Bladder Urgency and Loss of Fine Filling Sensation After Multiple Anorectal Surgeries
Most Likely Cause
Your bladder symptoms—urgency and loss of fine filling sensation—are most likely caused by pelvic floor dyssynergia (paradoxical puborectalis contraction) that developed from chronic straining and was worsened by repeated anorectal surgeries, creating a cycle of protective muscle guarding that disrupts both rectal and bladder sensory pathways. 1, 2, 3
The temporal relationship is critical: your symptoms began with the initial straining and anal fissure, partially improved after the first surgery, then worsened significantly after the fistulotomy 10 months ago. This pattern strongly suggests that each surgical intervention triggered additional pelvic floor muscle tension and sensory disruption rather than structural sphincter damage (since you have no incontinence). 2, 3
Why This Happens After Anorectal Surgery
Protective guarding patterns that developed during your painful fissure period persist even after surgical healing, creating chronic pelvic floor muscle tension that affects both bowel and bladder function. 2, 3
The lateral internal sphincterotomy and fistulotomy created neuropathic changes in the pelvic floor, leading to altered sensations rather than mechanical problems—you have preserved continence, which confirms intact sphincter integrity. 2, 3
Chronic straining before and after surgery disrupts the normal sensory feedback from both the rectum and bladder, because the pelvic floor muscles share common neural pathways and fascial connections. 1, 3
Rectal hyposensitivity (loss of fine filling sensation) commonly coexists with bladder urgency in patients with pelvic floor dysfunction, because the same sensory retraining deficit affects both organs. 1, 4
Diagnostic Evaluation You Need
Step 1: Confirm Pelvic Floor Dyssynergia (Before Any Treatment)
You must undergo anorectal manometry with sensory testing to objectively document the underlying pelvic floor dysfunction before starting therapy. 1
This test will measure:
Diagnosis of rectal hyposensitivity is confirmed when at least two sensory thresholds are abnormal (e.g., first sensation >60 mL, urge >120 mL). 1
This testing is essential because biofeedback fails when applied to patients without confirmed defecatory disorders on anorectal manometry. 1
Step 2: Bladder-Specific Evaluation (If Symptoms Persist After Pelvic Floor Treatment)
Urodynamic studies are only needed if bladder symptoms do not improve after completing a full course of pelvic floor biofeedback therapy, because most bladder urgency in this context is secondary to pelvic floor dysfunction rather than primary bladder pathology. 1, 4
Sensory urgency (increased perceived bladder sensation with low first desire to void and low capacity in the absence of infection or detrusor overactivity) is part of the same spectrum of bladder dysfunction as your pelvic floor disorder. 4
Evidence-Based Treatment Algorithm
First-Line Definitive Therapy: Pelvic Floor Biofeedback with Sensory Retraining
Initiate a structured 8-week pelvic floor biofeedback program (5–6 weekly 30–60 minute sessions) as your first-line therapy, achieving success in 70–80% of appropriately selected patients with your presentation. 1, 3
What This Therapy Does
Biofeedback enhances rectal sensory perception by using serial balloon inflations to train your brain's awareness of rectal filling that has become undetectable. 1, 3
The therapy applies operant conditioning with real-time visual feedback, converting unconscious pelvic floor muscle tension into observable data that you can consciously modify. 1, 3
Sensory adaptation exercises use progressive balloon distension; you report sensation thresholds at each step, gradually training awareness of smaller volumes. 1
Real-time visual display of anal sphincter pressure and abdominal push effort enables you to see pelvic floor activity and learn to coordinate abdominal effort with pelvic floor relaxation. 1, 3
Critical Requirements for Success
The therapist must be specifically trained in anorectal disorders and equipped to deliver simultaneous feedback on abdominal push effort and anal/pelvic floor relaxation using an anorectal probe with rectal balloon. 1, 3
Generic pelvic floor physical therapy (external techniques only) is insufficient—you need internal therapy with anorectal probe and balloon simulation because internal anal sphincter dysfunction and impaired rectal sensory feedback cannot be adequately treated with external techniques alone. 2, 3
