What treatment options are available for a male patient with a history of fistulotomy, who now experiences tension and loss of sexual sensation without pain, which he attributes to guarding and being over-focused?

Management of Post-Fistulotomy Tension and Sexual Dysfunction

For a patient experiencing tension (not pain) and loss of sexual sensation after fistulotomy attributed to pelvic floor guarding, the primary treatment should be pelvic floor physical therapy with biofeedback, combined with cognitive behavioral therapy to address the psychological overlay of hypervigilance and guarding.

Understanding the Clinical Problem

This presentation is consistent with overactive pelvic floor (OPF) syndrome developing post-surgically:

• The patient describes tension without pain, which distinguishes this from typical surgical complications 1
• The attribution to "over-focusing" and "guarding" suggests a neuromuscular pattern of chronic pelvic floor muscle hypertonicity 1
• Loss of sexual sensation in the context of muscle tension indicates that protective guarding is interfering with normal sexual response 1
• This is a recognized complication where the pelvic floor muscles remain in a state of chronic contraction, creating a feedback loop of tension and dysfunction 1

Primary Treatment Approach

Pelvic Floor Physical Therapy (First-Line)

Pelvic floor muscle training with biofeedback is the cornerstone of treatment for OPF-related sexual dysfunction:

• Digital palpation assessment should confirm elevated pelvic floor muscle tone before initiating therapy 1
• Biofeedback-assisted pelvic floor exercises specifically target the ability to relax (not just contract) the pelvic floor muscles 1
• Manual therapy techniques by a specialized pelvic floor physical therapist can directly address muscle hypertonicity 1
• Treatment typically includes internal and external myofascial release techniques 1

Psychological Interventions (Concurrent)

Cognitive behavioral therapy should be initiated alongside physical therapy:

• CBT addresses the hypervigilance and "over-focusing" the patient describes, which perpetuates the guarding response 1
• Mindfulness-based interventions help reduce the anxiety-tension cycle that maintains pelvic floor overactivity 1
• Educational interventions explaining the mind-body connection in pelvic floor dysfunction reduce catastrophizing 1
• Couple therapy may be beneficial if the sexual dysfunction is creating relationship distress 1

Adjunctive Medical Treatments

Muscle Relaxants

If conservative measures are insufficient after 8-12 weeks:

• Diazepam suppositories (5-10mg rectally at bedtime) can reduce pelvic floor muscle hypertonicity 1
• Oral muscle relaxants may provide systemic benefit but have less targeted effect 1
• These should be used as adjuncts to physical therapy, not replacements 1

Botulinum Toxin A

For refractory cases with documented severe hypertonicity:

• Injection into the pelvic floor muscles can provide prolonged muscle relaxation 1
• This should only be considered after failure of conservative management 1
• Requires specialized expertise in pelvic floor injection techniques 1

What This Is NOT

This presentation should not be confused with:

• Ischemic priapism - which presents with pain and rigid erection requiring emergency treatment 2
• Non-ischemic priapism - which presents with persistent tumescence, not tension 2
• Peyronie's disease - which involves penile deformity and plaque formation 2
• Standard erectile dysfunction - which would respond to PDE5 inhibitors 2, 3

The patient's description of tension without pain, and the temporal relationship to fistulotomy, clearly indicates a pelvic floor muscle dysfunction pattern rather than a vascular or structural penile problem.

Multimodal Treatment Protocol

The evidence strongly supports a combined approach:

1. Immediate referral to a pelvic floor physical therapist with sexual health expertise 1
2. Concurrent psychological evaluation for CBT or mindfulness-based therapy 1
3. Patient education about the neuromuscular basis of symptoms to reduce anxiety 1
4. Reassessment at 8-12 weeks to determine if medical adjuncts are needed 1

Common Pitfalls to Avoid

• Do not prescribe PDE5 inhibitors - this is not erectile dysfunction and will not address the underlying pelvic floor hypertonicity 2, 3
• Do not assume this will resolve spontaneously - chronic pelvic floor tension requires active intervention 1
• Do not focus solely on physical therapy without addressing the psychological component - the patient's description of "over-focusing" indicates significant cognitive involvement 1
• Do not delay referral to specialists - early intervention prevents chronic pain patterns from becoming entrenched 1

Expected Outcomes

Research consistently demonstrates that multimodal approaches combining physical therapy, biofeedback, and psychological interventions are effective in:

• Normalizing pelvic floor muscle tone 1
• Reducing pain and tension 1
• Improving sexual function 1
• Breaking the cycle of guarding and hypervigilance 1

The prognosis is generally favorable with appropriate multidisciplinary treatment, though improvement typically requires 3-6 months of consistent therapy 1.