Sexual function in adults with anorectal malformation: psychosocial adaptation. German Network for Congenital Uro-REctal Malformations (CURE-Net)

Adult urological outcomes for patients with anorectal malformation

Anorectal malformations (ARM) are rare congenital anomalies characterized by a spectrum of defects resulting in the absence of a normal anal opening with or without fistula. Urogenital involvement is common, and the fistulous tract may terminate in the genitourinary system in males or within gynecological structures in females. Surgical reconstruction occurs early in life and survival of these patients to adulthood is the norm. There has, therefore, been increased focus on their long-term outcomes to better anticipate and treat the sequelae that may impact their health and well-being as this population ages. For urologists, urinary health, sexual function, and fertility outcomes are of particular interest among this population. This article aims to provide a review of urological, sexual, and fertility outcomes for individuals born with ARM with a focus on key issues that may occur later in life to ensure adequate counseling, screening, and treatment.

Considerations and Outcomes for Adolescents and Young Adults With Cloacal Anomalies: A Scoping Review of Urologic, Colorectal, Gynecologic and Psychosocial Concerns

The objective of this scoping review is to provide a summary of the current literature regarding adolescents and young adults with histories of cloacal anomalies. Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews were used. Data were categorized into four domains-urologic, colorectal, gynecologic/obstetric, and sexual/psychosocial. The current literature has poor study quality and mostly consists of retrospective studies of small cohorts with varying definitions of outcomes. Women with cloacal anomalies are at high risk for urologic dysfunction but can maintain kidney health and achieve social continence with medical and surgical management. Sexual function and adult healthcare transition are areas ripe for improved future research.

Sexual and Reproductive Health Outcomes in Females With Cloacal Malformations and Other Anorectal Malformations

STUDY OBJECTIVE

To improve our understanding of reproductive health and sexual function in women with cloacal malformations and other anorectal malformations (ARMs) METHODS: An observational cross-sectional survey was administered to individuals assigned female at birth aged 12 to 55 with ARMs and cloacal malformations cared for at our institution. Data included age of thelarche/menarche and questions on body image, gynecologic anatomy, sexual function, and pregnancy.

RESULTS

Twenty-one patients responded in the ARM group and 30 in the cloacal malformation group. There were no differences in median age of thelarche/menarche in patients with ARMs (11/12.5 years) compared with patients with cloacal malformation (11/12 years). Patients with ARMs were more likely to have native vaginal tissue than those with cloacal malformations (n = 18, 82% vs n = 12, 40%; P = .03). There were no differences between groups regarding concerns about dyspareunia and functionality of their vagina (P > .05). Forty-two percent of patients with cloacal malformations and 30% of patients with ARMs reported having been sexually active. Two patients with cloacal malformations and 2 with ARMs reported having been pregnant. Patients with cloacal malformations reported a lower quality of life score (80.4) compared with those with ARMs (87.0) (difference > 4.5).

CONCLUSIONS

Patients with a cloacal malformation were less likely to have native vaginal tissue and reported a lower quality of life than those with ARMs. Despite this, patients with a cloacal malformation had similar reproductive health and sexual function compared with patients with ARMs. Our results reinforce the need for comprehensive sexual and reproductive health care for all women with ARMs.

Pediatric Bowel Management Options and Organizational Aspects

A bowel management program (BMP) to treat fecal incontinence and severe constipation is utilized for patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and functional constipation, decreasing the rate of emergency department visits, and hospital admissions. This review is part of a manuscript series and focuses on updates in the use of antegrade flushes for bowel management, as well as organizational aspects, collaborative approach, telemedicine, the importance of family education, and one-year outcomes of the bowel management program. Implementation of a multidisciplinary program involving physicians, nurses, advanced practice providers, coordinators, psychologists, and social workers leads to rapid center growth and enhances surgical referrals. Education of the families is crucial for postoperative outcomes, prevention, and early detection of complications, especially Hirschsprung-associated enterocolitis. Telemedicine can be proposed to patients with a defined anatomy and is associated with high parent satisfaction and decreased patient stress in comparison to in-person visits. The BMP has proved to be effective in all groups of colorectal patients at a 1- and 2-year follow-up with social continence achieved in 70–72% and 78% of patients, respectively, and an improvement in the patients’ quality of life. A transitional care to adult program is essential to maintain the same quality of care, and continuity of care and to achieve desired long-term outcomes as the patient reaches adult age.