Success rates of 70–80% are achievable only when the protocol includes real-time visual feedback, progressive sensory adaptation exercises, daily home relaxation practice, and proper toilet posture. 1
Adjunctive Measures During Biofeedback
Scheduled toileting after meals is recommended to harness the gastrocolonic response and reinforce normal defecatory timing. 1
Warm sitz baths (15–20 minutes, 2–3 times daily) provide temporary symptomatic relief and promote muscle relaxation, but are insufficient as definitive therapy. 1
Topical lidocaine 5% ointment can be applied to affected areas for neuropathic pain control. 2
Avoid constipating medications (e.g., opioids, anticholinergics, calcium-channel blockers) when feasible to prevent stool withholding that can worsen sensory dysfunction. 1
Predictors of Success
Patients with milder baseline hyposensitivity (lower sensory thresholds) respond more favorably to biofeedback. 1
Co-existing depression is an independent predictor of poor biofeedback efficacy—routine screening and concurrent treatment of mood disorders improve outcomes. 1
Expected Timeline
The dysesthesia and altered sensations typically improve significantly over 6–12 months with appropriate pelvic floor therapy and neuropathic pain management. 2
Biofeedback is effective within 8 weeks for most patients, with improvements maintained through the full treatment period. 5
Second-Line Option: Sacral Nerve Stimulation (Only After Failed Biofeedback)
Consider sacral nerve stimulation (SNS) only after completing an adequate 3-month biofeedback program without clinically meaningful improvement. 1, 6
Small studies suggest that SNS may improve rectal sensation in patients with defecatory disorders and rectal hyposensitivity, though evidence for functional bowel improvement remains limited. 1
SNS has demonstrated success in treating paradoxical puborectalis contraction with dramatic relief in straining and pain (pain score 0 from baseline 8 in one case series), with lasting improvement at 2-year follow-up. 6
Current evidence consists of retrospective case series showing modest functional benefit, indicating low-strength support—this is not a first-line therapy. 1
Pharmacologic Options for Bladder Urgency (Adjunctive, Not Primary)
If bladder urgency remains distressing despite pelvic floor therapy, consider mirabegron 25–50 mg daily as an adjunct, but this does not address the underlying pelvic floor dysfunction. 5
Mirabegron reduces mean micturitions per 24 hours by 0.42–0.61 episodes and improves urgency symptoms within 4–8 weeks. 5
This medication is appropriate only after anorectal testing confirms the diagnosis and ideally after initiating biofeedback therapy, because treating bladder symptoms alone without addressing pelvic floor dyssynergia will provide incomplete relief. 1
Anticholinergic medications should be avoided because they can worsen constipation and sensory dysfunction. 1
Critical Pitfalls to Avoid
Do not pursue additional surgical interventions (e.g., repeat sphincterotomy, anal dilatation), as this would likely worsen the neuropathic component rather than improve it. 2, 3
Manual anal dilatation is contraindicated because it carries a 30% temporary and 10% permanent incontinence rate. 1, 2
Do not continue escalating laxatives or bladder medications indefinitely without performing anorectal testing and transitioning to biofeedback therapy. 1
Avoid Kegel (strengthening) exercises, which are contraindicated for hypertonicity because they increase pelvic floor tone and can worsen symptoms—you need pelvic floor relaxation training instead. 1
Do not accept referral to a generic pelvic floor physical therapist who lacks anorectal probe equipment and training in dyssynergic defecation, because most therapists are equipped only for fecal incontinence (strengthening) rather than dyssynergia (relaxation and sensory retraining). 1
Where to Seek Care
Refer to a gastroenterology or specialized pelvic floor center that provides:
- Anorectal manometry with sensory testing 1
- Biofeedback therapy with sensory retraining protocols delivered by clinicians trained in anorectal physiology 1
- Internal therapy using anorectal probes with rectal balloon simulation 2, 3
The absence of incontinence or structural damage is favorable and suggests better potential for improvement with conservative management. 2