Anal and Ano-Urogenital Malformations: A

Histopathological Study of "Imperforate Anus" with a

Reconstruction of the Pathogenesis

Abstract (summary)

Histopathological information about "anorectal malformations" is scarce and the pathogenesis

still controversial. Autopsy specimens of 20 human fetuses and newborns with "main" types of
the disorder were studied histologically. Supplemented with surgical-anatomical data from the
literature and with information from our own and earlier embryological research in animal
models as well as from recent observations on the normal development of the human perineum,
the study allowed for a new reconstruction of the pathogenesis of the disorder. The histological
analysis of the malformations in human fetuses and newborns showed a ventralward deviation of
the anal canal as the principal deformity. Ano-urogenital communications and differently
structured ectopic anocutaneous canals issued from anywhere between the bladder and the
vestibular/urethral orifice (female urethra excluded) and between the orifice and the usual site of
the anus, respectively, or they ended blindly, but with a suggestion of lost communication. They
occurred isolated or in association with other primary or secondary regional anomalies. Patho-
embryological data from animal models revealed that the deviation was caused by defective
development of the dorsal cloaca and not by disturbances in a series of fusion processes inside
and outside the cloaca, as is currently believed. This mechanism fits well into recent adjustments
of ideas about the normal development of the perineum. The cause of the defect is still obscure,
but a malfunctioning of cells ingressing from an end-stage primitive streak that affects the dorsal
side of the prospective cloaca appears most likely. The data collected permit a new
reconstruction of the pathogenesis of anal and ano-urogenital malformations.

ABSTRACT

Histopathological information about "anorectal malformations" is scarce and the pathogenesis

still controversial. Autopsy specimens of 20 human fetuses and newborns with "main" types of
the disorder were studied histologically. Supplemented with surgical-anatomical data from the
literature and with information from our own and earlier embryological research in animal
models as well as from recent observations on the normal development of the human perineum,
the study allowed for a new reconstruction of the pathogenesis of the disorder. The histological
analysis of the malformations in human fetuses and newborns showed a ventralward deviation of
the anal canal as the principal deformity. Ano-urogenital communications and differently
structured ectopic anocutaneous canals issued from anywhere between the bladder and the
vestibular/urethral orifice (female urethra excluded) and between the orifice and the usual site of
the anus, respectively, or they ended blindly, but with a suggestion of lost communication. They
occurred isolated or in association with other primary or secondary regional anomalies. Patho-
embryological data from animal models revealed that the deviation was caused by defective
development of the dorsal cloaca and not by disturbances in a series of fusion processes inside
and outside the cloaca, as is currently believed. This mechanism fits well into recent adjustments
of ideas about the normal development of the perineum. The cause of the defect is still obscure,
but a malfunctioning of cells ingressing from an end-stage primitive streak that affects the dorsal
side of the prospective cloaca appears most likely. The data collected permit a new
reconstruction of the pathogenesis of anal and ano-urogenital malformations.

Key words: anal canal, congenital malformation, embryology, histopathology, pathogenesis,

urogenital system

INTRODUCTION

Congenital anorectal malformations form a broad and complicated spectrum of anal deformities
and associated regional anomalies that have been ordered in intricate and complicated
classification schemes, based mainly on clinical features [1-3] and based little on
histopathological research. The spectrum ranges from stenotic anus and ectopic perineal anus to
"imperforate" anus with or without communication with the urogenital system.

This predominantly clinical experience combined with often conflicting ideas about the normal
development of the structures have resulted in a great diversity of theories on the pathogenesis of
the disorder. These theories comprised, as main pathogenetical elements, a persisting anal
membrane, a defective development of the anal pit combined with disturbed fusion processes
subdividing the cloaca into an anal and a urogenital part, fusing genital folds, and a defective
dorsalward migration of the anus [4]. Observations in staged embryos from a herd of pigs with
anorectal malformations occurring as a hereditary trait and very similar to those in man proved
all these theories wrong and demonstrated that it was a defect in the dorsal part of the cloaca that
made the anal canal deviate in a ventralward direction [5,6]. These observations have since been
confirmed in another inbred pig model [7] and in mouse [8-11] and rat models [12].
Investigations into the normal development of pig [13] and man [14] demonstrated that the
separation of the anal and urogenital systems is the result of a marked alteration in the shape of
the cloaca by disproportionately strong growth of the mantle mesenchyme around the urogenital
compartment and that fusion processes have no role to play in either the division of the cloaca or
in the construction of the superficial perineum. The aim of the present study was to provide a
comprehensive histopathological analysis of main variants of the disorder in human fetuses and
newborns and to correlate the findings with data from animal models and from an investigation
of the normal development of the human perineum to permit a reconstruction of the
pathogenesis.

