Can over tense muscles 6 months after a low transsphincteric fistulotomy (a surgical procedure for anal fistula) cause loss of libido in a patient, and can treatment targeting muscle relaxation improve libido and sensations?

Muscle Tension After Fistulotomy and Loss of Libido

There is no established medical evidence linking pelvic floor muscle tension following low transsphincteric fistulotomy to loss of libido, and treatment should focus on the actual documented causes of sexual dysfunction in this population rather than pursuing unproven theories about muscle tension.

What the Evidence Actually Shows About Sexual Dysfunction After Anorectal Surgery

The documented causes of sexual dysfunction following pelvic/anorectal procedures are fundamentally different from what you're proposing:

• Loss of libido after anal cancer treatment with chemoradiotherapy is well-documented and relates to radiation damage, with patients reporting specific concerns about loss of libido, inability to enjoy sex, and erectile dysfunction 1
• Sexual dysfunction in these contexts stems from radiation-induced tissue damage, nerve injury, and psychological factors—not muscle tension 1
• After pelvic radiotherapy, the mechanism involves direct tissue injury and vascular compromise, which is why nurse-led late effects clinics and pelvic floor exercises are recommended for faecal urgency and incontinence, not libido 1

Why Muscle Tension is Unlikely to Be the Cause

The anatomical and physiological relationship between sphincter muscle tension and libido lacks any supporting evidence:

• Fistulotomy for low transsphincteric fistulas involves division of only the lower third of the external anal sphincter, which should not create chronic muscle tension that affects sexual function 2
• The primary complications documented after fistulotomy are continence disturbances (10-20% risk), not sexual dysfunction 3
• Studies examining sexual function after fistula repair focus on pain during intercourse, incontinence during intercourse, and vaginal caliber changes—not muscle tension affecting libido 4

Actual Risk Factors for Sexual Dysfunction You Should Evaluate

If you're experiencing sexual dysfunction 6 months post-fistulotomy, consider these evidence-based causes:

• Pain during intercourse: This is a documented complication that affects 23.5% of patients after fistula-related procedures and could be related to surgical scarring or inadequate healing 4
• Incontinence during intercourse: This affects 15% of patients and can profoundly impact sexual confidence and desire 4
• Psychological factors: The trauma of anorectal surgery, fear of incontinence, and body image concerns are significant contributors to reduced libido 1
• Testosterone deficiency: Loss of libido warrants evaluation of testosterone levels, with levels <230 ng/dL typically benefiting from testosterone replacement therapy after careful discussion of risks and benefits 1

Recommended Evaluation and Management Approach

Rather than pursuing muscle relaxation therapy without evidence, follow this algorithm:

1. Assess for mechanical complications:

   • Examine for persistent pain, which may indicate incomplete healing, abscess recurrence, or scar tissue 5
   • Evaluate continence status using validated tools like the Wexner Continence Grading Scale 6, 7
   • Check for signs of fistula recurrence (recurrence rates can reach 44% with inadequate initial drainage) 5

2. Evaluate hormonal status:

   • Measure total testosterone levels, as symptomatic men with decreased libido and TT <230 ng/dL usually benefit from a trial of testosterone replacement 1
   • Consider a 4-6 month trial if TT is 231-346 ng/dL with careful discussion of risks and benefits 1

3. Address psychological factors:

   • Sexual dysfunction after anorectal procedures has substantial psychological components that require counseling 4
   • Consider referral to a sexual health specialist or psychologist experienced in post-surgical sexual dysfunction 1

4. Rule out cardiovascular risk factors:

   • Men with erectile dysfunction over age 30 are at increased cardiovascular risk and warrant noninvasive cardiovascular evaluation 1
   • Lifestyle modifications including smoking cessation, regular exercise, weight loss, and Mediterranean diet can improve sexual function 1

Why Pelvic Floor Physical Therapy May Not Help Your Specific Problem

While pelvic floor exercises have a role in post-surgical care, they target different outcomes:

• Pelvic floor exercises and biofeedback are effective for faecal urgency and incontinence after pelvic radiotherapy, not for libido 1
• These interventions address mechanical dysfunction of the pelvic floor, not sexual desire 1
• There is no evidence that "over-tense" muscles cause loss of libido in the post-fistulotomy population

Critical Pitfall to Avoid

Do not pursue unproven treatments while ignoring established causes of sexual dysfunction:

• Attributing libido loss to muscle tension without evidence may delay appropriate evaluation for hormonal deficiency, psychological factors, or mechanical complications 1, 4
• The absence of any literature connecting sphincter muscle tension to libido after fistulotomy suggests this is not a recognized mechanism of sexual dysfunction in this population