What are the sexual side effects of puborectalis dysfunction in men and what mechanisms underlie them?

Sexual Side Effects of Puborectalis Dysfunction in Men

Puborectalis dysfunction in men causes sexual dysfunction through three primary mechanisms: dyspareunia (painful intercourse) from pelvic floor hypertonicity, impaired sensation during intercourse from muscle laxity or rupture, and erectile difficulties from disrupted pelvic floor muscle coordination during arousal and orgasm. 1, 2, 3

Direct Sexual Dysfunction Mechanisms

Pain During Intercourse (Dyspareunia)

• Puborectalis hypertonicity creates painful pelvic floor muscle spasm during sexual activity, reported in 38.5% of patients with levator ani and puborectalis rupture, though this likely represents chronic compensatory hypertonicity rather than the rupture itself. 1
• The puborectalis muscle contracts reflexively during penile stimulation as part of the "peno-motor reflex," and when this muscle is dysfunctional (either hypertonic or damaged), this normal reflex becomes painful or absent. 3

Impaired Genital and Pelvic Sensation

• Loss of normal puborectalis muscle function results in impaired sensation during sexual intercourse in 25% of patients with levator ani/puborectalis rupture, representing a direct sensory deficit from muscle denervation or mechanical disruption. 1
• The puborectalis and levator ani muscles contain proprioceptive nerve endings that contribute to pelvic awareness during sexual activity; when these muscles are damaged or lax, men lose critical sensory feedback during intercourse. 2, 4

Erectile and Orgasmic Dysfunction

• The puborectalis muscle contracts during glans penis stimulation as part of a coordinated pelvic floor response that increases prostatic urethral pressure and prevents urinary leakage during erection; dysfunction disrupts this coordination and can impair erectile rigidity and orgasmic sensation. 3
• During normal sexual arousal, electrical or mechanical stimulation of the glans penis triggers significant EMG activity increases in both the puborectalis and levator ani muscles (p < 0.01), with simultaneous increases in prostatic urethral and anal pressures; when puborectalis function is impaired, this reflex arc fails. 3
• The peno-motor reflex ensures that prostatic sphincter contraction squeezes prostatic secretions into the posterior urethra during orgasm while preventing urine or stool leakage; puborectalis dysfunction disrupts this coordinated response. 3

Indirect Sexual Dysfunction Through Associated Symptoms

Psychological Distress from Bowel Symptoms

• Men with puborectalis syndrome experience incomplete defecation (89%), intermittent evacuation (63%), and digital evacuation requirements (28%), creating significant psychological distress that extends to sexual confidence and relationship intimacy. 5
• The chronic nature of defecatory symptoms—with prolonged expulsion times (mean 38 seconds) and persistent rectal fullness—creates anxiety about bowel accidents during sexual activity, leading to sexual avoidance. 5

Pelvic Organ Prolapse and Body Image

• Puborectalis rupture commonly causes anterior and middle compartment prolapses (including rectocele in associated cases), with 32.7% of patients reporting colpophony (vaginal noise during intercourse in female partners), which creates embarrassment and sexual avoidance in heterosexual couples. 1
• Deviation of the anus to the side opposite the lesion occurs in 96.2% of puborectalis rupture cases, creating visible asymmetry that may affect body image and sexual confidence. 1

Urinary Incontinence During Sexual Activity

• Urinary incontinence affects 48.1% of patients with levator ani/puborectalis rupture, and the loss of coordinated pelvic floor contraction during sexual arousal increases the risk of urine leakage during intercourse or orgasm. 1
• The normal peno-motor reflex causes vesical pressure to drop significantly (p < 0.05) during glans stimulation while urethral sphincter pressure rises; when puborectalis function is lost, this protective mechanism fails and stress incontinence during sexual activity becomes more likely. 3

Prevalence and Clinical Context

High Prevalence of Unrecognized Dysfunction

• In a population-based study, 80% of asymptomatic men had some degree of pelvic floor muscle dysfunction on examination, with the puborectalis showing both more dysfunction and severer dysfunction than the external anal sphincter, indicating that sexual symptoms may be underreported or attributed to other causes. 4
• No clear dose-response relationship exists between muscle dysfunction severity and symptom number, meaning even severe puborectalis dysfunction may present with subtle or isolated sexual complaints rather than the full constellation of pelvic floor symptoms. 4

