Abstract
Benign anorectal diseases such as hemorrhoidal disease, anal fissure, anal pruritus, perianal abscess, and fistula are the most common ones. The aim of this study was to assess sexual function in patients after surgery for benign anorectal diseases. Sixty-one male patients with perianal fistulas, operated on at Department of General Surgery, Faculty of Medicine, completed a self-administered questionnaire including the International Index of Erectile Function (IIEF) score. The median IIEF score of the postoperative patients was significantly higher (24, range [10–25]) than that of preoperative patients (22, range [5–25]),
Introduction
Benign anorectal diseases including hemorrhoidal disease, anal fissure, anal pruritus, perianal abscess, and fistula are the diseases that are frequently encountered in our clinical practice. Patients usually present with complaints of constipation, difficulty in defecation, pain, and bleeding (Rao et al., 2016). These complaints significantly impair the patient’s quality of life by disrupting work performance, eating, defecation, and sleep patterns. A perianal fistula is defined as an abnormal connection that occurs between the anal canal’s dentate line and the perineal skin (Cooper & Keller, 2020). The most common etiological factor is the obstruction of crypts. In addition, it can be seen due to Crohn’s disease, trauma, fungal infections, anorectal neoplasms, and iatrogenic causes (Steele et al., 2011). Recurrence and fecal incontinence after surgical treatment are the most common complications (Malik & Nelson, 2008). Furthermore, sexual dysfunction may also occur as a result of anorectal diseases. These complaints are generally overlooked and unquestioned symptoms. In some patients, it has been observed that sexual functions improve after surgery due to the decrease in pain (Akkoca et al., 2023).
Stimulation of the glans penis evokes contraction of both the bulbocavernosus muscles (BCMs) and the external anal sphincter (EAS). This synchronous contraction of the two muscles led us to study their physioanatomic relationship and possible role in erection and ejaculation. The superficial fibers of the base loop of the EAS extended forward to the penile bulb where they were arranged into three groups: one median and two lateral. The median fibers, or the “retractor penis muscle,” were found inserted into the corpora cavernosa, and the lateral fibers, or the “compressor bulbae muscle,” into the perineal membrane. Upon glans penis stimulation, both the EAS and BCM contracted synchronously with similar latency and action potentials. During EAS anesthesia, the two muscles did not respond to glans penis stimulation. They contracted simultaneously with similar latency and action potentials upon inferior rectal nerve stimulation. The BCM is an integral part of the EAS, and the muscle in its entirety is appropriately named “anogenital muscle.” The muscle plays a dual and synchronous role in fecal control and sexual response (Shafik, 1999).
Due to this relationship, the reasons for sexual function impairment in patients with perianal fistula are better understood. This study was designed to investigate the effects of perianal fistula surgery on quality of life and sexual dysfunction using standardized and validated questionnaires.
Patients and Methods
This was a prospective study with a cross-sectional survey design. It was approved by our local Ethics Committee and all patients provided their written informed consent. We enrolled patients prospectively, from those presenting consecutively, with perianal fistula disorder at the General Surgery Departments of Gazi University Faculty of Medicine between 2017 and 2022, and 18 patients were also excluded since they had a history of irritable bowel syndrome, anal fissure, anorectal abscess, inflammatory bowel disease, cancer, and a history of any major psychiatric disorder/treatment and treatment with immunosuppressive drugs. All patients underwent examination of the anorectal region including an external exam, digital rectal exam and anoscopy and/or rectosigmoidoscopy, and pelvic magnetic resonanse imaging as part of diagnostic workup at the outpatient clinic where indicated. Patients with chronic anal fistula were classified according to the Modified Park Classification (intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric fistula; Bay et al., 2020).
Survey Methods
Sexual functions were evaluated with the IIEF scale. During each visit, one of the authors provided preliminary information about the survey, which took approximately 5 minutes. Patients who agreed to participate in the study were taken to a comfortable room to answer the survey questions alone. The three surveys were provided in printed form, and all questions were answered by the patients themselves. A co-author was available to explain any questions that the patients were unable to understand. According to the questionnaire results, the International Index of Erectile Function (IIEF) score was divided into five categories based on the total score. These categories were defined as follows, from low to high scores: severe, moderate, mild-moderate, mild, and no erectile dysfunction. Survey results were entered into a previously prepared SPSS database by one of the authors. Another author checked the accuracy of the data entered.
Sexual Dysfunction Symptoms
The IIEF is a five-item, self-administered questionnaire that was developed to detect and follow sexual dysfunction. It is quick to administer and requires no special training in terms of interpretation. The IIEF includes a score range between 5 and 25; where 5 indicates no sexual activity and 25 represents the best sexual function. The reliability and validity of the Turkish version of IIEF have been established.
