ANZ J. Surg. 2007; 77: 557–559 doi: 10.1111/j.1445-2197.2007.04151.

ORIGINAL ARTICLE

TREATMENT OF ANAL STENOSIS: A 5-YEAR REVIEW

DAMIAN CASADESUS, LUIS E. VILLASANA, HECTOR DIAZ, MARIANO CHAVEZ, INES M. SANCHEZ,
PEDRO P. MARTINEZ AND ANGELINA DIAZ
Department of Coloproctology, Calixto Garcia University Hospital, J and University, Plaza, Havana, Cuba

Background: Benign anal stenosis is an uncommon, disabling and incapacitating disease, occurring mainly after anorectal surgery.
Both non-surgical and surgical treatments have been devised in the treatment of anal stenosis with good results. We described the
results of the treatment of this disease in the Coloproctology Department of our institution.
Methods: A retrospective clinical study was undertaken over a 5-year period for consecutive patients operated on for anal stenosis.
Results: Twenty-three patients with benign anal stenosis were treated in our department. Haemorrhoidectomy was the most
common cause of anal stenosis (74%). Nineteen patients with moderate to severe symptoms of anal stenosis underwent surgical
treatment. Lateral mucosal advancement flap was the most frequently carried out operation (63.1%). Four patients were treated
with anal dilatation (17.3%). All patients had remission of the preoperative symptoms. There was no re-operation and only minor
complications were present in four patients: three patients with anal pruritus and one patient with temporary incontinence.
Conclusion: The easy performance, the absence of major complications and the good results obtained confirm that these methods
are effective and safe in the treatment of anal stenosis.

Key words: anal dilatation, anal stenosis, anoplasty, surgical flap.

INTRODUCTION of Calixto Garcia University Hospital between January 1996 and

December 2000. As this review conforms to the standards estab-
Benign anal stenosis is a rare and disabling condition. It is an lished by the National Health and Medical Research Council for
abnormal inelastic narrowing of the anal canal to a varying ethical quality review, ethics approval was not sought.7
extent due to stricture of the epithelial lining that has been
replaced by fibrous connective tissue. By far most of the cases In all cases, diagnosis was based on clinical examination.
are secondary to trauma, iatrogeny, inflammatory diseases, Patients complained of pain, bleeding and difficulty during defe-
radiation or neopla-sia.1 Patients with this condition can feel cation and increase stool frequency. Digital examination with the
ashamed and reduce their social activity because they complain little finger and endoscopic evaluation with a rigid rectosigmoi-
of pain, bleeding and difficulty during defecation with increased doscope 1 cm in diameter were possible in some patients with
bowel frequency and incontinence. mild stenosis of the anal verge. Two patients underwent a
previous operation for anal stenosis in another institution and
The treatment of anal stenosis is generally considered to be they were excluded of the present study.
difficult and various methods of treatment have been suggested.
Two surgical and one non-surgical technique were used. In
Conservative management with diet and fibre supplements has
each case the surgical technique was individualized according to
been suggested in the management of mild stenosis. Surgical
(i) the cause of the disease; (ii) the severity of the symptoms; and
repair of the anal stenosis with advancement and rotational flaps
involving skin, mucosa or both has a successful rate of more (iii) the extension of the stenosis (anal verge or anal canal). All
than 80% with low morbidity, complete resolution of symptoms surgical procedures were carried out under saddle block or local
and good acceptance from the patient.1–6 anaesthe-sia in prone jack-knife position. We used local
anaesthesia in six patients because the surgical treatment was
This manuscript reports the authors’ experience over 5 years
in treating patients with benign anal stenosis. carried out as a day procedure on ambulatory patients.
Preoperative preparation con-sisted in standard mechanical
bowel preparation with oral elec-trolyte solution and water
PATIENTS AND METHODS enemas before the operation to ensure cleansing of the distal
rectal segment. Antibiotic prophylaxis was not used.
A retrospective chart review was carried out of all patients with
benign anal stenosis evaluated in the coloproctology department We used lateral mucosal advancement flap anoplasty similar to
the procedure reported by Rakhmanine et al. 6 in 12 patients with
D. Casadesus MD PhD; L. E. Villasana MD; H. Diaz MD; M. Chavez moderate to severe symptoms of stenosis and predominant anal
MD; I. M. Sanchez MD; P. P. Martinez MD; A. Diaz MD. canal stenosis. In seven patients with moderate to severe symp-toms
of anal stenosis and predominant anal verge stenosis, we used Y-V
Correspondence: Dr Damian Casadesus, Washington 156 e/Infanta y Chur- anoplasty to repair the anal stenosis. Partial internal sphincterotomy
rucas. Cerro. Havana, Cuba.
Email: [email protected] was carried out in patients with a fibrotic muscu-lar component
contributing to the stenosis. A complete examin-ation with a
Accepted for publication 3 December 2006. conventional rectosigmoidoscope of 2 cm diameter

