What are the likely causes and recommended management for loss of deep pelvic sensation affecting sexual arousal and urinary perception in a 38‑year‑old man after lateral internal sphincterotomy, hemorrhoidectomy, fissurectomy, and low trans‑sphincteric fistulotomy with normal pudendal nerve testing?

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Loss of Deep Pelvic Sensation After Anorectal Surgery

Direct Answer

Your symptoms of blunted sexual arousal and urinary sensation after lateral internal sphincterotomy and fistulotomy are most likely caused by iatrogenic injury to the pelvic floor musculature and autonomic nerve plexuses during surgery, not pudendal nerve damage. The normal pudendal nerve testing confirms this is not a peripheral nerve compression issue but rather reflects disruption of the complex sensory-motor feedback loops involving the internal anal sphincter, pelvic floor muscles, and autonomic innervation that contribute to deep pelvic proprioception and arousal mechanisms 1.

Understanding the Mechanism

Sphincter Function and Pelvic Sensation

  • The internal anal sphincter (IAS) is anatomically distinct from deep pelvic autonomic nerves, being a superficial structure confined to the anal canal level, but it plays a critical role in pelvic floor proprioception 1.

  • Protective guarding patterns develop during painful defecation and persist even after the acute problem resolves, creating altered sensory-motor patterns in the pelvic floor 1.

  • The IAS extends approximately 1.2 cm cephalad from the proximal margin of the external anal sphincter, with 1.7 cm of overlap between the two sphincters—this anatomical relationship means surgical division affects a broader functional unit than just the sphincter itself 1.

Surgical Impact on Sensation

  • Sphincter defects have been documented in up to 12% of patients after hemorrhoidectomy, primarily due to excessive retraction and extensive dilation of the anal canal 1, 2.

  • Lateral internal sphincterotomy causes a significant decline in resting anal pressure that persists long-term—in one study, basal pressure dropped from 138 mm Hg pre-operatively to 110 mm Hg at 12 months, indicating permanent alteration of sphincter function 3.

  • The IAS is thin and pale pink, lying in close proximity to the anorectal mucosa, making it vulnerable to iatrogenic injury during anorectal procedures 1.

  • Wound-related complications occur in up to 3% of patients after lateral internal sphincterotomy and can result in permanent alterations in sphincter function 1.

Why Your "Anchor Point" Disappeared

The Proprioceptive Mechanism

Your description of a deep pelvic pressure "anchor point" for arousal suggests you relied on proprioceptive feedback from the pelvic floor musculature and anal sphincter complex. This is not uncommon—many individuals unconsciously use pelvic floor tension and sphincter tone as part of their arousal response.

  • The surgical division of the internal sphincter eliminated the baseline tone and stretch receptors that provided this proprioceptive feedback 3.

  • The fistulotomy further disrupted the anatomical integrity of the sphincter complex and surrounding tissues, compounding the sensory loss 1.

  • The granulation tissue requiring revision indicates prolonged inflammation and healing, which can cause fibrosis and further sensory nerve damage 2.

Why Urinary Sensation Changed

The blunted urinary sensation after your second surgery (fistulotomy) likely reflects:

  • Shared autonomic innervation between the anal sphincter complex and bladder neck—surgical trauma can affect the hypogastric and pelvic nerve plexuses that run in close proximity 1.

  • Altered pelvic floor muscle coordination affecting the sensation of bladder filling and voiding 1.

  • This is distinct from urinary retention (a common complication occurring in 2-36% after hemorrhoidectomy) and instead represents sensory blunting 2.

Management Approach

Immediate Assessment

You need specialized evaluation by a colorectal surgeon and pelvic floor physical therapist, not just reassurance that "time will heal it." Three years post-initial surgery and 7 months post-fistulotomy is sufficient time to conclude this is not resolving spontaneously.

  • Request anorectal manometry to objectively measure sphincter pressures and assess the degree of sphincter dysfunction 3.

  • Consider endoanal ultrasound to visualize sphincter defects and assess the extent of structural damage 2.

