Surg Clin N Am 82 (2002) 1225–1231

Anal stenosis and mucosal ectropion

Jorge A. Lagares-Garcia, MD, Juan J. Nogueras, MD*
Department of Colorectal Surgery, Cleveland Clinic Florida,
2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA

Definition, etiology, and incidence

Anal stenosis (AS) or stricture is defined as the loss of compliant natural
elasticity of the anal opening, which then becomes abnormally tight and
fibrous. It is a very disabling condition, worsened by the patient’s embar-
rassment, yet uncommon.
AS may follow any circumstance that causes scarring over the anorder-
mal area. Khubchandani has classified anal stenosis as congenital, primary,
and secondary. Among the congenital forms are imperforate anus and
anal atresia. Primary stenosis can be seen as the senile form or involutional
stenosis [1].
The vast majority of cases of AS are secondary to trauma, iatrogeny,
inflammatory diseases, or neoplasia, or are postradiation. Due to the rarity
of this pathology and the different referral patterns among institutions,
etiology ranges widely between published reports, as seen in the list below:
Hemorrhoidectomy, 31%–62%
Bowen’s disease, 26%
Fistulectomy, 4%–17%
Ileoanal anastomosis, 5%–10%
Paget’s disease, 7%–53%
Chronic laxative abuse, 17%
MOHD chemosurgery, 10%
Condyloma acuminata, 6%
Melanoma resection, 5%
Sphincteroplasty, 5%
Gracilis transposition, 5%
Cryosurgery, 4%

* Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic

Boulevard, Weston, FL 33331.
E-mail address: mcderme@ccf.org (J.J. Nogueras).

0039-6109/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 9 - 6 1 0 9 ( 0 2 ) 0 0 0 8 1 - 6
1226 J.A. Lagares-Garcia, J.J. Nogueras / Surg Clin N Am 82 (2002) 1225–1231

Postanal repair, 4%
Radiation, 4%
Fissurectomy, 2%
Hemorrhoidectomy is the most common surgical cause, with incidence
ranging between 3.8% and 1.5% [2,3], followed by Paget’s and Bowen’s dis-
ease. Fistulectomy and ileoanal anastomosis are also common causes.
Nonspecific inflammatory causes and infections such as tuberculosis and
venereal diseases can also produce AS. Radiation or perineal burns can
decrease the natural compliance of the perineal tissues with subsequent
fibrosis and AS [4,5].
Depending on the severity, AS can be classified as mild, moderate, or
severe. The passage of an index finger or medium Hill-Ferguson retractor
tightly, with forceful dilation or the inability to perform such maneuvers
hallmark each of the categories, respectively. Level of involvement is classi-
fied as Low AS located over the distal anal canal at least 0.5 cm below the
dentate line; mid AS extends from the previous point to 0.5 cm distal to the
dentate line; high AS lies proximal to 0.5 cm above the dentate line [6].

Symptoms and diagnosis

There is a low correlation between the clinical findings and the sympto-
matology of the patient. Elderly patients with a narrow anal canal opening
can have a relatively comfortable lifestyle and show no signs of AS.
Symptoms of constipation, a decrease in stool size, dyschezia, and tenes-
mus will prompt patient evaluation. Symptoms and rate of occurrence are
listed below [1,7,8]:
Pain, 37%–71%
Constipation, 22%–37%
Bleeding, 21%–47%
Leakage, 10%–23%
Diarrhea, 14%
Digitalization, 11%
Pain seems to be the most common complaint, followed by constipation
or bleeding. Frequently all of these symptoms overlap. Constipation may be
so severe that the patient may require digital assistance for evacuation of the
fecal material, provoking further trauma and aggravating the condition.
Diarrhea from chronic laxative use (‘‘paraffin anus’’) or from overflow fecal
impaction may also be a form of presentation. With time, this outlet
obstruction causes a retrograde distension of the rectal ampule and subse-
quent megarectum [5].
Physical examination immediately reveals the source of the complaints
through visualization of cicatricial tissue from previous perianal interven-
tions. Specifically, these appear as raised, irregular, scaly, brownish plaques
 J.A. Lagares-Garcia, J.J. Nogueras / Surg Clin N Am 82 (2002) 1225–1231 1227

with eczematoid features such as in Bowen’s disease; ulcerative, crusty or

papillary presentations of Paget’s disease; raised and pearly border ulcera-
tions of basal cell carcinoma; or the hard, flat, ulcerated masses from squa-
mous cell cancer. Anal condyloma or the malignant variant verrucous
carcinoma present as cauliflower-like lesions. They can be only histologi-
cally differentiated with local invasion and minimal dysplasia.
Perianal sexually transmitted diseases are part of the differential diagnosis
and we refer the reader to other sources for the manifestations in each
specific pathology.

