Anal Stenosis Following Sclerotherapy for Hemorrhoids: A Case Report

Anal Stenosis Following Sclerotherapy for Hemorrhoids: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Anal Stenosis Following Sclerotherapy for Hemorrhoids: A Case Report Peng Zhang, Li-Long Wu, Wen-wen Lv, Li-ping Yang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8111340/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract INTRODUCTION Sclerotherapy is a widely used non-surgical treatment for hemorrhoids but can lead to rare severe complications. We present a case of severe anal stenosis developing one year after sclerotherapy, a debilitating iatrogenic complication. PRESENTATION OF CASE A female patient presented with progressive difficulty in defecation for one year, acutely worsened over five days. One year prior, she underwent sclerotherapy for mixed hemorrhoids. Physical examination revealed severe anal stenosis admitting only the fingertip. Endoscopy and pelvic MRI confirmed a tight cicatricial stricture. She underwent V-Y advancement flap anoplasty combined with stricture incision. DISCUSSION Post-sclerotherapy stenosis results from excessive submucosal fibrosis and scar contracture. Diagnosis is primarily clinical, supported by endoscopy to exclude malignancy. Severe strictures require surgical correction. V-Y advancement flap anoplasty effectively relieves stenosis by introducing healthy tissue into the anal canal. CONCLUSION The patient achieved an excellent postoperative outcome with restored bowel function. Severe anal stenosis is a rare but devastating complication of hemorrhoid sclerotherapy. This case underscores the efficacy of V-Y advancement flap anoplasty. Clinicians should maintain high suspicion for this complication in patients with obstructive defecation symptoms post-injection. Anal stenosis Sclerotherapy Hemorrhoids Complication Case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. INTRODUCTION Hemorrhoids are a common anorectal disorder, and sclerotherapy, such as with Xiaozhiling injection, is a widely applied non-surgical treatment. The therapeutic principle of Xiaozhiling, a compound traditional Chinese medicine preparation, involves inducing localized coagulation, necrosis, and subsequent fibrosis of hemorrhoidal tissue [ 1 ] . While this therapy is generally considered safe, it is not without potential complications. Improper injection technique, excessive dosage, or incorrect injection sites can lead to adverse events such as severe pain, bleeding, infection, and, in rare instances, anal stenosis [ 2 ] . Anal stenosis secondary to sclerotherapy is an uncommon but serious complication. The underlying mechanism is thought to involve excessive fibrosis and contracture of the submucosal connective tissue following the chemical insult, leading to an irreversible cicatricial ring [ 3 ] . This condition can cause significant symptoms, including difficult defecation, pencil-thin stools, and abdominal bloating, severely impacting the patient’s quality of life. While early, mild cases may respond to conservative treatment like anal dilation, severe, established stenosis often necessitates surgical intervention. Here, we present the case of a female patient who developed severe anal stenosis one year after undergoing sclerotherapy for mixed hemorrhoids. We discuss her clinical features, diagnostic challenges, and the surgical management employed. This case report has been reported in line with the SCARE criteria [ 4 ] . 2. PRESENTATION OF CASE A female patient presented to our emergency department with a chief complaint of “difficulty in defecation for 1 year, worsening for 5 days.” One year prior, she had received “Xiaozhiling injection therapy” for “mixed hemorrhoids” at a local private clinic. Approximately 20 days post-procedure, she began to experience difficulty in defecation. Despite having a daily urge to defecate and normal stool consistency, she found evacuation difficult, with a persistent sensation of incomplete emptying and associated abdominal bloating. She self-medicated with over-the-counter laxatives and antibiotics, which provided temporary relief with the passage of loose stools. Five days before admission, the difficulty in defecation acutely worsened. Her symptoms did not improve even with laxatives; her stools became markedly thin, and even loose stools were difficult to pass, causing intolerable abdominal distension. Her past medical history was unremarkable. On physical examination, her abdomen was distended but non-tender. The external anal appearance was normal. Digital rectal examination revealed significant stenosis