Can altered sexual stimulation feelings, such as more vivid anal play sexual fantasies, in a patient with a history of depression, anxiety, and fatigue, be attributed to internal or external anal sphincter pressure after a fistulotomy?

Altered Sexual Sensations and Sphincter Pressure: Internal vs External Sphincter

Altered sexual stimulation feelings, including more vivid anal play fantasies pre-fistulotomy, are primarily mediated by the internal anal sphincter (IAS) through its tonic pressure and autonomic innervation, rather than the external sphincter.

Neurophysiologic Basis for Internal Sphincter Dominance

The internal anal sphincter generates the majority (70-80%) of resting anal canal pressure and is under autonomic control, making it the primary mediator of baseline sensory tone 1. Research demonstrates that:

• Resting anal pressure (controlled by IAS) was significantly lower in individuals engaging in anoreceptive activity (70.7 mm Hg vs 91.4 mm Hg in controls), while maximum squeeze pressure (EAS-mediated) showed no significant difference 1
• Sympathetic nerve stimulation of the presacral nerves causes sharp drops in anal tone (mean 59 cmH2O), demonstrating that IAS relaxation is neurologically mediated and can be modulated by autonomic arousal states 2
• The IAS responds to autonomic arousal and psychological states through sympathetic pathways, which explains why sexual fantasies and anticipation can alter perceived anal sensations even without physical stimulation 2

Why External Sphincter Plays a Secondary Role

The external anal sphincter is voluntarily controlled skeletal muscle that contributes primarily to squeeze pressure rather than baseline sensory tone:

• No significant EAS changes were found in individuals with extensive anoreceptive experience, indicating the EAS adapts without altering baseline sensory perception 1
• The EAS showed no EMG response to vaginal distension during sexual stimulation studies, while IAS activity increased progressively, demonstrating differential roles in sexual response 3
• Maximum squeeze pressures (EAS function) remained normal in anoreceptive individuals despite altered resting pressures, confirming EAS is not the primary mediator of altered sexual sensations 1

Clinical Implications for Pre-Fistulotomy Patients

Your patient's more vivid anal play fantasies likely reflect:

• Heightened IAS tone from chronic inflammation or anxiety associated with the fistula, creating increased baseline sensory awareness 1, 2
• Autonomic dysregulation related to depression and anxiety (noted in your patient's history), which directly modulates IAS tone through sympathetic pathways 2
• Psychological amplification of normal IAS-mediated sensations, where anxiety and anticipation increase autonomic arousal and subsequently IAS tone 2

Post-Fistulotomy Considerations

Fistulotomy necessarily divides portions of the internal sphincter, which will alter the neurophysiologic substrate responsible for these sensations:

• Permanent anatomical changes occur to the IAS during fistulotomy, affecting long-term tissue characteristics and sensory perception 4
• Neuropathic changes rather than mechanical sphincter damage typically cause altered sensations following anorectal surgery 5
• The underlying cryptoglandular infection predisposition persists indefinitely, requiring ongoing vigilance 4

Common Pitfall to Avoid

Do not assume these altered sensations represent purely psychological phenomena. The IAS is a smooth muscle organ under autonomic control that directly responds to emotional states, stress, and sexual arousal through measurable changes in tone and pressure 2. The patient's depression and anxiety are physiologically modulating IAS function, not merely creating "imagined" sensations.