From
Colorectal Channel
Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison
With Dr. Marc Levitt & Dr. Aaron Garrison · hosted by Dr. Todd Ponsky
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Video
Collaborative work: Complex Pediatric Anorectal Malformations 2017
Dr. Todd Ponsky · 23 min · Published Jun 2017
Video
Anorectal Malformation Management of Female Patients Part II: Pediatric...
28 min · Published Apr 2012
Video
Surgical Management Of Female Anorectal Malformation Patients Including...
57 min · Published Nov 2018
Video
Case Presentations Part II: Cloaca and Complex ARMs 2015
14 min · Published Oct 2015
Video
Cloaca - Long Common Channel
14 min · Published Nov 2018
Podcast
Colorectal Quiz Episode 17: Cloaca Part 1
Marc Levitt · 27 min · Published Jul 2021
Video
Validation of an anorectal malformation trainer - Can a high-fidelity model simulate real life?
1 min · Published Jun 2026
Video
Complications and Long-Term Outcomes of Patients With Cloacal Malformation After Bowel Neovagina...
1 min · Published Jun 2026
Video
Safety and utility of long-acting steroid injection for management of post-operative stricture...
1 min · Published Jun 2026
Video
Association Between Social Determinants of Health and Choice of Urinary Reconstruction in Children
1 min · Published Jun 2026
Video
The Perineal Body Preserving PSARP (PPP)
11 min · Published Jun 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Colorectal Quiz Ep. 50 -16th Annual European Pediatric Colorectal & Pelvic Reconstruction Conference
Marc Levitt · Published Mar 2026
Podcast
Colorectal Quiz: Episode 50 - 16th Annual European Pediatric Colorectal and Pelvic Reconstruction Conference, Stockholm, Sweden, October 2025 - What did we learn?
24 min · Published Mar 2026
Video
Colorectal Quiz Episode 33: Cloaca Exstrophy
Marc Levitt · 22 min · Published Sep 2025
Video
The Colorectal Quiz Episode 21: The History of Hirschsprung Disease
Marc Levitt · 15 min · Published Sep 2025
Video
Colorectal Quiz: Episode 49 – Collaborating for Kids: Colorectal & Pelvic Care (with Help from AI)
Marc Levitt · 40 min · Published Jul 2025
Podcast
Colorectal Quiz: Episode 49 - Collaborating for Kids: Colorectal & Pelvic Solutions (with a Little Help from AI)
Marc Levitt · 40 min · Published Jul 2025
Podcast
Long-term obstetric and gynecologic care for patients with anorectal malformations
21 min · Published Sep 2026
Podcast
Post-pubertal gynecologic evaluation and management of patients with anorectal malformations
22 min · Published Sep 2026
Podcast
Pre-pubertal gynecologic evaluation and management of patients with anorectal malformations
23 min · Published Sep 2026
Podcast
Methods of gynecologic evaluation for patients with anorectal malformations
21 min · Published Sep 2026
Podcast
Gynecologic care in patients with anorectal malformations: A primer and call to action
18 min · Published Sep 2026
Podcast
Evaluation and Management of Postsurgical Patient With Hirschsprung Disease Neurogastroenterology & Motility Committee: Position Paper of North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN)
17 min · Published Sep 2026
What the experts said
The most common prenatal ultrasound finding in cloaca is a pelvic mass, often representing a dilated vagina (hydrocolpos).
Fetal intervention for cloaca is unlikely to be necessary; babies should typically go to term.
Fetal hydrocolpos drainage has been performed at least once (case report from Japan) for massive hydronephrosis with impending renal loss, similar to bladder drainage for urethral valves.
In cloaca, there is one perineal hole below the clitoris and no anus; this is not ambiguous genitalia, there is no adrenal problem, and the baby is a normal female with two normal ovaries.
A urogenital sinus (single hole with normal anus present) may be associated with virilization and requires evaluation for adrenal hyperplasia and electrolyte abnormalities.
To examine a newborn for cloaca, grab the labia and lift them up and out with very good lighting to see if there is a single hole or distinct urethral, vaginal, and rectal orifices.
Many patients considered cloacas actually have vestibular fistulas; with better examination you can see three holes (urethra, vagina, and rectal opening in vestibule).
Initial workup for cloaca includes ultrasound for hydronephrosis and kidney number, spinal ultrasound for tethered cord, cardiac auscultation, and plain X-ray of spine to assess sacrum.
Intermittent catheterization of the common channel may decompress hydrocolpos, but is not reliable because the catheter may enter the urethra, right or left vagina, or rectum; success should be confirmed by ultrasound.
If hydrocolpos is bilateral, open into both vaginas at the dome, remove some of the common wall (septum), and one tube will drain both sides.
For vaginostomy, use an 8 or 10 French pigtail catheter (not a straight catheter) because as hydrocolpos recedes, straight catheters fall out but curled catheters do not.