within the anal canal, which did not admit the index finger. Palpation of the anal verge was painful, and the examining finger was stained with blood. Anoscopy could not be performed due to the severe stenosis. Laboratory investigations, including a complete blood count, liver and renal function tests, and electrolytes, were all within normal limits. A fecal occult blood test was positive. An electrocardiogram showed no abnormalities. On June 16, 2025, an attempt was made to perform an electronic colonoscopy. Due to the anal stenosis, a gastroscope was used instead. The scope could not pass through a stenotic ring located just above the dentate line in the lower rectum. Through the narrowed opening, the mucosa of the stenotic area appeared firm, with no visible mass or ulceration (Fig. 1 ). Three biopsies were taken from the stenotic site. The pathology report indicated “papillary-like hyperplasia of squamous epithelium with low-grade dysplasia at the rectal scar” (Fig. 2 ). On June 17, 2025, a pelvic MRI revealed irregular circumferential thickening of the lower rectal wall, with several enlarged lymph nodes noted around the upper rectum (Fig. 3 ). The patient was diagnosed with rectal stenosis. On June 18, 2025, she underwent surgery under general anesthesia. A pre-operative digital anal examination confirmed that the distal phalanx of the index finger could not pass through the anal canal (Fig. 4 A). The surgical procedures performed were: (1) Anoplasty; (2) Incision of rectal stricture. The steps were as follows: Ultrasonic Scalpel Scar Release: A longitudinal incision was made through the scar tissue at the posterior wall of the rectum (6 o’clock position), extending to the surface of the muscle layer and spanning 0.5 cm above and below the stenotic ring. The incision was extended circumferentially towards the 3 and 9 o’clock positions, gradually releasing the contracted tissue while preserving the normal mucosa and muscle layer, and avoiding the sphincter complex. V-Y Anoplasty at 6 o’clock: An inverted V-shaped flap was designed, starting 1.5 cm external to the anal verge with the apex pointing towards the stenotic ring. The base of the V was 2.5 cm wide, and the arms were 3 cm long. The scarred skin and subcutaneous fibrous tissue within the V-shape were excised. The apex of the V-flap was advanced into the rectum and sutured to the distal mucosal edge of the longitudinal incision using interrupted 3 − 0 absorbable sutures, ensuring a tension-free anastomosis. The sides of the flap were sutured to the anal canal mucosa to reconstruct the anal canal diameter. Hemostasis was meticulously achieved using an ultrasonic scalpel. Any minor bleeding points were controlled with 3 − 0 and 2 − 0 absorbable figure-of-eight sutures. A post-procedure digital examination confirmed that the anal canal could easily admit the index finger (diameter ≥ 1.5 cm) without resistance (Fig. 4 B). Postoperative pathology of the excised tissue on June 19, 2025, showed “chronic inflammation of the rectal mucosa with interstitial fibrosis.” A follow-up electronic colonoscopy on June 27, 2025, revealed scar-like changes at the anal verge and mild-to-moderate melanosis coli (Fig. 5 ). The patient was discharged on June 28, 2025, on traditional Chinese medicine treatment, in good condition. At her 3-month follow-up, she had resumed normal defecation, and her quality of life had significantly improved. 3. DISCUSSION This case highlights a severe iatrogenic complication of sclerotherapy for hemorrhoids. Although an effective treatment, sclerosant injection carries the risk of inducing excessive fibrosis, which, as demonstrated in our patient, can lead to debilitating anal stenosis [ 3 ] . The pathophysiology is thought to involve the diffusion of the sclerosant into the submucosa and muscularis layers, provoking an intense inflammatory reaction that is subsequently replaced by dense, contractile scar tissue [ 2 , 5 ] . The one-year delay before our patient developed severe symptoms underscores the progressive nature of this fibrotic process. The diagnosis of post-sclerotherapy anal stenosis is primarily clinical, based on the patient’s history and digital rectal examination, which characteristically reveals a firm, circumferential narrowing of the anal canal. Endoscopy is crucial for visualizing the extent of the stenosis and for obtaining biopsies to exclude malignancy, which is particularly important as inflammatory and dysplastic changes can be seen in chronic scar tissue, as was found in our initial biopsy [ 6 ] . Pelvic MRI can provide detailed information on the thickness