Treatment
Nonoperative or conservative management
Mild stenosis with minimal symptoms can usually be managed with diet-
ary modifications and ‘‘bulking’’ agents. Anal dilatation should be done
with the ‘‘natural’’ stretch of the passage of the fecal bolus through the rec-
tum and the anal canal. Despite reports in the literature of self-dilatation
after an initial exam and dilatation under anesthesia, using a Hegar’s dila-
tor, the resultant hematoma and further fibrosis may worsen the AS [1].
In patients with inflammatory bowel disease, however, this may be a reason-
able option, due to the chronicity and high risk of recurrence.

Surgical therapy
There are multiple surgical techniques that have been described for the
correction or improvement of AS. Moderate or severe AS is the usual indi-
cation for operative treatment. For mild and benign forms of AS, Notaras
advocates lateral internal sphincterotomy, which may be performed bilater-
ally if needed [9]. Before performance of bilateral internal sphincterotomy,
however, a complete examination, including the patient’s continence status
as well as physiologic testing, is recommended to avoid potentially resultant
fecal incontinence.
Replacement of diseased nonpliable tissue with elastic and compliant
neoanoderm is the basis for surgical therapy of AS. Advancement, transfer,
or rotational flaps are the main techniques of the colorectal surgeon for exci-
sion and coverage of the perianal area.
The vascular supply of these flaps is from unnamed vessels that perforate
in the submucosal or subdermal vascular plexus, or in subcutaneous tissues.
More complex rotational flaps based on named vascular pedicle can also be
performed if multiple procedures have already been performed or a wider
area of coverage is needed. We will briefly describe mucosal advancement
flaps and tissue transfer flaps. Complex reconstructions such as pedicled
scrotal island skin flaps [10], Limberg-type transpositions flaps [11], the
sliding-skin-graft method [12], internal pudendal flaps [13], or the use of
1228 J.A. Lagares-Garcia, J.J. Nogueras / Surg Clin N Am 82 (2002) 1225–1231

prepuce flaps [14] for coverage of the anodermal area are seen in the
literature as sporadic case reports; however, no defined, large prospective
series with a relatively long-term follow-up have been described.

Mucosal advancement anoplasty

Kubchandani [1] reported his results with a previously modified tech-
nique [15] in 53 patients with anal stenosis. This technique is performed in
the prone jackknife position after standard bowel preparation. An incision
is made lateral and perpendicular to the dentate line, extending into the
anal verge. The mucosa in undermined 2 cm to 5 cm, resulting in a trans-
verse wound. The scar tissue and excessive mucous membrane are excised and
the mucosa is sutured to the distal border of the internal sphincter at the
anal verge with interrupted polycolic acid sutures. The external part of
the wound is left open. Forty-four bilateral and 9 unilateral anoplasties
were performed with good results (82%) in the majority of patients, where-
as 11.3% had fair improvement of their symptoms.

Y-V anoplasty
The initial incision is made radially at the level of the stricture, making
the vertical limb of the Y. The wide portion of the Y is located further out
in the perianal area. Subdermal division of the tissues is undertaken to
improve mobilization. The resultant V flap is advanced at the base of the
vertical limb. Good results are obtained in between 64% to 100% of cases
(Table 1). Suture dehiscence, ischemic contracture, hematoma, flap necrosis,
or restricture are described complications.

V-Y advancement anoplasty

Rosen [16] initially described this technique for ectropion, but it has sub-
sequently been applied to the treatment of anal stenosis. After a radial exci-
sion of the stenosed segment, a V shaped flap that is at least 2 cm in length is
advanced to the mucocutaneous junction. A recent series by Hassan [17] of
15 patients reported easily managed complications, such as superficial
wound separation, flap hematoma, or recurrent stenosis. Flap necrosis was
not seen in this series, which may be explained by the broader base of the
advancement flap used. Some degrees of incontinence for gas or liquid were
seen in the nondiverted patients, with eventual resolution of symptoms.

