Anal Stenosis and Anorectal Malformations

My 3 month old daughter was diagnosed with anal stenosis after several bouts of stool infrequency, two of which lasted ten days without a bowel movement. We had to give her babylax to make her go. Her doctor wants her on a glycerin suppository, broken in half, two times a day. Is there any other treatment? Will she become dependent? He said it may take four months or more of this treatment. Could diluted juice help since she’s almost four months old? Any input will be helpful, since I can’t find information on her condition.
Kim Dennis – Nursing Student – Kenner, Louisiana

Dr. Greene’s Answer:

The gastrointestinal system is a long convoluted tube extending from the mouth, through the body, down to the anus. During development a portion of the tube may not form. This is called atresia (for example, in esophageal atresia, a section of the esophagus is missing). More commonly, a portion of the tube is too narrow. This is called stenosis. In pyloric stenosis for example, the pylorus (the valve at the outlet of the stomach) is too tight to permit stomach contents to pass through easily. Anorectal anomalies occur in about 1 of every 4,000 live births and include a wide spectrum of defects — some are minor and easily treated, some are complex and very difficult to manage.

Very early in development, the urinary tract and the embryonic rectum and anus are all part of the same structure. They separate by the seventh week of gestation. At the time of separation, the urinary tract already has an opening on the skin, but the anus is covered by a thin membrane. By eight weeks of gestation, the anal opening typically appears.

Anal stenosis refers to a narrowing of the anal opening, which makes it difficult for stool contents to pass through easily. Symptomatic children tend to be particularly colicky babies, because of the discomfort associated with the stool backing up. The stool may exit under pressure and look almost like a squirt gun. Treatment of this disorder usually involves gentle dilation of the anal opening. This is typically done twice a day. Every week a slightly larger lubricated dilator is passed to stretch the anus until it reaches normal size. In very mild cases, softening the stool may be sufficient until the anus grows sufficiently. Suppositories can make the child comfortable in the short run, but do run the risk of dependence. At around 4 months, apple or even prune juice may help the child to pass stool. Rarely, surgery is needed to insure an opening of adequate caliber. If this is an isolated anomaly, the prognosis is excellent.

Some children are born with no anal opening at all. This is called an imperforate anus. The rectum ends in a blind pouch, about 2 cm inside the perianal skin. Usually the sphincters are well developed. For these children, a colostomy is indicated during the newborn period, but once the final surgery corrects the defect, the prognosis is likewise excellent.

The most frequent anorectal defect seen in boys is the recto-urethral fistula, or a communication between the rectum and the lower part of the urethra. These children also require a colostomy before the definitive repair period. The long term prognosis for normal urethral and rectal function is good.

The rectovesical fistula is a communication between the rectum and the bladder. These children usually also have poorly developed sacral bones and sphincters. The prognosis for normal bowel function is poor.

For all anorectal malformations, there is a very good correlation between the degree of development of the sacral bone with the final bowel and bladder functioning after correction. Children with an absent sacrum will almost certainly have permanent incontinence. Those with a well-developed sacrum will generally have an excellent outcome.

Based on the treatment your doctor has prescribed, I can only assume your daughter has a very mild case of anal stenosis. Although her condition is concerning to you now, in a few months you will probably be privileged to change many dirty diapers each week.

Dr. Alan Greene

Dr. Greene is a practicing physician, author, national and international TEDx speaker, and global health advocate. He is a graduate of Princeton University and University of California San Francisco.

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  1. Kahif Mehdi

    I am a concerned Father of my 5 month old boy,

    when he was 4 month and so he was keeps scratching her for passing stool, i consult with the Dr. they perform dilation and inform us it a Nine size, it will be narrowing anal stenosis , he advice us dilation for 10 days, for size of 9 -10, 11-12, & 13-14.

    we preform dilation for 10 days in which our problem of constipation & scratching was resolve, he is happy & doing poop 4 time a day.

    aftar 10 days now we gone for follow up, dr. said 9-10 & 11 -12, 13 easily passing but 14 still get little narrowing, he advice us for dilation 6 week more.

    i am little confuse, is it really need to dilate further, as our problem of constipation has been resolved.

    please advise
    She as a very hard time making stool she goes every three to four days with out going I usually

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    • I’m happy that your son’s constipation has resolved! Generally with anal stenosis, once babies are able to poop comfortably several times a day, no further dilation is needed. It’s better to treat based on the how the baby is functioning rather than treating based on an average normal number. And it’s better to be a little too tight than a little too loose.

      If you get a chance, you may want to ask your doctor, though, why they suggested that. They may have a reason I don’t know about. Best, DrGreene

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      • Kahif Mehdi

        Thank you Dr. for your prompt response regarding my Query,

        As far as i Understand, According to Dr. 14 Size Dilator should easily pass on 5 month Baby but i thought a normal pinky size finger will not more than 13 size.

        Dr. said as soon as they start solid, it will be again a difficulty on passing stool as my baby on feed till now.

        beside this Dr. Said if he could able to make that size, we will look forward for Surgery.

        i am little concern my baby should we need to dilate further or we can consult another dr.

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        • Greetings. When starting solids, the stools do typically change (often firmer and smellier). Kids usually adjust to this fairly quickly. If difficulty passing stool happens again, it can be addressed at that time. But there may be no problem at all. When a parent is not quite comfortable about medical advice, I’m a fan of consulting another doctor, if available, and asking for their reasoning as well. Best, DrGreene.