of the rectal wall and help assess the involvement of surrounding structures and lymph nodes, although in this case, the enlarged lymph nodes were likely reactive rather than malignant. The management of anal stenosis depends on its severity. Mild stenosis may be managed with a program of regular anal dilation. However, for severe, established strictures, as in our patient, surgical intervention is the treatment of choice [ 7 ] . Various surgical techniques, collectively termed anoplasties, have been described. We opted for a V-Y advancement flap anoplasty, a well-established technique that relieves the stricture by introducing healthy, pliable skin and subcutaneous tissue into the narrowed anal canal, thereby increasing its circumference [ 8 ] . The use of an ultrasonic scalpel for scar release allowed for precise dissection and minimized bleeding. The patient’s excellent outcome, with a return to normal defecation, validates the effectiveness of this surgical approach. This case serves as a crucial cautionary tale for practitioners performing sclerotherapy. Strict adherence to proper technique is paramount. This includes using the correct dosage, ensuring the injection is placed in the submucosal layer in the upper anal canal (above the dentate line), and avoiding circumferential injections in a single session to prevent the formation of a contractile scar ring [ 2 ] . A limitation of this case report is the lack of objective preoperative ancillary studies, such as defecography results, which could have provided a more detailed assessment of the anorectal dynamics and sphincter function in the context of the stenosis. 4. CONCLUSION Severe anal stenosis is a rare but life-altering complication of sclerotherapy for hemorrhoids. Clinicians must maintain a high index of suspicion for this condition in patients who present with obstructive defecation symptoms following such procedures. Diagnosis relies on a careful history and physical examination, supplemented by endoscopy and imaging. While mild cases may respond to conservative measures, severe stenosis requires surgical correction. This case demonstrates the successful use of V-Y advancement flap anoplasty in treating severe post-sclerotherapy anal stenosis, restoring normal function and quality of life for the patient. Increased awareness and meticulous injection technique are essential to prevent this iatrogenic complication. Declarations Consent This study was exempted from approval by the Institutional Review Board of Qujing Traditional Chinese Medicine Hospital. Written informed consent was obtained from the patient for publication of this case report and accompanying images. Conflict of interest No potential conflict of interest was reported by the authors. Author Contribution Conceptualization: P.Zhang; Data curation: P.Zhang, L.L.Wu; Formal analysis: all authors; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript. References Zhang QH, Shao XW, Pan HH (2003) New clinical application progress of Xiaozhiling injection. China Pharm 14:78–79 Ge HX, Li P, Lei ZB (2014) Adverse reactions and rational application of Xiaozhiling injection. Chin Tradit Herb Drugs 36:431–434 Fan XS, Wang YM, Li H (2003) Problems and prospects of injection therapy for internal hemorrhoids. J Sino-Jpn Friendsh Hosp 17:249–250 Agha RA, Franchi T, Sohrabi C, Mathew G, for the SCARE Group (2020) The SCARE 2020 Guideline: Updating Consensus Surgical CAse REport (SCARE) Guidelines. Int J Surg 84:226–230 Yao L, Zhong Y, Xu J, Xu M, Zhou P (2006) Rectal stenosis after procedures for prolapse and hemorrhoids (PPH)—a report from China. World J Surg 30:1594–1595 Suh YJ, Park KJ, Kim Z et al (2013) Rectal Perforation Caused by Anal Stricture After a Hemorrhoidectomy. Ann Coloproctol 29:33–35 Leventoglu S, Mentes B, Balci B, Kebiz HC (2022) New techniques in hemorrhoidal disease but the same old problem: anal stenosis. Med (Kaunas) 58:362 Atalla ADG, Candelária PAP, Santos CHM et al (2024) Surgical approach for lower postoperative anal stenosis. J Coloproctol (Rio J) 44:e20230105 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8111340","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":545911672,"identity":"7d7e3466-21fe-46b4-b338-c614f178f9e5","order_by":0,"name":"Peng 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1","display":"","copyAsset":false,"role":"figure","size":60127,"visible":true,"origin":"","legend":"\u003cp\u003eEndoscopic view showing the stenotic ring just above the dentate line.