Talking about sexuality with your own child. The perspective of the parents of children born with arm

PURPOSE

Evaluate whether parents have ever discussed sexuality with their children with anorectal malformations (ARM), which sexuality issues they think should be addressed and who, in their opinion, should address these issues.

METHODS

Parents from the Italian Parents' and Patients' Association for Anorectal Malformation participated in meetings organized by the Association together with local Pediatric Surgical Units and were asked to fill in a questionnaire.

RESULTS

103 parents participated. Overall, 66% of parents had never talked about sex with their children. Children's age was marginally correlated with occasions to talk about sexuality (r = .202, p = 0.53) indicating that the older were the children, the more the parents talked about sexuality. The majority of parents reported that their children should have the possibility to talk about sex with them (72%), psychologists (57%), gynecologists/andrologists (47%), pediatric surgeons (33.5%), surgeons specialized in ARM (39.8%), friends (28%), nurses (24.7%) and teachers (20.4%), respectively. The most important topic they thought their children should address was handling serene sexuality, although the most common topic effectively discussed with them was the conception.

CONCLUSION

Psychologists, gynecologists/andrologists, and pediatric surgeons are seen as key resources for talking about sexuality. A great number of parents express the wish that their children had more opportunities to discuss sexual topics with pediatric surgeons.

Approach to the Adult Colorectal Patient with a History of Pediatric Abdominal Surgery

Children with colorectal diseases often undergo operative management in their youth. As these patients become adult, it is important for surgeons to understand their postoperative anatomy as well as the pathophysiology of their diseases. Here, we present a description of common colorectal diseases of childhood that may have significant impact on patients' presentations as adult. We also discuss the diagnosis and management of conditions that are usually seen early in life but may present during adulthood as well.

Need for transition medicine in pediatric surgery – health related quality of life in adolescents and young adults with congenital malformations

Survival rates of patients with visceral congenital malformations have increased considerably. However, long-term morbidity in these patients is high. In the last decades, these circumstances have led to a shift in goals of caretakers and researchers with a new focus on patients’ perspectives and long-term morbidity. Health-related quality of life (HrQoL) is the most commonly used patient-reported outcome measure to assess the impact of chronic symptoms on patients’ everyday lives. Most pediatric surgical conditions can cause a significantly decreased HrQoL in affected patients compared to the healthy population. In order to guarantee life-long care and to minimize the impact on HrQoL a regular interdisciplinary follow-up is obligatory. The period of transition from child-centered to adult-oriented medicine represents a critical phase in the long-term care of these complex patients. This scoping review aims to summarize relevant pediatric surgical conditions focusing on long-term-morbidity and HrQoL assessment in order to demonstrate the necessity for a well-structured and standardized transition for pediatric surgical patients.

A Comparison of Sexual Function in Male Patients with Anorectal Malformations Between the Conventional and Laparoscopic Approaches

Aim: To compare the incidence of erectile dysfunction and ejaculatory anomalies in male patients with anorectal malformation (ARM) after treatment with the sacroperineal approach (Group S) or laparoscopically assisted anorectoplasty (LAARP; Group L). Methods: Male patients who underwent repair of high- or intermediate-type ARMs at our center and aged ≥15 years as of November 2020 were enrolled. Patients with intellectual disabilities or chromosomal disorders were excluded. Sacroperineal anorectoplasty has long been routinely performed at our hospital, and LAARP was introduced as a standard procedure in 2000. The medical records of the outpatient clinic were retrospectively reviewed, and questionnaires were sent in November 2020. Data regarding erectile dysfunction, ejaculatory anomalies, and associated anomalies were collected and compared between the two groups. Results: Answers were obtained from 7/22 patients in Group S (32%) and 10/17 patients in Group L (59%). Patient characteristics were similar, but the median age at the time of replying was significantly different (22 [18-29] years in Group S and 19 [15-20] years in Group L, P = .0060). None of the patients had erectile dysfunction, but 3 patients in Group S (43%) and 5 patients in Group L (50%) had ejaculatory failure, with no significant difference between the two groups. Conclusions: The incidence of sexual dysfunction in male patients with ARM might be higher than that in the healthy population. Patients might abscond from their follow-up visits as they age; therefore, providing patients with accurate information on this issue before puberty is essential.

Gynecological and psycho-sexual aspects of women with history of anorectal malformations

PURPOSE

Women with anorectal malformation (ARM) are expected to have a normal life span, therefore, gynecological and psycho-sexual issues are also important. Aim of the study was to assess these aspects in adult females with history of ARM.

