After sphincteroplasty (pudendal‑nerve‑sparing repair) for low resting pressure of the internal anal sphincter and hypertonic puborectalis/external anal sphincter, why have I lost the rectal‑pelvic sexual sensations I previously experienced?

Loss of Rectal-Pelvic Sexual Sensations After Sphincteroplasty

Your loss of rectal-pelvic sexual sensations after pudendal-nerve-sparing sphincteroplasty is most likely caused by iatrogenic pudendal nerve damage during the intersphincteric dissection, combined with compensatory pelvic floor hypertonicity that developed postoperatively—not from the sphincter repair itself.

Understanding the Mechanism of Sensory Loss

The inferior rectal branches of the pudendal nerve (S2-S4) provide both motor innervation to the external anal sphincter and sensory innervation to the anal canal and perianal region 1. Despite the surgical intent to preserve these nerves, intersphincteric dissections place the inferior rectal branches at high risk because they course through the intersphincteric space 1. This anatomical vulnerability explains why you lost sensations even though the surgery was labeled "pudendal-nerve-sparing."

The Dual Injury Pattern

Your presentation suggests two concurrent problems:

• Neuropathic injury: The pudendal nerve branches were likely damaged during the intersphincteric approach, causing altered or absent sensory perception in the rectal-pelvic region 2, 1
• Secondary hypertonicity: Your puborectalis and external anal sphincter developed compensatory hypertonicity in response to the low internal sphincter resting pressure that prompted your original surgery 1, 3

This protective guarding pattern persists even after surgical correction and directly interferes with normal pelvic floor relaxation during sexual arousal 2, 3.

Why This Differs from Typical Post-Surgical Incontinence

Your case is unusual because most sphincteroplasty patients experience incontinence rather than sensory loss 4, 5. The key distinction:

• Typical sphincteroplasty complications involve mechanical sphincter failure with preserved sensation 4
• Your symptoms reflect neuropathic dysfunction with intact continence—altered sensations rather than mechanical problems 2
• The reversal of your normal anal canal resting pressure gradient (from the original low internal sphincter pressure) likely triggered chronic compensatory muscle tension 1, 5

Evidence-Based Treatment Algorithm

First-Line: Specialized Pelvic Floor Physical Therapy

Begin with intensive pelvic floor physical therapy 2-3 times weekly, focusing specifically on internal and external myofascial release 2. This addresses the hypertonicity component:

• Internal manual therapy to release puborectalis and external sphincter tension 2
• Gradual desensitization exercises guided by a therapist experienced in post-surgical pelvic floor dysfunction 2
• Muscle coordination retraining to reduce the protective guarding patterns that developed during your pre-surgical symptomatic period 2, 3
• Warm sitz baths to promote muscle relaxation 2

Success rates for pelvic floor biofeedback therapy exceed 70% in patients with dyssynergic pelvic floor patterns 1.

Adjunctive Neuropathic Pain Management

For the nerve injury component:

• Topical lidocaine 5% ointment applied to the affected perianal and anal canal areas can provide temporary relief of neuropathic dysesthesia 2
• This addresses the altered sensations that result from pudendal nerve branch injury rather than structural problems 2

Diagnostic Confirmation (If Not Already Performed)

If you have not yet undergone objective testing:

• Anorectal manometry will quantify whether your resting pressure remains low and whether paradoxical contraction (anismus) is present during simulated defecation 1
• High-resolution MRI can visualize the sphincter complex and identify any unrecognized structural complications from the surgery 1
• Digital rectal examination should reveal localized tenderness over the puborectalis if levator ani syndrome (chronic hypertonicity) has developed 1

Critical Pitfalls to Avoid

Do not pursue additional surgical interventions for your sensory loss 2. Further surgery would likely worsen the neuropathic component because:

• Your symptoms stem from nerve injury and myofascial dysfunction, not mechanical sphincter failure 2
• Revision surgery carries high risk of additional pudendal nerve damage 1
• Manual anal dilatation is absolutely contraindicated, with permanent incontinence rates of 10-30% 1, 3

Why Additional Surgery Would Fail

The evidence is clear that post-surgical sexual dysfunction after anal procedures is typically neuropathic and myofascial rather than mechanical sphincter failure, requiring physical therapy rather than surgical revision 2. Your intact continence confirms this pattern.

Prognosis and Realistic Expectations

The neuropathic component may be partially irreversible if significant axonal injury occurred 1. However:

• Addressing the hypertonicity through physical therapy can restore some pelvic floor relaxation capacity during sexual activity 2
• Sensory adaptation and neuroplasticity may gradually improve your perception over 12-24 months 2
• Complete restoration of pre-surgical sensations is unlikely if pudendal nerve branches were transected rather than merely stretched 1

What You Should Have Received Instead

Botulinum toxin injection represents a safer alternative to sphincteroplasty for anal sphincter dysfunction, achieving 75-95% cure rates with no risk of permanent incontinence or sexual dysfunction 2, 3. This reversible approach would have avoided the permanent nerve injury risk inherent in intersphincteric dissection 2.

Immediate Next Steps

1. Consult a pelvic floor physical therapist with specific experience in post-anorectal surgery rehabilitation 2
2. Trial topical lidocaine 5% for neuropathic symptom relief 2
3. Avoid any consideration of revision surgery at this stage 2
4. Continue conservative therapy for at least 6-12 months before concluding that maximum recovery has occurred 2, 1