In a male patient with pelvic‑floor guarding after lateral sphincterotomy and trans‑sphincteric fistulotomy, can tadalafil be used to treat chronic pelvic pain syndrome?

Tadalafil for Chronic Pelvic Pain Syndrome After Anorectal Surgery

Tadalafil 5 mg daily has limited proven benefit for chronic pelvic pain syndrome (CPPS), and in your specific post-surgical context with pelvic floor guarding, specialized pelvic floor physical therapy is the evidence-based first-line treatment, not tadalafil. 1, 2

Understanding Your Clinical Situation

Your patient's problem is fundamentally neuropathic pain and pelvic floor muscle tension rather than a vascular or smooth muscle issue that tadalafil would address. 1 The altered sensations and sexual dysfunction following lateral sphincterotomy are primarily dysesthesia and protective muscle guarding patterns that developed during the painful fissure period and persisted after surgery. 1, 2

Critical distinction: Patients with post-LIS sexual dysfunction typically have intact continence and intact sphincter structure—the problem is myofascial and neuropathic, not mechanical. 1

Evidence for Tadalafil in CPPS

Limited Supporting Evidence

• One randomized trial showed tadalafil 5 mg daily provided modest improvement in NIH-CPSI scores (-4.6 points) in men with refractory CP/CPPS, but it was significantly inferior to cernitin pollen extract for pain reduction. 3

• In Peyronie's disease (a different pelvic pain condition), daily tadalafil 5 mg demonstrated lower curvature progression rates and improved symptoms versus controls, working through collagen deposition reduction. 4

• One case report described symptom improvement in a female IC/PBS patient treated with tadalafil 5 mg daily over 12 months, theorizing benefit through bladder neck relaxation and pelvic vasodilation. 5

Why Tadalafil Is Not Your Answer Here

The mechanism of tadalafil—smooth muscle relaxation via NO-cGMP pathway—does not address the myofascial trigger points and neuropathic hypersensitivity that characterize post-sphincterotomy pelvic floor dysfunction. 1, 5 The AUA guideline on IC/BPS mentions PDE5 inhibitors for erectile dysfunction rehabilitation but does not recommend them for pelvic floor myofascial pain. 4

Evidence-Based Treatment Algorithm for Your Patient

First-Line: Specialized Pelvic Floor Physical Therapy

Initiate pelvic floor physical therapy 2-3 times weekly focusing on: 1, 2

• Internal and external myofascial release targeting pelvic floor trigger points
• Gradual desensitization exercises guided by the therapist
• Muscle coordination retraining to reduce protective guarding patterns
• Warm sitz baths for muscle relaxation

Evidence strength: The AUA IC/BPS guideline gives manual physical therapy for pelvic floor tenderness a Standard recommendation with Grade A evidence. 4 A randomized controlled trial showed 59% of patients with myofascial physical therapy reported moderate or marked improvement versus 26% with general massage (p<0.05). 4

In men with CPPS and pelvic floor dysfunction, trigger point release with paradoxical relaxation training improved sexual symptoms by 77-87% in responders, with 70% reporting clinical success. 6

Adjunctive Pharmacologic Management

• Topical lidocaine 5% ointment applied to affected areas for neuropathic pain control. 1, 2

• Consider gabapentin for neuropathic dysesthesia if topical therapy insufficient (though not specifically studied in this post-surgical context, it has evidence for neuropathic pain management). 4

Expected Timeline

Dysesthesia and altered sensations typically improve significantly over 6-12 months with appropriate pelvic floor therapy and neuropathic pain management. 2

Critical Pitfalls to Avoid

• Never pursue additional surgical interventions for post-LIS sexual dysfunction—this would worsen the neuropathic component rather than improve it. 1, 2

• Avoid manual anal dilatation entirely—it carries a 30% temporary and 10% permanent incontinence rate. 1, 7, 2

• Do not mistake this for a structural sphincter problem requiring surgical revision. The continence is intact; the issue is functional and sensory. 1

• Avoid pelvic floor strengthening exercises (Kegel exercises)—these should be avoided in patients with pelvic floor tension and trigger points, as they worsen the problem. 4

If You Still Want to Try Tadalafil

If conservative measures fail and you wish to trial tadalafil based on the limited CPPS evidence, use tadalafil 5 mg daily for at least 12 weeks. 3, 5 However, recognize this is off-label use with weak evidence in your specific post-surgical myofascial pain context, and it should be adjunctive to—not instead of—pelvic floor physical therapy. 1, 2, 8

The one comparative trial showed tadalafil was significantly inferior to cernitin for pain reduction in CPPS (only 8.9% achieved ≥50% pain improvement with tadalafil versus 50% with cernitin). 3

Future Prevention Strategy

For future patients with chronic anal fissures, botulinum toxin injection represents a safer alternative to lateral internal sphincterotomy, achieving 75-95% cure rates with no risk of permanent incontinence or sexual dysfunction. 1, 7, 2 This would have avoided your patient's current predicament entirely.