METHODS

Thirty-seven women from two ARM referral centers, aged ≥ 16, were identified. Gynecologic visit, cervicovaginal swab, pelvic ultrasound, FSH, LH, prolactin, progesterone, 17-β-estradiol, DHEAS, testosterone, TSH during follicular and luteal phases, and administration of FSFI questionnaire to screen the female sexual functioning were performed. Data were compared with six controls.

RESULTS

Nineteen patients, mean age 21.7 (16-45), participated to the study. Associated anomalies, mostly affecting limbs, vertebrae and genitalia, were present in 57.8% of cases. Mullerian anomalies were retrieved in 36.8%. Hormones' levels were normal. Concerning sexual functioning, four women (21%) reported dyspareunia or impossible penetration, four did not answer the FSFI questionnaire due to lack of confidence about their sexuality, and three scored lower than the cut-off value for female sexual function.

CONCLUSION

This study confirms the importance of a multidisciplinary long-term follow-up for ARM patients, including a careful study of the reproductive tract to detect and treat those conditions that could affect the fertility. Moreover, an appropriate psychological support should be provided.

Long-term Functional Urinary and Sexual Outcomes in Patients with Anorectal Malformations-A Systematic Review

Context

Long-term urinary and sexual outcomes after repair of anorectal malformations (ARMs) are currently affected by concomitant malformations of the urinary tract and genitalia, sacral anomalies, and the surgical approach. However, the overall prevalence of urinary and sexual dysfunction remains unclear.

Objective

To evaluate the prevalence of urinary and sexual dysfunction in patients aged >10 yr after repair of ARM in infancy.

Evidence acquisition

A systematic literature review was performed using the Medline, Embase, and Cochrane databases. Selected studies were reviewed according to the Consolidated Standards of Reporting Trials (CONSORT) and Standards for the Reporting of Diagnostic Accuracy Studies (STARD) criteria. We included studies reporting the prevalence of the following outcomes: urinary incontinence (UI), lower urinary tract symptoms (LUTS), neurogenic bladder dysfunction (NBD), sexual dysfunction (SD), erectile dysfunction (ED), ejaculatory dysfunction, and birth rate. We initially identified 588 studies, of which 17 were included for evidence synthesis.

Evidence synthesis

A probabilistic meta-analysis on each subgroup revealed the following combined prevalence estimates: UI 16% (95% confidence interval [CI] 7-27%), LUTS/NBD 36% (95% CI 13-62%), SD among women 50% (95% CI 34-66%), ED 12% (95% CI 7-18%), ejaculatory dysfunction 16% (95% CI 9-25%), and birth rate 20% (95% CI 7-38%). Subgroup analysis showed a higher prevalence of ED and ejaculatory dysfunction among patients with high ARM severity when compared to low ARM severity.

Conclusions

Among patients undergoing ARM repair, we found a high prevalence of long-term impairment of UI, ED, and SD. We stress the need for larger multicentre trials with more comparable populations to optimise treatment and follow-up regimens.

Patient summary

We reviewed long-term outcomes for patients with anorectal malformations who underwent surgery and found that both urinary incontinence and sexual dysfunctions are common for both males and females.

Empowering Patients and Health Professionals to Address Sexual Health in the Context of Anorectal Malformations and Hirschsprung's Disease

The aim of this study is to develop a tool that is aligned with patients' and health professionals' needs to address sexual health in the context of anorectal malformations and Hirschsprung's disease. A multiphased participatory action-research was conducted. First, an inventory of needs was made through interviews (11 patients, 11 professionals), three online focus groups (4 patients, 20 professionals), and a questionnaire (38 patients). Subsequently, four cocreation sessions with in total four patients and nine professionals were organized to translate the needs into a tool (in the form of a website). The websites' functionality was assessed via a questionnaire (n = 34). The website, directed to patients, their parents, and professionals, stimulates awareness, fills knowledge gaps, and shows possibilities for support. The website is expected to change restrictive attitudes toward sexual health and improve the legitimization of the topic needed for the allocation of resources and sexologists' involvement in current care pathways.

General complications after surgery for anorectal malformations

The introduction of posterior sagittal anorectoplasty (PSARP) by deVries and Peña in the early 80s has impacted to the treatment of patients with anorectal malformations (ARM). It gained great recognition worldwide in a very short time, and since then, surgeons dealing with the treatment of this complex malformation could achieve tremendous progress in contemporary management of this anomaly. Despite the growing experience and body of information globally, the treatment of ARMs continues to be a challenge to the pediatric surgeons due to the nature and the variability of the anomaly, and short- and long-term problems continue to exist even after nearly 40 years of the PSARP era. Today, knowing more about it, pediatric surgeons are committed to do more for their ARM patients to have them as physically and socially healthy individuals.