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  2. Sonya

    My son is almost 3 months old and has been having problems pooping since about 2 weeks old. He is fussy constantly won’t sleep unless being held and pushes constantly grunting and in pain. He is strictly breastfed and I have cut out all dairy from my diet. He has loose to soft stool and lots of gas that he can’t get out unless he is stimulated or if I hold his legs up and spread his anus open. We were sent to a GI specialist due to an X-ray showing trapped air but they said the X-ray was normal. The GI doc did a rectal exam very rough and acted like we were wasting her time bc our baby was too healthy to be there due to gaining weight. She ruled out Hirschsprung’s disease and said to just give him suppositories and lactulose. Well I just called her back the other day bc after her rectal exam he started pooping normal and passing gas with ease but it has been getting worse again and I suggested rectal stenosis but she insists it isn’t that she checked him but the way she rammed her finger in there she couldn’t have been able to tell bc she busted right through it. I have since started using my pinky lubed to dilate his little rectum for the past two days and he is a completely different baby, passing gas with ease and pooping normal without discomfort and he is sleeping peacefully not in my arms!!!

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    • Miroslav

      Dear Dr Greene,
      my name is Miroslav Krjak. I am from Slovak republic.I am a gynecologist.My grandson is now 9 months. He has a rectal stenosis. During the breastfeeding he have had no problem with stool.Problems started when he was 6 months old. GI ruled out Hirsprung s disesase but verified rectal stenosis. Modality of treatment is dilation of recti. It is very painful method for the baby but with small effect. Firs two days after dilation he is
      pooping normal ant then with suppositoria.He has no problem with passing gas at all.Do You think this modality of the treatment should proceed or would You recommend a different treatment? Thank You for your time.
      Miroslav Krjak,MD,PhD

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  3. VIANNE RODRIGUEZ

    I was always though that Apple juice would constipated the child even more I do give her plum juice but she mostly spits it out I bought her the plumber smart from suns weet she still doesn’t like it
    Thank you so much

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  4. VIANNE RODRIGUEZ

    I am a concerned mother my daughter who is now 20 weeks old keeps scratching her but
    She as a very hard time making stool she goes every three to four days with out going I usually have to put suppositories to make her go but sheven cries because she’s in pain she even started to bleed is there anything I can do to alleviate the pain and the itching of the anus is there any cream that I can use on her anus to stop the itching thank you

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  5. Renesa

    His stool is very thick like glue sometimes and sometimes its normal. Colour of stool is yellow

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  6. Renesa

    He is a breast-feeding baby and his weight is 6 kg. In this 3month he normally do his poo for only 2times. Please help me out

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  7. David L. Sharp, M.D.

    I’m delighted to see this dialogue occurring! “Mild” rectal stenosis has been around for a long time, and as Dr. Greene points out, is highly associated with infant colic. The medical literature has largely been ignoring this problem for several decades now, and I’d love to know why. I did not have colicky babies in my practice for 33 years and had the privilege of speaking with Dr. Morris Wessel in the early 1990’s. He had proposed a physiological cause for infant colic and commented, “I was that close.” He later wrote and said he would be doing more rectal exams. The digital rectal exam is both diagnostic and curative of rectal stenosis caused by residual membrane formation and an overly-tight internal anal sphincter muscle. For more details, please refer to my two books on Constipative Colic, available on Kindle/Amazon.

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    • Courtney D

      I am so relieved to have read this post and look forward in reading your book. I keep telling my doctor that something is not right with her rectum muscle and I feel very ignored. I hate that my daughter is in so much pain daily during her 1st few months of life. She’s 7 months and I literally have to spread her cheeks for the gas to release… I’ve told this to my doc and she’s fine with that as long as I do not stimulate the rectum.
      I’m literally headed to read your book now.
      Much thanks!

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      • Sonya

        How did things turn out for your little one? I’m in the process of going through the same things you have, I posted a comment on here with my baby’s problems

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  8. Rajesh Sahu

    Sir

    My 4 Months son doesn’t poo for 4-5 days in a stretch… We have to do anemia for his poo every time …. He often vomits after breast feeding and starts crying …

    Please advice ….

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  9. Nazibullah

    Age of the Kid : 1 year 1 month 20 days
    Report of Contrast Enema :
    Large gut is outlined by contrast up to cecum without any obstruction or hold up anywhere.
    No evidence of any filling defect noted.
    There is minimal stenosis seen at distal part of rectum visible colon is dilated.
    Residual contrast seen at 24 hours late film.

    Comment:
    Above findings due to suspected partial rectal stenosis, however, advice rectal biopsy for further evaluation if clinically suggest.

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    • Renesa

      My son is 3 nd half month old. But he totally do not poo. We have to use glycerine suppository to make him poo.Is there any remedie of it?

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  10. karly

    My pediatrician diagnosed my 4 month old son with mild anal stenosis last week but yesterday when I followed up with his g.i. doctor she did an internal exam – just like the pediatrician did, and the g.i. said he doesn’t have anal stenosis. I’m SO confused! Could my pediatrician ‘ s internal exam a few days prior repaired or stretched his an us enough to make the g.i. not think he has anal stenosis? My 4 month old baby boy is Always happy except when pooping or passing gas. He strains really hard. He is only breastfed and the g.i. had me eliminate dairy, soy and nuts from my diet a couple of months ago because they found occult blood in his diaper and he was uncomfortable pooping…I don’t necessarily agree with it though. What do you think? I’m at a loss, don’t want to stop nursing

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