What techniques should a pelvic floor therapist perform at each session for a patient with chronic pelvic‑floor pain following lateral sphincterotomy and trans‑sphincteric fistulotomy?

Pelvic Floor Physical Therapy Techniques for Post-Sphincterotomy Chronic Pelvic Pain

Pelvic floor therapists should perform internal and external myofascial release with manual trigger-point therapy, progressive muscle relaxation training, and gradual desensitization exercises at each session, avoiding any strengthening or Kegel exercises which will worsen the underlying muscle tension. 1, 2

Core Treatment Components at Each Session

Manual Myofascial Release (Primary Technique)

• Internal transvaginal or transrectal myofascial release targeting pelvic floor trigger points should be performed at every visit, as this technique achieved 63% significant pain improvement in patients with myofascial pelvic pain 3
• External myofascial work addressing the obturator internus, piriformis, and levator ani muscles should accompany internal work 1
• Sessions should occur 2-3 times weekly initially, with most patients requiring a mean of 9 sessions for completion 4

Progressive Desensitization Protocol

• Gradual desensitization exercises must be incorporated to address the neuropathic hypersensitivity that develops after sphincterotomy 1
• The therapist should systematically work from less sensitive to more sensitive areas, respecting pain thresholds while progressively expanding tolerance 1

Muscle Coordination Retraining

• Down-training exercises to reduce excessive pelvic floor muscle tone and break the protective guarding pattern that persists after surgery 1, 2
• Focus on muscle relaxation techniques rather than strengthening, as the problem is hypertonicity, not weakness 2, 5

Critical Techniques to AVOID

Never Perform Strengthening Exercises

• Pelvic floor strengthening (Kegel) exercises are contraindicated in this population because they worsen pelvic floor tension and trigger-point activity in chronic pelvic pain syndrome 2
• The AUA guideline gives this a Standard recommendation based on the understanding that these patients have hypertonic, not weak, pelvic floor muscles 2

Never Perform Manual Dilation

• Manual anal dilatation must never be performed as it carries a 30% temporary and 10% permanent incontinence rate 1, 2
• This intervention would worsen the neuropathic component rather than improve symptoms 1

Adjunctive Home Therapy Instructions

Self-Care Between Sessions

• Warm sitz baths should be prescribed for home use to promote sphincter and pelvic floor muscle relaxation 6
• Proper hydration and bowel regimen management to prevent constipation and reduce anal trauma 6

Topical Neuropathic Pain Management

• Coordinate with the referring physician to ensure topical lidocaine 5% ointment is prescribed for application to affected areas between therapy sessions 6, 1

Expected Timeline and Monitoring

Treatment Duration

• Dysesthesia and altered sensations typically improve significantly over 6-12 months with appropriate pelvic floor therapy 1
• Pain scores should be tracked at each visit using numeric rating scales, with average pain expected to decrease by approximately 60% (from ~5.08 to ~1.91) in responsive patients 4

Session Frequency Adjustment

• Begin with 2-3 sessions weekly, then taper frequency as symptoms improve and the patient demonstrates ability to perform home relaxation techniques 1
• Most patients complete treatment within 9 sessions on average, though post-surgical cases may require extended therapy 4

Multidisciplinary Coordination

Pain Management Integration

• The physical therapist should coordinate with pain management for consideration of gabapentin or pregabalin for neuropathic pain control 6
• Muscle relaxants may be prescribed by the physician (19% of similar patients required baclofen) to augment physical therapy 4

Behavioral Health Referral

• Screen for comorbid depression, anxiety, or post-traumatic stress disorder, as these are commonly associated with chronic pelvic pain and require concurrent treatment 7, 8
• Behavioral therapy should be integrated as part of the overall treatment plan 7

Documentation and Outcome Measures

Track at Each Visit

• Minimum, average, and maximum pain numeric rating scales (0-10) 4
• Percent global improvement assessment from the patient's perspective 4
• Functional outcomes (ability to sit, work, engage in activities) rather than just numerical pain ratings 6