Impact of Spinal Defects on Urinary and Sexual Outcome in Adults With Anorectal Malformations-A Cross-sectional Study

OBJECTIVE

To examine the impact of spinal defects on urinary function, sexual outcome and quality of life in adult patients born with anorectal malformations.

MATERIALS AND METHODS

A prospective cohort study at Odense University Hospital in Denmark was conducted. From 1985 to 2000, 93 patients were found eligible for participation. Twenty-seven (29%) consented to participate. One patient refrained from clinical examinations. Patients were examined with magnetic resonance imaging, uroflowmetry, and validated questionnaires on urinary function, sexual function, and quality of life.

RESULTS

There were 14 were females and 13 were males, median age of 25 (range 19-31) years and 23 (18-32) years, respectively. The type of anorectal malformations in females were vestibular fistula (n = 6), anocutaneous fistula (n = 4), anal stenosis (n = 3), and cloaca (n = 1). In males the type of malformations were anocutaneous fistula (n = 4), bulbar fistula (n = 4), rectovesical fistula (n = 2), anal stenosis (n = 1), rectal atresia (n = 1), and anal atresia with no fistula (n = 1). Patients with spinal defects had a lower average voiding rate compared to patients with normal spinal anatomy (P .03), a lower voiding-related quality of life (P .02), and a tendency was observed toward a worse total urinary incontinence-related quality of life score (P .06). Moreover in patients with spinal defect a tendency was seen toward a worse general quality of life (P .09).

CONCLUSION

Spinal defects detected by magnetic resonance imaging in adults with anorectal malformations were found to be associated with urinary voiding function.

Sexual well-being in adolescent and young adults born with arm: the perspective of the patients

PURPOSE

Sexual well-being and sexual functioning are understudied in patients born with ARM. The aim of this exploratory study was to investigate sexual history, main fears, and problems encountered during sexual relationships.

METHODS

Before participating in a sexual education intervention, 21 adolescents or young adults (12 males; mean 28.8; SD 10.6) born with ARM, answered a ten-item questionnaire specifically developed to evaluate sexual well-being. Percentages and Chi-square were calculated.

RESULTS

52.4% were married/had a partner. The majority (71%) declared that had sexual relationships. Mean age of the first sexual relationship was 18.8 (2.7) and 22.7 (3.8) for males and females, respectively. Females reported both more fear and experience of pain during sexual intercourse, compared to males. Main experienced problems and fears for male patients were loss of feces and premature ejaculation, followed by the fear of lack of erection and managing contraception. Main experienced problems and fears in females were loss of feces, pain, lack of desire, and lack of lubrication. In only few cases, patients asked for advices to a pediatric surgeon or to an adult surgeon specialized in ARM.

CONCLUSIONS

Adult and adolescent patients may benefit of andrological/gynecological evaluation, psychological support, and sexual counseling to improve their sexual well-being.

What do pediatric surgeons think about sexual issues in dealing with patients with anorectal malformations? The ARM-Net consortium members’ opinion

PURPOSE

Since pediatric surgeons aim to follow their patients with anorectal malformations (ARM) into adulthood the aim of this study was to investigate how pediatric surgeons deal with sexual issues related to ARM.

METHODS

In 2018, a questionnaire was developed by the working group "Follow-up and sexuality" of the ARM-Net consortium and sent to all consortium-linked pediatric surgeons from 31 European pediatric surgical centers. Obtained data were statistically analyzed.

RESULTS

Twenty-eight of 37 pediatric surgeons (18 males/10 females) answered the questionnaire. The majority of pediatric surgeons (82%) think they should talk about sexual issues with their patient. More than 50% of pediatric surgeons do not feel at all or only moderately confident discussing the topic of sexuality. Most pediatric surgeons require more support (96%) and wish to be trained in sexuality and sexual issues (78%) to feel confident towards their ARM-patients/parents. For optimal care, sexual issues with ARM-patients should be managed by a multidisciplinary team.

CONCLUSIONS

Pediatric surgeons feel that sexuality is an important issue for their ARM-patients, which they are primarily responsible of but should be managed in concert with a multidisciplinary team. A training in sexuality is wished to feel more confident about this specific issue.

Anorectal malformation & Hirschsprung's disease: A cross-sectional comparison of quality of life and bowel function to healthy controls

BACKGROUND

Patients with anorectal malformation (ARM) and Hirschsprung's disease (HD) face long-term disturbance in bowel function even after definitive surgery. This study evaluates the quality of life (QOL) of patients with ARM and HD, and compares them to healthy controls using self-report questionnaires.