2007 Royal Australasian College of Surgeons

558 CASADESUS ET AL.

was carried out soon after the operation. All patients were evalu- In our country in the first half of the last century, Togores 8 treated
ated weekly until complete operative wound healing was 203 patients with anal stenosis. He reported specific inflammation
obtained and until 6 months after the operation. (lymphogranuloma venereum), surgical complications and con-
Anal dilatation was the non-surgical technique used in the treat- genital malformation, as the cause of anal stenosis in 188, 8 and 7
ment of four patients. It was carried out in our outpatient clinic, patients, respectively. The history of previous anal surgery was the
twice a week, with a Hegar dilator, in patients with mild symptoms cause of anal stenosis in all our patients. This complication often
of anal stenosis and predominant anal verge stenosis. Three weeks occurs after haemorrhoidectomy;1,9 however, a well carried out
after the beginning of the treatment, all patients were trained to carry haemorrhoidectomy with delicate handling of the tissue, min-imal
out self-dilatation at home the day they did not attend the outpatient tissue excision, correct follow up and minimum postopera-tive
clinic. No laxatives or stool softeners were prescribed. dilatation can prevent anal stenosis after haemorrhoidectomy.
There is a minimal consensus as to the most successful way to
RESULTS surgically manage patients with this condition. Effective manage-
ment of anal stenosis changes according to centres, countries and
The study group consisted of 23 patients, 15 men, ranging in age surgeon experience. In patients with moderate to severe symp-toms
from 34 to 68 years. All patients complained of bleeding, pain or when the conservative treatment was not effective,
and increasing bowel frequency for a period of 3 months to 2 sphincterotomy and various anoplasty techniques have been sug-
years before admission. Haemorrhoidectomy was the most gested. They include scar excision, partial internal sphincter-otomy
common cause of stenosis and 64.7% was carried out using the and reshaping of the area with flaps of mucosa, skin or both of
Whitehead technique. various configurations. The technique to choose depends on the
Two surgical techniques were used in 19 patients. Lateral surgeon experience; however, the ideal technique should be sim-ple,
mucosal advancement flap anoplasty was the most common pro- preferably ambulatory, with minimal postoperative morbidity and
cedure used (Table 1). It was used in 6 of the12 patients as a day good patient acceptance. It should restore anal function, cor-rect the
procedure on ambulatory patients. Two patients experienced anal stenosis and prevent stenosis recurrence.
pruritus, which improved with better hygiene of the area. One In the present series, the treatment of anal stenosis was success-
patient presented with temporary anal incontinence to gas and ful in all patients after primary repair. This is similar to the pre-vious
liquids that improved in 6 weeks. In two patients who were absent results for repair of anal stenosis and other anal lesions with these
of the follow up for 2 weeks, there was a tendency to scar con- techniques. In a review of 13 studies involving 577 patients, good
traction and stricture recurrence, but they responded to non- results and low morbidity have been described (Table 2). Mucosal
operative treatment. Seven patients underwent Y-V anoplasty (Table advancement flap and Y-V anoplasty were used with good results in
1) with satisfactory results; one of them also experienced anal more than 82 and 90% of the patients, respectively, with 20
pruritus after surgery that subsided after 3 weeks. Completed complications. In our opinion, both techniques offered correct
healing was obtained after a mean of 1 month with both techniques. mobilization of the flap with adequate blood irrigation, without extra
Anal dilatation was the non-surgical treatment method used in skin incision and suture line tension.
four patients (Table 1). It was carried out with satisfactory Anoplasty with different shape island flaps has also good
results and without complications. No patient required dilatation results in the treatment of anal stenosis (Table 2). Angelchik et
over 6 months of follow up and digital examination was possible al.3 treated 19 patients with different aetiologies using Y-V or
in all patients without pain. diamond flap anoplasty. They reported three complications after
In all patients we obtained good results with complete resolution Y-V anoplasty and suggested that the risk of contraction,
of their preoperative symptoms. Colostomy was not carried out. infection and flap necrosis using diamond pedicle advancement
Anal ultrasound and anal manometry were not possible before the flap is less compared with the Y-V technique. The fact that the
treatment and were not carried out postoperatively as all patients flap receives blood and nerve supply through unnamed vessels
maintained a good continence during the follow-up period. and nerve extending through a fatty pedicle and not from a skin
or mucosal bridge decreases the possibility of flap necrosis and
makes the sensation relatively good. However, other
DISCUSSION complications have been described in relation to the donor area. 4
Anal stenosis is one of the most feared complications of anorectal Colostomy or ileostomy was not necessary as adjunct treatment to
surgery, resulting in important psychological stress for the patient. repair. Faecal diversion has only been described in patients who
underwent wide local excision of some perianal disease with large
perianal defects.16,17 This procedure causes greater emotional and
physical distress to the patient and appears to have minimal influ-
Table 1. Causes and treatment of anal stenosis ence in promoting healing and avoiding complications.
Causes No. Treatment Contradictory results have been reported in the published work
cases Y-V anoplasty LMAFA Anal concerning dilatations in the treatment of anal stenosis. It has been
dilatation reported to be useful in the treatment of anal stenosis sec-ondary to
Crohn’s disease, to radiotherapy and to prolonged used of
Haemorrhoidectomy 17 5 10 2 suppositories containing paracetamol, acetylsalicylic acid and
Fisurectomy 2 0 0 2 ergotamine.12,18–20 Eu et al. reported satisfactory results with anal
Fistulectomy 3 2 1 0 dilatation combined with bulk laxatives in 18 patients with post-
Bowen disease 1 0 1 0
haemorrhoidectomy anal strictures.21 Others have reported that
local excision
manual dilatation can be responsible of major and minor compli-
Total 23 7 12 4
cations with satisfactory results in only 28% of patients. 22 In our
LMAFA, lateral mucosal advancement flap anoplasty. series, anal dilatation was a simple, bloodless, minimally invasive

