In a patient who had a hemorrhoidectomy three years ago and a low‑grade fistulotomy ten months ago and now reports persistent tension of the entire lower anal sphincter, difficulty achieving orgasm, and a mildly altered urinary sensation, is pelvic‑floor hypertonicity the likely cause rather than nerve injury from the fistulotomy?

Pelvic Floor Hypertonicity Is the Likely Cause

Yes, pelvic floor hypertonicity—not direct nerve damage—is the most probable explanation for your persistent sphincter tension, difficulty with orgasm, and altered urinary sensation following fistulotomy. 1

Why Hypertonicity Rather Than Nerve Injury

• The intersphincteric dissection during fistulotomy places pudendal nerve branches at high risk, but the resulting injury typically manifests as a protective guarding pattern rather than complete denervation 1
• Your intact continence with altered sensation reflects neuropathic dysfunction triggering compensatory muscle hypertonicity, not the mechanical sphincter failure that would occur with complete nerve transection 1
• Low internal sphincter resting pressure from prior hemorrhoidectomy can trigger compensatory hypertonicity of the puborectalis and external anal sphincter, creating persistent pelvic floor tension that interferes with normal relaxation during sexual arousal 1
• The combination of hemorrhoidectomy three years ago plus fistulotomy ten months ago creates cumulative risk for both structural injury and chronic protective guarding 2

The Mechanism Behind Your Symptoms

Sexual Dysfunction

• Persistent pelvic floor guarding prevents normal muscle relaxation during sexual arousal, directly impairing orgasm 1
• Scar tissue formation creates areas lacking normal mechanoreceptors and proprioceptive feedback, disrupting the sensory feedback loop essential for sexual function 2

Altered Urinary Sensation

• Pudendal neuropathy from surgical trauma disrupts the sensory feedback loop for normal anorectal and pelvic function 2
• Devascularization and denervation of the anal sphincter complex extend to surrounding pelvic floor structures, affecting urinary sensation 2

The "Tension" You Feel

• This represents chronic hypertonicity (anismus) of the external anal sphincter and puborectalis muscle—a protective guarding pattern that persists after anatomical healing 1
• Digital rectal examination can demonstrate high resting anal sphincter tone or paradoxical puborectalis contraction, though you may not consciously perceive these motor abnormalities due to damaged sensory pathways 1

First-Line Treatment: Pelvic Floor Physical Therapy

Specialized pelvic floor physical therapy is the cornerstone treatment, achieving 90–100% success rates for the functional components of your condition. 3, 4

Specific Protocol

• Initiate intensive pelvic floor physical therapy 2–3 times per week, emphasizing internal and external myofascial release to reduce hypertonicity 1
• Techniques must include manual release of puborectalis and external sphincter tension, gradual desensitization exercises, and muscle-coordination retraining to break protective guarding patterns 1
• Perform isolated pelvic floor muscle contractions held for 6–8 seconds with 6-second rest periods, twice daily for 15 minutes per session, for a minimum of 3 months 3
• Warm sitz baths 2–3 times daily as adjunctive home therapy to promote relaxation of hypertonic pelvic floor muscles 1

If Physical Therapy Alone Is Insufficient

• Trigger or tender point injections, vaginal muscle relaxants, and cognitive behavioral therapy can be added as second-line options, either sequentially or in conjunction with ongoing physical therapy 4
• Topical lidocaine 5% ointment applied to the perianal and anal canal areas can provide temporary relief of neuropathic dysesthesia 1
• OnabotulinumtoxinA injections should be reserved as third-line treatment if second-line options fail 4

What You Must Avoid

Absolutely Contraindicated Interventions

• Manual anal dilatation is absolutely contraindicated—it carries a permanent incontinence risk of 10–30% 5, 1
• Additional surgical revision for sensory loss is contraindicated because your problem is neuropathic and myofascial, not mechanical sphincter failure 1
• Revision surgery carries high risk of further pudendal nerve injury 1
• Surgical sphincterotomy is contraindicated when the primary problem is pelvic floor hypertonicity rather than an anal fissure 1

Diagnostic Evaluation to Confirm Hypertonicity

• Anorectal manometry should be performed to quantify resting pressure and detect paradoxical contraction (anismus) during simulated defecation 1
• High-resolution pelvic MRI with gadolinium contrast is the preferred imaging modality if anatomical complications are suspected 2
• Digital rectal examination may reveal localized tenderness over the puborectalis if levator ani syndrome (chronic hypertonicity) has developed 1

Realistic Prognosis

• Significant axonal injury may render the neuropathic component partially irreversible 1
• Conservative physical-therapy-based treatment can restore some pelvic-floor relaxation capacity during sexual activity 1
• Sensory adaptation and neuroplasticity may gradually improve perception over 12–24 months, although full restoration is unlikely if nerve branches were transected 1
• The dysfunction is treatable but not fully reversible when significant nerve damage or vascular injury occurred during surgery 2

Immediate Action Plan

• Consult a pelvic floor physical therapist experienced in post-anorectal-surgery rehabilitation 1
• Trial topical lidocaine 5% for neuropathic symptom relief 1
• Avoid any revision surgery at this stage 1
• Continue conservative therapy for 6–12 months before assessing maximal recovery 1
• If severe, unremitting pain persists, referral to a pelvic pain specialist or urogynecologist is warranted 2

Key Clinical Pitfall

The largest identified barrier to care is access to specialized pelvic floor physical therapy. 4 If you cannot access in-person PFPT, experts recommend at-home guided pelvic floor relaxation, self-massage with vaginal wands, and virtual PFPT visits as alternatives. 4