MATERIALS AND METHODS

Twenty autopsy specimens, 6 from females and 14 from males, were obtained from stillborn
fetuses ranging in age from 19 to 40 weeks of gestation and from babies who were either
stillborn or who died within a few days of birth from congenital anomalies located elsewhere in
the body. Small specimens were kept intact, larger specimens were cut into slices, and from the
largest specimens, relevant parts were selected. Specimens were fixed in formalin, processed by
standard procedures, and embedded in paraffin. Depending on the size and structure, the blocks
were sectioned-serially, if necessary-in sagittal, transverse, or frontal planes. Single sections, step
sections, and serial sections were stained with hematoxylin and eosin. To reconstruct the
pathogenesis of the disorder, published data from recent research in experimental animals were
complemented with a review of sections from a previous study of 42 embryos, fetuses, and
newborn pigs from an inbred herd with the anomalies [5,6] and including an additional 9
specimens from a similar herd in Japan and 19 embryos and fetuses ranging from 11 to 22 days
postovulatory from an inbred strain of Short Danforth mice with anal malformations. They were
fixed in Bouin's fixative and were also treated using standard histological methods.

RESULTS

Female

A total of 6 specimens obtained from female fetuses and newborn babies without an anal
opening were available (Table 1). Apart from the absence of the anal opening, the external
appearance of the perineum varied, with a phallus-like structure in 3 specimens; a prominent
ventralward tapering, raphe-like structure extending from the coccygeal area to the vulva in 2
specimens; and a normal vulvar aspect in the remaining case.

Internal examination revealed connections between a wide anorectum and the trigone of the
bladder, vagina, a urogenital sinus-like structure, and vestibulum vaginae. Microscopic
examination showed that in all of these deformities, the rectum, though wider than usual, had
basically a normal histological structure and passed into an equally wide anal canal in the normal
manner.

Male

Fourteen specimens were obtained from male fetuses and newborn babies (Table 1). Apart from
the missing anus, external examination showed a normal perineum in 6 (cases 10 to 15) and
abnormal external genitals in 4 (cases 7 to 9), with either aphallia, a hypoplastic slightly bifid
scrotum, a hypoplastic scrotum, a bifid scrotum surrounding the penis, and a micropenis. Four
specimens demonstrated strikingly prominent dorsal raphes (cases 17 to 20), with dark segments
indicating meconium content inside narrow canals in 2. The canals extended over a variable
distance from the usual site of the anal orifice ventralward.

Internal examination revealed that in 7 cases the rectum was connected by narrow canals to the
base of a widely distended bladder or to the cranial part of the prostate, the caudal part of the
prostate, the membranous urethra, and the bulbar segment.

DISCUSSION

Histological analysis revealed several aspects that conflicted with current ideas about the
anatomical structure of these deformities, namely the condition of the rectum, the nature of the
"fistulas" between anorectum and urogenital system or perineal surface, and the distribution of
these communications. It also offered more information about associated regional anomalies.

Microscopy strongly indicated that the rectum, though widely dilated, was structurally normal
and that it was the anal canal that was primarily affected. [In this context, the terms "colon" and
especially "rectum" have been loosely used throughout the years. It has been pointed out recently
that rectum and anal canal are histologically and embryologically distinctly different structures,
albeit the muscularis propria of the rectum also envelops the anal canal [14]. For the
understanding of malformations in this area, this distinction is essential, and the use of precise
terminology is indispensable.] The observation of smooth muscular and neuronal abnormalities
in surgical specimens from the most distal part of the "rectal pouch" [15] cannot be considered
proof of deviation because that part of the pouch is in fact a dilated anal canal that normally is
surrounded by the terminal part of the muscularis propria of the rectum and has an incomplete
neuronal system [16]. With the rectum only secondarily affected, the terms "anal malformation"
and "ano-urogenital malformations," instead of the usual "anorectal malformation," were
preferred.

