Can pelvic floor therapy help a patient with a history of failed LIFT (Ligation of Intersphincteric Fistula Tract) procedure and no fecal or flatus incontinence, but experiencing a breezier feeling in the fistulotomy site with occasional small amounts of air leakage?

Pelvic Floor Therapy for Post-Fistulotomy Air Leakage

Pelvic floor biofeedback therapy is strongly recommended for your symptom of minor air leakage through the fistulotomy site, as this represents a mild form of flatus incontinence that responds well to sphincter strengthening exercises. 1

Why This Symptom Warrants Treatment

Your "breezier feeling" with occasional small air leakage, while subtle, represents partial sphincter dysfunction that falls within the spectrum of fecal incontinence (which includes flatus incontinence). 1 The American Gastroenterological Association's stepwise approach to incontinence management applies here, even for mild symptoms. 1, 2

Evidence Supporting Biofeedback for Your Situation

Biofeedback therapy specifically improves squeeze pressures and continence outcomes in patients with partial external sphincter failure, which is precisely what you're experiencing after your failed LIFT procedure. 2, 3 The mechanism works by:

• Strengthening pelvic floor muscles through electronic and mechanical devices 2
• Improving sphincter sensation and coordination 2
• Enhancing voluntary contraction ability to prevent unwanted gas passage 3

Treatment Protocol

You should undergo at least 3 months of structured biofeedback therapy before considering any other interventions. 2, 3 This duration is critical because:

• Conservative measures alone benefit only approximately 25% of patients 1, 2
• Biofeedback has proven efficacy for sphincter weakness without the risks of surgical intervention 1
• The therapy is completely free of morbidity 1

What to Expect from Therapy

The biofeedback program should include:

• Electronic and mechanical devices to improve pelvic floor strength 2
• Scheduled defecation programs to optimize bowel habits 2, 3
• Toilet training techniques 2

Context of Your Failed LIFT Procedure

Your history is particularly relevant because:

• Failed LIFT procedures result in 50% healing rates with subsequent interventions, suggesting ongoing sphincter compromise 4
• Post-LIFT complications can include wound dehiscence (up to 14% of cases), which may have contributed to your current symptoms 1
• Incontinence rates after LIFT are underreported in literature, but one study showed 16% of patients developed increased incontinence post-LIFT 1

Critical Pitfall to Avoid

Do not proceed with any additional surgical intervention (such as repeat fistulotomy or advancement flap) without completing at least 3 months of documented pelvic floor therapy. 3 This is especially important given:

• Your baseline sphincter function is already compromised from the failed LIFT 4
• Patients with recurrent fistula after previous surgery have increased risk of impaired continence 3
• Any sphincter-dividing procedure would worsen your current air leakage 3

If Biofeedback Fails After 3 Months

Should symptoms persist despite adequate biofeedback therapy, the progression algorithm would be:

1. Perianal bulking agents (dextranomer injection) as next-line therapy 1, 2
2. Sacral nerve stimulation for moderate-to-severe symptoms 1, 2
3. Sphincteroplasty only when bulking and sacral nerve stimulation are unavailable or unsuccessful 2

Baseline Assessment Recommended

Before starting biofeedback, document your current sphincter function with anorectal manometry and/or endoanal ultrasound to identify any structural defects from the failed LIFT. 3 This baseline assessment will:

• Guide the biofeedback protocol 3
• Provide objective measures to track improvement 3
• Identify if you're a candidate for future interventions should biofeedback fail 3