# Vestibular Fistula — GCMD Library living collection

Everything in the library about vestibular fistula — built automatically from dossiers that name it.

Updated: n/a · 6 episodes · 145 cited statements

## Episodes
### Surgical Management
- [Surgical Management Of Female Anorectal Malformation Patients Including...](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741) — video · 57:59 · [machine version](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741.md)
- [Imperforate Anus Rapid Fire: Update Course 2015](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984) — video · 6:54 · [machine version](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984.md)
- [Anorectal Malformation Management of Female Patients Part II: Pediatric...](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090) — video · 28:20 · [machine version](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090.md)
- [ARMs in Female Patients: Pediatric Colorectal Controversies 2014](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101) — video · 55:00 · [machine version](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101.md)
- [Update Course Rewind 2025: Perineal Body–Preserving PSARP: The New Standard?](https://team.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867) — video · 2:13 · [machine version](https://team.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867.md)

### Case-Based Learning
- [Pediatric Colorectal Contraversies Part II: Pediatric Colorectal...](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416) — video · 31:29 · [machine version](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416.md)

## Chapters
- [0:00](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=0) Vestibular fistula: primary repair versus colostomy timing and technique (Ep 1)
- [5:57](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=357) Recognition of Currarino syndrome and management of anorectal stenosis with presacral mass (Ep 1)
- [9:39](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=579) Colostomy location and technique to prevent prolapse and optimize subsequent repair (Ep 1)
- [19:29](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1169) Loop versus divided colostomy and implications for laparoscopic repair (Ep 1)
- [22:14](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1334) Cloacal malformation: hydrocolpos drainage and urinary decompression strategy (Ep 1)
- [0:00](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=0) Introduction and Diagnostic Cases (Ep 2)
- [2:59](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=179) Mobilization Technique and Debate (Ep 2)
- [8:36](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=516) Primary Repair Without Colostomy (Ep 2)
- [16:45](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1005) Perioperative Management and Research Gaps (Ep 2)
- [24:44](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1484) Vaginal Anomalies: Septum and Absent Vagina (Ep 2)
- [33:56](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2036) Vaginal Reconstruction Techniques (Ep 2)
- [44:56](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2696) Cloaca and Hydrocolpos Management (Ep 2)
- [0:00](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=0) Case presentation and initial management options for vestibular fistula (Ep 3)
- [2:35](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=155) Dilation technique and risks of prolonged dilation (Ep 3)
- [3:55](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=235) Sterile meconium concept and timing of repair (Ep 3)
- [5:28](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=328) Management of vestibular fistula with absent vagina (Ep 3)
- [0:01](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1) Vaginal Septa in Vestibular Fistulas: Recognition and Management (Ep 4)
- [5:15](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=315) Vestibular Fistula with Absent Vagina: Diagnosis and Surgical Approach (Ep 4)
- [10:10](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=610) Technical Aspects of Neovagina Construction and Reoperations (Ep 4)
- [17:12](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1032) Cloaca Management: Hydrocolpos and Initial Surgical Approach (Ep 4)
- [0:00](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=0) Diagnosis and Classification of Perineal and Vestibular Fistulas (Ep 5)
- [7:38](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=458) Surgical Technique: Extent of Rectal Mobilization (Ep 5)
- [12:47](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=767) Perioperative Management: NPO Duration and Colostomy Use (Ep 5)
- [17:56](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1076) Evidence Gaps and Need for Prospective Studies (Ep 5)
- [22:56](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1376) Vaginal Septum Recognition and Management (Ep 5)
- [28:10](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1690) Vestibular Fistula with Absent Vagina (Ep 5)
- [40:17](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2417) Common Perineal Groove (Ep 5)
- [44:12](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2652) Cloacal Malformations: Hydrocolpos Management (Ep 5)
- [0:00](https://team.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=0) Introduction and Session Overview (Ep 6)
- [0:32](https://team.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=32) Audience Poll Results and Published Outcomes Data (Ep 6)
- [1:13](https://team.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=73) Technical Approach and Clinical Considerations (Ep 6)
- [1:51](https://team.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=111) Summary and Closing (Ep 6)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- In every single redo of a female anorectal malformation, areolar tissue is found that had never been dissected by the original surgeon, suggesting inadequate anterior rectal wall mobilization led to perineal body disruption. — Mark (clinical) [Ep 2 · 6:38](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=398)
- The rectal blood supply is intramural, so injuring the rectal wall during dissection hurts its blood supply. — Mark (clinical) [Ep 2 · 14:12](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=852)
- About 2 to 5% of vestibular fistulas have a vaginal septum that should be identified at the time of rectal repair. — Mark (epidemiological) [Ep 2 · 27:40](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1660)
