FEATURES OF CLINICAL AND ANATOMICAL MANIFESTATIONS OF ANORECTAL MALFORMATIONS IN BOYS: FREQUENCY ANALYSIS

SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 92 FEATURES OF CLINICAL AND ANATOMICAL MANIFESTATIONS OF ANORECTAL MALFORMATIONS IN BOYS: FREQUENCY ANALYSIS F.M. Dusaliyev1, M.Sh. Boboyev2 Tashkent State Medical University1,2 https://doi.org/10.5281/zenodo.17451793 Abstract. The study analyzes the frequency, clinical, and anatomical characteristics of anorectal malformations (ARM) in boys based on 246 clinical cases treated at the Department of Pediatric Surgery, Tashkent Pediatric Medical Institute. The research highlights the predominance of fistulous forms (62.4%) among all ARM types, with rectoperineal and rectourethral fistulas being the most common. Non-fistulous variants such as anal membrane and anorectal agenesis without fistula were primarily diagnosed during the neonatal period. Diagnostic algorithms included clinical examination, radiography, ultrasonography, and contrast studies in accordance with the Krickenbeck classification (2005). Rare regional forms, including rectoscrotal and H-type rectourethral fistulas, were observed in 10.6% of cases. Associated anomalies were detected in 63% of patients, most frequently involving the cardiovascular and urinary tract systems. The results emphasize the importance of comprehensive diagnostic approaches for identifying complex and atypical forms of ARM to optimize surgical planning and postoperative outcomes. Keywords: anorectal malformations, rectourethral fistula, congenital rectal pouch, Krickenbeck classification, pediatric surgery. Introduction The prevalence of anorectal malformations (ARM) in infants demonstrates significant regional variations, reaching 56–64%, depending on the gender factor. Studies confirm the predominance of this pathology among male patients [1, 3, 9, 10], which may be explained by the incomplete consideration of all clinical forms of anomalies in existing works, including rare anatomical variants. Despite numerous publications devoted to the surgical management of ARM [2, 4, 8, 14], the issue of a differentiated approach to diagnosis and therapy, taking into account gender differences, remains relevant. This is due to the variability of the anatomical and functional characteristics of the urogenital tract, the frequency of concomitant defects, and the specificity of postoperative complications. The difficulties in treatment are associated with a high risk of dysfunctions (10–60% of cases), arising from diagnostic errors, intraoperative risks, and inadequate rehabilitation [5, 7, 11–13]. The aim of the study was to evaluate the incidence of various nosological forms, clinical and anatomical features, and associated anomalies in boys with ARM based on clinical data. Materials and Methods. The study included data from 504 children (246 boys, 258 girls) aged from 1 day to 15 years who underwent treatment at the clinics of the Department of Pediatric Surgery, Tashkent Pediatric Medical Institute. The primary diagnosis was made in 81.3% of patients (n = 200), while the remaining 18.7% (n = 46) were referred from other institutions with postoperative complications or with a stoma. The diagnostic algorithm included: clinical examination with assessment of the anorectal area; instrumental methods (ultrasonography, SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 93 multislice computed tomography, radiography); and specialized tests to determine the condition of the sphincter apparatus and identify associated anomalies. Results and Discussion. In newborns with the absence of the anal opening, the general condition was primarily assessed, and concomitant malformations were excluded. All patients underwent gastric intubation to verify intestinal obstruction and to exclude esophageal atresia. The structure of anorectal malformations (ARM) in boys included: atresias without fistulas (membranous form, rectal agenesis); fistulous forms (perineal, urethral, vesical, rectal pouch); and anomalies with a preserved anus (H-type fistulas, ectopia, stenosis). All cases were systematized according to the modified Krickenbeck classification (2005), with the identification of typical and rare forms (Table 1). Particular attention was paid to the detection of hidden fistulous connections between the rectum and urogenital structures, which require extended instrumental diagnostics. Table 1 Distribution of boys with anorectal malformations (ARM) by age and nosological forms Variants of ARM Type of ARM Newborns From 29 days to 3 months From 3 months to 1 year From 1 to 