Can fistulotomy scar tissue be trained or desensitized for sexual arousal in a patient who has undergone fistulotomy and is concerned about anal play?

Sexual Function After Fistulotomy: Scar Tissue and Sensory Adaptation

Unfortunately, fistulotomy scar tissue cannot be "trained" for sexual arousal, and the sensory changes are typically permanent, though neuroplastic adaptation to alternative erogenous zones may occur over time with psychological support.

Understanding Post-Fistulotomy Changes

The scar tissue that forms after fistulotomy fundamentally alters the anatomy and sensory innervation of the anal region:

• Fistulotomy creates permanent scarring by laying open the fistula tract and dividing sphincter muscle, which heals by secondary intention with fibrous tissue replacement 1
• Sensory nerve damage is inherent to the procedure, as the rich nerve plexus in the anoderm and perianal tissue is disrupted during tract excision 2, 3
• Scar tissue lacks the specialized sensory receptors (Meissner's corpuscles and free nerve endings) present in normal perianal skin that contribute to sexual sensation 3

What the Medical Literature Shows

Functional Outcomes After Fistulotomy

• Major continence impairment occurs in 26-28% of patients after fistulotomy, with only 26.3% maintaining perfect continence status (Vaizey score of 0) 3
• Minor incontinence and soiling affect an additional 11.6% of patients who had no baseline continence issues, representing altered sensation and sphincter function 4
• Keyhole deformity develops in 25% of cases when immediate sphincter repair is not performed, leading to chronic soiling and perianal irritation that further compromises the area 5

The Reality of Sensory Recovery

The medical literature provides no evidence that scar tissue can be "retrained" for sexual function:

• Scar tissue is metabolically inactive fibrous tissue without the capacity to regenerate specialized sensory nerve endings 2, 3
• Healing rates plateau at 81-95% by 5 years, but this refers to wound closure, not restoration of normal tissue architecture or sensation 3, 4
• No studies address sexual function recovery after fistulotomy, as the surgical literature focuses exclusively on continence and recurrence outcomes 2, 6, 3, 5, 4

Practical Approach for This Patient

Immediate Steps

The patient should schedule a follow-up consultation with their colorectal surgeon to discuss:

• Examination of the surgical site to assess healing, identify any keyhole deformity, and evaluate sphincter integrity 5
• Realistic expectations about sensory recovery, as the surgeon needs to explain that the altered sensation is likely permanent 3, 4
• Referral to pelvic floor physical therapy if there is associated pain, muscle tension, or dyssynergia that could be addressed 7, 8

Addressing Sexual Function Concerns

Neuroplastic adaptation to alternative erogenous zones is the most realistic approach:

• Sex therapy or counseling with a specialist experienced in sexual dysfunction after pelvic surgery can help the patient and partner adapt to changed anatomy
• Focus on developing sensitivity in other areas (perineum, genitals, other body regions) through gradual exploration and mindfulness techniques
• Psychological support is critical, as distress about the undisclosed anal play history may compound the functional concerns

What Will NOT Work

• Topical anesthetics or desensitizing agents are designed to reduce sensation, not restore it, and are contraindicated for this goal 1
• Aggressive manipulation or "training" of scar tissue risks creating new fistula tracts, abscesses, or chronic non-healing wounds 1, 7
• Surgical revision would only create more scar tissue and further compromise function 3, 4

Critical Caveats

Avoid These Pitfalls

• Do not attempt anal penetration during the healing phase (typically 6-12 weeks minimum), as this risks wound dehiscence, infection, or fistula recurrence 6, 5
• Watch for signs of recurrent fistula (drainage, pain, swelling), which occurs in 16.4% of cases and would require repeat surgery 3
• Screen for depression and anxiety, as sexual dysfunction after pelvic surgery significantly impacts quality of life and may require psychiatric intervention 3

Long-Term Considerations

• The patient's distress about not disclosing anal play is significant and suggests shame or fear of judgment that should be addressed therapeutically
• Future surgical procedures in this area (if fistula recurs) will create additional scarring and further compromise sensation 2, 4
• Continence issues may worsen over time, particularly if the patient had a complex fistula requiring division of significant sphincter muscle 3, 4

Bottom Line

The sensory changes from fistulotomy scar tissue are permanent and cannot be reversed through desensitization or training. The patient's best option is working with a sex therapist to develop alternative sources of sexual pleasure while processing the grief of losing this aspect of sexual function. The surgeon should have been informed about anal sexual activity preoperatively, as this might have influenced the surgical approach (favoring seton drainage or sphincter-sparing techniques over fistulotomy) 1, 7, 8. Moving forward, honest communication with healthcare providers is essential to optimize outcomes.