- Of 33 patients with vestibular fistula and absent vagina, 75% had urologic problems including neurogenic bladder, and 50% had CKD stage 3 or greater. (epidemiological) [Ep 2 · 37:17](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2237)
- Vestibular fistula with absent vagina requires aggressive urologic screening due to high rates of solitary kidneys, reflux, hydronephrosis, neurogenic bladder, and urinary tract infections. (clinical) [Ep 2 · 37:31](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2251)
- The ideal time to create a neovagina is when fixing the rectum, because the perineal body is open and the sigmoid pedicle reaches more easily in younger children with shorter pelvis. — Mark (opinion) [Ep 2 · 39:35](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2375)
- About 50% of cloacas have a bifid gynecologic system. — Mark (epidemiological) [Ep 2 · 45:50](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2750)
- Catheterization of cloaca should be done under ultrasound guidance initially to ensure the catheter enters the correct structure (right vagina, left vagina, bladder, or rectum). — Mark (clinical) [Ep 2 · 52:02](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=3122)
- Most patients with hydrocolpos can be successfully drained by draining the hydrocolpos only, without needing to drain the bladder separately. — Mark (clinical) [Ep 2 · 54:04](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=3244)
- Primary repair is preferred in the neonatal period with a very nice fistula; older patients may require colostomy (clinical) [Ep 1 · 1:14](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=74)
- Primary repair can be performed up to 3-4 months of age if surgeon is confident; otherwise two-operation approach is used (clinical) [Ep 1 · 1:32](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=92)
- Teenagers repaired with classical three-operation approach have beautiful perineum and perfect function (clinical) [Ep 1 · 2:28](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=148)
- Patients repaired primarily 7-8 years ago have more stenosis and adhesions because feces pass through during healing even with fasting (clinical) [Ep 1 · 2:57](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=177)
- Vestibular fistula patients with normal sacrum and no cord have excellent prognosis with good operation (clinical) [Ep 1 · 3:46](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=226)
- For babies born in hospital, operate within first 72 hours before colonization occurs (clinical) [Ep 1 · 4:34](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=274)
- For 6-month-old baby with megacolon, clean colon with GoLYTELY completely, then central line with 7-10 days NPO on parenteral nutrition before repair (clinical) [Ep 1 · 4:58](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=298)
- Oval-shaped anus with no radiating streaks is very specific for Currarino syndrome — Sabine (clinical) [Ep 1 · 6:35](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=395)
- Presacral mass corresponds to either anorectal stenosis (mass just in front of stenosis) or Currarino syndrome — Sabine (clinical) [Ep 1 · 7:43](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=463)
- Opening colostomy in mobile portion of colon will cause severe prolapse (clinical) [Ep 1 · 12:23](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=743)
- Opening colostomy in fixed portion of colon (end of descending colon) prevents prolapse (clinical) [Ep 1 · 12:02](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=722)
- Mucous fistula should be reduced in size and made tiny, only necessary for irrigation and diagnostic tests (clinical) [Ep 1 · 13:32](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=812)
- Transverse colostomy dysfunctionalizes a very long piece of colon (clinical) [Ep 1 · 16:19](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=979)
- It is extremely difficult to do a good distal colostogram through transverse colostomy because of difficulty applying enough hydrostatic pressure (clinical) [Ep 1 · 16:27](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=987)
- Colon perforation with distal colostogram occurred mainly through transverse colostomy (clinical) [Ep 1 · 16:58](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1018)
- Cleaning colon distal to transverse colostomy is almost impossible, leaving pool of meconium that colonizes (clinical) [Ep 1 · 17:07](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1027)
- With transverse colostomy and rectourinary fistula, urine gets trapped in colon, is absorbed, and can cause hyperchloremic acidosis (clinical) [Ep 1 · 17:30](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1050)
- Long-term transverse colostomy causes distal colon to become extremely dilated and full of meconium (clinical) [Ep 1 · 17:49](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1069)
- There is a direct relationship between degree of megacolon and degree of constipation the patient will have (clinical) [Ep 1 · 18:40](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1120)
- Loop colostomies have more prolapse than separated colostomies (clinical) [Ep 1 · 18:59](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1139)
- For laparoscopic repair, distal colostomy can act as traction to help dissect fistula, then take down and open new one simultaneously (clinical) [Ep 1 · 21:37](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1297)
- Cloaca is rarely diagnosed prenatally in second trimester; third trimester ultrasound more common (clinical) [Ep 1 · 22:52](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1372)
- Midline abdominal mass in cloaca patient is always hydrocolpos; never seen a cloaca with that mass that was not hydrocolpos (clinical) [Ep 1 · 24:42](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1482)
- Hydrocolpos compresses bladder trigone and produces acquired ureterovesical obstruction with megaureters and hydronephrosis (clinical) [Ep 1 · 25:56](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1556)
- Draining hydrocolpos makes hydronephrosis disappear (clinical) [Ep 1 · 26:18](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1578)
- Unnecessary nephrostomy, ureterostomy, or vesicostomy may be performed if urologist does not recognize that hydrocolpos drainage is the key (clinical) [Ep 1 · 26:23](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1583)
- Consequences of not draining hydrocolpos are urosepsis and infected hydrocolpos (pyocolpos) that permanently damages vagina (clinical) [Ep 1 · 27:10](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1630)
