One of the more painful and lesser discussed aspects of anal sex is the occurrence of anal fissures. If you’ve had one you know the searing pain associated with it and the weeks-long recovery time to get things back to working order down there. As with most things, prevention is the best treatment for anal fissures, so we brought in the good Dr. George to give us some tips on how to avoid them and what to do if we happen get them.
John: Hey Dr. George. The topic of the day is anal fissures. Let’s start with the basics and then work our way deeper into it, pun always intended. At the most basic level, what are anal fissures and what causes them?
Dr. George: An anal fissure is a tear in the lining of the anal sphincter. Basically, it could be a small scratch or it could be very, very significant tear. Now if you go onto Google looking for anal fissures, the main people you’re going to see suffering with them are women who’ve been pregnant, and the reason for that is because the muscles around the area were stretched beyond their capacity.
So, within the context of gay men, there are three reasons that they’re going to get anal fissures: One is constipation, that’s really having to strain to do a poo. The second is receptive anal intercourse when the muscle is not properly relaxed and the third is not using enough lube during sex.
(Editor’s Note: Dr. George goes further into the anatomy of the internal and external anal sphincter and how to properly penetrate in our feature Loosen Up! Dr George’s Tips for Pain-Free Anal. He gives us lots of great information on what bottoms and tops can do to facilitate a pain/ fissure free experience and what types of lube work best.)
We’ll talk about #2 first. So receptive anal intercourse- the ass has got two muscles in it. It’s got the external anal sphincter, and it’s got the internal annual sphincter. The internal anal sphincter will open with gentle stretch and the keyword here is gentle. One of the reasons that young bottoms get fissures is because the top is worried they’re going to lose their erection so they just force their way into the ass – not good.
I teach people how to dilate the muscle slowly. Basically, it just needs a little bit of gentle pressure or gentle tapping. With that very gentle pressure, the muscle will open in between 30 to 90 seconds. If you’re a bottom, it’s about you being able to control the rate of penetration; choosing positions where you can control how deep and how rapid the penetration goes. And for tops, if you’re worried about losing your erection, all you need to do is put lube onto the head of your cock, if using a condom put heaps of lube on the inside of the condom and the outside of the condom, and you put the head of the penis against the anal muscles and then gently tap, tap, tap. And you will feel the muscles slowly start to relax. When they first start to relax, just keep on tapping and then slowly you’ll find that the penetration happens naturally, and you’ll avoid causing any fissures.
Constipation, on the other hand, causes fissures for the exact same reason, because you’re forcing poo out against a muscle that hasn’t relaxed. So really, it’s about learning the sensations of relaxing those muscles, and the best way to learn that is with your own exploration. With the finger slowly start to massage your anal muscles and you will start to feel and learn at which point they start to relax. If at any point the muscle clamps down on your finger, it means that the muscle isn’t relaxed, and you’ve stretched it too hard. In that case, you back away and just do it again. This will help you relax your sphincter muscles for strain free bowel movements.
With regard to lube, most people forget is that skin is a high friction fabric. For instance, if you rub your hands together you make warmth that’s made purely from friction. So with sex, if you haven’t got enough lubricant on the penis or in the ass, the two skins are going to catch against each other and pull. And that’s when you can get a fissure. So, I recommend heaps and heaps and heaps of lube, you can never have too much lube. The lining of the ass is designed to absorb water, so if you’re using a water-based lube it’s going to get all goopy and globby. Most people don’t like water based lube because of this. If you don’t have allergies and if you’re not using condoms then I usually recommend something other than water-based lube, like a silicon-based lube. I think silicon is generally the best bet.
So, in summary, lots of lube, time, time, time and gentle pressure. That’s the magical triangle to opening up the ass for fissure free anal. It’s like a safecracker, you’ll be in and out. Nobody will know what happened – your pearls will be missing!
John: Not my pearls!!! (Laughs) Fantastic information doc – what can we do to help heal a fissure if we ever find ourselves suffering with one?
Dr George: The internal structure of the anus is about two to four centimeters long. Most people think it’s like a little round donut. It’s not, it’s more like a tube. With sphincters, when you have a fissure, the big issue is that when the muscle is all bunched up, so it’s hard for the edges to come together to heal. There’s a number of studies that were really interesting, that talked about using dilators and talked about using fingers for opening up the bum and anal massage.
What’s more, the studies showed that massage was more successful at curing anal fissures than using dilators (like a butt plug). And the reason for that is you get the biofeedback. When the muscle clamps down on your finger, you can feel that you are stretching it too tight. To heal the anal fissures, first we need to get blood into the area to allow it to heal, but also we need to let the muscle relax because it gets super, super tight. The muscle needs to learn that it’s safe for it to relax and that’s where the gentle massage with the finger comes in and it you have to go really, really slow. Massage, massage, massage. And if you feel the muscles slowly starting to open up, then you might want to go a little bit deeper and continue the massage. If you do that 5 minutes twice a day, studies show that you’ll find great success, and it’ll be great for your sex life as well.
