Beyond incontinence: a systematic review and meta-analysis of sexual dysfunction after anal fistula surgery

Traditional metrics for anal fistula surgery prioritize healing and continence, largely ignoring intimacy and psychosocial well-being. Addressing a critical literature gap, this novel systematic review and exploratory meta-analysis is the first to mathematically evaluate the sex-specific impacts of fistula surgery and seton placement on sexual function.

A Preferred Reporting Items for Systematic Reviews and Meta-Analyzes-compliant search of PubMed, Embase, Scopus, and Cochrane databases identified studies using validated sexual indices: International Index of Erectile Function (IIEF) for males and the Female Sexual Function Index (FSFI), and targeted quality-of-life surveys for cryptoglandular or Crohn's-associated fistulas. This study uniquely pooled continuous pre- and postoperative functional data using standardized mean differences.

A total of 18 studies were included. The systematic review established a stark, previously unquantified sex dimorphism in surgical recovery. Definitive surgical cure yielded highly significant improvements in IIEF (male) by eradicating chronic suppuration (P <.001). Conversely, FSFI (female) showed negligible improvement or active deterioration, frequently complicated by anterior-tract dyspareunia. Furthermore, this review quantified the "Seton Paradox:" although loose setons successfully mitigate sepsis, cross-sectional pooling demonstrated that they inflict severe, statistically significant impairment on female sexual function (P =.02) and drive high rates of body-image avoidance across both genders. Crucially, the synthesis of patient-reported data revealed a systemic failure in informed consent, showing that 79% of patients never received preoperative sexual counseling.

Anal fistula surgery inflicts a profound, sex-dimorphic toll on sexual function. As the first systematic review to objectively highlight this disparity and quantify the psychological burden of chronic setons, these findings mandate a clinical paradigm shift. Proactive counseling regarding dyspareunia, body image, and intimacy must become a mandatory component of preoperative informed consent.