What treatment options are available for a patient with erectile dysfunction (ED) and decreased anal libido, who has a history of anal surgery with scar tissue formation, reports full erections and ability to have orgasms, and experiences improved libido with waterjet massage table treatment?

Treatment Approach for ED with Decreased Anal Libido Post-Anal Surgery

This patient's symptoms—preserved penile erectile function but decreased anal sensation and libido following anal surgery with scar tissue—require addressing the localized sensory deficit rather than systemic ED treatment, with the waterjet massage response suggesting pelvic floor dysfunction or scar-related nerve compromise as the primary issue.

Clinical Context and Pathophysiology

This presentation is atypical for standard erectile dysfunction since the patient maintains:

• Full penile erections 1
• Ability to achieve orgasm 1
• Partner-unnoticed erectile quality 1

The key complaint centers on decreased anal sensation and libido, which temporarily improves with waterjet massage to the rectal area 1. This suggests:

• Scar tissue from prior anal surgery causing localized sensory impairment 2
• Pelvic floor dysfunction affecting anal/rectal sensation 3
• Nerve compromise from surgical trauma rather than systemic vascular or hormonal ED 2, 3

Recommended Treatment Algorithm

Step 1: Exclude Systemic ED Contributors

Even though penile function appears preserved, complete the standard ED evaluation:

• Cardiovascular risk assessment including blood pressure, fasting glucose, HbA1c, and lipid profile to identify diabetes, hypertension, and hyperlipidemia 1, 4, 5
• Total testosterone level if there is any component of decreased libido, as hypogonadism (<230 ng/dL) can affect both penile and overall sexual desire 1, 4
• Focused physical examination of the anal/rectal area to assess scar tissue extent, sensation, and sphincter tone 6, 4

Step 2: Address the Primary Problem—Localized Sensory Deficit

Since the patient responds positively to waterjet massage, the therapeutic focus should be:

Pelvic Floor Physical Therapy:

• Specialized pelvic floor rehabilitation targeting the anal/rectal region to address scar tissue restrictions and improve sensation 2, 3
• Manual therapy techniques to mobilize scar tissue and restore tissue pliability
• Biofeedback training to enhance awareness and control of pelvic floor muscles

Scar Tissue Management:

• Consider referral to colorectal surgery for evaluation of surgical scar revision if scar tissue is causing significant sensory impairment 2, 3
• Topical therapies or massage techniques to improve scar mobility

Hydrotherapy/Warm Water Therapy:

• Since waterjet massage provides symptomatic relief, recommend regular warm sitz baths or similar hydrotherapy approaches to improve local blood flow and sensation 1

Step 3: Pharmacological Considerations (If Needed)

PDE5 Inhibitors are NOT indicated as first-line treatment here since:

• Penile erectile function is preserved 1, 7, 5
• The problem is localized sensory deficit, not systemic erectile dysfunction 1
• PDE5 inhibitors work in 60-65% of men with ED but require adequate testosterone and intact neurovascular pathways 1, 4, 7, 5

However, consider:

• Testosterone replacement only if serum testosterone is <230 ng/dL and libido is globally decreased (not just anal libido), as testosterone improves overall sexual desire 1, 4
• Testosterone alone will not address the localized anal sensory deficit 1

Step 4: Psychosexual Counseling

Involve both patient and partner in discussions about:

• The nature of the sensory deficit and realistic expectations for recovery 1, 4
• Alternative sexual practices that may be satisfying given the current limitations 1, 4
• Cognitive-behavioral therapy if performance anxiety or psychological distress develops secondary to the sensory changes 1, 4

Critical Pitfalls to Avoid

Do not treat this as standard erectile dysfunction with PDE5 inhibitors as first-line therapy—the patient has preserved penile function, and the issue is localized sensory impairment from surgical scar tissue 1, 2, 3.

Do not overlook the surgical history—anal surgery with scar formation is the likely culprit for decreased anal sensation, and addressing the scar tissue directly (through physical therapy or surgical revision) is more appropriate than systemic ED medications 2, 3.

Do not dismiss the waterjet massage response—this therapeutic clue indicates that improved local blood flow and tissue stimulation can temporarily restore sensation, supporting the use of hydrotherapy and pelvic floor rehabilitation 1.

Do not ignore cardiovascular screening—even though penile function is preserved, ED can be an early marker of cardiovascular disease, and all men presenting with any sexual dysfunction warrant risk factor assessment 1, 4, 5.

Surgical Options (Last Resort)

If conservative measures fail and scar tissue significantly impairs quality of life:

• Surgical scar revision by a colorectal surgeon may be considered to release restrictive scar tissue and restore sensation 2, 3
• Arterial reconstructive surgery is NOT indicated here, as this is reserved for focal arterial occlusion in otherwise healthy men with recently acquired ED, not for localized sensory deficits from scar tissue 6