Fistulotomy and Erectile Dysfunction: No Direct Causal Link
Routine fistulotomy does not cause erectile dysfunction. The procedure involves division of anal sphincter tissue to treat perianal fistulas and has no anatomical or physiological mechanism to damage the neurovascular structures responsible for erectile function, which are located in the pelvis and penis—far from the surgical field 1, 2, 3.
Why Fistulotomy Does Not Cause ED
The external and internal anal sphincters divided during fistulotomy are separate anatomical structures from the pudendal nerves, cavernosal arteries, and corpora cavernosa that control erectile function 1, 2.
Prospective studies tracking patients after fistulotomy with sphincter division report only fecal incontinence complications (soiling, urgency), with no documentation of erectile dysfunction as a postoperative complication 1, 2, 3.
Division of up to 41% of the external anal sphincter and 32% of the internal anal sphincter during fistulotomy results in mild fecal incontinence symptoms but does not affect sexual function 1.
Even complex fistulotomy with primary sphincteroplasty—a more extensive procedure—reports only continence-related complications, not erectile or sexual dysfunction 2.
If ED Is Present: Evaluate Standard Causes
If erectile dysfunction has developed after fistulotomy, investigate the actual causes of ED rather than attributing it to the surgery. The timing may be coincidental, or psychological factors related to the surgery may be contributing 4, 5.
Mandatory Initial Workup
Measure morning (8–10 AM) serum total testosterone in every man with ED; testosterone deficiency (total testosterone <300 ng/dL) is a treatable cause that impairs response to other therapies 4, 5.
Obtain fasting glucose or HbA1c and a fasting lipid panel to identify diabetes and dyslipidemia, both of which cause vasculogenic ED 4, 5.
Screen for depression, anxiety, relationship conflict, and recent major life stressors, as psychological factors commonly precipitate or worsen ED 4, 5, 6.
Ask specifically about the presence of morning or nocturnal erections and erections during masturbation; preserved spontaneous erections indicate a psychogenic component rather than organic vascular or neurologic damage 4, 5.
Psychological Impact of Anal Surgery
Intrusive thoughts about the surgical site during sexual activity represent performance anxiety and trauma that require cognitive-behavioral therapy, not pelvic floor exercises 6.
Partner involvement in therapy is critical when sexual practices previously central to the relationship are now associated with distress 6.
Kegel Exercises: Not Indicated for Post-Fistulotomy ED
Pelvic floor (Kegel) exercises are not recommended for erectile dysfunction following fistulotomy because there is no sphincter-related mechanism causing the ED. Kegel exercises strengthen the pelvic floor muscles and may help with urinary incontinence or premature ejaculation, but they do not address the vascular, hormonal, or psychological causes of erectile dysfunction 4, 7, 8.
No guideline or research evidence supports the use of Kegel exercises for ED in the context of anal surgery 4.
If fecal incontinence from sphincter division is causing psychological distress that secondarily affects sexual function, the primary intervention is psychosexual counseling combined with pharmacologic ED treatment, not pelvic floor exercises 6.
First-Line Treatment for ED (Regardless of Cause)
Prescribe a phosphodiesterase-5 (PDE5) inhibitor (sildenafil, tadalafil, vardenafil, or avanafil) as first-line therapy for any man with ED, whether the cause is organic, psychogenic, or mixed 4, 5, 7, 8.
Educate the patient that sexual stimulation is required for PDE5 inhibitors to work and that at least five attempts at the maximum tolerated dose should be made before declaring treatment failure 4, 5.
If testosterone is low (<300 ng/dL), initiate testosterone replacement therapy concurrently, as this improves both libido and erectile function and enhances PDE5 inhibitor efficacy 4, 5.
Refer to a mental health professional for psychosexual counseling to address performance anxiety, intrusive thoughts about the surgical site, and relationship issues; combined pharmacologic and psychological therapy yields superior outcomes 4, 5, 6.
Critical Pitfalls to Avoid
Do not attribute ED to the fistulotomy itself—the surgery does not damage erectile structures, and assuming a causal link will delay identification of the true cause 1, 2, 3.
Do not delay testosterone testing when loss of libido accompanies ED; the combination makes testosterone deficiency highly probable and treatable 5.
Do not assume psychogenic ED requires only counseling—PDE5 inhibitors are effective for psychogenic ED and should be initiated concurrently with psychological therapy 4, 5.
Do not manage ED without evaluating cardiovascular risk—ED is a marker for underlying cardiovascular disease and predicts future cardiac events with a risk magnitude comparable to smoking 4, 5.