After a fistulotomy that removed about 30% of my internal anal sphincter, I no longer feel the rectal pressure sensation during masturbation that helped me orgasm; what is causing this and how can it be treated?

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Loss of Rectal Pressure Sensation After Fistulotomy

Your loss of rectal pressure sensation during masturbation is caused by damage to the internal anal sphincter (IAS) and its associated sensory nerve pathways from the fistulotomy, which removed approximately 30% of your IAS—this has disrupted both the mechanical pressure generation and the sensory feedback that previously contributed to your orgasmic response. 1, 2

Understanding the Mechanism of Your Symptom

Anatomical Basis of the Problem

The internal anal sphincter provides approximately 70-85% of resting anal tone and generates the baseline rectal pressure you previously felt during sexual arousal. 3, 4 When 30% of this muscle was removed during your fistulotomy, several critical changes occurred:

  • Reduced baseline sphincter tone: Your resting anal pressure has permanently decreased, eliminating the pressure sensation that contributed to orgasm 3
  • Disrupted sensory innervation: The intersphincteric dissection likely damaged the inferior rectal branches of the pudendal nerve (S2-S4), which provide sensory feedback from the anal canal 1
  • Loss of the bulbocavernosus reflex connection: Damage to the external anal sphincter coordination can impair the rhythmic contractions that normally occur during ejaculation and orgasm 2

The Sexual Function Connection

Research demonstrates that external anal sphincter injury directly affects erectile and ejaculatory function through disruption of the bulbocavernosus muscle activity. 2 In a study of 16 men with sphincter injury from anal fistula surgery, all experienced ejaculatory dysfunction (loss of forceful ejaculation in jets) and difficulty maintaining erection until ejaculation—symptoms that resolved after sphincteroplasty. 2

Current Management Strategy

Immediate Actions (Next 6-12 Weeks)

You must completely avoid any anal penetration or receptive anal stimulation for at least 6-12 months post-surgery to prevent catastrophic complications. 5, 6 The risks of premature resumption include:

  • Wound dehiscence requiring repeat surgery (41-59% failure rates for repair attempts) 5
  • Recurrent fistula formation (5.7-19% recurrence rate even without trauma) 5
  • Progression to permanent fecal incontinence requiring colostomy (31-49% of complex cases) 5

Apply topical 0.3% nifedipine with 1.5% lidocaine ointment three times daily for at least 6 weeks to reduce residual sphincter hypertonicity and promote healing, which achieves 95% healing rates for anal wounds. 7, 6

Diagnostic Evaluation Required

Before considering any resumption of anal stimulation, you need objective assessment:

  1. Anorectal manometry to quantify your current sphincter pressures and determine the extent of functional loss 1, 4
  2. 3D endoanal ultrasound or pelvic MRI to visualize the remaining sphincter anatomy, identify any ongoing inflammation, and assess for compensatory hypertonicity 1
  3. Digital rectal examination by a colorectal specialist to evaluate resting tone (IAS function) and squeeze augmentation (external sphincter function) 1

Referral to a colorectal surgeon with sphincter preservation expertise and a pelvic floor physical therapist is mandatory. 5, 6

Treatment Options for Sensory Recovery

Conservative Management (First-Line)

Pelvic floor biofeedback therapy achieves symptom improvement in more than 70% of patients with sphincter dysfunction and should be your initial therapeutic approach. 1 This therapy can:

  • Retrain remaining sphincter muscle coordination
  • Optimize compensatory mechanisms from the external anal sphincter
  • Address any paradoxical hypertonicity that may be masking residual function

Fiber supplementation (25-30g daily) with adequate fluid intake optimizes stool consistency and reduces mechanical stress on the healing sphincter. 1

Advanced Interventions (If Conservative Therapy Fails)

If biofeedback and conservative measures fail after 3-6 months:

  1. Dextranomer microspheres in hyaluronic acid (NASHA Dx) is the only FDA-approved bulking agent for sphincter dysfunction, achieving ≥50% symptom reduction in 52% of patients at 6 months 1