METHODOLOGY

A prospective study was performed recruiting patients with ARM or HD from September 2013 to December 2014 who had primary surgery done in our institution at least 2 years prior to participation. Age-matched and gender-matched controls were enrolled from our patients with minor outpatient complaints. All participants completed the following PedsQL™ scales (maximum score 100): 4.0 Generic Core Scales, 3.0 General Well-Being (GWB) Scale and 2.0 Family Impact (FI) Module. All were also scored on bowel function (BFS), with a maximum score 20. Appropriate statistical analysis was performed, with significance level <0.05.

RESULTS

There were 193 participants: 87 controls, 62 ARM, 44 HD. When comparing Core, GWB and FI scores, there were no significant differences between groups although controls had best scores indicating best QOL and general wellbeing, with least impact of the child's health on the family. BFS was significantly different with controls having best and ARM worst scores. There were no significant differences in scores between parent and child indicating intradyad consistency. There was significant positive correlation between BFS and Core (p<0.0001), and between BFS and GWB scores (p<0.005); and significant negative correlation between BFS and FI scores (p<0.0001).

CONCLUSIONS

Bowel function impacts quality of life. Those with ARM and HD can achieve good quality of life comparable to controls, based on patient and caregiver self-reported outcomes.

TYPE OF STUDY

Prospective comparative study LEVEL OF EVIDENCE: Level II.

Predicting sexual problems in young adults with an anorectal malformation or Hirschsprung disease

AIM

The aim of this study was to examine the prevalence of sexual dysfunction and distress and to assess whether sexual functioning could be predicted by psychosocial factors in childhood and adolescence in patients with an anorectal malformation or Hirschsprung disease.

MATERIAL AND METHODS

In 1998 patients completed a psychosocial questionnaire: The Self-Perception profile. To assess the prevalence of sexual distress and sexual functioning in adulthood (2015) the Female Sexual Function Index (FSFI), The Female Sexual Distress Scale (FSDS) and the International Index of Erectile Functioning (IIEF) were used.

RESULTS

In total 74 patients returned the questionnaires (26.2%). 36.8% of women reported sexual dysfunction and 45% experienced sexual distress. In our male sample 8.8% reported mild to moderate erectile dysfunction. In females perceived self-competence in adolescence was associated with sexual distress (p<.01). In male adolescents associations were found between perceived self-competence in romantic relations (p<.01) and in close friendships (p<.05) and sexual desire in adulthood.

CONCLUSION

Pediatric surgeons should be more aware of sexual problems patients may face at older age as a result of their congenital disease and treatment. More standardized care and follow-up are needed. Prognosis study-Level II.

Long-term bowel function, quality of life and sexual function in patients with anorectal malformations treated during the PSARP era

Anorectal malformations are an important group of congenital anomalies that vary widely in their anatomical characteristics and complexity. Understanding the long-term functional outcomes after modern treatments, and how these compare to the general population, are essential for ensuring that patients receive optimal, evidence-based care. With increasing appreciation of the wider impact of the illness on patients and their families, minimizing social disability from fecal incontinence and enabling normal social integration from the outset are key management concerns. This review summarizes the current knowledge on the functional outcomes by type of malformation, reflecting on the literature, and our institutional experience over a follow-up period of nearly 30 years.

Sexual Function, Fertility and Quality of Life after Modern Treatment of Anorectal Malformations

PURPOSE

Sexual dysfunction and impaired quality of life due to fecal incontinence are common after classic operations for anorectal malformations. We hypothesized that modern repairs may result in improved outcomes.

MATERIALS AND METHODS

Following ethical approval for this single institution cross-sectional study, all patients 16 years or older treated for rectourethral, vestibular or perineal fistula from 1983 onward were sent detailed postal questionnaires on sexual function and quality of life. Each respondent was age and gender matched to 3 controls randomly selected from the general population. Penoscrotal/gynecologic abnormalities were obtained from the records.

RESULTS

A total of 41 patients (62%) with a median age of 22 years participated in the study. Of the patients 20 were males with rectourethral fistula (prostatic in 60%), 10 were females with vestibular/perineal fistula and 11 were males with low malformations. Although experience of sexual relationships and orgasmic function were reported in comparable proportions to controls, age at coital debut was significantly delayed in all groups of patients (p ≤0.046). Erectile function was preserved after sagittal repair but absent ejaculations or azoospermia affected 3 males with rectourethral fistula (15%). Penoscrotal/gynecologic abnormalities affected 12% of patients. Overall quality of life scores were comparable to controls but a trend was found for lower scores on emotional items in males with rectourethral fistula (p = 0.06) and for a negative effect on sexual life in females (p = 0.03).