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8111340/v1/c3ea3f69ee04b8193d7979c9.jpeg"},{"id":96248374,"identity":"cd2ce5d0-41d6-47cc-beb5-b6eded6efa86","added_by":"auto","created_at":"2025-11-19 07:28:22","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":843810,"visible":true,"origin":"","legend":"\u003cp\u003eHistopathology of the biopsy from the stenotic site, showing papillary-like hyperplasia of squamous epithelium with low-grade dysplasia.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8111340/v1/30e4ada331bafb78ce57a4c5.jpeg"},{"id":96051268,"identity":"8a2eac4b-db4f-49a5-9a5b-2d70596dd772","added_by":"auto","created_at":"2025-11-17 06:40:06","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":204593,"visible":true,"origin":"","legend":"\u003cp\u003ePelvic MRI (T2-weighted image) showing irregular circumferential thickening of the lower rectal wall.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8111340/v1/0ac921964de0be4c6609893e.jpeg"},{"id":96051272,"identity":"da421c4f-4162-4b13-acc0-ab63080e3153","added_by":"auto","created_at":"2025-11-17 06:40:07","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1080419,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Pre-operative digital anal examination confirmed that the distal phalanx of the index finger could not pass through the anal canal (diameter ≤1.0 cm). (B) Post-procedure appearance after V-Y anoplasty, showing a widely patent anal canal.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8111340/v1/464a3a167d83765fd9137238.jpeg"},{"id":96051226,"identity":"def92695-65d0-4beb-920b-0b02734deba2","added_by":"auto","created_at":"2025-11-17 06:40:01","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":518440,"visible":true,"origin":"","legend":"\u003cp\u003eFollow-up colonoscopy showing scar-like changes at the anal verge and melanosis coli.\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8111340/v1/b29c300eed153268f37c8377.jpeg"},{"id":96372343,"identity":"209f0799-07c3-43a3-b7b4-b5b511f72768","added_by":"auto","created_at":"2025-11-20 10:27:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2999193,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8111340/v1/d299b821-101d-455c-8d42-555ad46288e7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anal Stenosis Following Sclerotherapy for Hemorrhoids: A Case Report","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eHemorrhoids are a common anorectal disorder, and sclerotherapy, such as with Xiaozhiling injection, is a widely applied non-surgical treatment. The therapeutic principle of Xiaozhiling, a compound traditional Chinese medicine preparation, involves inducing localized coagulation, necrosis, and subsequent fibrosis of hemorrhoidal tissue \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. While this therapy is generally considered safe, it is not without potential complications. Improper injection technique, excessive dosage, or incorrect injection sites can lead to adverse events such as severe pain, bleeding, infection, and, in rare instances, anal stenosis \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAnal stenosis secondary to sclerotherapy is an uncommon but serious complication. The underlying mechanism is thought to involve excessive fibrosis and contracture of the submucosal connective tissue following the chemical insult, leading to an irreversible cicatricial ring \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. This condition can cause significant symptoms, including difficult defecation, pencil-thin stools, and abdominal bloating, severely impacting the patient\u0026rsquo;s quality of life. While early, mild cases may respond to conservative treatment like anal dilation, severe, established stenosis often necessitates surgical intervention.\u003c/p\u003e\u003cp\u003eHere, we present the case of a female patient who developed severe anal stenosis one year after undergoing sclerotherapy for mixed hemorrhoids. We discuss her clinical features, diagnostic challenges, and the surgical management employed. This case report has been reported in line with the SCARE criteria \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"2. PRESENTATION OF CASE","content":"\u003cp\u003eA female patient presented to our emergency department with a chief complaint of \u0026ldquo;difficulty in defecation for 1 year, worsening for 5 days.\u0026rdquo; One year prior, she had received \u0026ldquo;Xiaozhiling injection therapy\u0026rdquo; for \u0026ldquo;mixed hemorrhoids\u0026rdquo; at a local private clinic. Approximately 20 days post-procedure, she began to experience difficulty in defecation. Despite having a daily urge to defecate and normal stool consistency, she found evacuation difficult, with a persistent sensation of incomplete emptying and associated abdominal bloating. She self-medicated with over-the-counter laxatives and antibiotics, which provided temporary relief with the passage of loose stools.