David

A. Oppenheimer,
M.D.
Barbara
A. Carroll,
M.D.
Stephen
J. Shochat,
M.D.

Real-time
invasive

sonography
method

Sonography

provides

a non-

of determining

the

level

of obstruction
in patients
with imperforate anus. The authors
describe
one technique
for evaluating
this anomaly
which
was employed
in 6 neonates.
A pouchperineum
distance
of less than 1.5 cm is
consistent

with

pouch
that
the bladder

a low

terminates
is indicative

Index

terms:
Anus,
imperforate,
newborn,
ultrasound
studies
ultrasonography,
7[0].1298)

Radiology

148:

127-128.

July

lesion,

while

anus

MPERFORATE

757.1433
(Abdomen,

congenital

MATERIALS
Six newborn

Infants,

#{149}

1983

is a common

Anus

anomaly

that

requires

rapid evaluation
and possibly
early surgical
decompression
in the
newborn
infant.
Appropriate
surgical
intervention
depends
upon
the position
of the distal
rectal
pouch
and its relationship
to the
puborectalis
portion
of the levatom sling.
High-frequency
real-time
ultrasound
provides
a noninvasive
method
of accurately
determining
the location
of the distal
rectal pouch
and readily
detects
associated
renal
anomalies.

above
the base of
of a high lesion.

#{149}

of Imperforate

real-time
(Diasonics).
through
gitudinal

infants

AND

with

METHODS

impenforate

anus

were

evaluated

with

sonography
using
a 7.5-MHz
mechanical
sector
scanner
All scans
were
performed
in sagittal
and transverse
planes
the anterior
abdominal
wall
with
the infant
supine;
a ionmidline
transpenineal
scan
was also performed.
After
lo-

cating
the rectal
pouch,
the relationship
of the distal
portion
base of the bladder
was determined,
since this is an anatomical
for the superior
extent
of the musculature
of the urogenital
phragm
The

was

(1).
distance

from

measured

sagittal

cally

projection,

gloved

hand

it transversely

anal
face.
structure

between

sonographem

with

ultrasonic

the

aligned

moving

in

the pouch

and

and

is known

out

of the

(Fig.
infant

to decrease

the

he

of renal
anomalies
were analyzed

slowly

oscillated
from

the

and

the

plane

of section.

(fingertip)
taken
since

the

transducer
penineal

sun-

echogenic
The

distance

was

measured

not
to perform
the Valsalva
ma-

pouch-perineum

associated
to assess the

on the

of a surgi-

outward

surface

Longitudinal
scans
through
the perineum
alternative
maneuver
in all patients,
with
tance
also being
measured
in this projection.
amination,
both
kidneys
were
evaluated,

dence
records

pouch

as a markedly

1). Care
was
was crying,

the

rectal

pouch

finger

angled

pouch

identified

the perineal

calipers
while
the

gel and
traveling

hand,
both

the

one

coupling

easily

distal

locating

lubricated

opposite

was

to the

After

motion

it to scan

fingertip

using
electronic
measurements

neuver

surface

as follows.

the

With

and

The

penineal

in a scratching

dimple.

caudally

the

in 2 infants

to the
marker
dia-

distance

(2).

were
performed
as an
the pouch-perineum
disAt the end of each
exsince
there
is a high
mci-

with imperfonate
accuracy
of the

anus.
ultrasonic

Patient
tech-

nique.

RESULTS
Of the 6 infants
evaluated,
2 demonstrated
rectal
pouch
above
the base of the bladder.
pouch
and the penineal
surface
measured
using
both
methods
(Fig.
2). Surgery
high
lesions
which
had not descended
accompanied
by unilateral
hydmonephmosis.
Four
From the Departments
of Radiology
(D.A.O.,
B.A.C.) and Pediatric
Surgery
(S.J.S.).
Stanford
University Medical
Center,
Stanford,
Calif. Revised
version
received
Nov. 12, 1982 and accepted
Dec. 27.
sjh
I

bladder

infants

whose

rectal

had

surgically-proved

through
the
tance of less

levator
sling
than 1.5 cm.

pouch

termination
of the distal
The distance
between
the
1 .7 and 2.0 cm, respectively,
confirmed
the
presence
of
through
the levator
sling,

extended
low

below

lesions

(Fig. 3). All 4 had

No renal anomalies

the

base

which

a pouch-perineum
were detected.

of the

descended

dis-

127

Figures

1-3

2.

3.

Sagittal
transabdominal
scan demonstrates
the distal rectal pouch
(arrow)
terminating
examiners
finger, which
is echogenic,
is seen at the anal dimple
(arrowhead).
Sagittal
transabdominal
scan
demonstrates
the distal
rectal
pouch
(++, 0) terminating

1.

2.

infant

with

high

imperfonate

Previous

DISCUSSION
The

various

forms

of

imperforate

anus
have
been
divided
into
two
groups
according
to the position
of the
distal
rectal
pouch
with
respect
to the
puborectalis
portion
of the
levator
sling
(1, 3). Low lesions
pass through
the

levator

not.