3 years From 3 to 7 years From 7 to 15 years Total Main clinical forms (n = 220) Anal membrane (n = 15) 15 – – – – – 15 Anorectal agenesis without fistula (n = 80) 80 – – – – – 80 Anal stenosis (n = 6) – – 3 3 – – 6 Rectoperineal fistula (n = 59) 14 7 28 7 2 1 59 Rectourethral fistula (n = 51) 11 3 19 8 10 – 51 Rectovesical fistula (n = 9) 1 – 4 4 – – 9 Total (n = 220) 121 10 54 22 12 1 Rare regional forms (n = 26) Anal ectopia (n = 5) – – 3 2 – – 5 Anorectal stenosis (n = 8) – – 5 3 – – 8 Rectoscrotal fistula (n = 6) 5 – – 1 – – 6 H-type rectourethral fistula (n = 1) – – – – 1 – 1 Rectal pouch (n = 6) 1 – 5 – – – 6 Total (n = 26) 6 – 13 6 1 – Grand Total 127 10 67 28 13 1 246 According to the data in the table, anorectal malformations (ARM) without fistula formation are predominantly diagnosed during the neonatal period. At an older age, both nonfistulous forms, such as ectopia and stenosis, and fistulous variants occur, which are accompanied by increasing defecation problems and complications after primary or palliative operations. The SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 94 frequency of occurrence of different types of ARM, their anatomic and clinical features, and the presence of associated anomalies vary. For a final diagnosis, the use of specialized diagnostic methods is required. Anal membrane was detected in 15 patients (6.1%). In this pathology, the anal opening is closed by a thin membrane, which stretches when the child cries, allowing meconium to show through. In such cases, the anal canal remains formed, and the muscular structures and sensitivity of the anorectal area are not impaired. This form of ARM, predominantly observed in boys, is considered the mildest variant of this anomaly. Anorectal agenesis without fistula was diagnosed in 80 children (32.5%). During the initial examination of newborns, the anal opening was absent, and a small depression or skin ridge was observed in its place. The median perineal raphe in this zone was disrupted. Irritation of this area with a sharp object or electrostimulation caused an anal reflex, indicating preservation of the anatomic structures responsible for the functioning of the rectal sphincter apparatus. The intensity of the anal reflex varied from minimal to normal levels. In some patients, positive dynamics were observed during follow-up. The diagnosis of persistent functional disorders caused by hypoplasia of the muscular complex, abnormalities in the formation of the sacrum and coccyx, as well as the determination of the height of the atretic rectal segment based on clinical data, presents significant difficulties. To clarify the diagnosis, radiological and ultrasonographic examinations are necessary. Sixteen to twenty hours after birth, an invertogram is performed in the prone position, with the infant placed on a pad with the abdomen elevated and the hips flexed at an angle of 45°. Ultrasonographic examination of the perineum performed in 24 patients demonstrated its informativeness and simplicity in diagnosis. Specific signs of rectal atresia with a fistula into the urogenital system include meconuria and pneumaturia, which are detected within the first hours or during the first two days after birth. In the presence of a urethral fistula, the urine excreted during urination is initially cloudy but then becomes clear; in addition, gases and feces may periodically pass independently of urination. However, the absence of these symptoms does not exclude a fistulous form of atresia, since their severity depends on the degree of filling of the blind end of the intestinal tube and the level of intestinal pneumatisation. To achieve the threshold level of intraluminal pressure, sufficient filling of the intestine with contents is required. Equally important parameters are the morphological and anatomic characteristics of the fistulous tract, including its diameter, length, and direction. Narrow fistulous channels may become obstructed with viscous meconium or mucus. Their obstruction may also occur as a result of intestinal blockage at higher levels, for example, with esophageal or duodenal atresia, as well as due to birth trauma or prematurity. In such cases, the severity of obstruction of the fistulous tract increases with its narrow lumen. Normalization of water-electrolyte balance and correction of hemodynamic disorders contribute to an increase in the amount of intestinal contents, stimulation of their movement, liquefaction of meconium, and an increase in intraluminal pressure, which in some cases can lead to spontaneous emptying of the fistulous tract. To identify