\u003c/p\u003e\u003cp\u003eFive days before admission, the difficulty in defecation acutely worsened. Her symptoms did not improve even with laxatives; her stools became markedly thin, and even loose stools were difficult to pass, causing intolerable abdominal distension. Her past medical history was unremarkable.\u003c/p\u003e\u003cp\u003eOn physical examination, her abdomen was distended but non-tender. The external anal appearance was normal. Digital rectal examination revealed significant stenosis within the anal canal, which did not admit the index finger. Palpation of the anal verge was painful, and the examining finger was stained with blood. Anoscopy could not be performed due to the severe stenosis.\u003c/p\u003e\u003cp\u003eLaboratory investigations, including a complete blood count, liver and renal function tests, and electrolytes, were all within normal limits. A fecal occult blood test was positive. An electrocardiogram showed no abnormalities.\u003c/p\u003e\u003cp\u003eOn June 16, 2025, an attempt was made to perform an electronic colonoscopy. Due to the anal stenosis, a gastroscope was used instead. The scope could not pass through a stenotic ring located just above the dentate line in the lower rectum. Through the narrowed opening, the mucosa of the stenotic area appeared firm, with no visible mass or ulceration (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Three biopsies were taken from the stenotic site. The pathology report indicated \u0026ldquo;papillary-like hyperplasia of squamous epithelium with low-grade dysplasia at the rectal scar\u0026rdquo; (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eOn June 17, 2025, a pelvic MRI revealed irregular circumferential thickening of the lower rectal wall, with several enlarged lymph nodes noted around the upper rectum (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe patient was diagnosed with rectal stenosis. On June 18, 2025, she underwent surgery under general anesthesia. A pre-operative digital anal examination confirmed that the distal phalanx of the index finger could not pass through the anal canal (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe surgical procedures performed were: (1) Anoplasty; (2) Incision of rectal stricture. The steps were as follows:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eUltrasonic Scalpel Scar Release: A longitudinal incision was made through the scar tissue at the posterior wall of the rectum (6 o\u0026rsquo;clock position), extending to the surface of the muscle layer and spanning 0.5 cm above and below the stenotic ring. The incision was extended circumferentially towards the 3 and 9 o\u0026rsquo;clock positions, gradually releasing the contracted tissue while preserving the normal mucosa and muscle layer, and avoiding the sphincter complex.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eV-Y Anoplasty at 6 o\u0026rsquo;clock: An inverted V-shaped flap was designed, starting 1.5 cm external to the anal verge with the apex pointing towards the stenotic ring. The base of the V was 2.5 cm wide, and the arms were 3 cm long. The scarred skin and subcutaneous fibrous tissue within the V-shape were excised. The apex of the V-flap was advanced into the rectum and sutured to the distal mucosal edge of the longitudinal incision using interrupted 3\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable sutures, ensuring a tension-free anastomosis. The sides of the flap were sutured to the anal canal mucosa to reconstruct the anal canal diameter.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eHemostasis was meticulously achieved using an ultrasonic scalpel. Any minor bleeding points were controlled with 3\u0026thinsp;\u0026minus;\u0026thinsp;0 and 2\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable figure-of-eight sutures. A post-procedure digital examination confirmed that the anal canal could easily admit the index finger (diameter\u0026thinsp;\u0026ge;\u0026thinsp;1.5 cm) without resistance (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB).\u003c/p\u003e\u003cp\u003ePostoperative pathology of the excised tissue on June 19, 2025, showed \u0026ldquo;chronic inflammation of the rectal mucosa with interstitial fibrosis.