Normal Anus and Anorectum with a Fistula

15.8.1 Fistula Between a Normal Anorectum and the Perineum

A fistula between a normal anorectum and the perineum is super-rare. Brem et al. [8] has described

Fourchette Fistula
Fig. 15.21 Diagrammatic SS of rectal atresia and proximal rectal stenosis
Fig. 15.23 Diagrammatic SS of normal anorectum, normal urethra and rectourethral fistula

one boy of Asian origin living in the USA, and we have seen one boy. A fistula between a normal anorectum and a normal male urethra is rare. It has been reported by Stephens and Donnellan [71], Hong et al. [31], Rintala et al. [57], and Sharma et al. [66], and we have also seen two cases (Fig. 15.23).

15.8.2 Fistula Between a Normal Anorectum and an Abnormal Male Urethra

A fistula between a normal anorectum and an abnormal male urethra is relatively more common. It has been reported by de Vries and Friedland [20], Stephens and Donnellan [71], Belmann [5], Senocak and Buyukpamukeu [63], Lal et al. [40], Al-Basam et al. [3], and the Japanese Study group [24]. Mishra et al.

[47] described five cases; all had a wide fistula, a narrow distal urethra and upper tract problems. Wakhlu and Wakhlu [76] have described four cases; three had hypoplasia of the anterior urethra and one had mega-lourethra. We have observed four cases; three were continent but passed most of their urine per anum and small amounts resembling tear drops per urethra (Fig. 15.24). The fourth had in addition an atypical superior vesical fissure; the connection between bowel and urethra was only recognized after the bladder was repaired.

15.8.3 Fistula Between a Normal Anorectum and the Vestibule

A fistula between a normal anorectum and the vestibule (or "perineal canal") is rare elsewhere but is relatively common in India. It was first reported by Bryndorf and Madsen [9] from Scandinavia. Brem et al. [8] reported this anomaly in 2 girls of Asian origin living in the USA, and Rintala et al. [57] reported on 12 girls from Finland. Almost all other reports have come from Asia and North Africa. We [14] reported 6 cases in 1969, added 10 more in 1980 [11], and 12 more in 1991 [12]. Other reports from India include 1 case from Chatterjee [10], 1 from Rao et al. [55], 58 from Wakhlu's group [77], 10 from Kulshrestha [38], 2 from Kutumbala et al. [39], 1 from Singh et al. [67], 1 from Arora et al. [2], 5 from Wani et al. [78]. Arora's patient had bilateral fistulas, one on either side of the fourchette [2]. The anomaly has also been reported from Vietnam [48], Japan [34,59,73,74], China [81] Pakistan [46], Qatar [33], and Egypt [44]. We now have 62 cases and have classified them as low or anovestibular and intermediate or rectovestibular fistulas (Figs. 15.25 and 15.26). The anterior wall of a rectovestibular fistula is generally closely adherent to the posterior wall of the vagina. Several surgeons have named the condition "perineal canal".

15.8.4 Fistula Between a Normal Anorectum and the Vagina

A fistula between a normal anorectum and the vagina is super-rare; we have a single case [12]. She was first seen at the age of 7 years. She passed stools per anum and also through the vagina. A huge fistula was found between the lower rectum and the vagina; at surgery the bowel and the vagina were found to share a common wall above the fistula (Fig. 15.27).

Fig. 15.24 Diagrammatic SS of normal anorectum, narrow urethra and rectourethral fistula
Anorectal Malformation
Fig. 15.25 Diagrammatic SS of normal anorectum and anoves-tibular fistula
Fig. 15.26 Diagrammatic SS of normal anorectum and rec-tovestibular fistula
Fig. 15.27 Diagrammatic SS of normal anorectum and recto-vaginal fistula
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