What treatment options are available for a male patient with diminished ejaculation three years after undergoing lateral sphincterotomy, fissureectomy, and hemorrhoidectomy?

Treatment Options for Diminished Ejaculation After Anorectal Surgery

This patient requires immediate referral to a urologist or sexual health specialist for comprehensive evaluation and management of persistent ejaculatory dysfunction, as pelvic floor physical therapy combined with behavioral modifications and potentially off-label pharmacotherapy represent the primary treatment pathways for this iatrogenic sexual dysfunction. 1

Understanding the Problem

The patient's diminished ejaculation three years post-surgery represents a form of anejaculatory orgasm (anorgasmia) that has become chronic. While the ability to orgasm remains intact, the ejaculatory volume or force is reduced. This is distinct from erectile dysfunction and requires separate evaluation and treatment. 1

Surgical Context and Mechanism

• Lateral internal sphincterotomy, while effective for chronic anal fissures, can cause alterations in pelvic floor muscle tone and neurovascular function that may affect sexual function 2, 3
• The anal sphincter hypertension that existed pre-operatively was likely secondary to the hemorrhoid disease itself, and surgical intervention altered the pelvic floor dynamics 2
• The three-year timeline suggests this is now a chronic condition requiring active intervention rather than expectation of spontaneous recovery 1

Primary Treatment Approach: Pelvic Floor Physical Therapy

Pelvic floor physical therapy should have been initiated early post-operatively and remains the cornerstone of treatment even at this late stage. 4

Components of Pelvic Floor Rehabilitation

• Manual physical therapy techniques to normalize muscle tone and improve muscle relaxation in the pelvic floor 4
• Pelvic floor muscle training (PFMT) tailored to the patient's specific clinical assessment, avoiding hyperactivity or increased tone situations 4
• Education about the relationship between pelvic floor function and ejaculatory physiology 4

Evidence Supporting This Approach

Pelvic floor physical therapy is simple, safe, and noninvasive, making it the preferred first-line approach for sexual dysfunction related to pelvic floor disorders. 4 The multifaceted approach combining manual therapy with targeted exercises has shown effectiveness in improving sexual function in males. 4

Behavioral and Psychological Interventions

Arousal Enhancement Strategies

• Modify sexual positions or practices to increase arousal, as adequate arousal is essential for optimal ejaculatory function through psychosexual mechanisms 1
• Incorporate alternative sexual practices, scripts, and sexual enhancement devices to increase both physical and psychological arousal 1
• The ejaculatory process involves multiple glands that fill with fluid during arousal; insufficient arousal time can result in decreased ejaculate volume 5

Partner Involvement

• Include the sexual partner in decision-making whenever possible, as this is fundamental to optimizing outcomes in ejaculatory disorders 1
• Open communication between partners about sexual needs and desires is essential 5

Medical Evaluation and Reversible Causes

Before initiating pharmacotherapy, the following must be addressed:

Hormonal Assessment

• Check morning testosterone levels, as progressively lower serum testosterone correlates with increased symptoms of delayed ejaculation and anorgasmia 1
• Offer testosterone replacement therapy per AUA guidelines if biochemically low testosterone is confirmed 1

Medication Review

• Review and adjust any medications that may contribute to ejaculatory dysfunction, particularly SSRIs, antipsychotics, and antihypertensives 1

Comorbid Erectile Dysfunction

• If erectile dysfunction coexists, treat it first according to AUA guidelines, as ED and anorgasmia share common risk factors and treatment sequencing matters 1

Pharmacological Options (All Off-Label)

Important caveat: No FDA-approved treatments exist for anejaculatory orgasm, and all pharmacotherapy is off-label with weak evidence. 1 Patients must understand the limited evidence base and potential for known/unknown side effects. 1

Sympathomimetic Agents (First-Line Pharmacotherapy)

• Pseudoephedrine 60-120 mg 1
• Ephedrine 15-60 mg 1
• Midodrine 5-40 mg 1

These may be considered on an individualized basis with appropriate counseling about weak evidence and off-label use. 1

Alternative Pharmacological Agents

Other agents with potential benefit include:

• Oxytocin 24 IU intranasal/sublingual 1
• Bethanecol 20 mg daily 1
• Yohimbine 5.4 mg three times daily 1
• Cabergoline 0.25-2 mg twice weekly 1
• Imipramine 25-75 mg daily 1

Psychological Considerations

Mental Health Screening

• Assess for history of sexual abuse, decreased emotional intimacy, and relationship conflict, which are associated with ejaculatory disorders and may require mental health referral 1
• Screen for depression and mood disorders, which significantly impact arousal levels and orgasmic capacity 1

Treatment Algorithm

1. Immediate referral to urologist or sexual health specialist for comprehensive evaluation 6
2. Initiate pelvic floor physical therapy with a therapist experienced in male sexual dysfunction 4
3. Implement behavioral modifications to enhance arousal and optimize ejaculatory function 1, 5
4. Check testosterone levels and treat if low 1
5. Review and adjust contributing medications 1
6. Consider trial of sympathomimetic agents (pseudoephedrine, ephedrine, or midodrine) with informed consent about off-label use 1
7. Include partner in treatment planning whenever possible 1
8. Consider psychological/couples counseling if relationship or mood factors are identified 1

Outcome Expectations

Patient and partner satisfaction is the primary target outcome, not arbitrary physiological measures. 1 Recovery may be gradual, and some degree of permanent change is possible given the three-year duration. However, meaningful improvement in quality of life and sexual satisfaction remains achievable with comprehensive treatment. 1

Critical Pitfall to Avoid

The most significant error in this case was the failure to provide early pelvic floor physical therapy education and referral immediately post-operatively. 4 While this opportunity was missed, initiating treatment now remains worthwhile and may still yield significant benefit. 4