Can a patient with a history of fistulotomy and current symptoms of burning sensation and impaired ejaculation ability experience improvement with treatment options such as antibiotics, topical anesthetics, and medications like sildenafil?

Management of Burning Sensation and Ejaculatory Dysfunction Post-Fistulotomy

Yes, burning sensation and ejaculation ability can be improved with targeted treatment, but the approach depends critically on identifying the underlying cause—whether infectious/inflammatory complications from the fistulotomy, neuropathic pain, or concurrent erectile dysfunction.

Diagnostic Priorities

The first step is distinguishing between different pain mechanisms:

• Assess for infectious or inflammatory complications from the prior fistulotomy, including abscess formation, recurrent fistula, or chronic inflammation, as these can cause persistent burning and sexual dysfunction 1
• Rule out organic causes before assuming psychological etiology, including prostatitis, medication effects, or post-surgical anatomical changes 1
• Evaluate for erectile dysfunction concurrently, as ED and ejaculatory disorders share common risk factors and treating ED first may resolve the ejaculatory complaints 1
• Check morning testosterone levels, as low testosterone correlates with ejaculatory dysfunction and should be replaced per standard guidelines if biochemically low 1

Treatment Algorithm for Burning Sensation

If Inflammatory/Infectious Etiology

• Antibiotics are widely used for perianal complications and recommended in practice guidelines, though they lack placebo-controlled trial evidence for fistula-related symptoms 2
• Relapse rates are high after antibiotic discontinuation, so antibiotics should be used adjunctively rather than as monotherapy 2

If Neuropathic Pain (Dysaesthesia)

This represents a critical distinction, as neuropathic pain will not respond to anti-inflammatory approaches:

• Start with topical lidocaine 5% ointment as first-line therapy for neuropathic burning sensation in the genital/perianal region 2
• Progress to amitriptyline for unresponsive cases, as this addresses neuronal sensitization that persists despite resolution of the original inflammatory condition 2
• Topical corticosteroids will not help neuropathic pain and should be avoided once the inflammatory phase has resolved 2

Treatment Algorithm for Ejaculatory Dysfunction

Primary Approach

• Treat concurrent erectile dysfunction first if present, as this may resolve the ejaculatory complaints without additional intervention 1
• Sildenafil is not indicated for ejaculatory dysfunction per se, but may be appropriate if ED is the primary issue 2

If Painful Ejaculation Persists

The AUA guideline emphasizes that patient and partner satisfaction is the primary outcome, not arbitrary physiological measures 2, 1:

• Selective serotonin reuptake inhibitors (SSRIs) are effective for premature ejaculation but are not specifically indicated for painful ejaculation 2
• Topical anesthetics (lidocaine/prilocaine cream) applied 20-30 minutes pre-intercourse can reduce pain during ejaculation 2
• Treatment must be tailored to the underlying cause rather than using a one-size-fits-all approach 1

Critical Caveats

Regarding the Fistulotomy History

• Fistulotomy has high healing rates (93-95.8%) but carries a 20% risk of continence impairment, mostly minor 3, 4
• Recurrence rates after fistulotomy range from 0-68%, and recurrent disease may require additional intervention 5, 3
• If fistula recurrence is suspected, re-evaluation with examination under anesthesia and imaging may be necessary before addressing sexual symptoms 2

Common Pitfalls to Avoid

• Do not assume symptoms are purely psychological without thorough organic workup 1
• Do not confuse painful ejaculation with premature ejaculation or anorgasmia, as these require different treatments 1
• Do not use topical corticosteroids for neuropathic pain, as they will be ineffective 2
• Recognize that painful ejaculation is underreported due to its sensitive nature and must be specifically asked about 1

Psychosexual Considerations

• Chronic genital disorders commonly lead to loss of sexual interest and dysfunction, independent of the physical symptoms 2
• Offer referral to appropriate expertise for psychosexual counseling if symptoms persist despite addressing organic causes 2