Sexual Arousal After Lateral Sphincterotomy and Fistulotomy
Deep sexual self-arousal is primarily tied to rectal sensation and external anal sphincter (EAS) activity rather than internal anal sphincter (IAS) pressure, and patients can regain arousal capacity without anal stimulation through specialized pelvic floor physical therapy with sensory retraining. 1, 2
Understanding the Neurophysiology
What Controls Sexual Arousal in This Context
Rectal sensation is closely associated with external anal sphincter electrical activity (r = 0.8, p < 0.0001), not with internal sphincter relaxation. 2
The perception of rectal sensations depends on slowly adapting mechanoreceptors lying parallel to the circular muscle of the rectal wall, which respond to distension patterns rather than simple pressure or volume. 3
Your preserved continence despite reduced IAS resting pressure indicates that the EAS and rectal sensory pathways remain functionally intact, which is favorable for recovery. 1, 2
Why Pressure Sensation Changed
Lateral internal sphincterotomy deliberately reduces IAS resting tone (the pressure you've lost), but this does not directly control sexual arousal mechanisms. 4
The altered pressure sensation you're experiencing represents neuropathic dysesthesia from surgical nerve disruption, not mechanical sphincter failure. 1, 5
This dysesthesia commonly develops after anorectal surgery and manifests as altered sensations rather than true mechanical problems. 1, 5
Primary Treatment Algorithm
First-Line Approach (Initiate Immediately)
Begin specialized pelvic floor physical therapy 2-3 times weekly focusing on:
Apply topical lidocaine 5% ointment to affected areas for neuropathic pain control. 1, 5
Advanced Sensory Retraining (Essential Component)
Biofeedback therapy with an anorectal probe and rectal balloon enhances rectal sensory perception and restores normal function in patients after lateral sphincterotomy or fistulotomy, with symptom improvement in more than 70% of patients with pelvic floor dysfunction. 1
Serial rectal balloon inflation training retrains sensory pathways through operant-conditioning principles, directly addressing your loss of sensation after surgery. 1
This training provides real-time feedback on dynamic changes, enabling effective retraining of the sensory pathways that control arousal responses. 1
A typical rehabilitation program consists of 8-10 weekly sessions, supplemented with home exercises. 1
Why Internal Therapy Is Mandatory
Internal anal sphincter dysfunction and impaired rectal sensory feedback cannot be adequately treated with external pelvic-floor techniques alone; therefore, internal therapy is required. 5
Biofeedback therapy specifically targets rectal sensation, tolerance of rectal distention, and coordination of the internal sphincter, which necessitates internal assessment and treatment. 5
Expected Timeline and Prognosis
The dysesthesia and altered sensations typically improve significantly over 6-12 months with appropriate pelvic floor therapy and neuropathic pain management. 1, 5
The absence of incontinence or structural damage is favorable and suggests better potential for improvement with conservative management. 1
Therapy success is strongly linked to provider competency and patient adherence to the full course of treatment. 1
Critical Pitfalls to Avoid
Do not pursue additional surgical interventions, as this would likely worsen the neuropathic component rather than improve it. 1, 5, 6
Avoid attributing sexual dysfunction to the fissure or surgery without thorough investigation—refer to urology or pelvic pain specialists for comprehensive assessment of pudendal nerve function if symptoms don't improve with pelvic floor therapy. 6
Do not assume that loss of IAS pressure means permanent loss of arousal capacity—the arousal mechanism depends on rectal sensation and EAS activity, both of which can be retrained. 1, 2
Therapist Qualifications Required
Pelvic-floor physical therapists should be specifically trained in anorectal disorders and equipped to deliver simultaneous feedback on abdominal push effort and anal/pelvic-floor relaxation. 1
The therapist must be competent in using biofeedback with internal anorectal probes and rectal balloon distension techniques. 1, 5
Mechanism of Recovery Without Masturbation
Deep breathing and variations in movement and muscle tension support sexual arousal perception, while elevated muscle tension, superficial breathing, and reduced body movement limit it. 7
Through self-awareness exercises and physical learning steps, patients can integrate their sexuality and increase its resistance to medical interferences. 7
The sensory retraining with rectal balloon inflation specifically reactivates the mechanoreceptors that trigger arousal sensations, independent of direct anal stimulation. 1, 3