- Transperineal catheter drainage of hydrocolpos will come out in two days and hydrocolpos will reform (clinical) [Ep 1 · 27:45](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1665)
- Drain hydrocolpos with permanent catheter through abdomen, not by dilating common channel (clinical) [Ep 1 · 27:52](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1672)
- Interventional radiology can drain hydrocolpos under ultrasound guidance if it is large enough and close to abdominal wall (clinical) [Ep 1 · 29:04](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1744)
- Vesicostomy is indicated when common channel is almost atretic and baby has difficulty emptying bladder after hydrocolpos drainage (clinical) [Ep 1 · 30:41](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1841)
- In vestibular fistulas where the opening is very close to the expected anal position, the perineal anatomy can improve significantly within a few weeks to a month, with the distance from the expected anus decreasing over time. (clinical) [Ep 3 · 1:17](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=77)
- As long as the child is stooling adequately, there is no urgency to perform definitive repair, and waiting at least a month to observe anatomic evolution is appropriate. (opinion) [Ep 3 · 1:49](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=109)
- Management of vestibular fistulas varies widely among pediatric surgeons, with some performing dilations, some doing primary operations, and some doing colostomies. (epidemiological) [Ep 3 · 2:01](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=121)
- Expert surgeons may be able to perform primary repair in the newborn period, but routine pediatric surgeons may not have the same capability. (opinion) [Ep 3 · 2:14](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=134)
- Primary repair in a newborn is technically challenging because it is hard to identify where the sphincter should be and the dissection plane between vagina and rectum is much thinner. — Belinda (clinical) [Ep 3 · 2:41](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=161)
- In settings without access to TPN and IV fluids where anoplasty healing is critical, colostomy with delayed repair may be more appropriate than primary repair. — Belinda (clinical) [Ep 3 · 2:55](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=175)
- Prolonged dilations cause scarring and inflammation that can make subsequent surgical repair more difficult. — Belinda (clinical) [Ep 3 · 3:20](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=200)
- Dilations should typically be limited to size 7 or 8, with patients maintained on stool softeners. — Belinda (clinical) [Ep 3 · 3:29](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=209)
- Dilations up to size 11 or 12 make subsequent repair technically difficult. — Belinda (clinical) [Ep 3 · 3:33](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=213)
- Dissection at 3 or 6 months of age can be just as tedious as newborn repair if dilations have caused local trauma. (clinical) [Ep 3 · 3:40](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=220)
- Conservative postoperative management includes keeping patients NPO for about a week and providing hyperalimentation (a 'medical colostomy'), though there is no data to support this approach. (clinical) [Ep 3 · 4:30](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=270)
- The primary reason for not operating in the immediate newborn period is the technical difficulty of the dissection, not concerns about stool sterility. (opinion) [Ep 3 · 5:09](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=309)
- It is harder to identify the exact center of the sphincter in a 2 kg baby than in an 8 or 9 kg baby. (clinical) [Ep 3 · 5:18](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=318)
- In a patient with vestibular fistula and absent vagina who has good prognosis for bowel control, the operation should either be aborted for later definitive planning, or a graft (colon or small bowel) can be used to replace the vagina while bringing the rectum/fistula down as a pull-through. (clinical) [Ep 3 · 5:57](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=357)
- In a patient with vestibular fistula and absent vagina who has poor prognosis for bowel control (such as those with sacral agenesis, tethered cord, or other conditions), the rectum/fistula can be used as the vagina and a more proximal piece of colon brought down as the pull-through. (clinical) [Ep 3 · 6:23](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=383)
- 2 to 5% of vestibular fistulas have a vaginal septum (epidemiological) [Ep 4 · 0:01](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1)
- The ideal time to remove a vaginal septum is when the rectum is being mobilized and the perineal body is open (clinical) [Ep 4 · 0:18](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=18)
- Women with longitudinal vaginal septa often learn to use one side of the vagina more than the other during intercourse and are often not bothered — Jerry (clinical) [Ep 4 · 2:37](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=157)
- During labor, women with longitudinal vaginal septa often blow the septum out, which can be repaired at that time — Jerry (clinical) [Ep 4 · 2:57](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=177)
- Menstrual hygiene is a major reason to remove vaginal septa - patients report needing tampons on each side or requiring both tampon and pad — Jerry (clinical) [Ep 4 · 3:10](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=190)
- Resecting a vaginal septum in an adolescent is not a difficult operation and can be done with electrocautery, getting as close to the cervix as possible without damaging it — Jerry (clinical) [Ep 4 · 3:50](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=230)
- In vestibular fistula, visual inspection of the introitus with spreading of an instrument is obligatory to look for vaginal septa (clinical) [Ep 4 · 4:11](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=251)
- 97% of vestibular fistula patients have normal vaginal anatomy without septa (epidemiological) [Ep 4 · 5:04](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=304)
- For vestibular fistula with absent vagina, sigmoid colon can be used as a vaginoplasty — Don (clinical) [Ep 4 · 7:32](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=452)
- In absent vagina cases, the rectal fistula can be dilated without doing a colostomy, because a sigmoid colostomy would interfere with blood supply needed for sigmoid vaginoplasty — Don (clinical) [Ep 4 · 7:42](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=462)
