What treatments can reduce neuropathic hypersensitivity of an oversensitive post‑fistulotomy site that impairs sexual arousal, given normal computed tomography and digital rectal examination with an intact sphincter?

Management of Post-Fistulotomy Neuropathic Hypersensitivity

Initiate pelvic floor physical therapy with internal myofascial release 2–3 times weekly combined with topical lidocaine 5% ointment for neuropathic pain control; this represents the evidence-based first-line approach for post-surgical pelvic floor hypertonicity that impairs quality of life. 1

Understanding the Underlying Problem

The hypersensitivity you describe—despite normal imaging and intact sphincter anatomy—represents central sensitization, a phenomenon where the nervous system amplifies pain signals and creates hypersensitivity even after tissue healing is complete 2, 3. This is not structural damage but rather a neuroplastic change in how your nervous system processes sensory input from the surgical site.

• Post-surgical pelvic floor muscle tension commonly develops after anorectal procedures as a protective guarding pattern that persists long after the initial injury has healed 1
• The protective muscle contraction that developed during the painful fissure period becomes "learned" by the nervous system and continues even when no longer needed 1
• Central sensitization manifests as pain hypersensitivity, allodynia (pain from normally non-painful stimuli), and heightened sensory awareness—exactly matching your clinical presentation 3

Evidence-Based Treatment Algorithm

Step 1: Specialized Pelvic Floor Physical Therapy (Primary Treatment)

This is not generic pelvic floor therapy—it requires internal techniques specifically targeting the anal sphincter complex and pelvic floor muscles:

• Internal myofascial release to address hypertonic external anal sphincter and puborectalis muscle tension 1
• Gradual desensitization exercises using graded exposure to reduce central sensitization 1
• Muscle coordination retraining to suppress paradoxical contraction patterns 4
• Frequency: 2–3 sessions per week initially 1
• Warm sitz baths as adjunctive home therapy to reduce muscle tension 5

The therapy must include internal assessment and treatment because external techniques alone cannot adequately address internal anal sphincter dysfunction and impaired rectal sensory feedback 1.

Step 2: Neuropathic Pain Management

• Topical lidocaine 5% ointment applied to affected areas for neuropathic pain control 1
• This addresses the central sensitization component by reducing peripheral nociceptive input that maintains the hypersensitivity 2

Step 3: Biofeedback with Sensory Retraining (If Available)

If you have access to a specialized center offering anorectal biofeedback:

• Biofeedback therapy with sensory retraining can directly address rectal hypersensitivity and improve sensory perception 4
• This uses real-time visual feedback of pelvic floor muscle activity to retrain abnormal sensory processing 4
• Success rates exceed 70% for anorectal sensory dysfunction when properly applied 4
• The therapy is completely free of morbidity and safe for long-term use 4

Important distinction: Most pelvic floor physical therapists lack the specialized anorectal probe and rectal balloon instrumentation needed for effective biofeedback targeting dyssynergic patterns 4. You need a gastroenterology-supervised program or specialized pelvic floor center with anorectal manometry equipment 4.

Expected Timeline and Prognosis

• Dysesthesia and altered sensations typically improve significantly over 6–12 months with appropriate pelvic floor therapy and neuropathic pain management 1
• Central sensitization is reversible but requires time and consistent treatment 2, 3
• The hypersensitivity represents neuroplastic changes that can be "unlearned" through proper sensory retraining 4

Critical Pitfalls to Avoid

Do NOT Pursue Additional Surgical Interventions

• Further surgery would likely worsen the neuropathic component rather than improve it 1
• Your imaging and digital rectal exam are normal—there is no structural problem to fix surgically 1
• The issue is functional (neuromuscular) not anatomical 4

Do NOT Accept Generic "Pelvic Floor Therapy"

• Standard pelvic floor strengthening exercises (designed for incontinence) are inappropriate for your condition 4
• You need relaxation and desensitization, not strengthening 1
• The therapist must be trained in internal anal sphincter work and have experience with post-surgical anorectal hypersensitivity 1

Avoid Manual Anal Dilatation

• This outdated technique carries a 30% temporary and 10% permanent incontinence rate and should never be used 5

Referral Recommendations

• Gastroenterology or specialized pelvic floor center for anorectal manometry with sensory testing to quantify the hypersensitivity 4
• Pelvic floor physical therapist with specific training in anorectal disorders and internal myofascial release techniques 1
• Consider pain management consultation if neuropathic symptoms are severe or refractory to topical lidocaine 2

Why This Approach Works

Central sensitization creates a state where the nervous system has "turned up the volume" on sensory signals from the surgical site 3. The combination of:

1. Internal myofascial release reduces peripheral nociceptive input that maintains central sensitization 1
2. Desensitization exercises gradually retrain the nervous system to process sensory input normally 1
3. Topical anesthetics interrupt the pain-tension-pain cycle 1
4. Sensory retraining biofeedback directly addresses the altered central processing 4

This multimodal approach targets both the peripheral muscle tension and the central nervous system changes that perpetuate your symptoms 2, 3.

A Note on Prevention

For future reference, botulinum toxin injection represents a safer alternative to lateral internal sphincterotomy for anal fissures, achieving 75–95% cure rates with no risk of permanent incontinence or sexual dysfunction 1. This information may be relevant if you counsel others facing similar surgical decisions.