Anatomic factors predict urinary continence in patients with anorectal€¦ · Background • Anorectal malformation a complex spectrum diagnosis characterized by anal mislocation

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Anatomic factors

predict urinary

continence in patients

with anorectal

malformation

Molly E Fuchs, Devin R Halleran, Yuri Sebastião, Laura Weaver, Hira Ahmad, Christina B Ching, Marc A Levitt, Richard J Wood and Daniel G Dajusta

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Background

• Anorectal malformation a complex

spectrum diagnosis characterized by anal

mislocation

• Associated with spinal cord and sacral

anomalies

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Background

AR

M IN

DEX

ARM Subtype

Sacral Ratio

Spine abnormalities

Distal rectal anatomy

Lateral radiograph

Degree of sacral development

Tethered cord or

myelomeningocele

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Background

• ARM index has been shown to predict

fecal continence

• No tool exists to predict urinary continence

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Purpose

• To identify if the anatomic factors that

make up the ARM index are associated

with urinary continence in ARM

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Methods

• Review of large ARM database

• Inclusion criteria

– Age > 4 yrs

– Complete data

– Patient reported continence

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Methods

• Definition of continence

– Volitional voiding per urethra

– Dry between daytime voids

– ≤ 1 accident per week

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MethodsA

RM

IND

EX

ARM Subtype

Sacral Ratio

Spine abnormalities

Simple

Moderate

Complex

Perineal, bulbar, vestibular, imperforate anus, anal stenosis,

rectal atresia, H type fistula

Cloacal < 3cm, Rectoprostatic, Rectovaginal

Cloaca > 3cm, Cloacal exstrophy, Rectobladder neck

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Methods

≥ 0.7

0.4 – 0.6

< 0.4

AR

M IN

DEX

ARM Subtype

Sacral Ratio

Spine abnormalities

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Methods

Normal

Tethered cord

Low conus

MMC

AR

M IN

DEX

ARM Subtype

Sacral Ratio

Spine abnormalities

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Results

• n = 434

• 57.5% male (n = 251)

• Median age 8.4 yrs (IQR 6 – 12.3)

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ResultsARM Severity

Simplen = 245

57%Moderate

n = 10123%

Complex

n = 88

20%

Lateral Sacral Ratio

≥ 0.7n = 229

53%

0.4 – 0.6n = 157

36%

< 0.4n = 4811%

Spinal Cord Findings

Normaln = 264

61%

MMCn = 19

4%

Tethered

Cordn = 151

35%

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Results

75.5%

57.4%

31.8%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Simple Moderate Complex

Continence Rates ARM Severity

(n = 245)

p < 0.0001p = 0.004reference

(n = 88)

(n = 101)

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Results

72.9%

56.1%

31.2%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

≥ 0.7 0.4 - 0.6 < 0.4

Continence Rate By Sacral Ratio

p = 0.000p = 0.001reference

(n =157)

(n = 229)

(n = 48)

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Results

73.5%

47.0%

26.3%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Normal Tethered Cord Myelomeningocele

Continence Rate By Spinal Cord Findings

p = 0.008p < 0.0001reference

(n = 264)

(n = 19)

(n = 151)

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Summary of findings

75.4

57.4

31.8

72.9

56.1

31.2

73.5

47

26.5

0

10

20

30

40

50

60

70

80

90

100

mild moderate severe

Summary of Results

ARM subtype

Sacral Ratio

Spinal CordFindings

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Future Directions

• Further analysis

– Weighted influence of each anatomic factors

– Determine which anatomic factor over rides

the others

• Continence calculator based on ARM index

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Conclusion

• Anatomic factors are independently

predictive of achieving urinary continence

in ARM

– ARM subtype

– Lateral sacral ratio

– Spinal abnormalities