Statistical Analysis
The data of the study were analyzed using the SPSS 23.0 (Statistical Package for Social Sciences) software. Descriptive statistics were performed for data evaluation. Categorical variables were presented as numbers and percentages, while continuous variables were presented as mean ± standard deviation or median (interquartile range [IQR]). The normal distribution of continuous variables was assessed using visual methods (histograms and probability plots) and analytical methods (Kolmogorov-Smirnov/Shapiro-Wilk tests). Differences between continuous variables that did not follow a normal distribution were analyzed using the Wilcoxon test. A
Results
A total of 61 patients were included in the study. The median age of the patients was 40 years (31.0–46.0). The median BMI value of the patients included in the study was 25.6 (23.0–28.1). Gas incontinence was observed in 14.8% of the patients, while fecal incontinence was observed in 6.6% of them during the preoperative period. When evaluating the patients’ erectile function according to the IIEF, they were divided into five categories. Category 1 represented severe erectile dysfunction, and Category 5 indicated no erectile dysfunction. In the preoperative period, four patients were observed to have severe erectile dysfunction according to the IIEF-EF index. However, in the postoperative period, no patient reported severe erectile dysfunction. Upon further examination of the four patients with severe ED in the preoperative period, it was observed that one patient improved to moderate severity, two patients improved to mild-moderate severity, and one patient scored full points in the questionnaire, indicating no erectile dysfunction (Table 1). These results show that perianal fistula patients with severe erectile dysfunction before surgery have a dramatic improvement in their sexual function after surgery. In addition, patients who did not have erectile dysfunction in the preoperative period did not develop erectile dysfunction in the postoperative period. The median preoperative sexual function score was 22.0 (19.5–25.0), while the median postoperative sexual function score was 24.0 (20.0–25.0). There was a statistically significant difference in sexual function scores between the preoperative and postoperative periods (
Distribution of Patients According to Some Descriptive Characteristics
Comparison of Sexual Function Scores Between Preoperative and Postoperative Periods
Wilcoxon signed-ranks test.
Discussion
For people who are social beings and constantly interacting in society, sexuality is a basic function and directly affects their quality of life (Greenberg et al., 2017). Sexuality and health are inseparable, and sexual dysfunction can negatively affect overall health (Bay et al., 2020). Benign anorectal diseases related to the pelvic floor and their surgical treatments can lead to impairments in patients’ sexual functions (Ho et al., 2011; Incrocci & Jensen, 2013; Sun et al., 2016). However, these conditions are often considered taboo or a source of embarrassment in cultural contexts and are thus not frequently discussed by patients. Therefore, it is essential for healthcare professionals to specifically inquire about sexual function disorders in individuals with benign anorectal diseases to address their concerns appropriately. During the literature review conducted for this study, it was surprisingly found that there is a very limited number of studies on the relationship between benign anorectal diseases and sexual function impairment. Despite a systematic search in various databases, only a few studies were found, and the data were found to be quite heterogeneous, making it challenging to draw generalized conclusions. Most of the studies in the literature focused on relatively less common recto-vaginal, ano-vaginal, and perianal fistulas, especially those associated with Crohn’s disease, and their impact on sexual function. Some of these studies reported that even after fistula closure, some women consistently had low Female Sexual Function Index (FSFI) scores, indicating persistent sexual dysfunction (Broholm et al., 2015). This observation suggests that anal fistula could permanently affect women’s sexual function. This finding is consistent with the results of another study on the quality of life in fecal incontinence, which showed that even after incontinence treatment, there was a lasting impairment in quality of life (Lefèvre et al., 2006). However, these studies supporting such observations are limited in number and have a small sample size, focusing mainly on the examination of patients with recto-vaginal and ano-vaginal fistulas, which constitute only 9% of all fistula cases (Lefèvre et al., 2006). Similarly, in another study examining the degree of sexual function impairment in patients with chronic anal fissures, it was found that 76% of male patients experienced erectile dysfunction during the acute phase (Shafik & El-Sibai, 2000). The studies also reported that anal fissures could have a significant impact on patients’ quality of life (Abramowitz et al., 2013; Griffin et al., 2004). Repair of the EAS has been shown to provide a treatment for fecal incontinence and erectile dysfunction. In our study, there was an increase in patients’ sexual scores after perianal fistula repair. Anorectal disorders are believed to affect erectile function, and this relationship needs further investigation (Shafik, 2001).
Only a few studies in the literature have specifically examined the anatomical and physiological relationship between the BCM, which is central to erectile function in men, and the EAS (Broholm et al., 2015; Shafik, 2001). These studies demonstrated that the muscle fibers originating from the EAS continue uninterrupted to the BCM. Stimulation of the glans penis induces synchronous contractions of the BCM and the EAS with the same action potentials, indicating that the BCM is an inseparable part of the EAS (Broholm et al., 2015). This connection could explain the erectile function impairment that may occur due to damage to the EAS in both fissures and transsphincteric fistulas. The results of these studies suggest the need for further research in this area. Anal fistulas are commonly seen in young patients, and the literature indicates that patients are on average younger than 45 years. In our study, the mean age was also 40 years. During the literature review, we also identified that psychiatric disorders could be a contributing factor in understanding the relationship between perianal fistula disease and erectile dysfunction. Depression has been shown to be the most frequently reported predictive factor for sexual function impairment in perianal diseases (Boudiaf et al., 2021). Moreover, mood disorders, including depression, are more common in benign anorectal diseases and are considered significant risk factors for sexual function impairment (Akkoca et al., 2023). In our study, when investigating the improvement of sexual function disorders after perianal fistula surgery, we focused solely on the physio-anatomical aspect of the issue. However, the positive change in the mood of patients, resulting from both the repair of external sphincter muscle damage and relief from symptom discomfort after perianal fistula surgery, may also contribute to the improvement of sexual function disorders. Therefore, we believe that the evaluation from a psychiatric perspective would also add value to the literature. As limitations of our study, it can be mentioned that only male patients were evaluated, and the number of patients was relatively small. This allowed us to eliminate potentially confounding factors and conduct the study with a more homogeneous group.
Conclusion
In conclusion, erectile dysfunction related to benign anorectal diseases in men significantly improve after surgical treatment of the anorectal disease.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
