Healing Beyond the Wound: Impact of Surgery on Quality of Life and Sexual Well-Being in Patients with Cryptoglandular Anal Fistula

Abstract

Introduction

Cryptoglandular anal fistulas significantly impair patients' quality of life (QOL) and sexual well-being. This prospective study evaluates the impact of surgery on QOL and sexual function.

Materials and Methods Fifty consecutive patients (42 males, 8 females) underwent preoperative MRI-based classification to guide tailored surgery. QOL scores, sexual QOL scores, and incontinence scores were recorded preoperatively and during follow-up. Surgeries included fistulotomy and fistulectomy with or without primary sphincteroplasty. Statistical analysis employed paired t-tests and McNemar's test.

Results

52% had simple, and 48% had complex fistulas. By 8 weeks, 100% of patients reported “very good” QOL (p = 0.02), up from 32% preoperatively. Sexual QOL significantly improved in males (mean score from 42.07 ± 2.64 to 48.14 ± 2.68; p < 0.001), with a non-significant trend in females (22.12 ± 2.75 to 23.75 ± 2.66; p = 0.47). Continence scores reached 0 (i.e., best) by 8 weeks in all patients.

Conclusion

Surgical intervention for cryptoglandular fistula-in-ano significantly improves both general quality of life and sexual health, while preserving continence.

 

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Keywords

anal fistula - cryptoglandular fistula - quality of life - sexual health - incontinence - fistulotomy - fistulectomy

Introduction

Anal fistula is a relatively common yet distressing surgical condition that significantly impairs patients' daily functioning and psychosocial well-being. Persistent foul-smelling discharge and perianal pain not only disrupt routine activities but also compromise the quality of life (QOL) in many ways.[1] [2] Beyond these physical symptoms, the anatomical position of the fistula raises important concerns regarding the impact on sexual well-being, an aspect often overlooked or underreported.[3] The stigma and embarrassment associated with perianal disorders often deter patients from openly discussing issues related to sexuality and self-image, particularly in conservative societies. This contributes to a striking gap in the scientific literature, with very few studies systematically evaluating the impact of surgical treatment for anal fistulas on sexual QOL. This prompted us to assess the impact of surgical intervention for cryptoglandular fistula-in-ano on overall and sexual QOL.

 

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Materials and Methods

Fifty consecutive adult patients with cryptoglandular fistula-in-ano were enrolled in this prospective study. All patients underwent preoperative high-resolution magnetic resonance imaging (MRI) to classify fistulas as simple or complex using the Standard Practice Task Force (SPTF) criteria.[4] Surgical strategy was individualized based on MRI findings and sphincter involvement: fistulotomy was performed in cases with ≤1/3rd sphincter involvement, while fistulectomy ± primary sphincteroplasty was reserved for those with more extensive sphincter encroachment.

To comprehensively assess postoperative outcomes, three validated instruments were used: the World Health Organization Quality of Life – Brief version (WHOQOL-BREF) questionnaire to evaluate general quality of life, the International Index of Erectile Function (IIEF) for male sexual function, and the Female Sexual Function Index (FSFI) for female participants.[5] [6] [7] Continence status was assessed using the Vaizey incontinence score.[8]

These assessments were conducted preoperatively and at 3, 6, 8, and 12 weeks postoperatively. Patient confidentiality and privacy were rigorously maintained throughout the study, especially during the administration of the sensitive sexual health questionnaires.

Data were analyzed using IBM SPSS Statistics for Windows, Version 29.0.2.0 (IBM Corp, Armonk, NY). Paired Student's t-test and McNemar's test were employed for comparison of quantitative and qualitative variables, respectively. A p-value <0.05 was considered statistically significant.

 

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Results

Our study was performed in the Department of Surgery in a tertiary teaching hospital in central India between 1^st July 2022 and 30^th January 2024. Prior clearance was obtained from the Institutional Ethical Committee (reference no IEC/2022/8629–124), and informed consent was taken from all patients.