- Sigmoid vaginoplasty and imperforate anus repair can be done in one stage laparoscopically with a backup colostomy — Don (clinical) [Ep 4 · 8:06](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=486)
- An alternative to sigmoid neovagina is to use the rectum as vagina and mobilize more proximal rectum down as neo-rectum (clinical) [Ep 4 · 8:45](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=525)
- Using rectum as vagina should only be done if the patient is unlikely to be continent, such as with spinal anomaly or absent sacrum, because rectum has value for continence (clinical) [Ep 4 · 8:58](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=538)
- Of 33 patients with absent vagina, 75% had urologic problems including neurogenic bladder — Shammael (epidemiological) [Ep 4 · 9:38](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=578)
- Of patients with absent vagina, 50% had CKD stage 3 or greater — Shammael (epidemiological) [Ep 4 · 9:47](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=587)
- Solitary kidneys, reflux, hydronephrosis, neurogenic bladder, and urinary tract infections are long-term sequelae in patients with absent vagina — Shammael (clinical) [Ep 4 · 9:52](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=592)
- Once absent vagina is diagnosed, aggressive screening of the urinary tract must be employed — Shammael (clinical) [Ep 4 · 10:02](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=602)
- Male ARM with any associated urologic problem requires urology collaboration (guideline) [Ep 4 · 10:16](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=616)
- Vestibular fistula with absent vagina is an important category requiring urology collaboration because a large percentage have serious urologic problems (clinical) [Ep 4 · 10:24](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=624)
- In absent vagina, the rectum separates nicely from the urethra with thick fibrous tissue, less adherent than rectum to posterior vagina (clinical) [Ep 4 · 10:38](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=638)
- The ideal time to fix the vagina is when fixing the rectum because the perineal body is open (opinion) [Ep 4 · 11:53](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=713)
- Neovagina is technically easier in younger children because the sigmoid pedicle reaches more easily when the pelvis is shorter (clinical) [Ep 4 · 12:04](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=724)
- For premenarchal girls with vaginal septum already missed at primary repair, there is no rush to operate unless another procedure is planned — Jerry (clinical) [Ep 4 · 15:08](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=908)
- A patient can have an isolated longitudinal vaginal septum with one Müllerian system, or two cervices indicating duplicated system — Jerry (clinical) [Ep 4 · 15:33](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=933)
- Vaginoscopy to identify one versus two cervices is important in determining whether a vaginal septum represents isolated septum or duplicated Müllerian system — Jerry (clinical) [Ep 4 · 15:33](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=933)
- There are two types of cloacas: lower ones (13 cm common channel or less) and complicated ones (13 cm or greater) (clinical) [Ep 4 · 17:32](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1052)
- Making the distinction between low and high cloacas helps avoid trouble in management (opinion) [Ep 4 · 17:32](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1052)
- Hydrocolpos may obstruct the distal ureters and cause bilateral hydronephrosis (clinical) [Ep 4 · 17:59](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1079)
- About 50% of cloacas have a duplicated gynecologic system (epidemiological) [Ep 4 · 18:11](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1091)
- For newborn cloaca with hydrocolpos, management includes open divided colostomy and decompression of vagina with pigtail catheter rather than formal vaginostomy — Jack (clinical) [Ep 4 · 18:30](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1110)
- Creating a colostomy can be challenging when hydrocolpos is very dilated, occasionally requiring vaginal decompression first — Jack (clinical) [Ep 4 · 18:51](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1131)
- Attempting cystoscopy at the time of colostomy creation in cloaca makes the colostomy very difficult — Jack (clinical) [Ep 4 · 19:08](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1148)
- For newborn cloaca, recommendation is to just divert and deal with vaginostomy without scoping at that time (opinion) [Ep 4 · 19:28](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1168)
- Scoping the vagina can be done at 2-3 months of age with better visualization and is more pleasant than doing it in the newborn period (opinion) [Ep 4 · 19:45](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1185)
- For large hydrocolpos that comfortably reaches the abdominal wall, a sutured tubeless vaginostomy can be done (clinical) [Ep 4 · 22:00](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1320)
- For hydrocolpos lower than abdominal wall, ideal is tube vaginostomy using a curled tube (Pezzer or Malecot) rather than straight tube (clinical) [Ep 4 · 22:00](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1320)
- With straight tube vaginostomy, as hydrocolpos recedes and inflammation resolves at about 2 months, the tube falls out, whereas curled tubes stay in place (clinical) [Ep 4 · 22:23](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1343)
- Much of hydrocolpos fluid can be vaginal secretions, but much can also be urine refluxing up — Don (clinical) [Ep 4 · 22:49](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1369)
- Urine is often as big a problem as vaginal dilatation in hydrocolpos — Don (clinical) [Ep 4 · 22:56](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1376)
- Alternative to tube vaginostomy is having family intermittently catheterize the cloaca 2-3 times daily to drain urine (clinical) [Ep 4 · 23:30](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1410)
- After the newborn period, the uterus stops secreting and most fluid in vaginal part of cloaca is urine refluxing back (clinical) [Ep 4 · 23:37](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1417)
- As vagina distends in cloaca, it obstructs the urethra causing more urine to leak into vagina in a perpetuating cycle (clinical) [Ep 4 · 23:58](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1438)