\u0026rdquo; A follow-up electronic colonoscopy on June 27, 2025, revealed scar-like changes at the anal verge and mild-to-moderate melanosis coli (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe patient was discharged on June 28, 2025, on traditional Chinese medicine treatment, in good condition. At her 3-month follow-up, she had resumed normal defecation, and her quality of life had significantly improved.\u003c/p\u003e"},{"header":"3. DISCUSSION","content":"\u003cp\u003eThis case highlights a severe iatrogenic complication of sclerotherapy for hemorrhoids. Although an effective treatment, sclerosant injection carries the risk of inducing excessive fibrosis, which, as demonstrated in our patient, can lead to debilitating anal stenosis \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. The pathophysiology is thought to involve the diffusion of the sclerosant into the submucosa and muscularis layers, provoking an intense inflammatory reaction that is subsequently replaced by dense, contractile scar tissue \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. The one-year delay before our patient developed severe symptoms underscores the progressive nature of this fibrotic process.\u003c/p\u003e\u003cp\u003eThe diagnosis of post-sclerotherapy anal stenosis is primarily clinical, based on the patient\u0026rsquo;s history and digital rectal examination, which characteristically reveals a firm, circumferential narrowing of the anal canal. Endoscopy is crucial for visualizing the extent of the stenosis and for obtaining biopsies to exclude malignancy, which is particularly important as inflammatory and dysplastic changes can be seen in chronic scar tissue, as was found in our initial biopsy \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Pelvic MRI can provide detailed information on the thickness of the rectal wall and help assess the involvement of surrounding structures and lymph nodes, although in this case, the enlarged lymph nodes were likely reactive rather than malignant.\u003c/p\u003e\u003cp\u003eThe management of anal stenosis depends on its severity. Mild stenosis may be managed with a program of regular anal dilation. However, for severe, established strictures, as in our patient, surgical intervention is the treatment of choice \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Various surgical techniques, collectively termed anoplasties, have been described. We opted for a V-Y advancement flap anoplasty, a well-established technique that relieves the stricture by introducing healthy, pliable skin and subcutaneous tissue into the narrowed anal canal, thereby increasing its circumference \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. The use of an ultrasonic scalpel for scar release allowed for precise dissection and minimized bleeding.\u003c/p\u003e\u003cp\u003eThe patient\u0026rsquo;s excellent outcome, with a return to normal defecation, validates the effectiveness of this surgical approach. This case serves as a crucial cautionary tale for practitioners performing sclerotherapy. Strict adherence to proper technique is paramount. This includes using the correct dosage, ensuring the injection is placed in the submucosal layer in the upper anal canal (above the dentate line), and avoiding circumferential injections in a single session to prevent the formation of a contractile scar ring \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eA limitation of this case report is the lack of objective preoperative ancillary studies, such as defecography results, which could have provided a more detailed assessment of the anorectal dynamics and sphincter function in the context of the stenosis.\u003c/p\u003e"},{"header":"4. CONCLUSION","content":"\u003cp\u003eSevere anal stenosis is a rare but life-altering complication of sclerotherapy for hemorrhoids. Clinicians must maintain a high index of suspicion for this condition in patients who present with obstructive defecation symptoms following such procedures. Diagnosis relies on a careful history and physical examination, supplemented by endoscopy and imaging. While mild cases may respond to conservative measures, severe stenosis requires surgical correction. This case demonstrates the successful use of V-Y advancement flap anoplasty in treating severe post-sclerotherapy anal stenosis, restoring normal function and quality of life for the patient. Increased awareness and meticulous injection technique are essential to prevent this iatrogenic complication.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cb\u003eConsent\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study was exempted from approval by the Institutional Review Board of Qujing Traditional Chinese Medicine Hospital. Written informed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConflict of interest\u003c/h2\u003e\u003cp\u003eNo potential conflict of interest was reported by the authors.