The communications between the anorectum and the urogenital system or the surface of the
perineum are generally misnamed "fistulas" and are considered to be ectopic anal canals with
ectopic anuses [17]. The present study revealed that there were in fact 2 histologically different
types of canals, namely "ano-urogenital communications" consisting of tissue elements of the
deep part of the anal canal only and "ectopic anocutaneous canals" demonstrating the
components of the deep and superficial parts of the anal canal. The latter comprised not only
those with an almost normal anus categorized as "anteriorly placed ectopic anus" or "anterior
perineal anus" [1,18,19] but also very narrow and long canals classified as "covered anus,
incomplete," or "anocutaneous fistula" [1,2,19,20] with, at best, minute "orifices" (Fig. 6).

The distribution of these ventralward deflected anal canals covers a wide area from the trigone of
the bladder to the usual site of the anus. Current classification schemes categorize them as related
to the bladder ("rectovesical"), persisting urogenital sinus or cloaca ("rectocloacal"), vagina
("rectovaginal"), vestibulum ("rectovestibular" or "anovestibular") and gynecological perineum
("anocutaneous") in the female [1-3,19], and related to the bladder ("rectovesical"), the proximal
urethra ["recto(posterior)urethral"], bulbus of the urethra ("rectobulbar"), rest of the spongy
urethra ("rectopenile" and "anopenile"), and perineal raphe ("perineal" or "anocutaneous") in the
male [1-3,20-24]. These classifications were based on clinical and surgical-anatomical
characteristics. The present histological approach, however, indicates a different categorization
for the rectovesical and rectovaginal types. Communications that seemed to issue into the
bladder macroscopically were found to relate to an area in the base of the bladder that
demonstrated urethral features histologically. This was well in conformity with the adjacent
position of the vaginal openings, as had been noticed before [19]. Earlier reports [25-28] lacked
the histological detail to decide on their nature, as was also the case in the "short colon" disorder,
in which the colon issues into the bladder halfway down the dorsal wall [29]. Communications
seemingly entering the caudal part of the vagina macroscopically were found to actually issue
into the transitional zone between the urethra and vestibulum, with the vagina(s) entering their
distal parts(30).

Conclusion

The principal abnormality in "imperforate anus" was a ventralward deviation of the anal canal.
The abnormal anal canal formed either an anourogenital communication consisting of the deep
part of the anal canal only or an ectopic anocutaneous canal consisting of deep and superficial
parts of the anal canal, or else it ended blindly with a strong indication of connections lost. The
abnormal anal canals can open anywhere between the usual site of the anus and the trigone of the
bladder but not in the rest of the bladder or the vagina. The anal malformation can occur isolated
or associated with regional anomalies, which can be primary deformities or secondary
complications. The histopathological findings of the present study fit well with new ideas about
the mechanisms of abnormal development, which have recently emerged from experiments in
animals [5-12] and a study of the normal development of the perineum [14]. Since human
specimens demonstrating early stages of the disorder are not availabl, such data are indispensable
to make a reconstruction of its pathogenesis. Combination of new data from studies of anal and
ano-urogenital malformations at fetal stages in man and at fetal and embryonic stages in animal
models and of normal development in man enables a reconstruction that encompasses the whole
spectrum of congenital anal malformation.

References

REFERENCES

1. Santulli TV, Kiesewetter WB, Bill AH. Anorectal anomalies: a suggested international
classification. J Pediatr Surg 1970;5:281-287.

2. Smith ED. Classification. In: Stephens FD, Smith ED, Paul NW, eds. Anorectal
Malformations in Children: Update 1988. New York: Alan R. Liss, 1988;211-222.

3. Peña A. Anorectal malformations. Semin Pediatr Surg 1995;4:35-47.

4. Stephens FD. Embryology of the cloaca and embryogenesis of anorectal malformations. In:
Stephens FD, Smith ED, Paul NW, eds. Anorectal Malformations in Children: Update 1988.
New York: Alan R. Liss, 1988; 177-210.

5. Van der Putte SCJ, Neeteson FA. The pathogenesis of hereditary congenital malformations of
the anorectum in the pig. Acta Morphol Neerl Scand 1984;22:17-40.