The

critical
approach

sling,

level
in

cephalad

+, 0) and
1.1 cm.

while

high

of the

rectal

determining
(4). High
lesions

lesions

do

pouch

is

the
surgical
are treated

reports

the perineal

have

surface

stated

that

pouch-perineum
2 (4) or 2.5

distance
of less than
(2) on inverted
radio-

cm

graphs
and
respectively,

B-mode
static sonograms,
indicates
descent
of the

rectal
pouch
through
the levator
In our series,
this criterion
was
able,
since
the pouch-perineum
tance
was 1 .7 cm in one infant

sling.
unrelidiswith
a

surgically-proved
infants
with

high lesion.
imperforate

All our
anus

distance

of less

had

low

a pouch-perineum

with
early
decompressive
colostomy,
followed
by a pull-through
operation,
while
low lesions
are often
ap-

than
1.5 cm, which
we consider
to be
the cut-off
point
for low
lesions.
The fluid-filled
bladder
is an excel-

proached
by direct
tion.
Imperforate

lent
the

with
a
anomalies

having
a
genitourinary

infant

incidence
of renal
with
high
lesions

distal
views

rectal
of the

this

at the

and
anal

examination

(4, 8). Direct

jection

of water-soluble

tenial
into the pouch
vocated
(5). A-mode

ultrasound

evaluate

imperforate

been

however,

proved

percutaneous

ma-

has also been

(9) and B-mode

been
anus.

unin-

contrast

have

of
the

radiopaque

dimple;

has

reliable

static

consists
with

used
Other

ad(2)

to
au-

thoms have
suggested
that visual
inspection
of the penineal
surface
would
suffice
for preoperative
evaluation
of
such
infants
(4, 10). In our study
of
real-time
sector
scanning,
it was not
our contention
to determine
which
of
these
methods
might
be most
helpful,
but only
to present
a simple
means
of
evaluating
this condition.

128

#{149}
Radiology

path through
which
to view
pouch.
In our series,
both

vator
sling
urogenital

evaluation

pouch
abdomen

water
rectal

infants
with surgically
high
had a rectal
pouch
that did
below
the base of the bladder.

toward

radiographic

invented

marker

exploraassociated

greater
tendency
malformations.

Traditional
of the
lateral

pemineal
anus
is

25-30%
(5-7),

the base

of the bladder

to the base

(curved

of the bladder

arrow).
(arrow)

The
in an

anus.

Sagittal
transperineal
scan shows the distal rectal pouch (white
The pouch-skin
distance
(between
cross hairs) was less than

3.

above

lies

is the caudal
portion
diaphragm
and thus

caudal

to the

base

rectal

of the

If the

distal

above
lesion

the base of the bladder,

must
be suspected.

nately,
structure

the

tances

below

Knowledge

lesions
not pass
The le-

and

pouch

levator
can

sling
lie at

the

bladder

that

the

of the
always

(black

their

base

Department
Division
Stanford
Stanford,

pouch-perineum

arrow

M.D.,

indicates

the

sacrum.

We wish to thank
and Meg Rose for

assistance.

A. Carroll,
M.D.
of Radiology
of Diagnostic
Radiology
University
Medical
Center
Calif. 94305

References
WB,
I. Its surgical

Nixon
HH.
Imperforate
anatomy.
J Pediatr
Sung

Kiesewetter

anus.

1967; 2:60-68.
2.

Schuster
SR, Teele
RL.
An analysis
of ultrasound
scanning
as a guide
in determination of high
or low
imperforate
anus.

J Pediatr
3.
4.

5.

Surg

1979; 14:798-800.

Kurlander
GJ. Roentgenology
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AJR 1967; 100:190-201.
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WB, Bill AH, Nixon
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Wagner
ML, Harberg
FJ, Kumar
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of imperfoHH,
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SanSurg

APM, Sinimperforate
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Pediatr Radiol 1973; 1:34-40.

Stephens
FD, Smith ED. Ano-rectal
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Chicago: Year Book,

7.

Singh

1971:212-256.

(8).

distance
is 1 .5 cm is useful
in identifying
a lesion
terminating
below
the
base of the bladder
as low;
and conversely,
a pouch
below
the base of the
bladder
and 1.5 cm or more
from the
perineal
surface
should
be considered
high
until proved
otherwise.
These
anatomical
criteria
were correct
in each
of our cases and were reliable
as long as
the bladder
could
be seen.
A modemately
urine-filled
bladder
was sufficient.

technical

Barbara

bladder.

is a mobile
various
dis-

open

Acknowledgments:
Ingrid
Peterson,

is identified

a high
Unfortu-

+). The

8.

MP, Haddadin
A, Zachary
RB, Pilling
DW.
Renal tract disease
in imperforate
anus. J Pediatr
Surg 1974; 9:197-202.
Berdon
WE, Baker DH, Santulli
TV, Amoury
R. The radiologic
evaluation
of imperforate
anus.
An approach
correlated
with current
surgical

concepts.

Radiology

1968;

90:

in the diagnosis

of

466-471.
9.

10.

Willital

GH.

Advances

anal and rectal

atresia
by ultrasonic-echo
examination.
J Pediatr
Surg
1971; 6:454457.
Seibert
JJ, Golladay
ES. Clinical
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of imperforate
anus:
clue to type of anal-

rectal

anomaly.

AJR 1979; 133:289-292.

July

1983