Persistent Cloaca: A Long-term Follow-up Study.

Sir,

Cloacal repair aims at achieving correct perineal anatomy and function of the bowel and the urogenital tract. Except for a few, most pediatric surgeons have limited experience with total urogenital mobilization (TUM) in infancy. It is a difficult procedure and even in the best of hands can be followed by serious complications such as urethral stenosis, complete vaginal and anal closure, tight introitus, neurogenic bladder, and urinary incontinence.[123] Up to 50% of patients may have urinary incontinence or may be dependent on clean intermittent catheterization after cloaca repair.[4]

Patients with postoperative complications go unreported, especially in India. Although here we can offer modern treatment free of cost, complications such as urinary incontinence are not easily supported by public health sector (government) and society as in the west.

We have done a follow-up study of 1 adolescent and 8 adult female patients born with cloaca, who had rectal pull through alone in infancy, leaving the urogenital region untouched. The length of the common channel was not assessed since TUM was not planned. Their urogenital problems were treated as they came up in adolescence and adulthood. The common channel after full growth was used as vagina with introitoplasty and dilatation or with surgical intervention for treatable genital anomalies if any. Their current urogenital status, bowel habits, sexual status, and quality of life are shown in Table 1.

Table 1

Associated anomalies, treatment, and the present status of study patients

Although there may have been a few unrecognized or empirically treated infections, all our patients had an intact urogenital complex and none had documented recurrent urinary tract infections until adolescence. Hence, we believe that leaving the urogenital complex intact is beneficial.

All our patients are now beyond adolescence and five got married. Three have reported regular sexual intercourse and one has conceived. Three patients, who are not married, had introitoplasty done for free menstrual flow. We believe that nearing puberty, the introitus should be assessed and thereafter before marriage, a dilatation program can be instituted. Four patients needed introitoplasty beyond 20 years of age. With these measures, the common channel was used as a vagina for regular intercourse.

Only one patient out of nine reported urinary and fecal incontinence which was associated with a poorly developed sacrum. All the others were continent for urine and stool.

Although our series is small, there is a strong case for not subjecting cloaca patients to TUM which has a sizeable potential of developing urinary incontinence. Furthermore, the common channel can be used as vagina along with introitoplasty and dilatation.

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Conflicts of interest

There are no conflicts of interest.