  • Obtain urodynamic studies if urinary symptoms are significantly affecting quality of life 2.

Pelvic Floor Rehabilitation

Pelvic floor physical therapy is your primary treatment option and should be initiated immediately 1.

  • A specialized pelvic floor therapist can teach you biofeedback techniques to re-establish proprioceptive awareness and voluntary control of remaining pelvic floor musculature 1.

  • Internal manual therapy may help release fibrotic tissue and improve tissue mobility 1.

  • Electrical stimulation therapy may help re-establish sensory pathways 1.

Sexual Function Rehabilitation

  • Work with a sex therapist experienced in pelvic floor dysfunction to develop alternative arousal pathways that do not rely on the lost proprioceptive feedback 1.

  • Consider vibration therapy or other sensory augmentation techniques to compensate for diminished sensation 1.

  • Phosphodiesterase-5 inhibitors (sildenafil, tadalafil) may improve genital blood flow and partially compensate for autonomic dysfunction, though this addresses vascular rather than sensory issues 1.

Critical Pitfalls to Avoid

Do Not Pursue Additional Surgery

  • Further surgical intervention on the sphincter complex will only worsen your sensory deficits 1, 2.

  • Manual dilatation is absolutely contraindicated due to unacceptably high incontinence rates (30% temporary, 10% permanent) and would further damage remaining sensory structures 1, 4.

  • Revision sphincteroplasty is not indicated because you do not have fecal incontinence—your problem is sensory, not motor 2.

Do Not Accept "It's All in Your Head"

Your symptoms are real and have a clear anatomical basis. The fact that pudendal nerve testing is normal does not exclude pelvic floor dysfunction—pudendal nerve testing only assesses peripheral nerve conduction, not the complex integration of sphincter proprioception, autonomic innervation, and central processing that underlies your symptoms 1.

Prognosis and Realistic Expectations

What Recovery Looks Like

  • Complete restoration of your pre-surgical sensation is unlikely because the surgical division of the internal sphincter is permanent and the proprioceptive receptors in that tissue cannot regenerate 3.

  • However, significant functional improvement is possible through neuroplasticity—your nervous system can learn to use alternative sensory inputs for arousal and bladder awareness 1.

  • Most patients who engage in dedicated pelvic floor rehabilitation report meaningful improvement in sexual function and quality of life within 3-6 months, though full adaptation may take 12-18 months 1.

Long-Term Outlook

  • The gradual increase in sphincter tone observed after lateral internal sphincterotomy (from 86 mm Hg at 1 month to 110 mm Hg at 12 months) indicates some recovery of sphincter function, though it remains permanently lower than baseline 3.

  • This partial recovery may allow some return of proprioceptive feedback, but it will likely remain diminished compared to your pre-surgical state 3.

  • Your quality of life outcome depends more on successful adaptation and compensation strategies than on anatomical restoration 1.

Specific Action Plan

  1. Within 1 week: Schedule consultation with a colorectal surgeon experienced in sphincter dysfunction for anorectal manometry and endoanal ultrasound 3, 2.

  2. Within 2 weeks: Begin pelvic floor physical therapy with a therapist certified in pelvic floor dysfunction (look for PRPC certification) 1.

  3. Within 1 month: Establish care with a sex therapist or urologist specializing in sexual dysfunction related to pelvic surgery 1.

  4. Ongoing: Commit to at least 6 months of intensive pelvic floor rehabilitation before concluding that maximum recovery has been achieved 1.

References

1
Guideline

Internal Anal Sphincter Function and Clinical Implications

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Guideline

Treatment of Anal Fissure

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Related Questions

In a 38‑year‑old man who underwent a lateral internal anal sphincterotomy (with hemorrhoidectomy, fissurectomy and low trans‑sphincteric fistulotomy) and now reports loss of deep‑pelvic “anchor” sensation and blunted urinary sensation, how much resting internal anal sphincter pressure is typically lost, and does this loss represent loss of passive IAS tone rather than a guarding contraction?
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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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