- Intermittent catheterization teaching should be done under ultrasound because the tube can go into right vagina, left vagina, bladder, or rectum (clinical) [Ep 4 · 24:23](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1463)
- Without ultrasound guidance, you may go 3 days without draining the correct vagina in duplicated systems (clinical) [Ep 4 · 24:43](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1483)
- Blind passage of catheter through perineum generally does not drain the structures you want to drain (clinical) [Ep 4 · 24:51](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1491)
- In one case, bedside ultrasound showed very dilated hemivaginas with echogenic fluid (probably meconium and urine) and patient creatinine was about 4 — Jack (clinical) [Ep 4 · 25:29](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1529)
- Ultrasound-guided tube placement for hydrocolpos drainage can be done in the ICU — Jack (clinical) [Ep 4 · 25:52](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1552)
- Before draining hydrocolpos, the bladder cannot be seen on ultrasound; after drainage, the bladder fills beautifully, demonstrating the physiology of ureteral compression (clinical) [Ep 4 · 26:05](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1565)
- In most patients, draining the hydrocolpos alone is sufficient; rarely you also need to drain the bladder (clinical) [Ep 4 · 26:26](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1586)
- In duplicated vaginal systems, both sides must be drained or only one side of hydronephrosis will improve (clinical) [Ep 4 · 26:34](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1594)
- During colostomy opening, the dome of hydrocolpos can be opened and some septum removed to create a single chamber (clinical) [Ep 4 · 26:58](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1618)
- If tube vaginostomy is placed and operation planned in a couple months, it may be difficult to bring the vagina down because it becomes fixed (clinical) [Ep 4 · 27:28](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1648)
- For very large hydrocolpos, you will almost always need to be in the abdomen anyway and can take down the vaginostomy at that time (clinical) [Ep 4 · 27:50](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1670)
- Perineal body-preserving PSARP is basically the same technique one would do in a bulbar fistula, but applied to a vestibular fistula, cleaning up the lateral planes before coming around the front. — Nelson (clinical) [Ep 6 · 1:13](https://team.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=73)
- Perineal body-preserving PSARP allows patients to go home earlier compared to classic PSARP. (clinical) [Ep 6 · 1:32](https://team.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=92)
- With perineal body-preserving PSARP, the surgeon does not have to worry about breakdown in the perineal body postoperatively. (clinical) [Ep 6 · 1:32](https://team.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=92)
- Perineal body-preserving PSARP is harder technically than opening it all the way anteriorly in a standard PSARP. (opinion) [Ep 6 · 1:36](https://team.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=96)
- If the surgeon is not sure where the anterior rectal wall is and where the vagina is during perineal body-preserving PSARP, conversion to a standard PSARP is appropriate. (clinical) [Ep 6 · 1:45](https://team.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=105)
- The forchette represents the boundary between perineal and vestibular fistula classifications, though this distinction can be ambiguous and 'Mother Nature is up there chuckling at us when we try to make these distinctions.' (clinical) [Ep 5 · 1:43](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=103)
- Don's mobilization goal for perineal/vestibular fistula repair is to mobilize just enough so the rectum reaches perineal skin with a little bit of tension, not necessarily achieving complete separation from vagina. — Don (clinical) [Ep 5 · 2:27](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=147)
- In every redo of a female ARM, the surgeon finds areolar tissue that had never been dissected by the original surgeon, suggesting the redo was needed because the perineal body disrupted when the anterior rectal wall was not freed enough and pulled back. (clinical) [Ep 5 · 5:40](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=340)
- Many female vestibular fistula redos were done in the newborn period without a backup colostomy, which may contribute to complications. — Don (clinical) [Ep 5 · 6:52](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=412)
- The host performs vestibular repairs primarily without colostomy, either in newborn period or within 3-4 months depending on child's condition, but acknowledges surgeons who want diversion cannot be criticized. (clinical) [Ep 5 · 15:00](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=900)
- If doing primary repair with simultaneous diversion, the host recommends repair plus colostomy at same time followed by colostomy closure, rather than newborn colostomy, delayed repair, then colostomy closure. (clinical) [Ep 5 · 15:22](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=922)
- The host waits until perineal body is healed (around day 6-7) before feeding after primary vestibular repair without colostomy, admitting this is based on bias from doing many redos where early feeding preceded dehiscence. (clinical) [Ep 5 · 16:28](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=988)
- Watching the perineal body carefully during NPO period allows intervention (re-suturing on day 6-7) before complete dehiscence, versus feeding early, sending home, and discovering at 3-4 week clinic visit that perineal body has fallen apart. (clinical) [Ep 5 · 16:50](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1010)
- In settings without hyperalimentation, 10% dextrose can be used for NPO periods up to 7 days in healthy, robust children, allowing surgeons in resource-limited settings to attempt NPO protocols. (clinical) [Ep 5 · 17:18](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1038)
- For delayed vestibular repairs, the host performs full GoLYTELY bowel prep until effluent is clear, plus or minus oral antibiotics (which recent evidence suggests may be advantageous), with patient admitted day before surgery. (clinical) [Ep 5 · 23:04](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1384)
- The host's protocol for primary vestibular repair includes PICC line, hyperalimentation, and careful perineal body examination on day 7; if healed, patient is fed and discharged; if separation is beginning (1-2 times per year), patient returns to OR for reinforcing sutures. (clinical) [Ep 5 · 23:55](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1435)
