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Benign Strictures of Anorectum
P. N. Joshi and C. Kale
1 4
14.1 Introduction
Nondistensible narrowing of the anal canal is
known as anal stenosis. In low strictures the normal upside-down funnel-shaped confi guration
gets reversed with the diameter of the anal canal
being greater than that of the anal verge. The
stricture may be a true anatomic one or functional
secondary to muscle spasm. Rectal Stricture is
chronic narrowing of rectum leading to obstruction to passage of faeces and making one not able
to pass a 12 mm cope. Acute strictures are
dynamic and reversible, while chronic strictures
are adynamic and irreversible. These strictures
are classifi ed on the basis of level (upper, middle,
lower, or diffuse), structure (annular, diaphragmatic, or tubular), and severity (mild which
allows well-lubricated index fi nger, moderate
which allows index fi nger with diffi culty and
force, or severe when there is resistance even to
little fi nger).
P. N. Joshi
Department of Proctology ,
Grant Medical College , Mumbai , India
drpnjoshi@rediffmail.com
e-mail:
C. Kale (*)
Department of General Surgery,
D.Y. Patil Medical College, Navi ,
Thane, Mumbai 400602 , India
Drckale@gmail.com
e-mail:
14.2 Diagnosis
These patients may present with constipation,
low gut obstruction, diarrhea, urgency, pain,
bleeding, and tenesmus. Low stricture can be felt
and assessed by digital rectal examination (DRE),
while upper ones need endoscopic examination.
If possible, the proximal colon and rectum should
be examined for any pathology. Biopsy should be
taken to confi rm the diagnosis. Contrast studies
will demonstrate the extent of disease and any
pathology in the proximal gut. Virtual colonoscopy, computerized tomography (CT) scan, or
magnetic resonance imaging (MRI) may be indicated under special situations.
14.3 Etiology
Various causative factors responsible are specifi c
infection like amoebic proctocolitis, tuberculosis,
lymphogranuloma venereum, gonorrhea, and actinomycosis. Infl ammatory bowel disease, sepsis,
ischemia, laxative abuse, trauma, operations on the
anorectum, and radiotherapy are other causes.
14.3.1 Amoebic Proctocolitis
Fulminating proctocolitis produces sloughing
of mucosa and submucosa of the colon and
© Springer India 2016
N.A. Chowdri, F.Q. Parray (eds.), Benign Anorectal Disorders:
A Guide to Diagnosis and Management, DOI 10.1007/978-81-322-2589-8_14
195
196
P.N. Joshi and C. Kale
rectum (Joshi 2001 ). In an individual who is
harboring amoebic infection, if operated upon
without prior medication, the lurking infection
fl ares up and produces sloughing of the mucosa
(Figs. 14.1 and 14.2 ). This is more common in
the rectum and anal canal. Diagnosis is made
by taking a rectal swab which will show the
presence of protozoa. The treatment consists of
instituting antiamoebic drugs. Once the disease
is controlled, the treatment of stricture should
be undertaken. In the early stage, use of dilators may suffi ce. If stricture is not amenable
to dilatation, operative intervention should be
considered. Anoplasty is done for anal stenosis. The rectal stricture is dealt by transsacral
or transabdominal approach. Later on regular dilatation may be required for satisfactory
result (Fig. 14.3 ).
14.3.2 Tuberculous Stricture
Tuberculous infection is nearly always secondary
to pulmonary tuberculosis (Williams 2004a ).
Bovine type of infection is very rare. The stricture
usually involves all coats of the bowel wall as compared to amoebic stricture which remains restricted
to the mucosa and submucosa (Joshi 2001 ). The
diagnosis is made by taking endoscopic biopsy
which will show caseation or presence of
Langhans-type giant cells. The antituberculosis
treatment should be started, and once the disease is
under control, the operative treatment is undertaken which consists of either stricturoplasty or
segmental resection (Figs. 14.4 and 14.5 ).
14.3.3 Lymphogranuloma Venereum
This is a sexually transmitted disease. It involves
the perirectal lymphatic which produces constriction of the rectal wall. These types of strictures
are now very rare and are diffi cult to treat.
Dilation does not suffi ce and the patient may
require permanent colostomy.