fistulous forms of ARM, the following diagnostic methods are used: catheterization followed by bladder irrigation, as well as repeated microscopic urine analyses to detect pathological impurities. Rectourethral fistulas were identified in 52 patients (21.1%). Depending on their level of location, the fistulous openings communicated either with the bulbar part of the urethra (44.2%) or with its prostatic part (55.8%). In most cases, these fistulas were combined with rectal atresia or with the H-shaped variant of communication in the presence of a preserved anal opening. In a single case (1 out of 52), a rectourethral fistula was diagnosed incidentally. SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 95 Rectourinary fistulas often remain undetected during the initial surgical intervention or are formed as a result of iatrogenic injury to the urethra during surgery. Among the 52 patients with rectourethral fistulas, the diagnosis was established at the neonatal stage in only 11 (21.1%) cases, and in 16 (28.8%) cases — after performing perineal proctoplasty. In 25 (48.1%) children who had previously undergone sigmoid colostomy in various medical institutions, the pathology was mistakenly diagnosed as rectal atresia without fistula. Only after a comprehensive examination in our clinic was the rectourethral fistula finally identified. Congenital and acquired (iatrogenic) fistulas, as well as their recurrences resulting from the failure of the transected fistulous tract (11.5%), are usually diagnosed in infancy or later. Clinically, the pathology manifests itself by the discharge of intestinal contents or urine through the urethra and/or anal opening, and the intensity of these manifestations may vary. The type of the clinical picture largely depends on the direction of the fistulous tract: • In fistulas originating from the urethra, urine is discharged not only through the urethra but also through the anal opening during urination (9.6%). Over time, the volume of urine excreted via the normal route decreases, probably due to progressive stenosis of the distal urethra in the fistula zone. • In obliquely descending fistulas starting from the rectum (11.5%), gases and intestinal contents pass through the urethra. • In 10 cases (19.2%), urine was discharged simultaneously through the urethra and rectum during urination. In some cases, fecal masses and gases were periodically discharged through the external urethral opening. This phenomenon is associated with the presence of an elongated fistulous tract between the rectum and the damaged urethra after surgery. The diagnosis of fistulous forms of pathology presents significant difficulties, but it is possible to identify characteristic signs that allow differentiation between congenital and acquired (iatrogenic) rectourethral fistulas: • Congenital fistulas usually open into the prostatic or bulbar part of the urethra and are characterized by a relatively well-formed connective channel. • Iatrogenic fistulas are more often localized in the membranous part of the urethra, accompanied by adhesion of its walls to the rectum, marked deformation, and stenosis in the area of the fistulous opening. The shape, direction, and diameter of the fistula can vary considerably, which must be taken into account when choosing a diagnostic approach. In cases of H-shaped fistulous communication, the examination includes a detailed assessment of the anatomic and functional condition of the anorectal region and precise determination of the fistula location. The most accessible and informative diagnostic method is rectal examination using a rectal speculum after the introduction of methylene blue through the external urethral opening. Additionally, urethrocystoscopy, urethrocystography, retrograde and antegrade irrigography with water-soluble contrast agents, and excretory urography are used. Additional information can be obtained by catheterizing the fistulous tract during urethrocystoscopy performed under medical sedation. A comprehensive diagnostic approach makes it possible not only to confirm the presence of a fistula but also to determine its anatomic characteristics and localization, as well as to identify possible associated anomalies of the urinary system and distal intestinal segments. These data are crucial for selecting the optimal surgical strategy. In rectourethral fistulas, there is a high risk of ascending urinary tract infection. The wider the fistulous tract and the longer the fecal matter remains in the rectum due to cicatricial stenosis SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 96 of