Post-Fistulotomy Sexual Dysfunction: Evaluation and Management
Direct Answer
This is a neuropathic and myofascial problem, not structural sphincter damage, and should be treated with specialized pelvic floor physical therapy focusing on internal myofascial release 2-3 times weekly, combined with topical lidocaine 5% ointment for neuropathic pain. 1, 2
Understanding the Problem
The decreased rectal tightness and reduced orgasmic pleasure you're experiencing is primarily neuropathic dysesthesia and pelvic floor muscle tension rather than mechanical sphincter failure. 1 This is a critical distinction because:
- Your continence is likely intact despite the altered sensations during sexual activity 1, 3
- The fistulotomy involved ≤30% of the sphincter, which is superficial and does not approach the deep pelvic autonomic nerves responsible for sexual and ejaculatory function 2
- Protective guarding patterns that developed during your painful fissure/fistula period persist even after surgery and contribute to altered sensations 1, 2, 3
Treatment Algorithm
First-Line: Specialized Pelvic Floor Physical Therapy
Initiate pelvic floor physical therapy 2-3 times weekly with a therapist specifically trained in anorectal dysfunction and internal myofascial release techniques. 1, 3 The therapy must include:
- Internal and external myofascial release targeting pelvic floor trigger points and muscle contractures 1
- Gradual desensitization exercises guided by your physical therapist 1
- Muscle coordination retraining to reduce protective guarding patterns 1, 3
- Warm sitz baths to promote muscle relaxation 1
Critical evidence: A randomized controlled trial demonstrated that 59% of patients receiving myofascial physical therapy reported moderate or marked improvement at 3 months, compared with only 26% receiving general therapeutic massage. 1
Adjunctive Pain Management
Important Caveat About Kegel Exercises
Do NOT perform standard Kegel (pelvic floor strengthening) exercises at this stage, as they may exacerbate muscle tension and spasm in patients with pelvic floor tenderness. 1 This is expert consensus from the American Gastroenterological Association and contradicts the general recommendation for Kegel exercises after fistulotomy 4, but applies specifically to patients with your presentation of altered sensations and dysesthesia.
Expected Timeline and Prognosis
- The dysesthesia and altered sensations typically improve significantly over 6-12 months with appropriate pelvic floor therapy and neuropathic pain management 3
- Manometric studies show that after fistulotomy, resting anal pressure gradually recovers over the first year, though it remains somewhat lower than baseline 5, 6
- Your symptoms reflect the temporary nature of post-surgical sensory changes rather than permanent structural damage 6
Critical Pitfalls to Avoid
Do NOT Pursue Additional Surgery
Additional surgical interventions should not be pursued for post-fistulotomy sexual dysfunction, as this would likely worsen the neuropathic component rather than improve it. 1, 3 The problem is not mechanical and cannot be fixed with more cutting.
Avoid Manual Anal Dilatation
Manual anal dilatation should be avoided entirely, as it carries a 30% temporary and 10% permanent incontinence rate. 1
Recognize This Is NOT Sphincter Failure
The distinction between sexual dysfunction after fistulotomy being typically neuropathic/myofascial rather than mechanical sphincter failure should be recognized, requiring physical therapy rather than surgical revision. 1
Why Internal Therapy Is Essential
Internal anal sphincter dysfunction and impaired rectal sensory feedback cannot be adequately treated with external pelvic floor techniques alone; therefore, internal therapy is required. 3 Biofeedback therapy specifically targets rectal sensation, tolerance of rectal distention, and coordination of the internal sphincter, which necessitates internal assessment and treatment. 3
Contextualizing Your Specific Case
Your fistulotomy involved ≤30% of the sphincter, which is considered a low fistula with minimal sphincter division. 7 Research shows:
- Even low fistulotomy can lead to transient fecal soiling in 11.5% of patients for 4-6 months, which then disappears or evolves into milder flatus incontinence 8
- 20% of patients experience deterioration in continence after fistulotomy, though the majority represents only minor incontinence 9
- Your symptoms of altered sensation during sexual activity fit the pattern of neuropathic dysesthesia rather than true incontinence 1, 2
Finding the Right Therapist
Seek a pelvic floor physical therapist who has specific training in anorectal dysfunction and internal myofascial release techniques to ensure appropriate management of post-surgical pelvic floor disorders. 1 Not all pelvic floor therapists have this specialized training, so explicitly ask about their experience with anorectal surgery complications.