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization: P.Zhang; Data curation: P.Zhang, L.L.Wu; Formal analysis: all authors; Writing\u0026ndash;original draft: all authors; Writing\u0026ndash;review \u0026amp; editing: all authors. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZhang QH, Shao XW, Pan HH (2003) New clinical application progress of Xiaozhiling injection. China Pharm 14:78\u0026ndash;79\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGe HX, Li P, Lei ZB (2014) Adverse reactions and rational application of Xiaozhiling injection. Chin Tradit Herb Drugs 36:431\u0026ndash;434\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFan XS, Wang YM, Li H (2003) Problems and prospects of injection therapy for internal hemorrhoids. J Sino-Jpn Friendsh Hosp 17:249\u0026ndash;250\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAgha RA, Franchi T, Sohrabi C, Mathew G, for the SCARE Group (2020) The SCARE 2020 Guideline: Updating Consensus Surgical CAse REport (SCARE) Guidelines. Int J Surg 84:226\u0026ndash;230\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYao L, Zhong Y, Xu J, Xu M, Zhou P (2006) Rectal stenosis after procedures for prolapse and hemorrhoids (PPH)\u0026mdash;a report from China. World J Surg 30:1594\u0026ndash;1595\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSuh YJ, Park KJ, Kim Z et al (2013) Rectal Perforation Caused by Anal Stricture After a Hemorrhoidectomy. Ann Coloproctol 29:33\u0026ndash;35\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeventoglu S, Mentes B, Balci B, Kebiz HC (2022) New techniques in hemorrhoidal disease but the same old problem: anal stenosis. Med (Kaunas) 58:362\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAtalla ADG, Candel\u0026aacute;ria PAP, Santos CHM et al (2024) Surgical approach for lower postoperative anal stenosis. J Coloproctol (Rio J) 44:e20230105\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Anal stenosis, Sclerotherapy, Hemorrhoids, Complication, Case report","lastPublishedDoi":"10.21203/rs.3.rs-8111340/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8111340/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eINTRODUCTION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSclerotherapy is a widely used non-surgical treatment for hemorrhoids but can lead to rare severe complications. We present a case of severe anal stenosis developing one year after sclerotherapy, a debilitating iatrogenic complication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePRESENTATION OF CASE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA female patient presented with progressive difficulty in defecation for one year, acutely worsened over five days. One year prior, she underwent sclerotherapy for mixed hemorrhoids. Physical examination revealed severe anal stenosis admitting only the fingertip. Endoscopy and pelvic MRI confirmed a tight cicatricial stricture. She underwent V-Y advancement flap anoplasty combined with stricture incision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDISCUSSION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePost-sclerotherapy stenosis results from excessive submucosal fibrosis and scar contracture. Diagnosis is primarily clinical, supported by endoscopy to exclude malignancy. Severe strictures require surgical correction. V-Y advancement flap anoplasty effectively relieves stenosis by introducing healthy tissue into the anal canal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient achieved an excellent postoperative outcome with restored bowel function. Severe anal stenosis is a rare but devastating complication of hemorrhoid sclerotherapy. This case underscores the efficacy of V-Y advancement flap anoplasty. Clinicians should maintain high suspicion for this complication in patients with obstructive defecation symptoms post-injection.\u003c/p\u003e","manuscriptTitle":"Anal Stenosis Following Sclerotherapy for Hemorrhoids: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-17 06:39:45","doi":"10.21203/rs.3.rs-8111340/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4b230f40-c3a0-420e-938a-3c10a22e2155","owner":[],"postedDate":"November 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-20T10:24:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-17 06:39:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8111340","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8111340","identity":"rs-8111340","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}