14.3.4 Actinomycosis
This type of infections occurs usually after
Fig. 14.1 Amoebic proctocolitis
ab
Fig. 14.2 Mucosal cast: ( a ) protruding through the anus; ( b ) expelled slough
perforation of bowel. Perforative appendicitis,
14 Benign Strictures of Anorectum
ab
197
Fig. 14.3 Amoebic strictures in the ( a ) midrectum and ( b ) anal canal
ab
Fig. 14.4 Tuberculosis stricture: ( a ) upper rectum ( b ) after stricturoplasty
198
Fig. 14.5 Stricturoplasty
Stricture rectum
upper part
P.N. Joshi and C. Kale
diverticular perforation, or perforation following
fecal impaction may result in actinomycotic
stricture formation. Endoscopic biopsy may help
in arriving at diagnosis. The resected specimen
shows sulfur sunray granules arranged in a sunray pattern which is diagnostic. Actinomycotic
infection responds to penicillin group of drugs.
The treatment consists of resection of the segment and proximal colostomy which may be
closed later on Haj et al. ( 2000 ) (Fig. 14.6 ).
14.3.5 Infl ammatory Bowel Diseases
Benign strictures of the colon and rectum are
more common in Crohn’s colitis (Keighley 2007 ;
Linares et al. 1988 ). This disease has to be differ-
entiated from tuberculous stricture. Evidence of
pulmonary tuberculosis and typical fi ndings of
caseation in the resected specimen are diagnostic
of tuberculosis infection. Surgical management is
indicated for established stricture after the patient
is stabilized on medical treatment. Strictures of
Crohn’s disease are treated by stricturoplasty or
segmental resection (Gumaste et al. 1992 ).
Strictures of ulcerative colitis are usually malignant unless proved otherwise. The surgical treatment of ulcerative colitis is total proctocolectomy,
and there is no scope for any conservative treatment of the stricture (Joshi 2001 ).
Vertical slitting Transverse
suturing
Fig. 14.6 Actinomycotic stricture following perforation
14.3.6 Ischemic Colitis
Individuals suffering from peripheral vascular
disease are likely to suffer from ischemic colitis
14 Benign Strictures of Anorectum
ab
Fig. 14.7 Ischemic stricture ( a ) in a patient ( b ) with peripheral vascular disease
199
(Joshi 2001 ). After an attack of bloody diarrhea,
they may develop one or multiple strictures of
the colon and rectum. The presence of vascular
disease should help in differentiating it from
amoebic stricture. The stricture involves all
coats of the bowel wall. The treatment includes
that for basic disease and stricturoplasty or segmental resection for established stricture
(Fig.
14.7 ).
14.3.7 Stricture Following Bowel Anastomosis
Stricture can occur after bowel anastomosis if
the site of anastomosis is narrower than the
proximal segment or if the vascular supply to
the anastomosing segment is jeopardized or following a leak after bowel anastomosis
(Joshi 2001 ). This is more commonly seen in
low anterior resection (Williams 2004a ).
Treatment consists of dilatations or redoing the
anastomosis.
14.3.8 Stricture Following Anorectal Surgery
Anal stenosis occurs more frequently after
classical Milligan-Morgan hemorrhoidectomy
(Liberman and Thorson 2000 ; Williams 2004b )
(Fig. 14.8 ). It can occur even after stapled ano-
pexy. It complicates radical amputative hemorrhoidectomy in 5–10 % of cases. Ninety percent
of anal stenosis is caused by overzealous hemorrhoidectomy. Narrowing of the anus results as
considerable amount of anoderm is sacrifi ced
without leaving normal skin in between, and the
healing of the wound occurs by secondary intension. Stricture can occur after fi stula surgery due
to cross adhesions while wound healing takes
place. Anorectal strictures occur after sclerotherapy and Kshar Sutra treatment of piles and fi stula
(Williams
sclerosants by quacks for the treatment of anorectal diseases also produces strictures.
Initially dilatation should be tried. If that fails
and for those with tight and long-standing
2004a , b ) (Fig. 14.9 ). Application of
200
P.N. Joshi and C. Kale
strictures, surgical treatments are warranted
which consists of excision of scar tissue and
some form of anoplasty depending on the nature
and severity of the stricture.
14.3.9 Strictures Following Traumatic Injuries
Traumatic injuries heal with secondary intention
and cross adhesion can produce anal stenosis.
Introduction of foreign body may cause scarring
of the anoderm which results in stenosis. These
are corrected by dilatations or anoplasty.
14.3.10 Postradiation Stricture
Cancers of the cervix, prostate, anus, and other
pelvic organs when treated with radiotherapy
may cause fi brotic changes of the anus and
rectum (Williams 2004b ). They are diffi cult to
treat since they are tubular strictures. The patient
usually requires complete excision with permanent stoma, though minor strictures may be
treated by dilatation or stricturoplasty.
14.3.11 Endometriosis
Endometriosis causes infl ammation leading to
stricture formations and may be treated by dilatations and hormone therapy. If it fails, surgical
correction is needed (Joshi 2001 ).
