Can Kegel Exercises Help After Fistulotomy with Internal Anal Sphincter Removal?
Yes, Kegel exercises can significantly improve both anal sphincter tone and likely ejaculatory function after fistulotomy that removed the internal anal sphincter, and should be started immediately as first-line therapy.
Evidence for Kegel Exercises After Internal Sphincter Division
Proven Efficacy for Incontinence Recovery
Regular Kegel exercises (50 repetitions daily for one year) can restore continence to near-preoperative levels after fistulotomy, even when the internal anal sphincter has been partially or completely divided 1, 2.
In patients who developed incontinence after fistulotomy (occurring in 20-31% of cases), Kegel exercises led to complete resolution in 50% and partial improvement in the remaining 50%, bringing incontinence scores back to statistically comparable preoperative levels 1.
When the internal anal sphincter is divided (as in TROPIS procedures for complex fistulas), 31% of patients develop incontinence—predominantly urge incontinence (24%) and gas incontinence (8%)—but regular Kegel exercises reduced this to only 13% of patients experiencing any symptoms at one-year follow-up 2.
Mechanism of Benefit
Fistulotomy significantly decreases maximum resting pressure (from 85.9 to 60.2 mmHg) by dividing the internal anal sphincter, but does not affect voluntary contraction pressure, which remains intact at approximately 160 mmHg 3.
Kegel exercises specifically target the external anal sphincter and puborectalis muscle, which generate voluntary squeeze pressure and compensate for the lost resting tone from internal sphincter division 1, 2.
The exercises work by strengthening the remaining intact external sphincter and retraining pelvic floor muscle coordination that was disrupted by protective guarding patterns during the original fistula pain 4.
Comprehensive Treatment Protocol
Immediate Postoperative Phase (Days 1-10)
Begin warm sitz baths 2-3 times daily to promote sphincter relaxation and reduce protective muscle tension 4.
Apply topical lidocaine 5% ointment to the surgical site for neuropathic pain control if hypersensitivity develops 4, 5.
Active Rehabilitation Phase (Day 10 onward)
Start Kegel exercises at 50 repetitions per day, continuing for a full 12 months 1, 2.
The exercises should focus on isolated pelvic floor muscle contractions: squeeze the anal sphincter as if stopping gas, hold for 3-5 seconds, then relax completely 1, 2.
Refer to a pelvic floor physical therapist with specific training in anorectal disorders for professional instruction, as incorrect muscle activation leads to treatment failure 5.
Comprehensive Pelvic Floor Therapy (Weeks 2-12)
Initiate formal pelvic floor physiotherapy 2-3 times weekly including internal and external myofascial release, gradual desensitization exercises, and muscle coordination retraining 4, 5.
Incorporate biofeedback therapy using anorectal probe placement with a rectal balloon to provide real-time feedback during muscle relaxation and contraction attempts 5.
Internal biofeedback is essential because external techniques alone cannot adequately address internal anal sphincter dysfunction and impaired rectal sensory feedback 4.
Expected Timeline and Outcomes
Short-Term Recovery (0-6 Months)
Most patients experience significant improvement in incontinence symptoms within 6 months of regular Kegel exercises, with mean incontinence scores dropping from 1.19 to 0.26 2.
Urge and gas incontinence—which account for 80-90% of post-fistulotomy incontinence—respond particularly well to pelvic floor exercises 1, 2.
Long-Term Prognosis (6-12 Months)
Dysesthesia and altered sensations typically improve significantly over 6-12 months with appropriate pelvic floor therapy, though some patients may experience persistent mild symptoms 4.
Success rates with comprehensive conservative therapy (Kegel exercises plus pelvic floor physiotherapy) can reach 90-100% when properly implemented 5.
Addressing Sexual Dysfunction
Direct Benefits for Ejaculatory Function
Pelvic floor exercises decrease anxiety, discomfort, and improve pelvic floor muscle coordination that directly affects sexual function 6, 5.
The American Society of Clinical Oncology guidelines specifically recommend pelvic floor (Kegel) exercises to decrease anxiety and discomfort and lower urinary tract symptoms, which share common pelvic floor muscle pathways with ejaculatory function 6.
Comprehensive Sexual Rehabilitation
Combine Kegel exercises with cognitive behavioral therapy to address the psychological components of sexual dysfunction that commonly develop after anorectal surgery 6, 5.
The same pelvic floor muscle coordination required for continence is essential for normal ejaculatory function, so strengthening these muscles addresses both problems simultaneously 6, 5.
Critical Pitfalls to Avoid
Do Not Pursue Additional Surgery
Never consider repeat surgical intervention for post-fistulotomy symptoms, as this would likely worsen the neuropathic component rather than improve it 4.
Manual anal dilatation is absolutely contraindicated, carrying a 30% temporary and 10% permanent incontinence rate 4.
Ensure Adequate Conservative Trial
A rigorous 3-month trial of comprehensive conservative therapy must be completed before considering any additional interventions 5.
Premature discontinuation of the exercise regimen leads to treatment failure—patients must understand the full 12-month commitment is essential for optimal recovery 1, 2.
Maintain Bowel Management
Continue constipation management with polyethylene glycol for many months until bowel motility normalizes, as premature discontinuation leads to treatment failure 5.
Implement scheduled toileting with proper posture (buttock support, foot support, comfortable hip abduction) to minimize strain on the healing sphincter 5.
When to Escalate Care
Indications for Advanced Testing
If symptoms persist after 3 months of comprehensive conservative therapy (Kegel exercises plus formal pelvic floor physiotherapy), consider anorectal manometry to identify anal weakness, altered rectal sensation, and impaired function 5.
Patients with low preoperative voluntary contraction pressure (<100 mmHg) or those who underwent multiple previous drainage surgeries are at highest risk for persistent incontinence and may require earlier specialist referral 3.
Advanced Treatment Options
Sacral nerve stimulation may be considered for moderate or severe fecal incontinence unresponsive to 3-6 months of comprehensive conservative measures 5.
However, the vast majority of patients (>80%) will achieve satisfactory outcomes with Kegel exercises and pelvic floor physiotherapy alone, making invasive interventions rarely necessary 1, 2.
Prognostic Factors
Favorable Indicators
Patients with intact preoperative voluntary contraction pressure (>160 mmHg) have excellent prognosis for full recovery with Kegel exercises 3.
Division of less than two-thirds of the external anal sphincter is associated with the lowest incontinence rates and best response to conservative therapy 7.
Risk Factors for Persistent Symptoms
Multiple previous drainage surgeries and low preoperative voluntary contraction pressure are independent risk factors for postoperative incontinence that may not fully resolve with exercises alone 3.
Division of over two-thirds of the external anal sphincter is associated with the highest incontinence rates, though even these patients benefit significantly from Kegel exercises 7.