In a patient who underwent a lateral internal sphincterotomy (LIS) with fissurectomy and hemorrhoidectomy three years ago and a low transphincteric fistulotomy involving less than 30 % of the sphincter seven months ago, now experiencing worsening pain, altered sensation and dyssynergia, is pelvic‑floor physical therapy the appropriate next step in management?

Pelvic Floor Physical Therapy Is the Appropriate Next Step

Yes, specialized pelvic floor physical therapy with internal myofascial release is the definitive next step for this patient experiencing worsening pain, altered sensation, and dyssynergia after LIS and fistulotomy. 1, 2

Understanding the Underlying Problem

Your symptoms represent neuropathic pain and pelvic floor muscle tension rather than structural sphincter failure, which is why continence remains intact despite the altered sensations. 1 The protective guarding patterns that developed during your painful fissure period have persisted and been compounded by the subsequent fistulotomy. 1, 2

The fistulotomy involving less than 30% of the sphincter should not have caused mechanical incontinence, confirming that your symptoms stem from myofascial dysfunction and dysesthesia rather than sphincter damage. 1

The Treatment Protocol

Initiate pelvic floor physical therapy 2–3 times weekly with the following components: 1, 2

• Internal and external myofascial release targeting pelvic floor trigger points and muscle contractures 3, 1
• Gradual desensitization exercises guided by your physical therapist to address the altered sensations 1
• Muscle coordination retraining to reduce the protective guarding patterns 1, 2
• Warm sitz baths to promote muscle relaxation 1

The American Gastroenterological Association specifically recommends manual physical therapy techniques that resolve pelvic, abdominal, and hip muscular trigger points, lengthen muscle contractures, and release painful scars and connective tissue restrictions for patients presenting with pelvic floor tenderness. 3 A randomized controlled trial demonstrated that 59% of patients receiving myofascial physical therapy reported moderate or marked improvement at 3 months, compared to only 26% receiving general therapeutic massage. 3

Additional Symptomatic Management

Apply topical lidocaine 5% ointment to affected areas for neuropathic pain control. 1, 4 This addresses the dysesthetic component of your symptoms while the physical therapy retrains the muscular dysfunction.

Expected Timeline

The dysesthesia and altered sensations typically improve significantly over 6–12 months with appropriate pelvic floor therapy and neuropathic pain management. 2 This is a gradual process requiring patience and consistent therapy attendance.

Critical Pitfalls to Avoid

Do not pursue additional surgical interventions. 1, 2 Further surgery would likely worsen the neuropathic component rather than improve it, as your problem is functional and myofascial, not structural. 1

Avoid Kegel exercises (pelvic floor strengthening). 3 The American Gastroenterological Association explicitly states that pelvic floor strengthening exercises should be avoided in patients with pelvic floor tenderness, as they can exacerbate muscle tension and spasm. 3

Never consider manual anal dilatation, which carries a 30% temporary and 10% permanent incontinence rate. 1, 4

Why Internal Therapy Is Essential

Internal pelvic floor therapy is specifically required because internal anal sphincter dysfunction and impaired rectal sensory feedback cannot be adequately treated with external techniques alone. 2 Biofeedback therapy targeting rectal sensation, tolerance of rectal distention, and coordination of the internal sphincter necessitates internal assessment and treatment. 2

Reflection on Your Surgical History

Botulinum toxin injection would have been a safer alternative to LIS, achieving 75–95% cure rates with no risk of permanent incontinence or sexual dysfunction. 1, 4 The mechanism involves temporary paresis of the anal sphincter rather than permanent division, allowing fissure healing through reversible sphincter relaxation without permanent damage. 1 This information may be relevant for other patients but does not change your current management path.

Finding the Right Therapist

Seek a pelvic floor physical therapist with specific training in anorectal dysfunction and internal myofascial release techniques. 3, 2 Not all pelvic floor therapists have expertise in post-surgical anorectal complications, so explicitly ask about their experience with patients who have undergone sphincterotomy and fistulotomy. 3