Can pelvic floor physical therapy help alleviate sphincter tension and altered sexual function in a patient with a history of lateral sphincterotomy?

Pelvic Floor Physical Therapy for Post-Sphincterotomy Complications

Pelvic floor physical therapy with biofeedback should be offered as first-line treatment for sphincter tension and sexual dysfunction following lateral sphincterotomy, as it can address both the pelvic floor muscle dysfunction and altered sensation that commonly develop after this procedure.

Understanding the Problem

Lateral sphincterotomy, while effective for healing chronic anal fissures (96% success rate), causes fecal incontinence in up to 45% of patients at some point postoperatively, with women affected more frequently than men (53.4% vs 33.3%) 1. Although most incontinence episodes are transient, persistent symptoms occur in approximately 15% of patients years after surgery 1. The procedure disrupts normal sphincter function and can lead to:

• Altered pelvic floor muscle coordination - The surgical division of the internal anal sphincter creates compensatory tension patterns in surrounding pelvic floor muscles 1
• Sphincter hypertonicity or dyssynergia - Remaining sphincter muscles may develop paradoxical tension as a protective response 2
• Sexual dysfunction - Pelvic floor tension and altered sensation in the anogenital region can directly impact sexual function 3, 4

First-Line Treatment: Pelvic Floor Physical Therapy

Pelvic floor physiotherapy should be offered as the initial conservative approach for patients experiencing persistent sphincter tension and sexual dysfunction after sphincterotomy 3. This recommendation is based on:

• Strong guideline support - The American College of Oncology recommends pelvic floor physiotherapy as first-line treatment for patients with persistent pain, urinary/fecal leakage, and pelvic floor dysfunction 3
• Comprehensive symptom management - PFPT can simultaneously address sphincter dysfunction, pelvic pain, and sexual dysfunction 4
• Evidence of effectiveness - PFPT with or without supplemental modalities can improve or cure symptoms of fecal incontinence, hypertonic pelvic floor disorders, dyspareunia, and pelvic floor myofascial pain 4

Biofeedback Therapy as Essential Component

Biofeedback therapy should be incorporated into the treatment plan for patients with post-sphincterotomy complications 5. The evidence supports this approach:

• For fecal incontinence - Biofeedback is recommended for patients with fecal incontinence who don't respond to conservative measures alone, with some evidence suggesting it enhances outcomes when combined with exercises 5, 6
• For pelvic floor dyssynergia - Biofeedback teaches muscle isolation using perineal EMG surface electrode feedback and real-time visualization, which is particularly valuable for retraining abnormal muscle patterns 2
• For chronic pelvic pain - A 12-week program of biofeedback-directed pelvic floor re-education significantly improved pain scores (median decrease from 5.0 to 1.0, P=0.001) and urgency scores in patients with chronic pelvic pain syndrome 7

Specific Treatment Protocol

The treatment should follow this structured approach:

Initial Conservative Measures (3 months minimum)

• Scheduled toileting with proper posture - Buttock support, foot support, and comfortable hip abduction 2
• Constipation management - Aggressive treatment with agents like polyethylene glycol, maintained for many months until bowel motility normalizes 3, 2
• Lifestyle modifications - Education about bladder/bowel dysfunction, timed voiding, and adequate fluid intake 3

Pelvic Floor Muscle Training Protocol

The specific exercise regimen should include 3:

• Contraction duration: 6-8 seconds per contraction
• Rest period: 6 seconds between contractions
• Repetitions: 15 contractions per session
• Frequency: Two daily sessions of 15 minutes each
• Minimum duration: 3 months to obtain optimal benefits
• Critical requirement: Instruction from trained healthcare personnel to ensure correct technique 3

Biofeedback Integration

Biofeedback should utilize anorectal probe placement with a rectal balloon to provide feedback regarding dynamic changes during attempted muscle relaxation and contraction 5. This is particularly important for:

• Muscle isolation training - Using perineal EMG surface electrode feedback to teach proper pelvic floor muscle activation and relaxation 5, 2
• Sensory retraining - Rectal desensitization training or sensory adaptation training using serial balloon inflation 5
• Real-time feedback - Allowing patients to visualize muscle activity patterns and correct dyssynergic patterns 5

Addressing Sexual Dysfunction

For persistent sexual dysfunction, the treatment should include 3:

• Pelvic floor exercises - Can decrease anxiety, discomfort, and improve pelvic floor muscle coordination that affects sexual function 3
• Cognitive behavioral therapy - Should be incorporated to address anxiety and psychological components 3
• Topical lidocaine - Can be offered for persistent introital pain and dyspareunia 3
• Low-dose vaginal estrogen (for women) - May be used for more severe symptoms or those who don't respond to conservative measures 3

Treatment Duration and Expectations

A rigorous 3-month trial of conservative therapy must be completed before considering any additional interventions 2. Success rates with comprehensive treatment approaches can reach 90-100% when properly implemented 5. Treatment success is measured by:

• Improvement in frequency and severity of incontinence episodes 5
• Reduction in pain and tension symptoms 7
• Enhanced sexual function and quality of life 4
• Patient-reported satisfaction with outcomes 5

When to Escalate Care

If symptoms persist after 3 months of comprehensive conservative therapy, consider 5:

• Anorectal manometry - To identify anal weakness, altered rectal sensation, and impaired function 2
• Perianal bulking agents - Intraanal injection of dextranomer when conservative measures and biofeedback fail 5
• Sacral nerve stimulation - For moderate or severe fecal incontinence unresponsive to conservative measures 5
• Sphincteroplasty - May be considered when other interventions have failed, though this adds additional surgical risk 5

Critical Pitfalls to Avoid

• Premature discontinuation of constipation management - Treatment may need to be maintained for many months before bowel motility and rectal perception normalize 3
• Inadequate professional instruction - Pelvic floor exercises without proper instruction from trained healthcare personnel often fail due to incorrect muscle activation 3
• Ignoring behavioral comorbidities - Psychiatric and behavioral comorbidities must be addressed concurrently as they significantly impact treatment adherence and outcomes 5, 2
• Insufficient treatment duration - The minimum 3-month duration is essential; shorter trials are inadequate to assess true treatment response 3, 2
• Overlooking the need for specialized equipment - Effective biofeedback for post-surgical complications requires equipment that provides simultaneous feedback on abdominal push effort, anal relaxation, and pelvic floor activity 5

Provider Selection

Referral to a pelvic floor physical therapist with specific training in anorectal disorders is essential 5, 3. Many therapists are trained primarily for urinary dysfunction but lack expertise in anorectal and sexual dysfunction management 5. The provider should have:

• Access to appropriate biofeedback equipment with anorectal probe capabilities 5
• Experience treating post-surgical pelvic floor complications 5
• Ability to address both sphincter dysfunction and sexual dysfunction concurrently 4