Early urologic considerations in patients with persistent cloaca

Cloacal malformations represent one of the most complex conditions among anorectal malformations. Urologic conditions occur with an increased frequency in cloaca patients compared to patients with other types of ARM. The morbidity of the upper and lower urinary tract dysfunction/malformations at times can be severe; manifested by urinary tract infection, lower urinary tract symptoms, urinary incontinence, chronic kidney disease, and even end stage renal disease. Long-term follow-up of patients with cloaca has described significant chronic kidney disease and end-stage renal disease. Whether this rate of chronic kidney disease is a function of intrinsic renal dysplasia or acquired renal injury from neurogenic bladder is currently unknown. However, it is well known that severe lower urinary tract dysfunction, no matter the etiology, poses significant risk to the upper tracts when untreated. Neonatal assessment of the urinary tract accompanied by early identification of abnormal structure and function is therefore fundamental to minimize the impact of any urologic condition on the child's overall health. Adequate management of any associated bladder dysfunction is essential to preserving renal function, minimizing risk of urinary tract infection, and potentially avoiding need for future reconstructive surgery. This article summarizes our institution's approach to the ongoing early urologic management in patients with cloaca.