CONCLUSIONS

While erectile and orgasmic function appear preserved after sagittal repair, further evaluation of fertility issues in males with rectourethral fistula is indicated. Larger multicenter studies are needed to confirm our findings.

Prevalence of Active Long-term Problems in Patients With Anorectal Malformations: A Systematic Review

BACKGROUND

Anorectal malformations are a spectrum of congenital anomalies of the rectum with high infantile survival rates and variable outcomes. Long-term (>10 years old) active problems associated with this condition have been poorly investigated.

OBJECTIVE

The purpose of this review was to systematically define the prevalence of the most common active long-term problems in patients with a history of anorectal malformation repair.

DATA SOURCES

MEDLINE, EMBASE, and the Cochrane Library were searched electronically using the OVID search platform.

STUDY SELECTION

Original articles from August 1, 1994, to October 20, 2015, that included outcome data for patients aged ≥10 years with anorectal malformation. Cloaca was excluded from the study.

INTERVENTIONS

Prevalence estimates of anorectal malformations were obtained from published articles. CIs were ascertained in the logit scale after transforming prevalence into log odds and were then transformed into the original scale. The same method was used for subgroup analysis investigating high and low anorectal malformations.

MAIN OUTCOME MEASURES

The overall prevalences of fecal, urinary, and sexual dysfunction were analyzed.

RESULTS

Twelve studies including 455 patients with a history of anorectal malformation repair were included for analysis. The range of reported prevalence of long-term active problems was as follows: fecal incontinence, 16.7% to 76.7%; chronic constipation, 22.2% to 86.7%; urinary incontinence, 1.7% to 30.5%; ejaculatory dysfunction, 15.6% to 41.2%; and erectile dysfunction, 5.6% to 11.8%.

LIMITATIONS

The study was limited by its retrospective, small size; multiple complex associated anomalies often not reported; and heterogeneous composition of patients with limited stratification analysis.

CONCLUSIONS

There is an overall high prevalence of active long-term issues in adolescents and young adults with anorectal malformations. Additional multicenter research is needed to define characteristics and predictors of long-term outcome, to implement effective follow-up, and to transition to adult health care.

Congenital cloaca: Long-term follow-up results with emphasis on outcomes beyond childhood

Persistent cloaca remains a challenge for pediatric surgeons and urologists. Reconstructive surgery of cloacal malformations aims to repair the anorectum, urinary tract, and genital organs, and achieve fecal and urinary continence as well as functional genital tract capable for sexual activity and pregnancy. Unfortunately, even in most experienced hands these goals are not always accomplished. The endpoint of the functional development of bowel, urinary, and genital functions is the completion of patient's growth and sexual maturity. It is unlikely that there will be any significant functional improvement beyond these time points. About half of the patients with cloaca attain fecal and urinary continence after their growth period. The remaining half stay clean or dry by adjunctive measures such as bowel management by enemas or ACE channel, and continent urinary diversion or intermittent catheterization. Problems related to genital organs such as obstructed menstruations, amenorrhea, and introitus stenosis are common and often require secondary surgery. Encouragingly, most adolescent and adult patients are capable of sexual life despite often complex vaginal primary and secondary reconstructions. Also, cloacal malformation does not preclude pregnancies, although they still are quite rare. Pregnant patients with cloaca require special care and follow-up to guarantee uncomplicated pregnancy and preservation of anorectal and urinary functions. Cesarean section is recommended for cloaca patients. The self-reported quality of life of cloaca patients appears to be comparable to that of female patients with less complex anorectal malformations.

Psychosocial adaptation: an evolutionary concept analysis exploring a common multidisciplinary language

AIMS

To provide the first known concept analysis of psychosocial adaptation, exploring its evolution from the concept adaptation. We also determine how psychosocial adaptation is conceptualized across nursing, health, sociobehavioural and education disciplines.

BACKGROUND

Psychosocial adaptation is an important conceptual term that is poorly defined in nursing and other health, sociobehavioural and education disciplines. A thorough understanding of the concept's application in nursing and across disciplines can help to clarify its meaning, facilitate a more effective common language between disciplines and inform future psychosocial adaptation research.

DESIGN

Rodger's evolutionary view guided this concept analysis.