A total of 50 consecutive patients were enrolled, 42 males and 8 females. The age ranges from 22 to 59 years in males and 27 to 55 years in females, respectively. Preoperative MRI identified 24 as simple and 26 as complex fistulas. The fistula tract was inter-sphincteric in 21, trans-sphincteric in 28, and supra-sphincteric in 1 patient. Simple fistulotomy was done in 20 patients, while 30 patients required fistulectomy with sphincteroplasty in the form of primary sphincter repair.

Patients were categorized based on their preoperative WHO-QOL scores as having 'Good' (n = 16) or 'Moderate' (n = 34) quality of life. At 3, 6, 8, and 12 weeks postoperatively, a progressive and statistically significant shift toward 'Very Good' QOL was observed in both groups ([Table 1]).

Table 1 Impact of Surgery on Quality of Life as assessed by World Health Organization Quality of Life – Brief version

World Health Organization Quality of Life – Brief version
Pre-op QOL	Postop week 3		Postop week 6		Postop week 8		Postop week 12
	Good	Very good	Good	Very good	Good	Very good	Good	Very good
Good ( n  = 16)	3	13	3	13	1	15	0	16
Moderate ( n  = 34)	19	15	19	15	4	30	3	31
p value	0.05		0.049		0.02		0.001

Abbreviation: QOL, Quality of Life.

Mean WHO-QOL scores improved steadily across all subgroups - males versus females, simple versus complex procedures, and fistulotomy versus fistulectomy - from preoperative to 12-week follow-up. No statistically significant difference was observed between males and females at any point. However, patients undergoing simple procedures or fistulotomy consistently reported higher QOL scores compared with those with complex procedures or fistulectomy with sphincter repair, with several time points showing significant differences. [Table 2] and [Fig. 1] highlight the progression of mean WHO-QOL scores over time for males versus females, simple versus complex procedures, and fistulotomy versus fistulectomy with sphincter repair. The trends show consistent improvement postoperatively, with better outcomes generally associated with simpler procedures.

Table 2 Impact of Surgery on Quality of Life in Three subgroups as assessed by Mean World Health Organization Quality of Life – Brief version

	QOL Scores (mean values)		P Values
	Males	Females
Preop	68.88 ± 6.102	68.25 ± 5.339	0.786
3rd week	70.17 ± 5.441	70.13 ± 4.764	0.984
6th week	70.76 ± 5.591	70.29 ± 5.605	0.523
8th week	71.93 ± 5.761	71.50 ± 5.210	0.846
12th week	72.55 ± 5.265	71.38 ± 5.012	0.564
	Simple	Complex
Preop	70.85 ± 3.916	66.54 ± 6.959	0.009
3rd week	72 ± 3.298	68.17 ± 6.315	0.009
6th week	72.38 ± 3.90	68.54 ± 6.427	0.013
8th week	73.88 ± 4.023	69.67 ± 6.343	0.007
12th week	73.96 ± 3.810	70.63 ± 5.970	0.022
	Fistulotomy	Fistulectomy with sphincter repair
Preop	70.80 ± 4.313	67.91 ± 6.373	0.12
3rd week	72.40 ± 3.269	69.20 ± 5.728	0.05
6th week	72.67 ± 4.082	69.63 ± 5.902	0.08
8th week	73.87 ± 3.833	71 ± 6.088	0.10
12th week	74.27 ± 4.061	71.54 ± 5.458	0.09

Abbreviation: QOL, Quality of Life.

Fig. 1 Progression of mean WHO-QOL scores over time for males versus females (A), simple versus complex types (B), and fistulotomy versus fistulectomy with sphincter repair (C).

Post-operatively, the sexual QOL improved significantly in males but not in females ([Table 3]). However, the continence improved after 6 weeks.