2007 Royal Australasian College of

Surgeons
TREATMENT OF ANAL STENOSIS 559

Table 2. Anal stenosis techniques, references, number of patients, good results and complications. A review of 15 years
Techniques First author, reference No. cases Good results (%) No. complications
Mucosal advancement flap Khubchandani1 53 82.3 dno
Rakhmanine et al.6 95 90 11
Carditello et al.10 149 97 0
Y-V anoplasty Angelchik et al. 3† 19 100 3
Maria et al.9† 42 93 6
Aitola et al.11 10 90 0
Sayfan J.12 3 100 0
Island flap Pearl et al.2 25 92 0
Sentovich et al.4 29 90 20
Pidala et al.13 28 91 7
S-plasty and advancement flap Gonzalez et al.14 17 94 1
Sarner’s flap or Musiari’s flap de Medeiros5 30 100 0
Habr-Gama et al.15 77 87 5
†Y-V anoplasty or diamond island flap anoplasty. dno, data not obtained.

procedure carried out on ambulatory patients. In our experience, 10. Carditello A, Milone A, Stilo F, Mollo F, Basile M. Surgical
anal stenosis achieved good results in a progressive programme treatment of anal stenosis following hemorrhoid surgery.
with regular self-dilatation, with no morbidity and at little cost in Results of 150 combined mucosal advancement and internal
patients with mild stenosis. sphincter-otomy. Chir Ital 2002; 54: 841–4.
11. Aitola PT, Hiltunen KM, Matikainen MJ. Y-V anoplasty com-
In conclusion, we treated 23 patients with benign anal stenosis
bined with internal sphincterotomy for stenosis of the anal
using anal dilatation, lateral mucosal advancement flap and Y-V canal. Eur. J. Surg. 1997; 163: 839–42.
anoplasty with good results and with minor complications.
12. Sayfan J. Ergotamine-induced anorectal strictures. Report of
five cases. Dis. Colon Rectum 2002; 45: 271–2.
13. Pidala MJ, Slezak FA, Porter JA. Island flap anoplasty for anal
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2007 Royal Australasian College of Surgeons