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.

An Assessment of Health Related Quality of Life Using the Child Health and Illness Profile-Adolescent Edition in Adolescents With Chronic Kidney Disease Due to Underlying Urological Disorders

PURPOSE

We examined health related quality of life in adolescents with congenital urological disease causing kidney disease using a generic health related quality of life instrument. We then compared the results to those in adolescents with medical kidney disease and to population based norms.

MATERIALS AND METHODS

The Child Health and Illness Profile-Adolescent Edition was administered to 113 patients 10 to 18 years old with chronic kidney disease. Mean domain and subdomain scores for adolescents with urological disease were compared to those of adolescents with medical kidney disease and to population based norms.

RESULTS

The cohort included adolescents with an underlying diagnosis of congenital urological anomaly (37 patients) or other causes of kidney disease (76). Compared to adolescents with kidney disease caused by other factors, those with congenital urological disease scored statistically significantly better in the Child Health and Illness Profile-Adolescent Edition subdomain of Limitations of Activity (mean 22.3 [SD 2.5] vs 20.4 [SD 5.0], p = 0.04). Compared to population norms, adolescents with congenital disorders scored lower in the Disorders domain (mean 16.5, 95% CI 14.2 to 18.9) but better in the Risks domain (mean 25.9, 95% CI 25.1 to 26.6) and in the Home Safety and Health subdomain (mean 25.2, 95% CI 23.7 to 26.6).

CONCLUSIONS

As assessed by the Child Health and Illness Profile-Adolescent Edition generic health status questionnaire, adolescents with kidney disease due to underlying congenital urological disease had fewer limitations of activity compared to those with underlying medical kidney disease. Except for low scores in the Disorders domain, children with underlying urological disease did not have significant impairments in any other domain compared to population based norms.

Assessment of sexual functioning, mental health, and life goals in women with vaginal agenesis

Vaginal agenesis is a congenital disorder defined by the incomplete formation of the vagina and other reproductive organs, often including the cervix, uterus, and fallopian tubes. For the patient, this frequently means infertility and an underdeveloped vagina with the subsequent difficulty to have vaginal intercourse. The patient with vaginal agenesis and her family then encounter a variety of psychological concerns that must be addressed during diagnosis, including weighing treatment options, managing interventions, and coping with long-term issues following diagnosis and treatment, such as partnership concerns and infertility. In this study, seven patients between the ages of 18 and 34 completed questionnaires assessing demographic information, sexual functioning, mental health, self-esteem, and life goals. Sexual functioning results were highly variable. Participants reported significant emotional reactions at diagnosis as well as anxiety about the disorder, specifically its role in relationships. However, overall, the group showed average levels of mental health and self-esteem. Participants also showed positive coping techniques through conceptualization of life goals.

Dilation as treatment for vaginal agenesis and hypoplasia: a pilot exploration of benefits and barriers as perceived by patients

Reconstructive surgery has been the traditional treatment for the short vagina. Recently vaginal dilation has been recommended due to its low morbidity. Small retrospective studies have reported success rates of up to 80% but include neither clear definitions of "success" nor exploration of factors associated with compliance and outcome. The first 10 women prescribed vaginal dilation treatment at a specialist gynaecological clinic during the study period were interviewed and asked to complete the Multi-dimensional Sexuality Questionnaire (MSQ), with an assessment of perceived vaginal characteristics. The participants scored lower scores on sexual esteem, sexual assertiveness and sexual satisfaction and higher scores in sexual anxiety, sexual depression and fear of sexual relationships in comparison with the standardisation sample. Dilator treatment must be subject to the same scrutiny as any intervention. Vaginal dilation can have a negative emotional impact on women and psychological intervention may be needed to maximise efficacy.

Long-term outcomes of anorectal malformations

Anorectal malformations (ARMs) and cloacal anomalies are rare and complex malformations of the lower gastrointestinal and genitourinary tracts. They affect approximately 1 in 3,500 live births. The treatment of these patients has traditionally focused on achieving urinary and faecal continence, with preservation of renal function. With improved surgical techniques and paediatric intensive care facilities, these patients now live relatively normal lives, with a near-normal life expectancy. Comparing results reported by different surgeons is difficult because a wide range of terminology is employed to describe the anomalies encountered. This paper attempts to simplify some of the reported outcomes of bowel function to allow a more direct comparison between groups. Urinary outcomes were not so easily comparable due to the disparity in assessing patient outcomes. Therefore, before a global analysis of all groups can take place, a standardised terminology will be necessary. At present there is a gap in the published literature of comprehensive follow-up in this group of patients, particularly regarding reproductive and sexual functioning. More detailed information on long-term outcomes is needed in these patients to facilitate informed decision-making by the primary physician (usually the paediatric surgeon) and the parents on behalf of their child.

Discordant sexual identity in some genetic males with cloacal exstrophy assigned to female sex at birth

BACKGROUND

Cloacal exstrophy is a rare, complex defect of the entire pelvis and its contents that occurs during embryogenesis and is associated with severe phallic inadequacy or phallic absence in genetic males. For about 25 years, neonatal assignment to female sex has been advocated for affected males to overcome the issue of phallic inadequacy, but data on outcome remain sparse.

METHODS

We assessed all 16 genetic males in our cloacal-exstrophy clinic at the ages of 5 to 16 years. Fourteen underwent neonatal assignment to female sex socially, legally, and surgically; the parents of the remaining two refused to do so. Detailed questionnaires extensively evaluated the development of sexual role and identity, as defined by the subjects' persistent declarations of their sex.

RESULTS

Eight of the 14 subjects assigned to female sex declared themselves male during the course of this study, whereas the 2 raised as males remained male. Subjects could be grouped according to their stated sexual identity. Five subjects were living as females; three were living with unclear sexual identity, although two of the three had declared themselves male; and eight were living as males, six of whom had reassigned themselves to male sex. All 16 subjects had moderate-to-marked interests and attitudes that were considered typical of males. Follow-up ranged from 34 to 98 months.

CONCLUSIONS

Routine neonatal assignment of genetic males to female sex because of severe phallic inadequacy can result in unpredictable sexual identification. Clinical interventions in such children should be reexamined in the light of these findings.

[Psychological aspects of genital surgery in childhood]

Although the children's urogenital surgery is discipline in expansion which successfully solves even the most complicated anomalies of urogeniral tract, only lately there is enough attention paid on the psychological aspects of these anomalies and surgical operation on genitals. The boys with hypospadias, phimosis and other congenital anomalies represent a risky group for the difficulties in forming the sexual identity and for the appearance of different psychopathology in their childhood and later in life. The surgical operation itself presents a traumatic situation for the child and it may discredit the later psychosexual development of these boys in a great deal. The priority is increasing the sensitivity of children's surgeons for these problems, not only for modernizing the surgical operation, considering the knowledge of normal psychological stages of development, but also for recognizing the psychological phenomena on time and for the consultative joining of the appropriate experts. It is very important to work with these children's parents in view of offering them help for better accepting their child's organic problem, to be less anxious on account of the anomaly and the operation itself and to be more able for better understanding of their child's feelings and his experience. The child's actual psychological condition and his later psychosexual development depend to a great extent on their parent's correct attitude. The caustical survey of the boys with hypospadias illustrates some of the psychological problems which appear with children who had an reparation of hypospadias.