14.4 Treatment Options
14.4.1 Diet and Medical Treatment
Basic pathology should be addressed before
undertaking any treatment. Initially most
Fig. 14.8 Anal stenosis following hemorrhoidectomy
a b
Fig. 14.9 Stricture following fi stula surgery
of the patients can be managed by dietary
14 Benign Strictures of Anorectum
201
modifi cations, stool softeners, and local
lubricating ointments.
14.4.2 Dilatations
Dilatation of the stricture is the primary or the
adjunct line of treatment for most of the strictures
of the anorectum. It can be done by fi ngers or dilators which should be well lubricated. The procedure should be gentle and gradually increased in
width. Initially it should be done by the surgeon
himself preferably under anesthesia, then under
supervision till patient is confi dent to do it himself.
The inaccessible strictures should be dilated with
Proctoscope. The interval between the dilatations
should be more frequent initially and gradually
prolonged depending on the response. Once fully
dilated, patient needs to be followed at regular
intervals to prevent restenosis.
Rectal strictures are dilated endoscopically by
balloon. Self-expanding metal stents are used in
patients not fi t for surgery.
Nonoperative management is indicated for
mild strictures, post-IBD and postradiotherapy
strictures, and those at risk of healing complications after surgery
14.4.3 Surgical Treatment
Surgical treatment is indicated for those patients
with failed medical treatment and long segment,
chronic, moderate to severe, diffuse tubular, complex, and impassable strictures.
14.4.3.1 Sphincterotomy
Lateral internal sphincterotomy is a simple and
safe procedure and can be done alone for mild
stenosis. It is preferably done by open method, so
that overlying scar tissue can be excised in the
same sitting. Wound is left open to heal by secondary intention. Pain is relieved and at the same
time obstruction is also relieved
consensus for their use. Small segment
strictures can be opened vertically and sutured
in transverse fashion after mobilization of fl aps
14.10 ). For moderate to severe stenosis,
(Fig.
various fl ap designs which have been reported
include V-Y fl ap, Y-V fl ap, U fl ap, house fl ap,
diamond fl ap, mucosal advancement fl ap, and
rotational S fl ap (Figs. 14.11 , 14.12 , 14.13 ,
14.14 , 14.15 , 14.16 , and 14.17 ) (Liberman and
Thorson 2000 ).
Mechanical bowel preparation and prophylactic antibiotics are used prior to these
procedures.
The basic principle of all these fl aps is to
break the continuity of scar by normal skin tissue. While designing these fl aps, one should be
sure that the fl ap has adequate vascularity by
keeping a wide base and pedicle.
These fl aps are selected depending on the
etiology, extent, severity, and level of the defect
(Sherief Showkie and Meagan Costedio 2013 ).
The type of fl ap to be used is based on the surgeon’s familiarity and choice as well as the local
anatomy and the availability of adequate perianal
skin for use in the various fl aps. A partial lateral
internal sphincterotomy may also be required for
satisfactory results.
Flaps can be classifi ed into advancement,
island, and rotational fl aps:
1. Advancement fl aps – A rectal mucosal or
perianal skin fl ap is raised preserving the
vascularity and continuity with surrounding
tissues. This is then advanced and placed
over the raw area. The bloods supply to these
fl aps comes from submucosal or subdermal
vessels.
2. Island fl aps – The fl ap is disconnected from
surrounding tissue. The blood supply comes
from subcutaneous perforators, e.g., diamond
fl ap and house fl ap.
3. Rotational fl aps – Large fl aps are raised bilat-
erally and rotated, usually done when there is
extensive loss of anal canal tissue.
14.4.3.2 Anoplasty (Stricturoplasty)
Various anoplastic procedures have been
reported, but as of yet, there is no universal
V-Y or Y-V anoplasty has been used in the
treatment of severe low anal stenosis with good
results. The house fl ap and diamond fl ap are
202
Fig. 14.10 Stricturoplasty
P.N. Joshi and C. Kale
Stenosis Vertical incision
V-Flap
Defect after
opening
stricture
Anus
Fig. 14.11 V-Y fl a p
marked
recommended for stenosis extending from the
dentate line to the perianal skin, allowing primary
closure of the donor site and an increase in anal
canal diameter along its length. U-fl ap anoplasty
is used for the treatment of anal stenosis
associated with mucosal ectropion. In U fl ap,
Transverse Wound ClosureStricture opened
V-Flap
advanced
V-Flap
advanced
and stitched
in position
donor defect is left open to heal by secondary
intention. Rotational S fl ap is best used for the
treatment of Bowen’s disease or Paget’s disease,
where a large amount of skin has to be excised
and new skin rotated into the area (Giuseppe
et al. 2009 ).