DATA SOURCES

Peer-reviewed English and Spanish manuscripts published between 2011-2013 were retrieved from the following databases: CINAHL, Psych INFO, PubMed, Scopus and LILACS.

REVIEW METHODS

Eighty-nine articles related to psychosocial adaptation were included in the analysis. Findings identify key attributes, antecedents and consequences associated with the use of the concept. Findings were compared vis-a-vis reported characteristics of adaptation.

RESULTS

The attributes characterizing psychosocial adaptation are: change, process, continuity, interaction and influence. In psychosocial adaptation, new life conditions serve as antecedents, while consequences are good or bad outcomes. Important features of the evolution of this concept include its broad appropriation across the reviewed disciplines. The attributes of psychosocial adaptation, have some similarities to those of general adaptation. Both concepts include an aspect of change, but unlike adaptation, psychosocial adaptation has branched away from biological descriptors, such as homeostasis and tends to focus on relational characteristics, such as interaction and influences.

Psychosexual Well-Being after Childhood Surgery for Anorectal Malformation or Hirschsprung's Disease

INTRODUCTION

Anorectal malformations (ARMs) and Hirschsprung's disease (HD) are congenital malformations requiring pelvic floor surgery in early childhood, with possible sequelae for psychosexual development.

AIMS

To assess psychosexual well-being in adult ARM and HD patients related to health-related quality of life.

METHODS

Eligible for this cross-sectional two-center study were all patients aged ≥18 years who had been operated for ARM or HD. Exclusion criteria were intellectual disability, comorbidity affecting sexual functioning, and cloacal malformation.

MAIN OUTCOME MEASURES

Participants completed the International Index of Erectile Functioning, Female Sexual Functioning Index, Female Sexual Distress Scale, Hirschsprung and Anorectal Malformation Quality of Life Questionnaire, and sexual education questionnaire.

RESULTS

Response rates were 32% and 37% for ARM and HD patients, respectively. We studied 70 participating ARM and 36 HD patients (median age 26 years). We excluded 10 patients with sexual inactivity in the past 4 weeks. Six of 37 men with ARM (16%) reported moderate to severe erectile dysfunction, vs. two of 18 men with HD (11%). Thirteen and 10 of 26 women with ARM (50% and 38%) reported sexual dysfunction or sexual distress, respectively, vs. eight and three of 15 women with HD (53% and 20%). Quality of life and type of malformation or operation were not associated with self-reported psychosexual problems. Addressing sexuality with special interest to the congenital anomaly during medical care was reported to be insufficient by 42 ARM (60%) and 22 HD patients (61%).

CONCLUSION

Approximately 13% of male ARM and HD patients reported erectile dysfunction, while 50% female ARM and HD patients reported sexual dysfunction not related to quality of life or type of malformation. Both ARM and HD patients felt a need for better addressing sexual concerns during medical care. Further research is needed to optimize form and timing of this education.

Sacral neuromodulation for fecal incontinence and constipation in adult patients with anorectal malformation--a feasibility study in patients with or without sacral dysgenesis

PURPOSE

The aim of this study was to evaluate both the feasibility and effectiveness of sacral neuromodulation for fecal incontinence and constipation in adult patients who had undergone surgical repair of anorectal malformations (ARM).

METHODS

Patients with ARM with or without sacral dysgenesis who presented with fecal incontinence, constipation, or combined symptoms were treated with sacral nerve stimulation (SNS). Success of SNS was assessed by scores preoperatively and after a 3-week test period: Cleveland Clinic Incontinence Score (CCI), Surgical Working Group for Coloproctology (CACP) continence score, German version of the Fecal Incontinence Quality of Life Scale, and Cleveland Clinic Constipation Score (CCCS). The follow-up results of the patients who received a definitive pacemaker were used to evaluate the long-term effect of SNS in patients with ARM.

RESULTS

Four patients with fecal incontinence and one patient with constipation (two males, three females; median age 24 years [13; 31]) were treated with SNS between May 2012 and May 2013. Four patients had a normal sacrum; one patient had a sacral dysgenesis. Preoperatively and after the test phase, median CACP continence scores were 8 [1; 10] and 11.5 [3; 16], median CCI 14 [12; 19] and 13 [11; 17], and median Fecal Incontinence Quality of Life Scale improved in all categories. For constipation, CCCSs were 16 and 7.

CONCLUSION

Sacral neuromodulation is a feasible treatment modality for adult patients with ARM with a normally developed sacrum. Patients with sacrum dysgenesis are not suited for SNS because a definitive quadripolar electrode could not be anchored in the absence of a sacral bone.