- The host does not use a Foley catheter during or after vestibular/perineal fistula repair, believing urine leaking on the perineum is not a big deal. (clinical) [Ep 5 · 25:31](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1531)
- About 2-5% of vestibular fistulas have a vaginal septum that must be identified; the ideal time to address the septum is during initial rectal mobilization when the perineal body is open. (epidemiological) [Ep 5 · 26:51](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1611)
- Formal vaginoscopy is not necessary for every vestibular fistula; visual inspection of the introitus with spreading is sufficient, but if a septum is seen, then vaginoscopy should be performed to evaluate cervix/cervices. (clinical) [Ep 5 · 28:28](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1708)
- Common perineal groove is a mucosal-lined channel between vagina and anus in patients with otherwise normal urethra, vagina, and anus; the vast majority become normal skin over time if observed. (clinical) [Ep 5 · 10:36](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=636)
- If common perineal groove causes mucus production, it is a simple fix to unroof the mucosa and suture it up; it is often associated with perineal fistula. (clinical) [Ep 5 · 10:43](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=643)
- Patients with vestibular fistula and absent vagina should undergo clinical evaluation for VACTERL association features because of the association with this specific anomaly pattern. (guideline) [Ep 5 · 11:41](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=701)
- Of 33 patients with ARM and absent vagina in one series, 75% had urologic problems including neurogenic bladder, and 50% had CKD stage 3 or greater, including solitary kidneys, reflux, hydronephrosis, neurogenic bladder, and UTIs. — Don (epidemiological) [Ep 5 · 36:15](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2175)
- Once the diagnosis of absent vagina is made in ARM, aggressive urologic screening must be employed; this is one of three ARM categories requiring mandatory urology collaboration (along with males with any urologic association and cloacas). (guideline) [Ep 5 · 36:42](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2202)
- Don's preferred method for ARM with absent vagina is to use sigmoid colon as neovagina, delaying repair to dilate the rectal fistula without newborn colostomy (to preserve sigmoid blood supply), then performing laparoscopic sigmoid vaginoplasty with rectal repair and backup colostomy at older age. — Don (clinical) [Ep 5 · 33:57](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2037)
- The alternative approach to absent vagina is to use the existing rectum as neovagina and mobilize more proximal bowel as neo-rectum, but this should only be done if the patient is unlikely to be continent (spinal anomaly, absent sacrum) because rectum has value for continence. (clinical) [Ep 5 · 35:25](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2125)
- In vestibular fistula with absent vagina, the rectum separates from the urethra through very thick, fibrous tissue that is not nearly as adherent as rectum to posterior vagina, creating space to bring through the neovagina. (clinical) [Ep 5 · 37:18](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2238)
- Gynecologists typically recommend delaying neovagina construction until teenage years, but pediatric surgeons prefer doing it at the time of rectal repair because the perineal body is open (ideal opportunity) and the sigmoid pedicle reaches more easily in younger children with shorter pelvises. (opinion) [Ep 5 · 37:49](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2269)
- There are two distinct types of cloacas: lower ones (common channel ≤3cm) and complicated ones (common channel ≥3cm); making this distinction helps avoid trouble in management. (clinical) [Ep 5 · 44:32](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2672)
- Hydrocolpos may obstruct the distal ureters and cause bilateral hydronephrosis; about 50% of cloacas have a duplicated gynecologic system. (epidemiological) [Ep 5 · 44:40](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2680)
- There is no rush to scope the vagina in a newborn with cloaca; it is better to divert the patient and perform vaginoscopy at 2-3 months of age when visualization is better and the procedure is more pleasant. (clinical) [Ep 5 · 46:25](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2785)
- For hydrocolpos drainage, if it is large and comfortably reaches the abdominal wall, a sutured tubeless vaginostomy can be performed; if lower, use a curled tube rather than straight tube because hydrocolpos recedes from abdominal wall as inflammation resolves and straight tubes fall out at about 2 months. (clinical) [Ep 5 · 48:40](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2920)
- Much of the fluid in hydrocolpos can be vaginal secretions, but much can also be urine refluxing up, so urine is often as big a problem as vaginal dilatation. — Don (clinical) [Ep 5 · 49:30](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2970)
- If using intermittent catheterization for hydrocolpos, the teaching should be done under ultrasound guidance because the catheter can go into right vagina, left vagina, bladder, or rectum, and three days may pass without draining the correct structure; blind passage through the perineum often fails to drain intended structures. (clinical) [Ep 5 · 51:00](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=3060)
- In most cloaca patients, successful drainage can be achieved by draining the hydrocolpos only, but on rare occasion the bladder must also be drained; awareness that there is often a right and left hemivagina is critical because only draining one side will only improve one side of hydronephrosis. (clinical) [Ep 5 · 53:00](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=3180)
- During surgical opening of colostomy for cloaca, the dome of the hydrocolpos can be opened and a portion of the septum removed to create a single chamber for easier drainage. (clinical) [Ep 5 · 53:38](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=3218)
