Is it safe to engage in anal play after a fistulotomy, given that I have a history of multiple anorectal surgeries, my provider has confirmed healing with no incontinence, but I've noticed increased odor and ease of opening on the left side?

Post-Fistulotomy Anal Play Safety Assessment

You should avoid anal play at this time due to concerning signs of incomplete healing or structural changes, specifically the increased odor and asymmetric anal opening that suggest possible wound complications or altered sphincter integrity. 1, 2

Why This Matters for Your Specific Situation

Your provider confirmed endoscopic healing and no incontinence, which is excellent. However, the two symptoms you describe—increased odor and easier opening on the left side—are red flags that warrant caution before resuming anal play:

The Odor Issue

• Increased anal odor after fistulotomy can indicate incomplete wound healing, residual infection, or altered sphincter function that allows small amounts of fecal material to leak into the surgical site or perianal area. 1
• Even without frank incontinence, fistulotomy creates a healing wound that may have microscopic gaps allowing bacterial colonization and odor production. 3, 4
• The World Journal of Emergency Surgery guidelines note that wound-related complications including non-healing wounds occur in up to 3% of fistulotomy patients, and these can present subtly. 1

The Asymmetric Opening

• The fact that your left side opens more easily suggests either residual surgical defect or sphincter weakness on that side. 2, 3
• Fistulotomy inherently divides sphincter muscle fibers—even "low" fistulotomies can cause gas and urge incontinence in 20% of patients, with only 26.3% maintaining perfect continence status long-term. 3, 4
• Research shows that 28% of fistulotomy patients develop major incontinence (Vaizey score >6), and minor continence impairment like post-defecation soiling occurs in 11.6% even when patients report "no incontinence." 3, 5

What You Need Before Resuming Anal Play

Return to your provider specifically to address these two findings before any anal penetration:

• Request objective continence assessment using validated scoring (Vaizey or Cleveland Clinic scores) rather than just asking "do you have incontinence?" Many patients don't recognize minor soiling or gas leakage as incontinence. 3, 4, 5
• Consider 3-dimensional endoanal ultrasound to evaluate sphincter integrity and ensure complete wound healing, as this is more sensitive than visual inspection alone for detecting residual defects. 5
• The odor specifically needs investigation—this could represent low-grade infection, incomplete fistula healing, or a small unrecognized abscess that wasn't visible on scope. 1

The Timing Problem

• Most fistulotomy studies show healing occurs over 6-12 months, not just the initial weeks. 2, 6, 3
• Recurrence rates are 16.4% after fistulotomy, with most recurrences becoming apparent within the first year. 3
• Introducing trauma (anal play) to a healing surgical site significantly increases risk of wound breakdown, infection, and fistula recurrence. 1, 2

Critical Pitfall to Avoid

Do not assume that "scope looked good" means you're ready for anal penetration. The endoscopic view shows mucosal healing but cannot assess:

• Sphincter muscle integrity 5
• Microscopic wound healing 3
• Functional sphincter strength 4
• Presence of small fluid collections or early abscess formation 1

Specific Next Steps

1. Schedule follow-up specifically mentioning the odor and asymmetric opening—these are objective findings that need evaluation. 1, 3
2. Request formal continence scoring (not just "do you leak?") to establish baseline function. 3, 4
3. Consider pelvic floor physical therapy or Kegel exercises (50 contractions daily) which have been shown to significantly improve post-fistulotomy continence and may address the asymmetric weakness. 4
4. Wait minimum 6 months from surgery before considering anal penetration, and only after formal clearance addressing your specific symptoms. 2, 3

The Bottom Line on Multiple Prior Surgeries

Your history of multiple anorectal surgeries puts you at 5-fold increased risk of continence impairment compared to first-time fistulotomy patients. 5 This makes the conservative approach even more critical—you have less sphincter reserve to tolerate additional trauma or complications. The asymmetric opening you're noticing may represent cumulative sphincter damage from prior procedures, making protection of remaining function paramount. 2, 5