What could be causing my decreased ejaculation intensity and altered sensation, which started after developing an anal fissure, and how can it be treated?

Decreased Ejaculation Intensity After Anal Fissure: Understanding the Connection

Your decreased ejaculation intensity and altered sensation following anal fissure development is likely unrelated to the fissure itself, as there is no established physiological mechanism connecting anal fissures to ejaculatory dysfunction. The temporal association you've noticed is most likely coincidental rather than causal.

Why Anal Fissures Don't Cause Ejaculatory Changes

Anal fissures are localized tears in the anal canal that do not affect the neurological or vascular pathways involved in ejaculation. 1

• Anal fissures involve a longitudinal tear in the anoderm extending from the dentate line to the anal verge, with approximately 90% located posteriorly in the midline 1
• The pathophysiology centers on internal anal sphincter hypertonia and decreased anodermal blood flow, creating an ischemic ulcer 1
• There is no anatomical or physiological connection between anal sphincter function and the ejaculatory reflex, which involves the sympathetic nervous system, vas deferens, seminal vesicles, and prostate 1

What You Should Consider Instead

Medication-Related Causes

If you've been prescribed any medications for urinary symptoms or other conditions around the same time, this could explain your symptoms. 2

• Alpha-blockers like tamsulosin cause abnormal ejaculation in a dose-dependent manner, including ejaculation failure, decreased ejaculation, and retrograde ejaculation 2
• In clinical trials, abnormal ejaculation occurred in 8.4% of patients on 0.4mg tamsulosin and 18.1% on 0.8mg, compared to 0.2% on placebo 2

Pain-Related Factors

Severe anal pain from the fissure may indirectly affect sexual function through pain anticipation, muscle tension, or psychological distress. 1

• Anal fissures cause severe pain with defecation that persists for 1-2 hours, which can create generalized pelvic floor tension 3
• Chronic pain conditions can lead to protective muscle guarding in the pelvic region 1

Recommended Treatment Approach for Your Anal Fissure

You should pursue aggressive conservative management of your anal fissure, as treating the underlying condition may help clarify whether there's any connection to your ejaculatory symptoms. 1

First-Line Conservative Management

• Increase dietary fiber to 25-30g daily through diet or supplementation to soften stools and minimize anal trauma 4, 5
• Ensure adequate fluid intake throughout the day to prevent constipation 1
• Perform warm sitz baths 2-3 times daily to promote internal anal sphincter relaxation 4, 5
• Approximately 50% of acute anal fissures heal with these measures alone within 10-14 days 1, 4, 5

Pharmacologic Treatment

If conservative measures fail after 2 weeks, add compounded topical 0.3% nifedipine with 1.5% lidocaine applied three times daily for at least 6 weeks. 6, 4

• This combination achieves 95% healing rates after 6 weeks of treatment 6, 4
• Pain relief typically occurs after 14 days of treatment 6, 4
• The calcium channel blocker reduces internal anal sphincter tone by blocking L-type calcium channels, increasing local blood flow to the ischemic ulcer 6, 5
• Lidocaine provides local anesthesia, reducing pain and breaking the pain-spasm-ischemia cycle 6

Critical Pitfalls to Avoid

• Never undergo manual anal dilatation, as it carries unacceptably high permanent incontinence rates of 10-30% 4, 5
• Do not use hydrocortisone beyond 7 days due to risk of perianal skin thinning and atrophy 6, 4

When to Consider Surgery

Surgical treatment should only be considered for chronic fissures (>8 weeks duration) that have failed comprehensive medical management. 1

• Lateral internal sphincterotomy is the gold standard surgical procedure with healing rates over 90% 1, 7
• Surgery carries a risk of fecal incontinence, which makes medical management preferable as first-line therapy 7, 8

What to Do About Your Ejaculatory Symptoms

You should seek evaluation from a urologist or sexual medicine specialist to investigate your ejaculatory dysfunction independently of the anal fissure. The evaluation should include:

• Complete medication review, particularly for alpha-blockers, antidepressants, or antihypertensives 2
• Assessment for other urological conditions affecting ejaculation
• Evaluation for psychological factors or pelvic floor dysfunction

The lack of any established connection between anal fissures and ejaculatory function in the medical literature strongly suggests these are separate issues requiring independent evaluation and treatment. 1, 3, 7, 8, 9, 10