The influence of anorectal malformations on fertility: a systematic review

PURPOSE

This systematic review aims to give an overview of available evidence concerning the influence of anorectal malformations (ARM) on fertility.

METHODS

We conducted a search in PubMed, EMBASE and Cochrane Library conformed to the PRISMA standards. All studies reporting on fertility and ARM were included.

RESULTS

2,905 studies were identified. Based on title, abstract and full text, nine articles on 429 patients remained to answer the research question. Childbirth rate was the only reported outcome parameter to describe fertility. An overall childbirth rate of 27 % (range 0-57 %) was found. Mean age at time of study ranged from 23 to 35 years. There was no statistical significant difference in childbirth rate between female and male patients, based on seven studies (p = 0.45). Patients with a more complex type of ARM (imperforated anus without fistula, rectourethral bulbar and prostatic fistulas, rectobladderneck fistulas and cloacal malformations) had a lower childbirth rate compared to healthy controls, whereas in patients with a less complex ARM (rectoperineal or rectovestibular fistula) the childbirth rate was similar to healthy controls. Patients with a more complex type of ARM had a significant lower childbirth rate than patients with a less complex type of ARM (18 vs 47 %, respectively) (p = 0.0001). When further dividing these patients by gender, this difference was only seen in female patients (p = 0.04).

CONCLUSION

In patients with a more complex type of ARM a lower childbirth rate was found compared to healthy controls and patients with a less complex type of ARM. The latter was only seen in female patients. However, conclusions concerning fertility in ARM patients have to be taken with caution due to limited quality of the studies. Further investigation is recommended.

Sacral neuromodulation for fecal incontinence and constipation in adult patients with anorectal malformation--a feasibility study in patients with or without sacral dysgenesis

PURPOSE

The aim of this study was to evaluate both the feasibility and effectiveness of sacral neuromodulation for fecal incontinence and constipation in adult patients who had undergone surgical repair of anorectal malformations (ARM).

METHODS

Patients with ARM with or without sacral dysgenesis who presented with fecal incontinence, constipation, or combined symptoms were treated with sacral nerve stimulation (SNS). Success of SNS was assessed by scores preoperatively and after a 3-week test period: Cleveland Clinic Incontinence Score (CCI), Surgical Working Group for Coloproctology (CACP) continence score, German version of the Fecal Incontinence Quality of Life Scale, and Cleveland Clinic Constipation Score (CCCS). The follow-up results of the patients who received a definitive pacemaker were used to evaluate the long-term effect of SNS in patients with ARM.

RESULTS

Four patients with fecal incontinence and one patient with constipation (two males, three females; median age 24 years [13; 31]) were treated with SNS between May 2012 and May 2013. Four patients had a normal sacrum; one patient had a sacral dysgenesis. Preoperatively and after the test phase, median CACP continence scores were 8 [1; 10] and 11.5 [3; 16], median CCI 14 [12; 19] and 13 [11; 17], and median Fecal Incontinence Quality of Life Scale improved in all categories. For constipation, CCCSs were 16 and 7.

CONCLUSION

Sacral neuromodulation is a feasible treatment modality for adult patients with ARM with a normally developed sacrum. Patients with sacrum dysgenesis are not suited for SNS because a definitive quadripolar electrode could not be anchored in the absence of a sacral bone.

Adolescents with anorectal malformation: physical outcome, sexual health and quality of life

BACKGROUND

The necessity of referring adolescents with anorectal malformation (ARM) from pediatric units to adult care is unclear. The issue requires knowledge about the health of the adolescent.

OBJECTIVE

To examine the physical outcome, sexual health and quality of life (QoL) in adolescents with ARM.

METHODS

At medical counseling, 24 adolescents with ARM, 15-21 years of age, answered questionnaires about physical outcome according to the Krickenbeck follow-up and QoL according to SF 36 and gastrointestinal quality of life (Giqli). Matched control groups were used; 15 adolescents participated in deep interviews about sexual health and body imaging.

RESULTS

Fecal soiling, constipation and gas incontinence were much higher for ARM patients compared with controls (p<0.05). QoL regarding large bowel function was lower for both genders compared with controls (p<0.05). Females scored lower in physically related QoL (p<0.05). Social and sexual adaption to the symptoms was obvious in the deep interviews.

CONCLUSION

Adolescents with ARM have considerable intestinal symptoms, which influence QoL and require adaption in intimate situations. A referral to adult care seems to be important, and continuous cooperation between the pediatric surgeon and adult care is suggested.