CASE REPORTS
Internal Pudendal Flap Anoplasty for
Severe Anal Stenosis
R e p o r t o f a Case
Edgar Saldana, M.D.,* Christian Paletta, M.D.,* Navyash Gupta, M.D.,%
Anthony M. Vemava, Walter E. Longo,
From the Department o f Surgery, Sections of*Plastic a n d %Colon a n d Rectal Surge~, St. Louis University
School o f Medicine, St. Louis, Missouri
PURPOSE: A technique for introducing anoderm into the
anal canal is described. METHODS: An internal pudendal
flap was used. RESULTS: This technique was totally
success-ful in alleviating anal stenosis and maintaining
fecal conti-nence. CONCLUSION: Internal pudendal flap
should be in the armamentarium of the colon and fecal
surgeon for treating severe anal stenosis. [Key words: Anal
stenosis; Internal pudendal flap; Anoplasty]
Saldana E, Paletta C, Gupta N, Vernava AM, Longo WE.
Internal pudendal flap anoplasty for severe anal stenosis.
Dis Colon Rectum 1996;39:350-352.
nal stenosis, an a b n o r m a l narrowing of the anal A canal, is
m o s t frequently c a u s e d b y previous anal surgery. T r e a t m e n t of
this abnormality d e p e n d s
o n its severity and location within the anal canal.:
Most cases of mild a n d m o d e r a t e anal
stenosis are
palliated b y high fiber diet, b u l k laxatives, and gentle,
digital dilation. Occasionally, lateral internal sphinc - t e r o
t o m y m a y b e required. 2-3
Severe anal stenosis is characterized b y a significant
deficit in the anoderm . A n u m b e r of
procedures have
b e e n described to introduce healthy anodelTn and skin
into the anal canal, such as V-Y anoplasty, S anoplasty, and
island flap anoplasty. 4-7 We report successful use of
internal pudendal flap anoplasty to treat severe anal
stenosis of the lower anal canal following a previous
circumferential excision of perianal Paget's disease.
REPORT OF A CASE
A previously healthy, 80-year-old white male pre-sented
to his dermatologist with two years of intractible pruritis
ani. A circumferential eczemoid lesion was
Address reprint requests to: Dr. Longo: St. Louis University Health
Sciences Center, Department of Surgery, 3635 Vista Avenue at Grand
Boulevard, P.O. Box 15250, St. Louis, Missouri 63110-0250.
noted at the anal verge. Biopsies w e r e consistent with
Paget's disease of the anus. He was treated b y circum-
ferential excision of this lesion, and tissue coverage was
provided b y a skin graft. Postoperatively, he developed
a w o u n d infection, and over time the w o u n d healed b
y secondary intention; however, severe anal stenosis de-v e
l o p e d (Fig. 1). This was initially treated by anal dila-tion
and sphincterotomy; however, his symptoms pro-gressed to
chronic fecal impact_ion. Diameter of his anal verge was
1.5 cm. The patient was offered and agreed to undergo a
reconstructive procedure to introduce ano-derm and skin
into the anal canal. An internal pudendal flap anoplasty was
the procedure chosen.
TECHNIQUE
The patient u n d e r w e n t a full mechanical, oral, and
intravenous antibiotic b o w e l preperation . The patient
was p l a c e d in the lithotomy position. The b l a d d e r
was catheterized, a n d the D o p p l e r p r o b e was u s e d
to localize the internal p u d e n d a l artery medial to the
ischial tuberosity. The flap was t h e n m a r k e d on the
skin with arterial s u p p l y at the b a s e (Fig. 2). This flap
was b a s e d posteriorly o n the terminal b r a n c h e s of
the internal p u d e n d a l vessels and m e a s u r e d 5 • 12
cm. The m o s t distal portion of the flap e x t e n d e d to
just b e n e a t h the groin crease at the inguinal ligament.
Surgery was initiated b y release of the anal cicatrix.
A full-thickness incision w a s m a d e at the 2 o'clock
position. This incision was e x t e n d e d through scar
tissue to the internal sphincter. The internal sphincter was
then digitally dilated. The internal p u d e n d a l flap (IPF)
was then dissected.
Incision for IPF was b e g u n anteriorly and e x t e n d e d
through skin and s u b c u t a n e o u s tissue to d e e p fascia
350
Vol 39, No, 3 INTERNAL PUDENDAL FLAP ANOPLASTY 351

Figure 1. Preoperative appearance of the anus showing extensive scarring and anal stenosis.

Figure 2. Outline of flap to be mobilized into the anal Figure 3. Mobilization of the flap.
canal.

m a r g i n w a s r e a c h e d . O n c e the flap w a s elevated, it w a

o n b o t h sides. A subfascial p l a n w a s d e v e l o p e d just o v s t h e n r o t a t e d t o w a r d t h e a n u s (Fig. 3). T h e flap w a s
e r t h e thigh a d d u c t o r m u s c l e s . Care w a s t a k e n n o t t r a n s p o s e d a n d set in place . A 4 - 0 m o n o f i l a m e n t
to injure t h e v a s c u l a r p e d i c l e as the p o s t e r i o r skin
352 SALDANA ET AL
Figure 4. Flap sutured to anal canal.
a b s o r b a b l e suture was u s e d to suture the tip of the
flap to the anal m u c o s a (Fig. 4). Placement of the m o s t
distal sutures was aided with the use of a rectal specu - lum.
D o n o r site o f the inner thigh was closed in layers, and a
closed suction drain w a s secured . Post-operatively, the
flap was m o n i t o r e d b y visual inspec - tion for signs of
ischemia or congestion . The patient w a s p r e v e n t e d f r
o m sitting for the first p o s t o p e r a t i v e w e e k . H e
was given nothing b y m o u t h for five days to p r e v e n t
a n y fecal soilage o f the w o u n d during its early healing
phase . Anal dilation w a s reinitiated at three w e e k s to p
r e v e n t recurrent stricture of the anus. H e has m a i n t a i
n e d fecal continence .
DISCUSSION
The most troublesome complaint of patients with anal
stenosis is difficulty with defecation, w h e n constipation,
obstipation, painful bowel movements, and bleeding
frequently occur. Initially, conservative therapy with bulk
laxatives and anal dilators is used. If this fails, excision of
the scar and sphincterotomy are performed . Anoplasty is
indicated for severe anorectal stricture as a result of
narrowing of the anal canal caused b y contrac-ture of
epithelial lining b y fibrous connective tissue. If less than 50
percent of the anal circumference is in-volved, advancement
flaps should suffice; however, if 50 percent or m o r e of the
anal canal needs to b e recon-structed, a rotation flap of skin
should b e considered.
Internal p u d e n d a l thigh flap w a s described in 1989 b y
W e e a n d J o s e p h 8 a n d has s u b s e q u e n t l y b e c o
m e k n o w n as the "Singapore flap. ''9 This fasciocutaneous
flap was originally described for vaginal r e c o n s t m c -
Dis Colon Rectum, March 1996
tion and is an axial flap b a s e d o n terminal b r a n c h e s
of the internal p u d e n d a l arteries. The flap has p r o v e
n to h a v e a reliable b l o o d supply, 1~ and advantages of
using it for anoplasty include bringing healthy tissue to the
area, which is thin, supple, and sensate. IPF should b e in
the a r m a m e n t a r i u m of the colon a n d rectal s u r g e
o n for treating severe anal stenosis.
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