I had a straining injury three years ago that caused altered rectal sensation and mild bladder symptoms, underwent surgeries, and 7 months after a fistulotomy my rectal and bladder sensations have further dulled; what urgent investigations and management should I pursue?

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Urgent Neurological and Pelvic Floor Evaluation Required

You need immediate anorectal manometry with sensory testing and urodynamic studies to evaluate for iatrogenic pelvic floor nerve injury, as progressive sensory dulling after fistulotomy suggests surgical trauma to the pudendal nerve or pelvic floor innervation. 1, 2

Critical Diagnostic Pathway

Immediate Investigations (Within 2 Weeks)

Anorectal manometry with comprehensive sensory testing is your first-line diagnostic test because it will objectively measure:

  • Rectal sensory thresholds (first sensation, urge to defecate, maximum tolerable volume) to quantify the degree of hyposensitivity 2
  • Anal sphincter resting and squeeze pressures to assess for sphincter injury 1, 2
  • Rectoanal coordination during simulated defecation 2

The International Anorectal Physiology Working Group protocol requires at least two abnormal sensory parameters (e.g., first sensation >60 mL and urge >120 mL) to diagnose rectal sensory impairment 2. Your progressive dulling strongly suggests this diagnosis.

Urodynamic studies with post-void residual measurement must be performed because:

  • Altered bladder sensation after pelvic surgery indicates possible pudendal or autonomic nerve injury 1
  • Post-void residual assessment identifies bladder emptying dysfunction 1
  • Multichannel cystometry can detect detrusor underactivity or altered compliance 1

Neurological Red Flags Requiring Urgent MRI

Order lumbosacral spine MRI with contrast immediately if you have:

  • Progressive bilateral symptoms (both rectal AND bladder) 1
  • Any lower extremity weakness, numbness, or gait changes 1
  • Saddle anesthesia or perineal numbness 1

This constellation raises concern for cauda equina syndrome or spinal cord compression, which the American Gastroenterological Association identifies as a neurologic cause of constipation requiring urgent intervention 2. The 7-month progressive course makes this less likely but cannot be excluded without imaging.

Secondary Investigations (If Initial Tests Abnormal)

Fluoroscopic defecography should be performed if:

  • Anorectal manometry shows discordant results (abnormal sensory but normal motor function) 2
  • You need to visualize structural complications from fistulotomy (e.g., keyhole deformity, sphincter defect) 1

Pelvic floor MRI is reserved for chronic cases (>8-12 weeks) or when anatomical abnormalities require confirmation 2.

Understanding Your Injury Pattern

Why Fistulotomy Caused Worsening

Fistulotomy divides sphincter muscle and creates permanent anatomical changes. Research shows:

  • 41% of external anal sphincter and 32% of internal anal sphincter is typically divided during fistulotomy 3
  • Division of >67% of external sphincter causes the highest incontinence rates 3
  • Rectal tone increases and compliance decreases after fistulotomy, even with preserved sphincter function 4

Your worsening sensory dulling 7 months post-fistulotomy suggests either:

  1. Direct pudendal nerve injury during dissection in the intersphincteric space 1, 5
  2. Chronic pelvic floor hypertonicity causing secondary sensory impairment 2, 4
  3. Rectal compliance changes that alter mechanoreceptor function 4

The Straining Injury Connection

Your initial straining injury 3 years ago likely caused pelvic floor neuropathy that was subclinical until surgical trauma unmasked it. The American Gastroenterological Association notes that rectal sensory impairment can result from chronic straining and pelvic floor trauma 2.

Management Algorithm

If Anorectal Manometry Confirms Sensory Impairment

Biofeedback therapy with sensory retraining is your definitive first-line treatment:

  • Achieves 76% adequate symptom relief in refractory anorectal complaints 2
  • Specifically targets rectal hyposensitivity through operant conditioning 2
  • Uses stepwise balloon distension to retrain sensory awareness 2

Critical caveat: Screen for depression before starting biofeedback, as elevated depression scores independently predict poor biofeedback response and correlate with higher sensory thresholds 2.

If Urodynamic Studies Show Bladder Dysfunction

Pelvic floor physical therapy addressing both bowel and bladder is essential because:

  • Shared neuromuscular pathways mean pelvic floor dysfunction affects both systems 2
  • The concurrent bladder and bowel symptoms suggest common underlying dyssynergia 2

If Neurological Imaging Shows Spinal Pathology

Immediate neurosurgical referral is mandatory for any cord compression or cauda equina findings 1, 2.

Common Pitfalls to Avoid

  1. Do not assume symptoms will spontaneously improve – progressive sensory dulling over 7 months indicates established nerve injury requiring active intervention 2

  2. Do not repeat colonoscopy – you had recent surgical intervention and no alarm features (bleeding, weight loss, anemia); colonoscopy is not indicated 2

  3. Do not delay anorectal testing – waiting for "conservative management" to fail wastes time when objective diagnosis is immediately available 2

  4. Do not attribute everything to IBS – up to one-third of chronically constipated patients have an evacuation disorder that requires specific treatment 2

  5. Do not order pelvic MRI first – anorectal manometry is the essential first-line test; imaging is reserved for discordant results or chronic refractory cases 2

Prognosis and Realistic Expectations

Research on post-fistulotomy outcomes shows:

  • 24% of males develop some degree of incontinence after fistulotomy 6
  • 34% experience incontinence at median 7.8-year follow-up, with complex fistulas having worse outcomes 7
  • Rectal sensation plays a significant role in post-fistulotomy soiling, with higher maximum rectal volume thresholds predicting incontinence 6

Your sensory impairment may be partially reversible with biofeedback if nerve injury is incomplete, but complete recovery is unlikely if pudendal nerve transection occurred 2, 4.

Urgent Referrals Required

Gastroenterology or pelvic floor specialist for:

  • Anorectal manometry with sensory testing 2
  • Biofeedback therapy coordination 2

Urology for:

  • Urodynamic studies 1
  • Bladder dysfunction management 1

Neurosurgery (if MRI shows spinal pathology) 1, 2

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Constipation Assessment and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

5
Guideline

Management of Low Transsphincteric Fistula in Patients Planning to Defecate in Diapers

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

6
Research

Can anal manometry predict anal incontinence after fistulectomy in males?

Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland, 2004

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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