the anal canal, the higher the likelihood of infection. The discharge of urine through the rectum causes significant discomfort to the child, provoking maceration of the perineal skin and severe itching. Postoperative complications may include: insufficiency of the anal sphincter leading to chronic constipation or fecal incontinence; decompensated colostasis accompanied by progressive dilatation of the distal colon and the development of megacolon; nutritional disorders manifested by anemia and hypotrophy, especially when anorectal anomalies are combined with elongation of certain segments of the large intestine. Rectovesical fistula was diagnosed in 9 (3.7%) patients. In this anomaly, the rectum opens into the neck of the urinary bladder. As a rule, this pathology is accompanied by underdevelopment of the levator muscles, the muscular complex, and the external sphincter. Deformations of the sacrum and signs of dyskinesia are frequently observed. Differential diagnosis between a rectovesical fistula and a rectourethral fistula is difficult. A distinguishing feature of a rectovesical fistula is the discharge of turbid urine and gases exclusively during urination. In contrast, in the case of a urethral fistula, gases and fecal matter may pass through the external urethral opening regardless of urination, and during urination itself, the urine is initially cloudy and then becomes clearer. Radiological examination reveals the presence of fluid in the urinary bladder, which requires confirmation by contrast urethrocystography and urethrocystoscopy. One of the features of this form of ARM is that the rectovesical fistula is located most proximally among all rectourinary fistulas in boys. It requires surgical correction via an abdominoperineal approach, using a combined posterior sagittal and abdominal access or laparoscopic assistance. Congenital rectal pouch (CRP) was identified in 6 (2.4%) boys after the creation of a sigmoid colostomy for a non-fistulous form of ARM with signs of low intestinal obstruction during the first 1–2 days of life. Retrospective analysis showed that the cause of progressive low intestinal obstruction was the excessive accumulation of intestinal contents in the rectal pouch due to a narrow fistulous tract. A characteristic radiological sign of a congenital rectal pouch in rectal atresia is the presence of gas within the bladder cavity. However, due to the rarity of this pathology and the lack of sufficient diagnostic experience at the initial stages, this radiological sign was not identified in a timely manner in 2 patients. The final diagnosis was established at later stages of diagnosis and surgical treatment at the following ages: 1 month – 1 patient; 3 months – 1 patient; 5 months – 2 patients; 6 months – 2 patients. During surgical intervention for sigmoid colostomy closure, a saclike dilation of the shortened colon filled with intestinal contents was found. The pouch had thickened walls, absence of haustra and fat appendices, as well as a hypertrophied mucous membrane. In the absence of a transitional zone between the normal bowel segment and the cystic dilation (up to 12 cm in diameter), the fistulous communication opened into the urinary bladder. According to the classification by Narasimharao K.L. (1984), two types of congenital rectal pouch are distinguished, including four subtypes. In our study, 5 patients corresponded to the complete involvement type, which is characterized by the absence or insufficient length of the colon for pull-through, requiring coloplasty using the rectal pouch: - Type I – complete involvement of the colon (4 patients); - Type II – complete involvement with partial development of the cecum (1 patient). In one patient, Type III was diagnosed – subtotal involvement of the proximal and transverse colon, where the colon length was sufficient for pull-through without the need for coloplasty. Type IV – cystic dilatation of the left colon segments was not observed in our study. SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 97 Type of complete involvement Type of incomplete involvement Fig. 1. Schematic representation of various types of congenital rectal pouch (CRP). Illustration from the manual by Holschneider M.A. and Hutson M.J Rectoperineal fistula was detected in 59 (24.0%) out of 246 boys with anorectal malformations (ARM). This pathology is predominantly manifested by anterior displacement of the opening, which opens along the midline in the area of the anal dimple extending to the scrotum. A variant of rectoperineal fistula is the location of the opening along the midline raphe