What could be causing my difficulty in achieving sexual arousal and ejaculation, particularly after a recent low transsphincteric fistulotomy, given my history of depression, anxiety, and fatigue?

Sexual Dysfunction Following Low Transsphincteric Fistulotomy

Direct Answer

Your symptoms of reduced ejaculatory force, decreased pleasure, and loss of arousal from previously stimulating activities (like bicycle riding) following anal fistulotomy most likely represent nerve damage from the surgery affecting the pelvic floor and perineal nerves, compounded by your underlying depression and anxiety which independently contribute to sexual dysfunction. 1

Understanding the Problem

Post-Surgical Nerve Damage

• Anal surgery, particularly fistulotomy, can damage the pudendal nerve branches and alter pelvic floor muscle function, directly affecting ejaculatory mechanics and genital sensation. 1 This explains why ejaculation now "takes more effort" and feels less forceful—the coordinated muscle contractions required for normal ejaculation have been disrupted.

• The loss of arousal from bicycle riding (perineal pressure stimulation) strongly suggests diminished perineal sensation from surgical nerve injury, as this area is innervated by branches that may have been affected during the fistulotomy procedure. 1

Depression and Anxiety as Contributing Factors

• Depression and anxiety independently cause decreased libido, arousal difficulties, and orgasmic problems through both psychological mechanisms and neurochemical pathways. 2, 3 Your history of these conditions means you have overlapping causes for sexual dysfunction.

• Anhedonia (inability to experience pleasure) from depression directly impairs sexual arousal and orgasmic capacity, which may explain why previously arousing stimuli no longer work. 3

Diagnostic Evaluation Required

Essential Laboratory Testing

• Morning serum total testosterone is mandatory, as low testosterone correlates with both ejaculatory dysfunction and reduced libido. 4, 1 Progressively lower testosterone levels are associated with increased symptoms of delayed ejaculation and anorgasmia. 4

• Basic metabolic panel, lipid profile, and hemoglobin A1c to assess for metabolic conditions causing neuropathy or vascular disease. 1

Focused Physical Examination

• Neurological assessment of perineal sensation and anal sphincter tone to evaluate for surgical nerve damage. 1

• Genital, perineal, and abdominal examination to assess for surgical complications, masses, or evidence of nerve injury. 1

Sexual History Details Needed

• Ejaculatory latency: how long it takes to ejaculate now versus before surgery. 1 This distinguishes between delayed ejaculation versus anorgasmia.

• Orgasm quality: whether you still experience orgasm despite reduced ejaculatory pressure. 1 Orgasm and ejaculation are distinct neurological events that can be impaired independently. 4

• Assessment of erectile function, as erectile dysfunction and ejaculatory disorders share common risk factors, and ED should be treated first if present. 4, 5

Treatment Algorithm

Step 1: Address Reversible Medical Causes

• If testosterone is low, initiate testosterone replacement therapy per AUA guidelines, as this improves both erectile and ejaculatory function in hypogonadal men. 4, 1

• If you are taking SSRIs for depression/anxiety, these medications commonly cause delayed ejaculation, decreased libido, and erectile dysfunction. 6 Consider switching to bupropion, mirtazapine, or agomelatine, which have fewer sexual side effects. 3

Step 2: Treat Coexisting Erectile Dysfunction First

• If erectile dysfunction coexists with your ejaculatory problems, treat the ED first with PDE5 inhibitors (sildenafil, tadalafil, vardenafil), as ED treatment may resolve ejaculatory complaints. 4, 5 ED and ejaculatory disorders share common risk factors, and the chronology matters for treatment sequencing. 4

Step 3: Behavioral and Psychological Interventions

• Modify sexual positions or practices to increase arousal and physical stimulation, as adequate arousal is essential for optimal ejaculatory function through psychosexual mechanisms. 4, 5

• Referral to a mental health professional with sexual health expertise is appropriate, as psycho-behavioral strategies may enhance arousal and remove barriers to sexual excitement related to your depression and anxiety. 1, 5

• Include your sexual partner in decision-making when possible, as this is fundamental to optimizing outcomes in ejaculatory disorders. 4

Step 4: Pharmacological Options (All Off-Label)

Important caveat: No FDA-approved treatments exist for ejaculatory dysfunction; all pharmacotherapy is off-label. 4

• Pseudoephedrine 60-120 mg taken 120-150 minutes prior to sexual activity may improve ejaculatory force and sensation by enhancing sympathetic nervous system activity. 4, 1

• Oxytocin 24 IU intranasal/sublingual during sexual activity may enhance ejaculatory function and orgasmic pleasure. 4, 1

• Other options with weaker evidence include ephedrine 15-60 mg (1 hour before sex), bethanecol 20 mg daily, yohimbine 5.4 mg three times daily, or imipramine 25-75 mg daily. 4

Step 5: Pelvic Physical Therapy

• Pelvic floor physical therapy may help restore coordinated muscle function after anal surgery, potentially improving ejaculatory force and reducing discomfort. 7 Post-surgical changes in pelvic floor muscle function can alter ejaculatory mechanics. 1

Critical Pitfalls to Avoid

Don't Assume It's "All in Your Head"

• While depression and anxiety contribute to sexual dysfunction, the temporal relationship with your surgery strongly suggests organic nerve damage as the primary cause. 1 Both factors are likely operating simultaneously.

Medication Side Effects Matter

• If you're taking SSRIs, these cause delayed ejaculation or inability to ejaculate, decreased sex drive, and erectile problems in a dose-dependent manner. 6 This is reversible with medication adjustment. 3

Treatment Success Is About Satisfaction, Not Physiology

• The primary treatment outcome is your satisfaction and quality of life, not achieving arbitrary physiological measures like pre-surgical ejaculatory force. 4, 1 Complete restoration to pre-surgical function may not always be achievable. 1

Sexual Dysfunction Is Underreported

• Many patients don't volunteer sexual complaints due to embarrassment, so clinicians must specifically ask about these symptoms. 1 You did the right thing by bringing this up.

Prognosis

• Many men experience improvement with appropriate treatment, though complete restoration to pre-surgical function may not always be achievable. 1

• The combination of addressing low testosterone (if present), optimizing depression/anxiety treatment, behavioral modifications, and potentially adding sympathomimetic agents offers the best chance for meaningful improvement. 4, 1, 5