Another thing with fissures, when you’re doing the finger massage with your finger, you can also use some over the counter hemorrhoid creams. However, the cream that you really want to use is the one that has glycerin, trinitride, nitroglycerin or any nitric oxide in it because they help relax the muscle. As far as I’m aware, at least on the American market, you might need a prescription from your doctor. In Australia it’s over the counter. You want to get to good stuff. Talk with your doctor about that, because this is bread and butter for a gay men’s health doctor.
John: What about Nifedipine ointments?
Dr. George: It’s a compound that’s the next level up, the calcium channel blockers. It does have pretty good success, but it’s got to get compounded and it usually works within two to three weeks if it’s applied twice a day. I would use the massage method to apply those ointments.
The other thing that’s really important to be mindful of is constipation. You gotta avoid it like the plague. So, you wanna use stool softeners. I recommend daily psyllium husks. You’ve got a brand in America called Metamucil which is basically psyllium husks plus Tang. But the trick with psyllium is that you have to have plenty of water because its job is to hold water in the poo to make it soft. I personally advise my patients to just do a teaspoon of their favorite psyllium fiber supplement, mix it into a glass of water, drink it down and then have a second glass of water immediately after. Your poo should be about the consistency of toothpaste. Doing a poo should be effortless. If you can, raise your knees up a little bit with a Squatty Potty, or even just a couple of old phone books if you still have those there. Anything that brings the knees up a bit brings that anal canal into a straight line, which makes it easier to do a poo, so it’s less likely to cause excessive stretch and pain.
John: And what if all this still doesn’t work?
Dr. George: At the end of the line, if you’ve tried all the simple measures, and you’ve seen your family practitioner without any luck, then you might need to see a colorectal surgeon, and options that they have include Botox injections which can help and certainly relax the muscle. And then there’s operations, but you want to avoid the operations because they’re very, very painful and the success rate isn’t that great. Simple measures work best. Prevention works absolutely best.
One last thing, on anal fissures and anal sex, the internal anal sphincter is very, very sensitive to your mood. If you are tired, if you are stressed out, if you do not want to have sex at this exact point, that muscle will clamp shut super tight, the same as if you were being chased by a lion in the Sahara. That muscle is super tight when you’re running away from a lion because you don’t want to leave any scents or anything behind. So if you’re not in the mood for sex, don’t have sex because the muscles are going to be tight. It’s a recipe for a tear and so you gotta be in the mood.
John: Fascinating. And because I have to ask doc, can you have sex with anal fissures?
Dr. George: You can have sex with anal fissures, but I can’t guarantee it’s going to be fun because the fissure is painful while it’s healing. Sex is a very good way of dilating the internal and external sphincter which helps heal, but if you’re going to have sex with an anal fissure, the two limiting factors are lubrication, you have to have stacks of it. And the other thing is pain. The minute you have pain, those muscles are going to clamp down. So if it’s painful, back away, do something else. If it’s painful to open the ass, you have to allow that fissure a good month or so to heal. If after that month you’ve still got discomfort, that’s when I would start a gentle regime of massage and gentle dilatation with your finger, to see whether the pain eases.
John: And what about STI infections?
Dr George: Any cut or tear around the ass is going to make transmission of, say, a blood-to-blood infection easier, the most obvious ones being HIV, hepatitis B, hepatitis C, they’re the three that are most likely to be transmitted. But any anal sex will easily transmit chlamydia, gonorrhea, syphilis, and all of those other nasties. I recommend getting a regular sexual health screening. And remember, if you’re living with HIV and you’re on successful treatment with an undetectable viral load, you can’t transmit HIV. Undetectable, is untransmittable, and if you are not HIV positive but on PrEP, you are also protected on that front.
John: And finally what types of food would we want to avoid while dealing with fissures?
Dr. George: Avoid anything that makes you constipated. So, what’s that? Edd salad, I suppose. If you have problems with constipation, have tinned pears. They’re bloody brilliant. Eat a high fiber diet, get your five servings of vegetables, two pieces of fruit every day and you should be pooing lovely and soft. If by chance you still are not, add in the pears, then if you’re still not, add in your daily fiber supplement as well. High fiber with plenty of water.
John: Thanks Dr. George. This will hopefully help lots of our readers.
Dr. George Forgan- Smith is an expert in gay men’s health dedicated to the bear, leather and kink communities which he serves faithfully in Melbourne, Australia. In addition to working at the Collins Street Medical Centre and creating tons of educational content for his social media accounts (links below), he is the creator of The Healthy Bear website which he uses to share vital health information pertaining to and about our community.
Stay in touch with Dr George and up to date on the latest in gay men’s health by signing up to his mailing list HERE.
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