Table 3 Impact of Surgery on Sexual function and continence scores

	Pre-op	3rd week	6th week	8th week	12th week
Mean FSFI Scores for Female patients	22.12 ± 2.75	22.65 ± 2.54	22.75 ± 2.86	22.75 ± 2.86	23.75 ± 2.66
P value		0.6975	0.6619	0.6619	0.4720
Mean IIEF scores for Male patients	42.07 ± 2.64	37.14 ± 2.68	36.14 ± 2.68	45.14 ± 2.68	48.14 ± 2.68
P value		<0.001	<0.001	<0.001	<0.001
Mean Continence score	0.48 ± 0.80	0.36 ± 0.62	0.06 ± 0.23	0.00	0.00
P value		0.40	0.0006

Abbreviations: FSFI, Female Sexual Function Index; IIEF, International Index of Erectile Function.

Continence Score = Vaizey scores

Continence scores were analyzed by type of fistula and type of surgery performed. While preoperative continence scores were significantly higher in complex fistulas compared with simple ones (p = 0.048), postoperative differences diminished over time, with both groups achieving complete continence by the 8th week ([Table 4]). Similarly, although fistulectomy ± sphincteroplasty had slightly higher preoperative scores than fistulotomy, the difference was not statistically significant, and both groups showed full continence recovery by week 8 ([Table 5]). The trends in both are shown in [Fig. 2].

Table 4 Impact of Surgery on mean continence score in simple versus complex fistula

Type Of Fistula	Pre-op	Post-op 3rd week	Post-op 6th week	Post-op 8th week	Post-op 12th week
Simple	0.26 ± 0.52	0.38 ± 0.62	0.03 ± 0.27	0.00	0.00
Complex	0.70 ± 0.97	0.33 ± 0.62	0.08 ± 0.27	0.00	0.00
P Value	0.048	0.77	0.449

Table 5 Impact of Surgery on mean continence score according to type of fistula surgery

Type of Surgery	Pre-op	Post-op 3rd week	Post-op 6th week	Post-op 8th week	Post-op 12th week k
Fistulotomy	0.35 ± 0.65	0.20 ± 0.40	0.05 ± 0.21	0.00	0.00
Fistulectomy ± Sphincteroplasty	0.56 ± 0.88	0.46 ± 0.71	0.06 ± 0.24	0.00	0.00
P Value	0.36	0.14	0.88

Fig. 2 Trend in continence scores over time for simple versus complex types, and fistulotomy versus fistulectomy with sphincter repair.

 

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Discussion

Our prospective study shows the therapeutic value of surgery in substantially enhancing the patients' overall quality of life and sexual well-being; notably, the restoration of continence and marked improvement in male sexual health. This underscores the importance of QOL and patient-centered outcomes in addition to fistula healing.

A review of literature across PubMed, Research Gate, and Scopus revealed a striking paucity of data on the impact of fistula-in-ano surgery on quality of life and sexual function. Existing studies are limited, methodologically heterogeneous, and often focus on less common fistula types—such as recto-vaginal, ano-vaginal, or those associated with Crohn's disease—making it difficult to draw broadly applicable conclusions. This prompted us to conduct this prospective study.

Baseline WHOQOL scores in our cohort were notably low, with 68% of patients reporting “Moderate” and 32% “Good” quality of life—none reported a “Very Good” QOL preoperatively. This aligns with previous studies,[9] [10] [11] which reported reduced QOL in 60–70% of patients with fistula-in-ano. However, those studies employed scoring tools originally developed for other gastrointestinal conditions or assessed only selected domains of QOL, limiting their generalizability. Furthermore, reliance on subjective self-reported measures introduces potential bias, as factors like psychological resilience and social support may influence perceptions and are often inadequately captured by generic QOL assessments. In contrast, our study demonstrated a consistent and statistically significant improvement in WHOQOL scores at each postoperative time point (3rd, 6th, 8th, and 12th week), culminating in 94% of patients reporting a “Very Good” QOL by week 12 ([Tables 1] and [2], [Fig. 1]). Similar improvements have been observed in other studies,[12] [13] [14] although those too often employed non-specific scoring systems or included outcomes confounded by fecal incontinence. We addressed these limitations by using the full WHOQOL-BREF instrument and a dedicated, separate scoring system for continence, allowing for a more accurate and nuanced evaluation of postoperative recovery and patient well-being.

