Can my pelvic floor be restored to normal function despite prior perineal trauma, a recent fistulotomy, and new urinary urgency and burning after starting systemic diazepam?

Can Pelvic Floor Function Be Restored After Trauma and Surgery?

Yes, pelvic floor function can be restored to normal or near-normal in most women through structured pelvic floor muscle training, even after perineal trauma and fistulotomy, but your new urinary symptoms after starting diazepam likely represent protective muscle guarding rather than permanent nerve damage—a distinction that fundamentally changes your prognosis from excellent to guarded. 1

Understanding Your Current Symptoms

Your constellation of urinary urgency and burning after starting systemic diazepam, combined with recent fistulotomy and prior perineal trauma, most likely represents pelvic floor muscle guarding—a protective reflex causing involuntary muscle hypertonicity that temporarily disrupts bladder sensory feedback without actual nerve damage. 1 This is critical because:

• Guarding is reversible: The nerves remain structurally intact but signal transmission is distorted by myofascial dysfunction and the fact that post-surgical scar tissue lacks mechanoreceptors needed for accurate bladder-filling perception. 1
• Temporal pattern favors guarding: Symptoms that appear or worsen within days to 2-3 weeks after surgery and fluctuate with stress, anxiety, or body position indicate preserved nerve pathways rather than structural damage. 1
• Diazepam paradox: While benzodiazepines theoretically relax muscles, systemic diazepam can paradoxically worsen pelvic floor dysfunction by disrupting the normal neuromuscular feedback loop and potentially masking the conscious control needed for proper pelvic floor relaxation. 1

Red Flags Requiring Immediate Evaluation

Before proceeding with conservative management, you must rule out serious nerve injury. Seek emergency evaluation within 12-48 hours if you develop: 1

• Bilateral leg weakness or numbness
• Saddle anesthesia (numbness in the perineal/genital area)
• Loss of anal sphincter tone or new fecal incontinence
• Complete urinary retention with absent bladder sensation
• Progressive worsening of sensory loss beyond 2 weeks post-surgery

These findings suggest cauda equina syndrome or broader S2-S4 nerve root involvement requiring urgent MRI. 1

Evidence for Pelvic Floor Restoration

The American College of Physicians provides strong evidence (Grade A, high-quality) that pelvic floor muscle training is first-line treatment for stress urinary incontinence and mixed incontinence in women. 2 This recommendation applies even after trauma because:

• Success rates are 90-100% when comprehensive pelvic floor physiotherapy is properly implemented for guarding-predominant dysfunction. 1, 3
• Pelvic floor muscle training achieves cure or significant symptom improvement with better satisfaction and quality of life compared to no treatment, based on multiple randomized trials. 2
• The mechanism works: Functional retraining improves pelvic floor muscle strength, endurance, power, and—critically for your case—relaxation in patients with pelvic floor dysfunction. 4

Your Treatment Algorithm

Phase 1: Immediate Steps (Weeks 1-4)

Prioritize pelvic floor relaxation ("down-training"), NOT strengthening exercises. 1, 5

• Stop all Kegel/strengthening exercises immediately: Performing strengthening contractions when hypertonicity is present will worsen your symptoms. 1, 3
• Begin relaxation-focused pelvic floor physiotherapy: This involves conscious muscle release, deep diaphragmatic breathing, and gentle stretching performed 10-15 minutes twice daily. 1, 5
• Warm sitz baths: 15-20 minutes daily to promote muscle relaxation and interrupt the pain-spasm cycle. 1
• Bladder sensation diary: Record the time of day when sensation is best/worst; morning improvement after rest strongly suggests guarding rather than nerve injury. 1
• Consider topical lidocaine: Applied to painful perineal areas before voiding to interrupt the pain-spasm cycle. 1

Phase 2: Structured Rehabilitation (Months 1-3)

Work with a pelvic floor physical therapist trained in dysfunction management (not just general physical therapy). 2, 5 The standardized protocol includes: 5