of the scrotum, which was observed in 6 (2.4%) boys. Among 65 patients with fistulas of this localization, 54 (83.1%) showed narrowing of the fistulous opening. The degree of narrowing was determined using Hegar dilators. An opening that did not allow the passage of a dilator with a diameter corresponding to the child’s index finger was considered narrowed. The diameter of the fistula in 19 (29.2%) patients corresponded to Hegar dilators No. 2–3, which was classified as a narrow fistula. In such cases, partial low intestinal obstruction developed, requiring periodic dilatation before surgical intervention. In 35 (53.8%) patients, the fistulous tract corresponded to Hegar dilators No. 4–6 (fistulas of medium width). These patients developed difficulty in defecation starting from 2–3 months of age, which worsened with the introduction of complementary feeding. In 19 (29.2%) of them with short fistulous tracts, dilatation provided a satisfactory effect without the need for surgical intervention. In 11 (17.0%) patients, the fistulous tract freely passed Hegar dilators No. 7–10, which was classified as a wide fistula. In this group, defecation difficulties were generally absent, and surgical correction was not required. Anal ectopia was diagnosed in 5 (2.1%) boys. The differential diagnosis of anal ectopia, in which anterior displacement affects the sphincter apparatus, was performed in comparison with the perineal fistula, taking into account the characteristic position of the anal dimple and the determination of the Rossolimo reflex in the area of the normal anus. The Anal Position Index (API) was used for diagnosis, with the following results obtained: ≤ 0.22 — in 3 (60.0%) patients; ≤ 0.33 (significant anterior displacement of the anus) — in 1 (20.0%); ≤ 0.40 (moderate anterior displacement) — in 1 (20.0%). As a rule, significant narrowing is not observed in anal ectopia. However, 2 (40%) children had constipation, and 1 (20.0%) of them had persistent colostasis. Contrast irrigography in these patients revealed: dolichocolon in one and dolichosigma in two patients. In 2 (40.0%) cases, the irrigogram was within normal limits. Stenosis of the anal opening involving the rectum was diagnosed in 14 (5.7%) patients. In 6 cases, stenosis was easily determined during perineal examination and manifested as narrowing of the anal opening located in its typical position. The SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 98 degree of stenosis was assessed using Hegar dilators. The anal opening that freely passed a dilator corresponding to the diameter of the child’s index finger was considered non-stenotic. Table 2. Incidence and Types of Associated Anomalies in Boys with Anorectal Malformations (ARM) Note: Values in parentheses indicate multiple congenital anomalies. Abbreviations: CVS — Cardiovascular system; UTS — Urinary tract system; GIT — Gastrointestinal tract; MS — Musculoskeletal system; CNS — Central nervous system. In anorectal stenosis, in addition to the diameter, the length of the constriction is important, as it determines the severity of defecation difficulties. The length of the stenosis was measured Variants of ARM Nosological Forms CVS UTS GIT MS Spinal Column CNS Down Syndrome Other Multiple Anomalies Major Clinical Forms Anal membrane (n = 5) 2 (2) (1) – (1) (1) (1) – – 3 (6) Anorectal agenesis without fistula (n = 41) 12 (6) 6 (7) (3) (2) 4 (7) (1) 3 (4) (1 ) 16 (31) Anal stenosis (n = 3) – – 3 – – – – – – Rectoperineal fistula (n = 40) 4 5 (4) 23 (4) 1 (1) (4) – – (1 ) 7 (14) Rectourethral fistula (n = 37) 1 (3) 6 (16) (8) (1) 7 (16) (2) (1) (2 ) 23 (49) Rectovesical fistula (n = 8) (2) 1 (6) – – 2 (3) – – – 5 (11) Rare Regional Forms Anal ectopia (n = 4) – – 2 (1) – 1 (1) – – – 1 (2) Anorectal stenosis (n = 5) – – 4 (1) – (1) – – – 1 (2) Rectoscrotal fistula (n = 5) 1 (1) 2 (1) 1 – – – – – 1 (2) H-type rectourethral fistula (n = 1) – 1 – – – – – – – Rectal pouch (n = 6) (1) (4) 2 (4) – – – – – 4 (9) Total = 155 (220) 20 (15) 21 (39) 35 (21) 1 (5) 14 (33) (4) 3 (5) (4 ) 61 (126) SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 99 using the M.D. Levin (2015) method with a tube equipped with an inflatable cuff or a Foley catheter. After inserting the tube into the rectum to a depth of 5–6 cm, the cuff was inflated with 4–5 ml of saline. The tube was then slowly withdrawn until resistance was encountered, marking the level of the anal opening. After deflation, the tube was removed, and the distance from the mark to the lower edge of the cuff was taken as the length of the stenosis. In 6 (42.9%) cases, the stenosis length