- If a tube vaginostomy is placed for hydrocolpos, it may be difficult to mobilize the vagina for definitive repair months later because it becomes fixed to skin, though this can be taken down if laparotomy is needed anyway for a large hydrocolpos. (clinical) [Ep 5 · 54:08](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=3248)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Starting lateral dissection before attempting to separate the common anterior wall is key; the lateral plane defines the anterior plane. — Mark summarizing the discussion [Ep 2 · 14:34](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=874)
- Coming in from lateral to anterior and starting more proximally (where structures are easier to separate) rather than at the perineum improves the dissection plane. — Mark summarizing the discussion [Ep 2 · 15:25](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=925)
- A systematic review found that early enteral nutrition appears better than later nutrition in anorectal malformation repair, but all studies were retrospective and poor quality. — Mark summarizing the discussion [Ep 2 · 19:54](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1194)
- Women with longitudinal vaginal septum often learn to work around it for intercourse and may be asymptomatic, but menstrual hygiene (tampon use) is a major reason for resection. — Mark summarizing the discussion [Ep 2 · 30:32](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1832)
- Vaginal septum resection in adolescents is not a difficult operation and can be done with electrocautery, getting as close to the cervix as possible without damaging it. — Mark summarizing the discussion [Ep 2 · 31:29](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1889)
- If a vaginal septum is found in a 6-year-old after anorectal malformation repair, there is no rush to remove it before puberty unless another operation is planned. — Mark summarizing the discussion [Ep 2 · 42:29](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2549)
- For absent vagina with vestibular fistula, sigmoid neovagina is preferred, using sigmoid colon mobilized laparoscopically and brought to the perineum, with backup colostomy. — Mark summarizing the discussion [Ep 2 · 34:56](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2096)
- For newborn cloaca with hydrocolpos, an open divided colostomy should be performed, and the vagina decompressed with a pigtail catheter rather than formal vaginostomy. — Mark summarizing the discussion [Ep 2 · 46:12](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2772)
- Cystoscopy at the time of colostomy creation in cloaca makes the colostomy creation very difficult and should be avoided; scope at 2–3 months instead. — Mark summarizing the discussion [Ep 2 · 46:48](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2808)
- Intermittent catheterization of the cloaca 2–3 times daily can drain urine from the vagina and avoid the need for vaginostomy tube in many cases. — Mark summarizing the discussion [Ep 2 · 51:09](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=3069)
- In hydrocolpos compressing the ureters, once the hydrocolpos is drained, the bladder fills beautifully, demonstrating the physiology of ureteral compression. — Mark summarizing the discussion [Ep 2 · 53:50](https://team.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=3230)
- For vestibular fistula, Professor Liam prefers primary repair around day 5-7 of life — Em Gootee summarizing the discussion [Ep 1 · 0:34](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=34)
- About 30-40% of anorectal stenosis or rectal atresia cases will have a presacral mass — Em Gootee summarizing the discussion [Ep 1 · 8:38](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=518)
- MRI is the best way to show a presacral mass — Em Gootee summarizing the discussion [Ep 1 · 8:45](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=525)
- For anorectal stenosis repair, open posteriorly only to preserve anterior dentate line and avoid anterior rectal dissection — Em Gootee summarizing the discussion [Ep 1 · 8:57](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=537)
- Loop colostomy is never completely diverting no matter how much surgeons believe it is — Em Gootee summarizing the discussion [Ep 1 · 14:37](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=877)
- Spillage across loop colostomy causes urinary tract infections in patients with fistulas — Em Gootee summarizing the discussion [Ep 1 · 15:05](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=905)
- Cleaning out distal colon at colostomy creation takes about 20-30 minutes and is very important — Em Gootee summarizing the discussion [Ep 1 · 15:42](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=942)
- Distal sigmoid colostomy makes laparoscopic operation more difficult and may require opening to take down mucous fistula — Em Gootee summarizing the discussion [Ep 1 · 21:07](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1267)
- Best tube for hydrocolpos drainage is curled pigtail tube because hydrocolpos recedes into pelvis over months; straight tube will fall out — Em Gootee summarizing the discussion [Ep 1 · 28:14](https://team.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1694)
- Traditional teaching held that operations should be performed in the newborn period when meconium is sterile, rather than at 2-3 months when stool is colonized, and that if waiting 2-3 months, colostomy should be performed to divert stool. — The host summarizing the discussion [Ep 3 · 4:01](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=241)
- Some pediatric surgeons repair anorectal malformations at any age with colonized stool present and feed the child on postoperative day 1 or 2, with probably similar complication rates. — The host summarizing the discussion [Ep 3 · 4:52](https://team.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=292)
- Gynecologists typically recommend teenager age for vaginal reconstruction in isolated vaginal anomalies — The host summarizing the discussion [Ep 4 · 11:09](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=669)
- Laparoscopic approach for hydrocolpos management includes left upper quadrant port for visualization, right lower quadrant percutaneous vaginostomy tube, and left lower quadrant diverting colostomy — The host summarizing the discussion [Ep 4 · 21:13](https://team.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1273)
- 2023 publications on perineal body-preserving PSARP demonstrated at one year follow-up: no dehiscence, no prolapse, and only 13% of patients required revision of their anal stricture. — The host summarizing the discussion [Ep 6 · 0:46](https://team.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=46)
- Two-thirds of patients undergoing perineal body-preserving PSARP went home on postoperative day one. — Jill Knepprath summarizing the discussion [Ep 6 · 1:01](https://team.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=61)
