What are Vaginal Abnormalities: Cloacal Abnormalities?

Female Reproductive System
Female Reproductive System

As a baby develops, three (3) openings normally form for the intestinal, genital and urinary tracts. In early stages of pregnancy, these three openings join together in a sac called "Cloaca." They then separate from each other to form the anus, vagina and urethra. In rare cases, this area may develop incorrectly. A "persistent cloaca" may form if these tracts fail to undergo complete separation from each other. This is when the intestinal, genital, and urinary tracts open into one common cavity, with one opening.

This birth defect happens during pregnancy. It can affect 1 in every 50,000 babies. Not much is known about how to prevent it. Here we provide some basic information to help.



What are the Symptoms of Cloacal Abnormalities?

In some cases the 3 tracts come together at a low point. A newborn with this defect has no visible anus (the opening where feces leave the body). Everything else looks normal. There is often a wide common channel that drains freely. Urinary obstruction is not a problem.

In other cases the 3 tracts come together at a high point. For these newborns, the common channel is long, so draining waste is more difficult. Urinary tract infections are common.

Other issues:

  • The clitoris may look like a penis (gender confusion)
  • There may be more than one vagina and cervix
  • The vagina can be obstructed leading to an abdominal swelling
  • The anus may be malformed
  • There may be other problems with the ureters and kidneys
  • The spinal cord can be abnormal
  • The heart can have structural defects
  • Limbs can be deformed


How are Cloacal Abnormalities Diagnosed?

They are most often found at birth. The doctor will see that the newborn has only one opening. Often it is hooded and elongated. The baby will also have abdominal swelling.

The tests to confirm the diagnosis include:

Ultrasound

An abdominal ultrasound is done to see swelling in the bladder, vagina and rectum. It will also show if there is a buildup of urine in the kidneys and ureters. This can happen when urine stays in the bladder and can't drain. Kidney problems can happen in 60 – 80% of cases.

Retrograde Genitogram

In this test, dye is added into the common channel and an X-ray is taken. The dye helps the doctor understand the areas that cannot be seen. It can also show other, related problems.

This must be followed by endoscopy to get a closer look with a fiber-optic camera. This will help the surgeon decide on treatment.

MRI

Lastly, an MRI of the pelvis and spine will be done. This will look for spinal defects. The heart can also be checked by echocardiogram.



How are Cloacal Abnormalities Treated?

Surgery is needed to treat these issues. The method depends on the type and extent of the problem. It is important to work with an experienced pediatric urologist.

Repair

The first goal is to stabilize the newborn. This may involve a loop colostomy. This would let the child pass stool and mucus from the colon out through a space in the abdominal wall. For this, the colon is split into two. The open ends are sewn to the abdomen to make a stoma or opening. The stoma can drain the upper colon to let stool pass, while mucus can drain from the lower part.

Because the bladder is most often swollen, the baby will need a catheter to drain urine. And because of fluid build-up from hormones, the vagina may also need decompression.

Reconstruction

This can start once the baby is stable and the anatomy is clearly defined. This occurs around age 6 months to 1 year.

If the common channel is less than 4 cm in length, the rectum is detached from the vagina. The common channel is brought down to the surface of the skin. The channel is then divided, and the openings of the vagina and urethra are put in the right places. If the channel is more than 4 cm, the surgical repair will be more complicated and can result in urinary incontinence.

At 2 to 3 weeks after surgery, the rectum is stretched to avoid narrowing. The colostomy is closed after 3 months.



What Happens After Treatment?

Many parents have questions about their child’s ability to control urine or feces after surgery. The result depends on how serious the problem was at first.

In milder cases, 9 out of 10 babies have good control and a nearly normal pattern with stools. Urinary control is also better in the milder cases (where the common channel is less than 4 cm long).

Around 7 or 8 out of 10 patients with more severe cloacal anomalies will have good control. They will have very few episodes of leaking. The others may have long-term problems and will need further care.

There may also be neurological issues in leaking, which may affect up to 1/3 of patients. Learning to self-catheterize can help with bladder emptying. Some may benefit from enema-treatments for better bowel emptying and stool control.

Once the cloacal abnormality is fixed, a normal and enjoyable sex life is possible.