Can a patient with a history of fistulotomy and current symptoms of burning sensation and impaired ejaculation ability be restored to a new baseline?

Can Sexual Function Be Restored After Fistulotomy?

Yes, restoration to a new baseline is possible for patients experiencing burning sensation and impaired ejaculation after fistulotomy, with the best outcomes achieved through sphincter reconstruction surgery combined with treatment of any underlying anal pathology. 1, 2

Understanding the Problem

The symptoms you describe—burning sensation and impaired ejaculation—are consistent with the "anocavernosal erectile dysfunction syndrome," where anal sphincter pathology directly affects sexual function through involvement of the bulbocavernosus muscle (BCM), which is anatomically part of the external anal sphincter. 3

• The BCM plays a critical role in both erection and ejaculation by compressing the penile bulb and dorsal penile vein, acting as a "suction-ejection pump" during the ejaculatory process. 3
• Anal sphincter damage from fistulotomy can disrupt BCM function, leading to erectile and ejaculatory dysfunction even when standard erectile function tests appear normal. 3

Treatment Algorithm for Restoration

Step 1: Assess Current Anal Sphincter Status

• Obtain 3-dimensional endoanal ultrasound to evaluate sphincter integrity and identify any defects from the previous fistulotomy. 2
• Perform anorectal manometry to assess sphincter pressures and function. 1
• Conduct proctosigmoidoscopy to rule out active inflammation or other anal pathology (fissures, proctitis) that could contribute to symptoms. 4

Step 2: Treat Any Active Anal Pathology

• If anal fissure is present, treat it first—studies show that erectile and ejaculatory dysfunction associated with anal fissures resolves in 94% of acute cases and 90% of chronic cases after fissure healing. 3
• If recurrent fistula or abscess is present, drainage and medical management must precede definitive reconstruction. 4

Step 3: Sphincter Reconstruction Surgery

For patients with sphincter defects and sexual dysfunction after fistulotomy, fistulotomy with immediate sphincteroplasty offers the best chance of restoration:

• Success rates for healing are 84-96% at long-term follow-up (mean 29-96 months). 5, 1, 2
• Sexual function improvement is significant: In one study of 16 men with erectile and ejaculatory dysfunction after anal fistula surgery, all were cured after sphincteroplasty. 3
• Continence improvement occurs in 70% of previously incontinent patients, with Wexner scores improving from 6.75 to 1.88 (p < 0.005). 1

Step 4: Post-Surgical Expectations

Timeline for recovery:

• Initial healing assessment at 6 months with endoanal ultrasound. 2
• Functional improvement typically occurs within 3-12 months after surgery. 1
• Long-term stability is excellent, with most improvements maintained at 5+ years follow-up. 5

Important Prognostic Factors

Favorable factors for restoration:

• Male sex shows a protective effect against postoperative dysfunction (OR = 0.66). 5
• Recurrent fistulas paradoxically have better outcomes with sphincteroplasty (86.5% healing rate). 5
• Non-high fistula tracts have better functional outcomes (84.3% healing). 5

Risk factors for persistent dysfunction:

• History of multiple previous fistula surgeries increases risk of continence impairment 5-fold (RR = 5.00,95% CI 1.45-17.27). 2
• High trans-sphincteric fistulas show 4-fold increased risk of incontinence. 5
• Large fistulas (>3 cm) and decreased vaginal caliber (in women) are associated with persistent sexual dysfunction. 6

Common Pitfalls to Avoid

• Do not assume erectile dysfunction is unrelated to the anal surgery—the anatomical connection through the BCM means anal pathology directly affects sexual function. 3
• Do not delay reconstruction if sphincter defect is documented—earlier intervention (within 2 years) may have better outcomes, though data are limited. 1
• Do not perform reconstruction in the presence of active inflammation—control any proctitis or active Crohn's disease first if present. 4
• Do not neglect to counsel about realistic expectations—while most patients improve significantly, 12-17% may experience some degree of persistent minor dysfunction (typically post-defecation soiling rather than major incontinence). 5, 2

Addressing Ejaculatory Dysfunction Specifically

If ejaculatory dysfunction persists despite anatomical correction:

• Obtain detailed sexual history to distinguish between premature ejaculation, delayed ejaculation, or anejaculation. 7
• Rule out concurrent erectile dysfunction, as ED should be treated first if present. 7
• Consider pharmacologic therapy with SSRIs (paroxetine, citalopram, or sertraline) if the pattern suggests premature ejaculation secondary to anxiety about the anal symptoms. 8
• Involve the partner in treatment decisions to optimize outcomes. 8

The bottom line: Restoration to a new functional baseline is achievable in 84-94% of patients through sphincter reconstruction surgery, with the best outcomes in men with documented sphincter defects who undergo timely surgical repair. 1, 2, 3