- Perineal body-preserving PSARP is a good choice for patients but can be a trickier approach than standard PSARP. — Jill Knepprath summarizing the discussion [Ep 6 · 1:51](https://team.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=111)
- Conversion to the standard PSARP approach is a valid pivot when there is doubt about anatomy during perineal body-preserving PSARP. — Jill Knepprath summarizing the discussion [Ep 6 · 2:00](https://team.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=120)
- Eva advocates complete separation of rectum from vagina to the areolar plane because incomplete mobilization may cause retraction and wound problems, though this results in losing more rudimentary internal sphincter tissue. — The host summarizing the discussion [Ep 5 · 2:50](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=170)
- The rectal blood supply is intramural, so injuring the rectal wall during dissection hurts its blood supply, making vaginal injury preferable to rectal injury during separation. — The host summarizing the discussion [Ep 5 · 13:09](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=789)
- Starting laterally before attempting anterior separation is key to safely creating two structures from the common wall; the lateral plane defines the anterior plane. — The host summarizing the discussion [Ep 5 · 13:35](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=815)
- Mark (the host) advocates coming in from lateral to anterior, and notes that structures are easier to separate more proximally than right at the perineum, so starting higher and working proximal to distal helps find the right plane. — Don summarizing the discussion [Ep 5 · 14:25](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=865)
- Eva's systematic review on perioperative nutrition in ARM found that giving early enteral nutrition seems better than later nutrition (as in adult surgery), but all existing studies are retrospective and poor quality. — The host summarizing the discussion [Ep 5 · 18:48](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1128)
- About 1000 patients have been studied regarding perioperative nutrition in ARM, but they are all retrospective and bad quality studies; good prospective cohort studies are needed before attempting large multi-center randomized trials. — The host summarizing the discussion [Ep 5 · 19:37](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1177)
- Rapid learning healthcare systems allow continual accrual of experience with rapid statistical modeling to provide real-time point-of-care results for rare diseases where traditional multi-center trials introduce excessive variability. — The host summarizing the discussion [Ep 5 · 22:24](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1344)
- Jonathan uses a Foley catheter to keep alkaline urine away from the fresh wound, though acknowledging uncertainty about the actual benefit. — The host summarizing the discussion [Ep 5 · 26:15](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1575)
- Jerry Pierce (gynecologist) explains that women with longitudinal vaginal septums are often asymptomatic with intercourse (learning to use one side) and can labor successfully (either blowing out the septum or having it resected during repair), but menstrual hygiene is a major problem requiring tampon in each side or tampon plus pad. — The host summarizing the discussion [Ep 5 · 29:17](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1757)
- Vaginal septum resection in adolescents is not difficult; it can be done with electrocautery, removing as much as possible close to the cervix without damaging it. — The host summarizing the discussion [Ep 5 · 30:30](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1830)
- If a vaginal septum is discovered at age 6 in a child whose anus was already repaired, Jerry recommends waiting until puberty unless the child needs another operation anyway, as there is no rush in the premenarchal period. — The host summarizing the discussion [Ep 5 · 41:23](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2483)
- The primary determinant of whether a patient has a vaginal septum versus double vagina (uterine didelphys) is the number of cervices seen on vaginoscopy; an isolated longitudinal vaginal septum can exist with one müllerian system. — The host summarizing the discussion [Ep 5 · 42:13](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2533)
- Common perineal groove may represent arrested embryologic development, analogous to an opened-up perineal fistula extending to the scrotum in males. — The host summarizing the discussion [Ep 5 · 11:13](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=673)
- Michael's approach to newborn cloaca with hydrocolpos is open divided colostomy with pigtail catheter vaginal decompression rather than formal vaginostomy, and he avoids cystoscopy at the time of colostomy creation because it makes the procedure very difficult. — The host summarizing the discussion [Ep 5 · 45:10](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2710)
- Doctor Speck describes a laparoscopic approach to cloaca with hydrocolpos: cystoscopy and vaginoscopy to decompress, left upper quadrant laparoscope port for visualization, percutaneous right lower quadrant vaginostomy tube, and left lower quadrant diverting colostomy. — The host summarizing the discussion [Ep 5 · 47:52](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2872)
- Doctor Rosen (Curry) advocates intermittent catheterization of the cloaca 2-3 times daily to drain urine and avoid leaving a tube in the vagina for months; after the newborn period, most fluid is urine refluxing into the vagina because vaginal distension obstructs the urethra in a self-perpetuating cycle. — The host summarizing the discussion [Ep 5 · 50:01](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=3001)
- Steve Krauss describes bedside ultrasound-guided drainage of hydrocolpos in a critically ill newborn with creatinine of 4 and very echogenic fluid (probably meconium and urine); after drainage, the previously invisible bladder filled beautifully, demonstrating that hydrocolpos compresses ureters and prevents bladder filling. — The host summarizing the discussion [Ep 5 · 51:58](https://team.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=3118)

## Changelog
- Sep 17: 1 item added automatically
- Sep 9: 1 item no longer name vestibular fistula
- Sep 8: 1 item added automatically
- Sep 7: 5 items added automatically

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