Why does a 38‑year‑old male, after lateral sphincterotomy, hemorrhoidectomy, fissurectomy and a low transphincteric fistulotomy (resting internal anal sphincter pressure reduced from ~138 to ~110 mm Hg), experience complete loss of deep‑pelvic “anchor” sensation for sexual arousal and bladder fullness, and does differentiating loss of internal anal sphincter tone from guarding affect his management?

Post-Sphincterotomy Sensory Loss: Neuropathic Dysesthesia, Not Mechanical Failure

Your complete loss of the deep pelvic "anchor" sensation is neuropathic dysesthesia and protective pelvic floor muscle guarding—not simply reduced internal anal sphincter tone—and requires specialized pelvic floor physical therapy rather than concern about the degree of pressure loss. 1, 2

Why the "Anchor" Is Completely Gone (Not Just Diminished)

The critical misunderstanding: You're experiencing altered nerve signaling and chronic muscle tension patterns, not a proportional reduction in sphincter pressure. 1, 2

The Neuropathic Component

• Your surgeries (lateral sphincterotomy, fissurectomy, and fistulotomy with revision) created neuropathic pain and dysesthesia in the pelvic floor nerves, fundamentally changing how sensory information is processed. 1
• This is not about having "less pressure to feel"—it's about the sensory pathways themselves being disrupted and sending altered signals to your brain. 1, 2
• The fact that you passed pudendal nerve pinprick testing does not rule out neuropathic dysesthesia, as these are different types of nerve dysfunction. 1

The Myofascial/Guarding Component

• Protective guarding patterns developed during your prolonged painful fissure period and have persisted even after surgical healing. 1, 2, 3
• This chronic pelvic floor muscle tension actively blocks normal sensory perception during sexual arousal and bladder filling. 1, 2
• Critical point: The warm water bath test you performed does not differentiate guarding from tone loss because neuropathic dysesthesia and chronic myofascial tension don't respond to simple warm water relaxation the way acute muscle spasm would. 1, 3

Why Your Pressure Numbers Don't Explain the Problem

Your internal anal sphincter pressure dropped from 138 to 110 mm Hg—but this mechanical change is not the cause of your sensory loss. 4

The Evidence on Pressure Changes

• Post-sphincterotomy patients maintain resting pressures of 110 mm Hg (exactly your level), which is still significantly higher than healthy controls (73 mm Hg), yet they remain continent and symptom-free. 4
• The 28 mm Hg reduction you experienced represents a 20% decrease, not a complete loss of sphincter function. 4
• No patients in long-term studies reported permanent functional problems with this degree of pressure reduction. 4

Why You Feel Nothing Instead of "Less"

• Your brain relied on a specific pattern of proprioceptive and pressure signals for sexual arousal—this was a learned sensory integration, not just raw sphincter pressure. 1, 2
• The combination of nerve injury, altered tissue architecture from multiple surgeries, and chronic protective guarding has disrupted the entire sensory pattern, not just reduced its intensity. 1, 2
• Think of it like cutting specific wires in a complex circuit—the system doesn't just get dimmer, it stops functioning in that particular way entirely. 1

The Bladder Sensation Connection

Your new urinary bluntness after the fistulotomy revision confirms this is pelvic floor myofascial dysfunction, not isolated sphincter mechanics. 1, 3

• Bladder fullness sensation relies on pelvic floor proprioception and muscle coordination, which are disrupted by the same protective guarding and neuropathic changes affecting your sexual arousal. 1, 3
• This temporal correlation (worsening after fistulotomy revision with granulation tissue) suggests progressive pelvic floor muscle tension from repeated surgical trauma and healing complications. 1, 3

Treatment Algorithm (Not More Surgery)

Do not pursue additional surgical interventions—this will worsen the neuropathic component. 1, 2, 3

First-Line Treatment (Start Immediately)

• Specialized pelvic floor physical therapy 2-3 times weekly focusing on internal and external myofascial release. 1, 2, 3
• Topical lidocaine 5% ointment to the perianal area for neuropathic pain management. 1, 2, 3
• Gradual desensitization exercises guided by your physical therapist to retrain sensory pathways. 1, 2, 3
• Muscle coordination retraining to reduce the protective guarding patterns that developed during your 3+ years of anal pain and multiple surgeries. 1, 2, 3

Adjunctive Measures

• Warm sitz baths to promote muscle relaxation (though as you've discovered, this alone is insufficient). 1, 2, 3

Expected Timeline

• Dysesthesia and altered sensations typically improve significantly over 6-12 months with appropriate pelvic floor therapy and neuropathic pain management. 1, 3
• The absence of incontinence and your preserved sphincter integrity (110 mm Hg is well above the continence threshold) are favorable prognostic factors. 1, 4

Critical Pitfalls to Avoid

• Do not interpret your symptoms as "not enough sphincter left"—your 110 mm Hg resting pressure is adequate and higher than healthy controls. 4
• Do not seek sphincter reconstruction or revision—this would create more scar tissue and worsen neuropathic symptoms. 1, 2, 3
• Do not assume that because warm water doesn't help, nothing will—neuropathic dysesthesia and chronic myofascial tension require specialized neuromuscular retraining, not simple relaxation. 1, 3

What You're Actually Perceiving

When you try to feel the "anchor" sensation:

• You're not perceiving diminished IAS tone (which is still 50% higher than normal controls). 4
• You are perceiving disrupted sensory integration from neuropathic changes plus active interference from chronic pelvic floor muscle guarding. 1, 2
• The distinction between "perceiving low tone" versus "perceiving guarding" is clinically irrelevant—both are manifestations of the same neuropathic-myofascial problem requiring the same treatment approach. 1, 2, 3

Your 110 mm Hg sphincter tone is mechanically sufficient—the problem is sensory processing and muscle coordination, which pelvic floor physical therapy specifically addresses. 1, 2, 3, 4