After a fistulotomy, the patient has increased anal sphincter tension but no pain—should the duration and intensity of pelvic‑floor physical therapy be increased?

Post-Fistulotomy Sphincter Tension Without Pain: Pelvic Floor Therapy Optimization

Yes—both the duration and intensity of pelvic floor physical therapy should be increased, specifically by adding internal myofascial release techniques 2–3 times weekly and extending treatment for 6–12 months. 1

Understanding the Post-Surgical Problem

The increased sphincter tension you're observing represents protective guarding patterns that developed during the painful pre-operative period and persist even after successful fistulotomy. 1 This is fundamentally a pelvic floor muscle tension disorder, not a sphincter hypertonia problem requiring pharmacologic relaxation. 1

• The patient likely has intact continence and preserved sphincter integrity, but the external anal sphincter and pelvic floor muscles remain in a chronic state of hypertonicity from months of protective spasm. 1
• This differs from anal fissure pathophysiology, where the internal anal sphincter drives the pain-spasm-ischemia cycle. 2

Critical Treatment Algorithm

Step 1: Initiate Comprehensive Internal Pelvic Floor Therapy

Increase therapy frequency to 2–3 sessions per week with the following components: 1

• Internal myofascial release targeting the puborectalis, external anal sphincter, and levator ani muscles 1
• External myofascial release of the gluteal and pelvic floor musculature 1
• Gradual desensitization exercises using progressive tactile stimulation 1
• Muscle coordination retraining with biofeedback to restore normal defecation dynamics 1, 3

Why internal therapy is essential: External pelvic floor techniques alone cannot adequately address internal anal sphincter dysfunction and impaired rectal sensory feedback. 3 Biofeedback therapy specifically targets rectal sensation, tolerance of distention, and coordination of the internal sphincter, which necessitates internal assessment and treatment. 3

Step 2: Add Adjunctive Home Measures

• Warm sitz baths 2–3 times daily to interrupt the postoperative pain-spasm cycle and promote muscle relaxation 1, 3
• Topical lidocaine 5% ointment applied to affected areas for neuropathic pain control if any dysesthesia develops 1

Step 3: Avoid Contraindicated Interventions

Do NOT use sphincter-relaxing medications (calcium-channel blocker creams, nitroglycerin ointment, or botulinum toxin injections) in this patient. 3 These agents target internal anal sphincter hypertonia—appropriate for anal fissures—but will worsen continence when used for post-fistulotomy myofascial tension, which is a neuropathic/myofascial problem rather than a spasm disorder. 3

Absolutely avoid any additional surgical interventions, including manual anal dilatation (which carries 10–30% permanent incontinence risk) or revision procedures, as these would worsen the neuropathic component. 1, 2

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. 1 This extended timeline reflects the time required to retrain chronic protective guarding patterns.

Evidence Context and Nuances

The research evidence on fistulotomy outcomes shows that 20% of patients develop some degree of postoperative incontinence (mostly minor soiling or flatus incontinence), 4 and fistulotomy significantly decreases maximum resting pressure from baseline. 4 However, your patient has increased tension without pain, suggesting a paradoxical protective response rather than sphincter injury.

One study found that low preoperative voluntary contraction pressure and multiple previous drainage surgeries are independent risk factors for postoperative incontinence, 4 but these factors predict weakness, not the hypertonicity your patient exhibits. This reinforces that the current presentation is a reversible myofascial disorder amenable to physical therapy.

Common Pitfalls to Avoid

• Do not interpret increased tension as a sign of sphincter hypertonia requiring pharmacologic relaxation—this is external sphincter and pelvic floor muscle guarding, not internal sphincter spasm. 1, 3
• Do not pursue imaging or manometry unless continence symptoms develop, as the diagnosis is clinical and these tests will not change management. 1
• Do not reassure the patient that symptoms will resolve spontaneously—active intervention with structured pelvic floor therapy is required for optimal recovery. 1