Can tadalafil be added to the pelvic‑floor rehabilitation program for a patient with pelvic guarding due to loss of anal sphincter sensory feedback after lateral sphincterotomy and trans‑sphincteric fistulotomy?

Tadalafil as Adjunct to Pelvic Floor Rehabilitation for Post-Surgical Pelvic Guarding

Tadalafil is not recommended as an adjunct to pelvic floor rehabilitation for pelvic guarding following anal sphincter surgery, as there is no evidence supporting its use for this indication, and the primary treatment should be biofeedback-based pelvic floor therapy alone. 1, 2, 3

Evidence-Based Treatment Algorithm

First-Line Treatment: Biofeedback Therapy Alone

Pelvic floor biofeedback therapy is the definitive treatment for pelvic floor dysfunction following sphincter surgery, with success rates of 70-80% when properly implemented. 1, 2, 3

The treatment approach should follow this sequence:

• Initiate structured biofeedback therapy for at least 3 months before considering any other interventions, as this is the American Gastroenterological Association's recommended first-line treatment for partial sphincter dysfunction. 1

• The biofeedback program must include electronic and mechanical devices to improve pelvic floor strength, scheduled defecation programs, and toilet training techniques. 1

• Baseline anorectal manometry and/or endoanal ultrasound should be performed to document current sphincter function, identify structural defects from the prior surgeries, guide the biofeedback protocol, and track improvement. 1, 2

Why Tadalafil Is Not Indicated

The evidence base for tadalafil is limited to erectile dysfunction, not pelvic floor muscle dysfunction or sensory feedback issues:

• Tadalafil (a phosphodiesterase type 5 inhibitor) is recommended only for erectile dysfunction in prostate cancer survivors and men with pelvic trauma causing erectile dysfunction. 4, 5

• The single study examining tadalafil in pelvic trauma addressed erectile dysfunction following pelvic fracture-induced urethral injury, not anal sphincter dysfunction or pelvic floor guarding. 5

• No evidence exists supporting tadalafil for improving anal sphincter sensory feedback, pelvic floor muscle coordination, or guarding patterns. The mechanism of action (smooth muscle relaxation via nitric oxide pathway) does not address the neuromuscular dysfunction underlying pelvic floor guarding.

Mechanism of Biofeedback for Your Patient's Condition

Biofeedback specifically addresses the pathophysiology of pelvic guarding by training patients to relax pelvic floor muscles and restore normal coordination through visual or auditory feedback. 2, 3

• The therapy gradually suppresses nonrelaxing pelvic floor patterns through operant conditioning and relearning processes. 4, 2

• For patients with sensory loss (as in your case with loss of anal sphincter sensory feedback), biofeedback improves rectal sensory perception and enhances voluntary contraction ability. 4, 1, 2

• Biofeedback strengthens anal musculature and improves sphincter function in patients with partial sphincter failure, which is the relevant pathology after lateral sphincterotomy and trans-sphincteric fistulotomy. 1

Treatment Progression If Biofeedback Fails

Only after 3 months of adequate biofeedback therapy should alternative interventions be considered. 1, 3

The American Gastroenterological Association's progression algorithm is:

1. Perianal bulking agents 1, 3
2. Sacral nerve stimulation 1, 3
3. Sphincteroplasty (if structural defects are documented) 1, 3

Critical Implementation Points

• Seek gastroenterologist-supervised programs with instrumented biofeedback capability and verify the provider uses visual monitoring to demonstrate anorectal push/relaxation results. 3

• The biofeedback program should include pelvic floor muscle training with proper toilet posture, ensuring buttock support, foot support, and comfortable hip abduction to avoid simultaneous co-activation of abdominal and pelvic floor musculature. 4

• Biofeedback is completely free of morbidity and safe for long-term use, unlike pharmacological interventions. 2

Common Pitfalls to Avoid

• Do not add medications like tadalafil without evidence of benefit for the specific pathology. The guarding pattern requires neuromuscular retraining, not smooth muscle relaxation. 1, 2, 3

• Do not skip biofeedback and proceed directly to sacral nerve stimulation or surgery, as biofeedback is the recommended first-line treatment. 3

• Ensure adequate trial duration (at least 6 sessions with proper technique over 3 months) before declaring biofeedback failure. 1, 3