6. Van der Putte SCJ. Normal and abnormal development of the anorectum. J Pediatr Surg
1986;21:434-440.

7. Ikebukuro K, Ohkawa H. Three-dimensional analysis of anorectal embryology. Pediatr Surg

Int 1994;9:2-7.

8. Hashimoto R, Oda S, Inouye M, et al. The pathogenesis of anorectal malformation induced by

all-trails retinoid acid in mice. Cong Anom 1993;32:133-142.

9. Mesrobian H-GJ, Sessions RP, Lloyd RA, Sulik KK. Cloacal and urogenital abnormalities
induced by etrinate in mice. J Urol 1994; 152:675-678.

10. Kluth D, Lambrecht W. Current concepts in the embryology of anorectal malformations.

Semin Pediatr Surg 1997;6:180-186.
11. Liu Y, Sugiyama, Yagama K, Ohkawa H. Sharing of the same embryonic pathway in
anorectal malformations and anterior sacral myelomeningocele formation. Pediatr Surg Int
2003;19:152-156.

12. Qi BQ, Beasley SW, Frizelle FA. Clarification of the processes that lead to anorectal
malformations in the ETU-induced rat model of imperforate anus. J Pediatr Surg 2002;37:1305-
1312.

13. Van der Putte SCJ, Neeteson FA. The normal development of the anorectum in the pig. Acta
Morphol Neerl Scand 1983;21:107-132.

14. Van der Putte SCJ. The Development of the Perineum in the Human. Berlin: Springer-
Verlag, 2005.

15. Meier-Ruge WA, Holschneider AM. Histopathologic observations of anorectal abnormalities

in anal atresia. Pediatr Surg Int 2000; 16:2-7.

16. Weinberg AG. Hirschprung's disease-a pathologist's view. Perspect Pediatr Pathol
1975;2:207-239.

17. Gans SL, Friedman NB. Some new concepts in the embryology, anatomy, physiology and
surgical correction of imperforate anus. West J Surg Obstet Gynecol 1961;63:34-50.

18. Stephens FD. The female anus, perineum and vestibulum: embryogenesis and deformities.
Austr NZ J Obstet Gynaecol 1968;8:55-73.

19. De Vries PA. High, intermediate and low anomalies in the female. In: Stephens FD, Smith
ED, Paul NW, eds. Anorectal Malformations in Children: Update 1988. New York: Alan R. Liss,
1988;73-98.

20. Smith ED, Stephens FD. High, intermediate and low anomalies in the male. In: Stephens FD,
Smith ED, Paul NW, eds. Anorectal Malformations in Children: Update 1988. New York: Alan
R. Liss, 1988;17-72.

21. Currarino G. The various types of anorectal fistula in male imperforate anus. Pediatr Radiol
1996;26:512-522.

22. Endo M, Hayashi A, Ishihara M, et al. Analysis of 1992 patients with anorectal
malformations over the past two decades in Japan. J Paediatr Surg 1999;34:435-441.

23. Japan Study Group of Anorectal Anomalies. A group study for the classification of anorectal
anomalies in Japan with comments to the International Classification (1970). J Pediatr Surg
1982;17:302-308.

24. Shah AA, Shah AV. Imperforate anus with rectopenile fistula. Pediatr Surg Int 2003;19:559-
561.
25. Magnus RV. Congenital rectovesical fistula and its associated anomalies. Aust NZ J Surg
1972;42:197-204.

26. Escobar LF, Weaver DD, Bixler D, et al. Urorectal septum malformation sequence. Am J Dis
Child 1987;141:1021-1024.

27. Wheeler PG, Weaver DD, Obeime MO, et al. Urorectal septum malformation sequence:
report of thirteen additional cases and review of the literature. Am J Med Genet 1997;73:456-
462.

28. Liang X, Loffe OB, Sun C-CJ. Cloacal dysgenesis sequence: observations in four patients
including three fetuses of second trimester gestation. Pediatr Dev Pathol 1998;1:281-288.

29. Wardham H, Gangopadhyay AN, Singhal GD, et al. Imperforate anus with congenital short
colon (pouch colon syndrome). Review of eighteen cases. Pediatr Surg Int 1990;5:124-126.

30. Hendren WH. Management of cloacal malformations. Semin Pediatr Surg 1997;6:217-227.