• Diagnostic assessment at each session: Electromyography and manometry analyzed in 4 phases to track progress and modify treatment
• Down-training: Continued focus on relaxation for at least 3 months before any strengthening
• Accessory muscle isolation: Learning to relax abdominal and gluteal muscles that may be compensating
• Discrimination training: Relearning proper sensory feedback from the pelvic floor
• 8-10 sessions at weekly intervals with integration of home exercises and lifestyle modifications

Phase 3: Strengthening (Months 3-6+)

Only after achieving adequate relaxation, begin graduated strengthening: 2, 5

• Proper Kegel technique: Isolated pelvic floor muscle contractions held for 6-8 seconds with 6-second rest periods
• Frequency: Performed twice daily for 15 minutes per session
• Duration: Minimum 3 months of consistent practice for sustained benefit
• Supervision: Must be taught and supervised by a trained healthcare professional to ensure proper technique

Addressing the Diazepam Issue

The American College of Physicians recommends against systemic pharmacologic therapy for stress urinary incontinence (Grade A, low-quality evidence). 2 For your situation:

• Discuss with your prescribing physician whether diazepam is essential or if alternative anxiety management (cognitive-behavioral therapy) could be substituted. 1
• If diazepam must continue, recognize it may complicate your pelvic floor rehabilitation by interfering with neuromuscular feedback.
• Bladder training (behavioral therapy extending time between voiding) is recommended for urgency symptoms and can be implemented alongside relaxation training. 2

When to Consider Advanced Imaging

Do NOT pursue imaging in the first 3-4 weeks—most guarding-related symptoms resolve with conservative care, and premature imaging leads to unnecessary tests and costs. 1, 3 Consider MRI pelvis with gadolinium contrast only if: 2, 1, 3

• Symptoms persist unchanged beyond 3-4 weeks despite proper relaxation therapy
• Pain intensifies while sitting (meeting Nantes criteria for pudendal neuralgia)
• You develop any red-flag signs listed above
• Symptoms progressively worsen rather than fluctuate

MRI can detect nerve compression, hematoma, abscess, or fistula recurrence and visualize the pudendal nerve directly with MR neurography. 2, 1

Expected Timeline and Prognosis

For guarding-predominant dysfunction (your most likely scenario): 1

• Symptom improvement typically begins within days to 2-3 weeks with conscious relaxation
• Substantial improvement by 6-8 weeks with proper physiotherapy
• Full restoration of function by 3-6 months in most cases

For true pudendal nerve injury (less likely but possible): 1

• Expectant management for 3-6 months, as many injuries recover spontaneously
• Prognosis is unpredictable; some recover fully, others have persistent deficits
• Neuropathic pain agents (gabapentin, pregabalin, duloxetine) may be needed
• Referral to a pelvic pain specialist or urogynecologist for severe, unremitting symptoms

Critical Pitfalls to Avoid

• Premature strengthening: Initiating Kegel exercises before achieving adequate relaxation is the most common error and will set back your recovery. 1, 3
• Premature discontinuation: Both guarding and nerve injury require sustained treatment for several months; stopping therapy at 4-6 weeks is too early. 1, 3
• Ignoring multicompartment involvement: Your prior perineal trauma may have affected anterior, middle, and posterior compartments; comprehensive assessment prevents missing occult defects. 3
• Self-directed therapy without professional guidance: Pelvic floor rehabilitation requires trained supervision to ensure proper technique and progression. 2, 5

Additional Supportive Measures

• Weight loss if BMI >25: Obesity independently worsens pelvic floor dysfunction and prolapse progression. 2, 3
• Manage chronic constipation: Straining increases intra-abdominal pressure and perpetuates pelvic floor weakness. 3
• Cognitive-behavioral therapy: Addresses anxiety and fear that perpetuate protective guarding. 1

Your prognosis for restoration of normal pelvic floor function is excellent if you commit to proper relaxation-focused physiotherapy for at least 3 months before attempting any strengthening exercises. 1, 3 The key is recognizing that your symptoms likely represent reversible muscle guarding rather than permanent nerve damage, and treating accordingly with patience and proper technique.