was up to 1 cm; in 5 (35.7%) — up to 2 cm; and in 3 (21.4%) — more than 2 cm. Differential diagnosis of anorectal stenosis and the rectal form of Hirschsprung’s disease was performed using contrast irrigography and rectal biopsy. During comprehensive examination, 220 associated malformations were identified in 155 (63.0%) patients. In 94 (60.6%) of them, combined anomalies were isolated, while 61 (39.4%) children had associated anomalies of two or more systems (multiple malformations). The total number of anomalies was 126 (Table 2). Clinical verification of associated anomalies was performed using specialized diagnostic methods. Conclusion. It should be noted that anorectal malformations (ARM) in boys account for 48.8% of the overall structure of this pathology in children. Fistulous forms (62.4%) predominate, with rectoperineal fistulas posing no diagnostic difficulties. Rectourethral fistulas mainly occur in cases of rectal atresia and in H-type communications with a normally developed anus, although they are relatively rare. Such fistulas often remain undetected until the primary surgical intervention or are identified following iatrogenic injuries to the urethra during surgery. The diagnosis of certain forms of this anomaly requires the application of specialized diagnostic methods, particularly in cases of rectourethral fistulas and congenital rectal pouch, as these present the greatest diagnostic challenges. Rare regional variants of ARM were identified in 10.6% of patients. Associated anomalies were observed in all anatomical forms of this pathology; however, their frequency and clinical complexity varied significantly. REFERENCES 1. Akselrov M.A., Evdokimov V.N., Emelyanova V.A., Verkholantsev O.A. Minimally invasive technologies in colostomy formation in neonates with high anal and rectal atresia. Medical Journal. 2018; No.1: 50–53. 2. Vinokurova N.V., Tsap N.A. Comprehensive approach to the treatment of anorectal malformations in children. Bulletin of the Ural State Medical University. 2018; No.1: 18–21. 3. Degtyarev Yu.G. Congenital anorectal anomalies: a differentiated approach to diagnosis and treatment (experimental-clinical study). Doctoral dissertation abstract, Minsk, 2017. 48 p. 4. Krushelnitskaya Yu.V. Epidemiological and clinical-genetic characteristics of congenital gastrointestinal malformations in children. PhD abstract, Moscow, 2018. 24 p. 5. Levin M.D. Pathological physiology of anorectal malformations: from a new concept to a new treatment. Clinical and Experimental Gastroenterology. 2015; No.11: 38–48. 6. Morozov D.A., Nikitina A.N., Tikhonova I.A. Associated pathology in children with anorectal malformations. Saratov Scientific Medical Journal 'Surgery of Newborns'. 2007; No.2: 26– 28. 7. Shchapov N.F., Mokrushina O.G., Gurevich A.I. et al. Rehabilitation of infants after correction of anorectal malformations. Pediatric Surgery. Moscow, 2014; No.4: 16–19. 8. Ergashev N.Sh., Otamuradov F.A. Frequency, nosological structure, and anatomical features of anorectal anomalies in girls. Bulletin of the Association of Physicians of Uzbekistan. Tashkent, 2016; No.2: 51–55. SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 100 9. Almaramhy H.H. Incidence and spectrum of anorectal malformations in Western Saudi Arabia. Saudi Medical Journal. 2012; 33(12): 1334–1339. 10. Cuschieri A. EUROCAT Working Group. Descriptive Epidemiology of Isolated Anal Anomalies: A Survey of 4.6 Million Births in Europe. Am J Med Genet. 2001; 103(3): 207– 215. 11. Ergashev N.Sh., Otamuradov F.A., Ergasheva N.N. Anomalies of the spine and spinal cord in children with anorectal malformations. European Science Review – Austria, Vienna, 2016; No.9–10 (September–October): 148–150. 12. Levitt M.A., Kant A., Peña A. The morbidity of constipation in patients with anorectal malformations. Journal of Pediatric Surgery (USA). 2010; 45(6): 1228–1233. 13. Moore S.W. Associations of anorectal malformations and related syndromes. Pediatric Surgery International. 2013; 29(7): 665–676. 14. Holschneider A., Hutson J., Peña A., Bekhit E., Chatterjee S., Coran A. et al. Preliminary report on the International Conference for the Development of Standards for the Treatment of Anorectal Malformations. Journal of Pediatric Surgery (USA). 2005; 40(5): 1521–1526. 15. Khurramov F.M., Khamidov B., Sattarov Zh.B. Modern approaches to the diagnosis and treatment of Hirschsprung’s disease in children. EJMNS. 2025; 5: 83–93. 16. Dusaliev F.M., Khurramov F.M., Khamidov B. Incidence and clinical-anatomical features of anorectal malformations in boys. EJMNS. 2024; 4: 129–139.