BACKGROUND: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. METHODS: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. RESULTS: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. CONCLUSION: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.
The published study highlights an important gap in current practice. While MRI remains the gold standard for postoperative evaluation due to its high sensitivity and specificity, its cost and limited availability in some regions may limit routine use. In this context, the development of a Jabalpur Transperineal Ultrasonography-Based Scoring System (J-TPUSS) represents a pragmatic attempt to bridge this disparity. However, several methodological and interpretative concerns merit consideration, which we have discussed in the letter.
