Principles of management of the persistent cloaca in the female newborn

The persistent cloaca in the female newborn is one of the most complex and challenging developmental malformations that the pediatric urologist will encounter. A review of 5 patients seen at this center and 34 completely documented cases was undertaken to characterize the defects and devise a logical diagnostic and therapeutic approach. Diagnostic steps include the search for associated anomalies, which were present in the upper urinary tract (33 per cent), gastrointestinal tract (13 per cent), cardiovascular system (13 per cent), central nervous system (10 per cent) and respiratory tract (5 per cent). Delineation of the cloaca and its anatomic relationships is determined by abdominal x-rays, injection of contrast material into the cloacal channel, excretory urography and endoscopy with selective catheterization. Surgical treatment begins with a diverting right transverse colostomy in the newborn period followed by rectal pull-through when the patient weighs 25 pounds. Vaginal pull-through should be performed at the same time as the rectal pull-through if the vagina enters the cloaca high. If the cloacovaginal communication is low a vaginoplasty by a posterior flap procedure can be done when the child is 10 to 12 years old. Even is anatomy is reconstructed in an ideal manner urinary and fecal continence cannot be assured since congenital neurologic dysfunction is not uncommon.