Clinical Assessment Algorithm

Step 1: Targeted Sexual History

• Specifically ask about dyspareunia (pain location, timing during intercourse), impaired genital sensation, erectile rigidity changes, orgasmic quality, and any urinary or fecal leakage during sexual activity. 1, 2
• Screen for digital evacuation requirements, incomplete defecation, and prolonged straining, as these defecatory symptoms predict puborectalis dysfunction and correlate with sexual dysfunction severity. 5

Step 2: Physical Examination Findings

• Perform bidigital palpation to assess puborectalis tone; hypertonia is palpable in 34% of puborectalis syndrome cases and predicts dyspareunia, while laxity or asymmetry suggests rupture and predicts sensory loss. 5
• Look for anal deviation (present in 96.2% of rupture cases) and assess perineal sensation and the bulbocavernosus reflex to identify peripheral neuropathy that may compound sexual dysfunction. 1, 6

Step 3: Diagnostic Confirmation

• Defecography is the most useful, simple, and noninvasive method for diagnosing puborectalis syndrome, showing abnormal puborectalis impression on the posterior anorectal wall, reduced anorectal angle opening under straining (mean 113°), and prolonged expulsion time (mean 38 seconds). 5
• Anorectal manometry detects increased external anal sphincter pressure under straining in 68.8% of cases, though it is less specific than defecography for puborectalis syndrome diagnosis. 5
• Endoanal and perineal ultrasound confirm levator ani and puborectalis rupture in cases with traumatic etiology (typically obstetric trauma in female partners, but relevant for understanding the condition). 1

Treatment Approach for Sexual Dysfunction

First-Line: Pelvic Floor Biofeedback with Sensory Retraining

• Structured pelvic floor biofeedback (5-6 weekly 30-60 minute sessions using anorectal probes with rectal balloon simulation) achieves 70-80% success rates for puborectalis dysfunction and directly improves sexual function by restoring normal muscle coordination and sensation. 7
• Biofeedback trains patients to relax hypertonic puborectalis muscles during straining and sexual activity, converting unconscious paradoxical contraction into observable data that can be consciously modified through real-time visual feedback. 7
• For sensory deficits from puborectalis laxity or rupture, sensory adaptation training during biofeedback enhances rectal and pelvic sensory perception, with success rates exceeding 70% when applied correctly. 7

Surgical Repair for Traumatic Rupture

• Transvaginal levator ani and puborectalis muscle repair achieved full restoration of normal function (Wexner score 0/20) in 78.8% of patients, with all patients reporting improvement in sexual function postoperatively. 1
• Dyspareunia resolved or improved by ≥50% in all 20 patients (38.5% of the cohort) who reported it preoperatively, demonstrating that anatomic repair directly addresses sexual pain. 1
• Impaired sensation during intercourse improved in all 13 patients (25% of cohort) who reported it preoperatively, indicating that surgical restoration of muscle integrity restores proprioceptive feedback. 1

Adjunctive Measures

• Screen for and treat comorbid depression, as it is an independent predictor of poor biofeedback efficacy and compounds sexual dysfunction through loss of libido and relationship distress. 7
• Include partners in treatment planning, as their distress and sexual function are mutually influential with the patient's recovery; referral to sex therapy helps couples develop a new sexual paradigm based on current function. 6, 8

Key Clinical Pitfalls

• Do not assume that absence of bowel symptoms means normal puborectalis function; 80% of asymptomatic men have pelvic floor muscle dysfunction on examination, and sexual complaints may be the only presenting symptom. 4
• Avoid attributing erectile dysfunction solely to vascular or hormonal causes without assessing pelvic floor function; the peno-motor reflex is essential for normal erectile rigidity and orgasmic sensation, and puborectalis dysfunction disrupts this reflex. 3, 2
• Do not prescribe Kegel (strengthening) exercises for puborectalis hypertonicity, as they increase pelvic floor tone and worsen dyspareunia; relaxation training through biofeedback is the appropriate intervention. 7
• Recognize that defecography is more diagnostically useful than anorectal manometry for puborectalis syndrome, as manometry detects increased sphincter pressure in only 68.8% of cases while defecography shows characteristic findings in all cases. 5