Can cutting of the external or internal anal sphincter (EAS/IAS) during surgical procedures such as lateral sphincterotomy or hemorrhoidectomy cause permanent ejaculation dysfunction in a patient with a history of pelvic floor surgery?

Lateral Sphincterotomy and Fistulotomy Do Not Cause Permanent Ejaculation Dysfunction

Cutting the external or internal anal sphincter during lateral sphincterotomy or fistulotomy does not cause permanent ejaculation dysfunction. These superficial anorectal procedures do not approach the deep pelvic autonomic nerves responsible for sexual and ejaculatory function 1.

Anatomical Distinction

The critical distinction lies in surgical depth and nerve anatomy:

• Lateral internal sphincterotomy and fistulotomy are superficial procedures that involve only the anal sphincter muscles at the anal canal level 1
• Ejaculatory function is controlled by deep pelvic autonomic nerves (hypogastric plexus, pelvic splanchnic nerves) located several centimeters away from the surgical field 1
• These deep autonomic nerves are only at risk during deep pelvic dissection such as rectal cancer surgery or radical prostatectomy, which are anatomically and surgically distinct from anorectal procedures 1

What Actually Occurs: Neuropathic Sensory Changes (Not Ejaculatory Dysfunction)

When sexual dysfunction is reported after lateral sphincterotomy, it represents:

• Neuropathic pain and dysesthesia rather than structural sphincter or nerve damage 2, 1
• Pelvic floor muscle tension and protective guarding patterns that developed during the painful fissure period and persist after surgery 2, 3
• Altered sensations with intact continence rather than mechanical problems 2, 1
• Hypersensitivity of contact receptors rather than loss of ejaculatory nerve function 3

Management Algorithm for Post-Sphincterotomy Sexual Discomfort

If a patient develops sexual discomfort after lateral sphincterotomy:

• Initiate specialized pelvic floor physical therapy 2-3 times weekly focusing on internal and external myofascial release, gradual desensitization exercises, and muscle coordination retraining 2, 3, 1
• Apply topical lidocaine 5% ointment to affected areas for neuropathic pain management 2, 1
• Prescribe warm sitz baths to promote muscle relaxation and reduce symptoms 2, 1
• Expect significant improvement over 6-12 months with appropriate therapy 1

Critical Pitfalls to Avoid

• Do not pursue additional surgical interventions, as this would worsen the neuropathic component rather than improve it 2, 3, 1
• Avoid manual anal dilatation entirely, as it carries a 30% temporary and 10% permanent incontinence rate 2, 3
• Recognize that this is myofascial/neuropathic pain requiring physical therapy, not structural nerve damage requiring surgical revision 2, 1

Documented Complications of Sphincterotomy (Not Including Ejaculatory Dysfunction)

The actual complications of lateral internal sphincterotomy include:

• Incontinence occurs in 2-12% of patients after hemorrhoidectomy with sphincter manipulation 4
• Temporary incontinence in 7-8.7% after lateral sphincterotomy, with no permanent incontinence reported 5
• De novo incontinence in 8.9% after lateral sphincterotomy for chronic anal fissure 6
• Transient gas incontinence that resolves over time 7

Notably, ejaculatory dysfunction is not listed among these complications in any guideline or research study.

Alternative to Lateral Sphincterotomy

For patients concerned about any sphincter-related complications:

• Botulinum toxin injection achieves 75-95% cure rates for chronic anal fissures with no risk of permanent incontinence or sexual dysfunction 2, 1
• Consider botulinum toxin after 8 weeks of failed topical therapy (calcium channel blockers first-line, nitroglycerin second-line) 2
• The mechanism involves temporary, reversible sphincter relaxation without permanent structural damage 2