterior sagittal anorectoplasty at 3-4 months of age. This entails division of the anorectal sphincter, careful separation of posterior urethra from rectum, mobilization of the rectum and placement in continuity with the sphincter, and finally refashioning of the sphincter muscle mechanism.
The prognosis is favourable: 60-70% of patients have voluntary bowel movements by 3 years of age; soiling becomes more likely with increasing initial abnormality of the sacrum.
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