Assumption of universal improvement in quality of life following fistula surgery has been challenged,[10] reporting that some patients experienced persistent pain and functional limitations, resulting in poorer QOL compared with their preoperative status. However, such outcomes may reflect the early postoperative period, where pain and healing-related discomfort are expected. With adequate follow-up, these symptoms often resolve, potentially leading to long-term QOL improvement.

Sexual function is frequently compromised in patients with anal fistula, similar to other perianal pathologies.[15] The anatomical complexities of the pelvic floor—particularly the involvement of ano-genital muscles and the external anal sphincter—may explain alterations in sexual function when the fistula tract traverses these structures.[3] Additionally, poor perineal hygiene and persistent discharge can negatively affect both psychosocial well-being and sexual self-image. Given the lack of a standardized, gender-neutral sexual function tool, we employed the IIEF and FSFI for males and females, respectively.[6] [7] Among males, sexual function scores initially declined in the early postoperative period but showed significant improvement by later follow-ups. This early dip may reflect postoperative pain and discomfort from wound discharge. As healing progressed, these factors resolved, likely restoring confidence, which translated into improved scores. A similar trend has been reported in previous studies.[16] In contrast, female patients showed a marginal, non-significant improvement in sexual function throughout the postoperative period ([Table 3]), echoing earlier findings that noted positive trends without statistical significance.[10] [17] This gender difference may stem from greater social inhibition among females compared with males in reporting sexual satisfaction outcomes. Cultural norms often make Indian women more reluctant to openly discuss sexual health, leading to potential underreporting of this score despite real improvements.

Psychological factors like anxiety and depression can substantially influence postoperative sexual function outcomes. A limitation of our study—shared by many previous ones—is the lack of assessment of these variables. Moreover, evaluating sexual function presents inherent challenges, including the sensitivity of available tools and the reliability of patient self-reporting.

Surgery for fistula-in-ano requires a careful balance between minimizing recurrence and preserving continence—an important determinant of QOL. In our study, all patients ultimately achieved full continence to both feces and gas. Preoperatively, a few patients had Vaizey continence scores of 1 or 2, largely due to pad use, which the scoring system includes. Mean continence scores improved significantly by the first and second follow-ups, with all patients reporting perfect continence by the third and fourth (p = 0.0006; [Tables 4] and [5], [Fig. 2]). It is important to note, however, that early postoperative scores of 1 or 2 may reflect wound discharge rather than true incontinence secondary to sphincter division. These findings align with earlier studies.[18]

Our study has several strengths, including its prospective design, MRI-based fistula classification to guide tailored surgical intervention, and the use of validated, gender-specific tools for assessing sexual function and continence. Additionally, the use of the comprehensive WHOQOL-BREF scoring system allowed a more holistic assessment of quality of life. However, a few limitations remain. The relatively small sample size, especially among female participants, may limit the generalizability of our findings across genders. We also did not assess the psychological factors, such as anxiety, depression, or body image disturbances that can significantly influence sexual and overall quality of life. Cultural barriers, particularly among Indian women, may have affected the accuracy of self-reported sexual health outcomes. Future research should focus on larger and more gender-balanced cohorts, incorporate psychological assessments, and explore the use of unified sexual health scoring systems that are culturally sensitive and applicable across populations.

 

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Conclusion

Surgical management of cryptoglandular fistula-in-ano, when tailored to fistula complexity, leads to significant improvements in QOL and sexual function while preserving continence. Our findings underscore the importance of a holistic, patient-centered approach that addresses the importance of QOL and patient-centered outcomes in addition to fistula healing.

 

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Conflict of Interest

The authors report no conflict of interest.

Authors' Contributions

All authors have equally contributed in study design, data collection and analysis, and article writing and proofreading.

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Publication History

Received: 02 May 2025

Accepted: 16 July 2025

Article published online:
27 August 2025