14 Benign Strictures of Anorectum
203
Y Incision
Anus
Fig. 14.12 Y-V fl a p
Fig. 14.13 U fl a p
Fig. 14.14 House fl a p
U Flap
Anus
Flap
marking
Defect after
opening
stricture
Defect after
incising stricture
Defect
Flap
raised
U Flap
raised
Flap
raised
Donor
Defect
Flap
advanced
and
stitched
Flap advanced
and Stitched
Flap
advanced
and
Stitched
Anus
Fig. 14.15 Diamond fl a p
Fig. 14.16 Mucosal
Marking for
diamond flap
Anus
advancement fl a p
Anus
If less than 50 % of the anal circumference is
involved, an advancement fl ap should suffi ce. If
50 % or more of the anal canal needs to be
reconstructed, a rotational fl ap of the skin should
be considered.
Defect after
incising stricture
Defect after
incising stricture
Flap
raised
Mucosal
Flap
Advanced
Complications following these procedures
include fl ap necrosis, suture line dehiscence,
local infection, incontinence, restenosis, mucosal
ectropion, pruritus, urinary tract infection, and
retention of urine.
Flap
advanced
and
Stitched
Flap
Stitched
204
P.N. Joshi and C. Kale
Flap
making
Anal Canal
Fig. 14.17 S fl a p
a
Defect after
a′
b
excising stricture
b′
b′
b
14.4.3.3 Surgery for Rectal Strictures
Rectal strictures are treated by endoscopic
dilatation, stricturotomy (using urethrotome at
four places), transanal stricturoplasty, sleeve
advancement of the rectum, or resection of
stricture with reanastomosis (Chia et al 1991 ;
Johansson 1996 ).
14.4.3.4 Colostomy
Colostomy is indicated for patients with low,
long, and severe strictures which are not amenable to other methods of treatment. Usually sigmoid colostomy is preferred unless the patient
has some associated pathology in the proximal
gut which also needs to be addressed.
14.5 Summary
The treatment for anorectal strictures should be
individualized depending on the etiology,
nature, and extent of the disease. In general
mild cases will respond to dietary modifi cations, stool softeners, and regular digital or
instrumental dilatations. Open sphincterotomy
is useful for functional stenosis. Patients with
severe stenosis should be treated by some form
of anoplasty. Permanent stoma should be
reserved for selected cases.
a
a′
Flaps
stitched
Flaps mobilized
and advanced
Bibliography
Chia YW, Ngoi SS, Tung KH. Use of the optical urethrotome
knife in the treatment of a benign low rectal anastomotic
stricture. Dis Colon Rectum. 1991;34(8):717–9.
Giuseppe B, Serafi no V, Federica C, et al. Surgical treat-
ment of anal stenosis. World J Gastroenterol.
2009;15(16):1921–8.
Gumaste V, Sachar DB, Greenstein AJ. Benign and malig-
nant colorectal strictures in ulcerative colitis. Gut.
1992;33:938–41.
Haj M, Nasser G, Loberant N, Cohen I, Nesser E, Eitan
A. Pelvic actinomycosis presenting as ureteric and
rectal stricture. Dig Surg. 2000;17:414–7.
Johansson C. Endoscopic dilation of rectal strictures: a
prospective study of 18 cases. Dis Colon Rectum.
1996;39(4):423–8.
Joshi PN. Benign strictures of colon, rectum and anus.
Indian J Coloproctol. 2001;16:25–7.
Keighley MRB. Anorectal disorders. In: Fischer JE, edi-
tor. Master of surgery. 5th ed. Philadelphia: Lippincott
Williams & Wilkins; 2007.
Liberman H, Thorson AG. How I do it. Anal stenosis. Am
J Surg; 2000;179:325–9.
Linares L, Moreira LF, Andrews H, Allan RN, Alexander-
Williams J, Keighley M. Natural history and treatment
of anorectal strictures complicating Crohn’s disease.
Br J Surg. 1988;75:653–5.
Showkie S, Costedio M. Anal fi ssure and anal stenosis. In
disorders of anorectum and pelvic fl oor. Gastroentrol
Clin. 2013;42(4):745–52.
Williams NS. The rectum. In: Russel RCG, Williams NS,
Bulstrode CJK, editors. Bailey & Love’s short practice
of surgery. 24th ed. London: Arnold; 2004a.
Williams NS. The anus and anal canal. In: Russel RCG,
Williams NS, Bulstrode CJK, editors. Bailey & Love’s
short practice of surgery. 24th ed. London: Arnold; 2004b.