Table 1
Y-V anoplasty
Author Year n Results
Maria [26] 1998 29 90% complete resolution and healing
Angelchik [7] 1993 12 100% excellent or satisfactory
Ramajunan [27] 1988 21 85% excellent
Gingold [28] 1986 14 64% complete satisfaction
 J.A. Lagares-Garcia, J.J. Nogueras / Surg Clin N Am 82 (2002) 1225–1231 1229

Rectangular flap
An initial description of this technique by Sarner [18] included a rectan-
gular full-thickness graft that is mobilized to the dentate level in a tension-
free manner. Interrupted sutures are used for securing the graft. Multiple
sites up to four quadrants can be done and closure of the donor site is not
required. Adequate relief of AS has been described using this technique.

Diamond flap
The diamond advancement flap was initially described by Caplin and
Kodner in 1986 [19]. The excision of the diseased portion of skin is done,
leaving a diamond defect. This is then covered by a flap designed in the same
shape that will be advanced to the intra-anal portion of the defect. Excellent
results are reported with this technique (Table 2) and complications similar
to Caplin and Kodner can be seen.

House flap
A longitudinal incision is made extending from the dentate line to the dis-
tal end of the stricture. The length of the incision corresponds to the length
of the ‘‘walls’’ of the proposed house flap, and the sides of the flap measure
equally to the stenosis; the ‘‘roof’’ is made with the peak as high as the
length of the sides. The completed house flap is advanced, lining the entire
length of the anal canal, and sutured in place (Fig. 1). As initially described
in 1992, then in a four-year retrospective review published in 1996, Christen-
sen et al and Sentovich et al [20,21] obtained complete satisfaction in 82% of
patients and improvement of the symptoms in 89%. At the Cleveland Clinic
Florida, our most recent experience showed 50% of patients with complete
or almost complete improvement of the symptoms and 50% with slight
improvement of the symptoms using this technique [8].

S-plasty
Initially described for the correction of the ectropion secondary to a
Whitehead hemorrhoidectomy, the abnormal tissue is removed and replaced
with skin, fixing the mucocutaneous junction at the normal position. The
skin coverage is provided by a double-rotational flap, outlined by a large
‘‘S,’’ with the anal canal in the center. After mobilization of the flaps, the
apex is brought to the anterior cut edge of mucosa and sutured in place with
interrupted sutures. The side of the flap is sutured to the lateral wall as far as

Table 2
Diamond flap anoplasty
Author Year n Results
Caplin [19] 1986 16 100% satisfactory
Angelchik [7] 1993 7 100% satisfactory
Pidala [24] 1994 28 91% improved
Maria [26] 1998 13 100% healing
1230 J.A. Lagares-Garcia, J.J. Nogueras / Surg Clin N Am 82 (2002) 1225–1231

Fig. 1. House flap. A longitudinal incision is made extending from the dentate line to the distal
end of the stricture. The length of the incision corresponds to the length of the ‘‘walls’’ of the
proposed house flap and the sides of the flap measure equally to the stenosis; the ‘‘roof’’ is made
with the peak as high as the length of the sides. The completed house flap is advanced, lining the
entire length of the anal canal, and sutured in place.

the posterior canal. The lower flap is similarly fixed to the anal canal. Excel-
lent results are reported in all patients undergoing this type of repair, with
minimal morbidity.
Anal ectropion
Anal ectropion defines the abnormal position of anal mucosa into the
anodermal junction or more distal into the perianal skin. Classically, it is
seen after hemorrhoidectomy and was initially described by Ferguson fol-
lowing the Whitehead procedure [22]. Despite the initial description, later
reports in 556 patients from Wolff and Culp had no ectropion using such
technique [23].
General complaints include discomfort with seepage, pruritus, bleeding,
pain, and occasionally, tenesmus. This gets translated into the ‘‘wet anus’’
syndrome.
On physical examination, an area of ectopic mucosa is seen further out of
the mucocutaneous junction. Lichenification of the skin from chronic pru-
ritic changes, erythema, or maceration of the skin may be added physical
findings.
The goal for therapy is to restore the ectopic mucosa to the original level
proximal to the dentate line. Flap selection will include most of the alterna-
tives used for anal stenosis, with good results overall reported in the litera-
ture. For short areas of ectropion, diamond-shaped, house-shaped, or V-Y
advancement flaps have been used [16,19,24]. Larger areas of ectropion can
be repaired using S-plasty with excellent anatomic results [25].
 J.A. Lagares-Garcia, J.J. Nogueras / Surg Clin N Am 82 (2002) 1225–1231 1231

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