  2. Sacral nerve stimulation (SNS) targets the S2-S4 nerve roots that supply both the external anal sphincter and contribute to pelvic sensory pathways—this may partially restore the neural feedback loop you've lost 1

  3. Sphincteroplasty to repair the IAS defect could theoretically restore some pressure sensation, as demonstrated in the study where sphincter repair restored both continence and normal erectile/ejaculatory function 2

Realistic Expectations and Sexual Adaptation

The Hard Truth

Resuming pain-free anal intercourse with restoration of your previous pressure sensation may not be achievable given the extent of permanent sphincter damage. 6 The manometric data shows that even after sphincter healing, resting pressures remain significantly lower than pre-surgery baseline. 3

Graduated Approach If Cleared by Specialists

Only after meeting ALL criteria (complete wound healing, normal manometry, no inflammation on imaging, minimum 6-12 months post-surgery) should you consider: 5, 6

  • Starting with external anal stimulation only for several weeks before any internal stimulation 5
  • Using generous water-based lubricants and beginning with very small diameter objects 5
  • Applying topical calcium channel blockers prophylactically before and after any activity 5, 6

Alternative Sexual Practices

Prioritize quality of life over resuming specific sexual practices to avoid permanent fecal incontinence. 5, 6 Consider:

  • External anal and perineal stimulation without penetration 6
  • Prostate stimulation via other routes if that was your goal
  • Exploring other erogenous zones that don't risk catastrophic sphincter failure

Critical Warnings

Never undergo the following procedures, as they will worsen your condition:

  • Manual anal dilatation (causes permanent incontinence in 10-30% of patients) 7, 1
  • Repeat sphincterotomy (would further compromise your already damaged sphincter) 5, 6
  • Cutting setons (result in 57% incontinence rates) 6

Any perianal abscess during the healing phase dramatically worsens outcomes and may lead to fecal diversion with a permanent colostomy. 5

References

1
Guideline

Nerve Supply and Dysfunction of the Anal Sphincter

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Research

Should we care about the internal anal sphincter?

Diseases of the colon and rectum, 2012

5
Guideline

Post-Fistulotomy Care and Risk Assessment

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

6
Guideline

Management of Post-Surgical Anorectal Complications

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

7
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Related Questions

Do I need my pre‑operative internal anal sphincter (IAS) resting pressure value to regain sensation after a lateral internal sphincterotomy, and will the permanent reduction in IAS tone compromise continence?
Why does a 38‑year‑old male, after lateral sphincterotomy, hemorrhoidectomy, fissurectomy and a low transphincteric fistulotomy (resting internal anal sphincter pressure reduced from ~138 to ~110 mm Hg), experience complete loss of deep‑pelvic “anchor” sensation for sexual arousal and bladder fullness, and does differentiating loss of internal anal sphincter tone from guarding affect his management?
In an adult who has undergone a lateral internal sphincterotomy and a trans‑sphincteric fistulotomy, does preserved continence indicate that sexual sensation is also intact, or are internal anal sphincter (IAS) pressure and sexual signaling unrelated?
In a 38‑year‑old man who underwent a lateral internal sphincterotomy (with hemorrhoidectomy and fissurectomy) three years ago and a subsequent low trans‑sphincteric fistulotomy revision, why is the loss of his deep‑pelvic “anchor” sensation for sexual arousal and urinary perception greater than a simple diminution, and what amount of internal anal sphincter resting pressure is typically lost after such a sphincterotomy?
In a 38‑year‑old man who underwent a lateral internal anal sphincterotomy (with hemorrhoidectomy, fissurectomy and low trans‑sphincteric fistulotomy) and now reports loss of deep‑pelvic “anchor” sensation and blunted urinary sensation, how much resting internal anal sphincter pressure is typically lost, and does this loss represent loss of passive IAS tone rather than a guarding contraction?
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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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