What could be causing numbness and lack of sensation in the pelvic floor region in a patient with a history of hemorrhoidectomy, fissurectomy, and lateral sphincterotomy?

Pelvic Floor Numbness After Anorectal Surgery: Nerve Injury Assessment

The numbness and lack of sensation in the pelvic floor region following hemorrhoidectomy, fissurectomy, and lateral sphincterotomy most likely represents iatrogenic pudendal or perineal nerve injury from the surgical procedures, and requires urgent neurologic and anorectal evaluation to assess for permanent nerve damage.

Primary Concern: Surgical Nerve Injury

The combination of these three anorectal procedures significantly increases risk for nerve damage:

• Lateral sphincterotomy specifically divides the internal anal sphincter and can injure branches of the pudendal nerve that provide sensation to the perianal region and pelvic floor 1
• Hemorrhoidectomy and fissurectomy can cause denervation of the pelvic floor through direct nerve trauma or devascularization during tissue excision 1
• Loss of sensation (rather than pain) indicates sensory nerve dysfunction, which is a recognized complication of pelvic floor surgery leading to functional impairment 1

Critical Diagnostic Steps

Immediate Physical Examination Components

The digital rectal examination must specifically assess 1:

• Anal reflex testing using light pinprick or scratch on perianal skin to evaluate intact sensory innervation
• Resting sphincter tone and squeeze pressure to assess motor function
• Perineal descent during simulated defecation and elevation during squeeze
• Observation for patulous anal opening which may indicate neurogenic dysfunction 1

Specialized Testing Required

Anorectal manometry is the essential first diagnostic test 1:

• Identifies anal weakness and reduced rectal sensation objectively
• Quantifies sphincter pressures to assess degree of denervation
• Should be performed before considering any additional interventions 1

Anal imaging with endoanal ultrasound or MRI should follow 1:

• Endoanal ultrasound visualizes internal sphincter integrity and can identify surgical trauma 1
• MRI is superior for external sphincter defects, atrophy, and assessment of pudendal nerve pathology 1
• MRI pelvis with high soft-tissue resolution can directly visualize pelvic floor musculofascial structures and detect denervation changes 1

Differential Considerations

Rule Out Serious Underlying Pathology

While nerve injury is most likely, you must exclude 2:

• Occult perianal sepsis or abscess formation causing nerve compression
• Atypical complications if there were pre-existing atypical fissures suggesting inflammatory bowel disease, which could cause progressive neurologic symptoms
• Excessive scarring from surgery causing nerve entrapment 1

Functional vs. Structural Causes

• Reduced rectal sensation can coexist with structural defects and may represent either nerve injury or altered sensory processing 1
• However, complete numbness strongly suggests structural nerve damage rather than functional sensory changes
• The timing immediately post-surgery makes iatrogenic injury the primary concern

Management Approach

Conservative Initial Management

If nerve injury is confirmed but incomplete 1:

• Pelvic floor physical therapy may help with neuromuscular re-education if some innervation remains
• Time for nerve recovery (3-6 months) before considering additional interventions
• Avoid further surgical procedures until full neurologic assessment is complete

When to Escalate

Refer to colorectal surgery and neurology if 1:

• Complete sensory loss persists beyond 3 months
• Associated fecal incontinence develops (indicating combined sensory and motor denervation)
• MRI demonstrates significant nerve injury or muscle atrophy
• Patient develops chronic pain syndromes or complex regional pain

Critical Pitfall to Avoid

Do not attribute this symptom to simple pelvic floor dysfunction or constipation 2. The surgical history combined with numbness (not pain) indicates structural nerve injury requiring specific neurologic evaluation, not empiric laxative therapy or behavioral modifications alone 1.