Vesicostomy is rarely needed in cloaca; the problem is usually hydrocolpos compressing the trigone and distal ureters, not bladder drainage. Draining the hydrocolpos relieves the ureteral obstruction.
Vesicostomy is indicated only when the bladder does not drain after successful hydrocolpos decompression, which occurs in very rare circumstances with very long narrow common channels or absent urethra.
Vesicostomy is also indicated in the rare circumstance of massive bilateral ureteral reflux, where decompressing the system protects the ureters until later repair.
Hydrocolpos develops because urine preferentially fills the vagina through the vaginal fistula rather than exiting the common channel, likely due to mechanical factors (steep urethral angle).
Hydrocolpos fluid is typically a turbid combination of mucus and urine; maternal estrogen effect can increase mucus production and rarely cause blood in the hydrocolpos.
Hydronephrosis in cloaca is caused by hydrocolpos pressing forward on the trigone and compressing the distal ureters where they enter the bladder.
Cystoscopy in the newborn period is not advantageous; the required scope is tiny, visualization is poor, the perineum is swollen, and it is better to minimize OR time in newborns.
Laparoscopic approach to colostomy and hydrocolpos drainage (described by Michigan group) provides excellent visualization and is a valuable technique.
For massive hydrocolpos extending above the umbilicus, use a lower midline incision to access the dome, and consider a tubeless vaginostomy sutured to the abdominal wall like a G-tube.
Urogenital sinus (single perineal opening with normal anus) requires workup for adrenal problems causing virilization, though it can occur without virilization.
Most urogenital sinuses can be managed with perineal urogenital mobilization without touching the rectum; high UG sinus cases may require a transrectal (Astra) approach.
Definitive cloaca repair timing: perform endoscopy and cloacography at 2–3 months of age, then repair anytime thereafter within one year, ideally before 6 months if managing from birth.
The two critical endoscopic measurements are common channel length (from perineum to urethral takeoff) and urethral length (from urethral takeoff to bladder neck); urethral length determines the surgical approach.
Traditional classification uses 3 cm common channel length (≤3 cm straightforward, >3 cm complicated), but urethral length is equally important and not mentioned in published papers.
Endoscopy can falsely suggest the rectum is reachable when it is actually a long narrow fistula with healthy rectum high in the abdomen; contrast study (cloacogram) is needed to assess this.
3D cloacogram reconstruction is superior to 2D fluoroscopy; experienced surgeons answer anatomy questions more correctly with 3D imaging, and printed 3D models may be even better.
Cloaca patients benefit from collaborative multidisciplinary approach; the days of a single surgeon handling these cases alone are over.
Urogenital mobilization, first described by Alberto Pena in 1996, mobilizes urethra and vagina as a unit without operating on the wall between them, eliminating the 10% urethral-vaginal fistula rate of prior techniques.
Urogenital mobilization is appropriate when common channel is ≤3 cm AND urethral length above the takeoff is at least 1.5–2 cm; this leaves adequate urethral length after splitting the common channel.
With inadequate urethral length, do not perform total urogenital mobilization; instead leave the common channel to become the urethra and separate the vagina from it—a technically demanding operation.
After separating vagina from common channel, repair the common channel and cover with anorectal fat pad and possibly SIS to ensure well-healed urethra and avoid urethral-vaginal fistula.
If urogenital mobilization is attempted but the complex does not reach, the only option is abdominal delivery of the urogenital complex; if this fails, separating the vagina from a circumferentially dissected common channel risks devascularizing and losing the urethra.
Urogenital mobilization with inadequate urethral length leaves the patient with urinary leakage that cannot be controlled without tightening or closing the bladder neck.
Separating the vagina from the common channel and leaving the common channel as the entire urethra gives the patient about a 4 cm urethra, allowing intermittent catheterization and continence.
Type 1 cloaca (common channel ~1 cm with adequate urethral length): mobilize the vagina and leave the urethra slightly hypospadiac; patient will void if no neurogenic bladder component.
Patients with tethered cord or neurogenic bladder need a visible urethral orifice that is easily catheterized; slightly hypospadiac urethra is acceptable only if certain the patient will void and not need intermittent catheterization.
When native vagina does not reach after full mobilization, options include vaginal switch (disconnect one side preserving ovarian blood supply, switch dome down, remove septum) or vaginal replacement.
For vaginal replacement, left colon is the preferred option; sigmoid may be used depending on the vascular arcade.
Tissue engineering of vaginas using patient stem cells is on the horizon (work at Wake Forest and Mexico); this would revolutionize cloaca care by eliminating the need for vaginal replacement.
Complex cloacas requiring specialized expertise include those with common channel >3 cm or urethral length (takeoff to bladder neck) <1.5 cm.
The most common problem in redo cloacas is the surgeon never realized it was a cloaca and only fixed the rectum, leaving the urogenital sinus untouched.
The second most common redo problem is inadequate mobilization of structures, leaving the patient with a stenosed or lost vagina.