I'm experiencing diminished pressure and pleasure during ejaculation, less frequent and less pleasurable spontaneous erections, and uncomfortable ejaculation, following a history of fistulotomy and anal pathology, what could be the cause and treatment for my symptoms?

Diminished Ejaculatory Pressure and Pleasure Following Anal Surgery

Your symptoms of reduced ejaculatory pressure, uncomfortable ejaculation, and less pleasurable spontaneous erections following fistulotomy likely represent nerve damage from the anal surgery, and you should be evaluated by a urologist for formal assessment of ejaculatory dysfunction and potential testosterone deficiency. 1, 2

Understanding Your Symptoms

Your constellation of symptoms—diminished ejaculatory pressure, reduced pleasure during ejaculation, uncomfortable ejaculation, and altered spontaneous erections—represents a form of ejaculatory dysfunction that warrants systematic evaluation. 1

Connection to Your Surgical History

• Fistulotomy procedures can cause nerve damage affecting sexual function, particularly when complex anal fistulas involve significant sphincter muscle division. 3
• The pudendal nerve, which controls ejaculatory function and penile sensation, runs in close proximity to the anal surgical field and can be injured during fistulotomy procedures. 1, 2
• Post-surgical changes in pelvic floor muscle function following anal surgery can alter the mechanics of ejaculation, reducing the force and pleasure of ejaculation. 1

Immediate Diagnostic Steps

Sexual History Assessment

You need a detailed sexual history focusing on: 1, 2

• Exact timing: When symptoms began relative to your fistulotomy surgery
• Pain characteristics: Location, severity, and timing of discomfort during ejaculation (before, during, or after) 2
• Ejaculatory latency: How long it takes you to ejaculate now versus before surgery 1
• Orgasm quality: Whether you still experience orgasm despite reduced ejaculatory pressure 1
• Erectile function: Whether you can achieve and maintain erections adequate for intercourse, and whether morning/nocturnal erections are present 4

Laboratory Testing

• Morning serum total testosterone is essential, as low testosterone correlates with ejaculatory dysfunction and reduced libido. 1, 4, 2
• Basic metabolic panel, lipids, and hemoglobin A1c to assess for conditions causing neuropathy (diabetes) or vascular disease. 1

Physical Examination

• Genital, perineal, and abdominal examination to assess for surgical complications, masses, or evidence of nerve damage. 1, 2
• Neurological assessment of perineal sensation and anal sphincter tone. 1

Treatment Algorithm

First-Line: Address Underlying Causes

If testosterone is low (biochemically confirmed): 1, 4, 2

• Testosterone replacement therapy should be initiated per AUA guidelines, as this improves both erectile function and ejaculatory function in hypogonadal men. 4
• Testosterone optimization may also improve response to other treatments. 4

If erectile dysfunction coexists with ejaculatory problems: 1, 4

• Treat the erectile dysfunction first, as ED and ejaculatory disorders share common risk factors and ED treatment may resolve ejaculatory complaints. 1, 2
• PDE5 inhibitors (sildenafil, tadalafil, vardenafil) are effective in 60-65% of men with ED. 4
• Start at lower doses and titrate to maximum dose, requiring at least 5 separate attempts at maximum dose before declaring treatment failure. 4

Second-Line: Behavioral and Psychological Interventions

• Referral to a mental health professional with sexual health expertise is appropriate for ejaculatory dysfunction, as psycho-behavioral strategies may enhance arousal and remove barriers to sexual excitement. 1
• Modifying sexual positions or practices to increase arousal may benefit men with delayed or uncomfortable ejaculation. 1
• These approaches avoid the risks of pharmacotherapy and should be initiated early. 1

Third-Line: Pharmacotherapy for Ejaculatory Dysfunction

For delayed ejaculation specifically: 1

• Pseudoephedrine 60-120 mg taken 120-150 minutes prior to sex 1
• Ephedrine 15-60 mg taken 1 hour prior to sex 1
• Oxytocin 24 IU intranasal/sublingual during sex 1

These medications may improve ejaculatory force and sensation, though evidence is limited. 1

Fourth-Line: Advanced Interventions

If medical management fails after adequate trials: 4

• Intraurethral alprostadil suppositories 4, 5
• Intracavernosal vasoactive drug injection therapy 4, 5
• Vacuum erection devices 4
• Referral to urology for consideration of these second-line therapies 4

Critical Clinical Pitfalls to Avoid

Do not assume your symptoms are purely psychological without ruling out organic causes. 2 Your history of anal surgery with subsequent sexual dysfunction strongly suggests nerve injury as the underlying etiology. 3

Do not delay testosterone testing. 4 The combination of ejaculatory dysfunction with altered spontaneous erections makes testosterone deficiency a likely and treatable contributor. 4, 2

Do not confuse your symptoms with premature ejaculation or simple erectile dysfunction. 2, 6 Your description of reduced ejaculatory pressure and uncomfortable ejaculation represents a distinct condition requiring different treatment approaches. 1, 2

Do not accept "this is just how it is after surgery" as an answer. 1 While nerve injury from fistulotomy can cause persistent sexual dysfunction, multiple treatment options exist that may significantly improve your symptoms. 1, 3

Prognosis and Expectations

• Fistulotomy with sphincteroplasty has a 95.8% success rate for fistula healing but can cause minor continence and sexual function impairment in some patients. 3
• Patients with recurrent fistulas requiring multiple surgeries have higher rates of functional impairment. 3
• Treatment success for ejaculatory dysfunction is measured by patient and partner satisfaction, not arbitrary physiological measures. 1, 2
• Many men experience improvement with appropriate treatment, though complete restoration to pre-surgical function may not always be achievable. 1