Pain from anal sex and how to prevent it

Dear Reader,

While serious injuries from anal sex are relatively rare, any time you have internal pain or see blood, it’s a good idea to get checked out. Bleeding following anal sex can be attributed to a number of conditions such as hemorrhoids, anal fissures, and colonic perforation (more on these in a bit). At the same time, several of these conditions may result from other factors, including ongoing constipation and severe diarrhea. Given all the potential risk factors and sources for bleeding and pain, a health care provider will be best at determining the cause of the discomfort and directing you to appropriate treatments.

A few of the potential complications of anal sex include but aren’t limited to:

• Hemorrhoid: This is a swollen vein in the anal area. Hemorrhoids (sometimes called piles) can be fragile and prone to bleeding, causing pain around the anus. However, they aren’t typically associated with the type of internal pain you’ve described. You can frequently feel a hemorrhoid as a swollen, tender lump in the anal area. You'll often notice blood from a bleeding hemorrhoid on toilet paper after a bowel movement or on the stool itself.
• Anal fissure: This is a small tear in the lining of the anus. Even small fissures can be pretty painful because they often cause spasms of the opening of the anus. They heal slowly because they're irritated repeatedly during bowel movements. With anal fissures, you may also see blood on toilet paper or on the stool itself.
• Colonic perforation: This is a hole (perforation) in the colon. A rare, but serious, complication that requires hospitalization, surgery to repair the hole, and antibiotics to prevent infection. A colonic perforation will usually cause severe pain and pressure in the abdomen and fever. This condition requires immediate medical attention.

In order to give you a diagnosis, a health care provider will likely start with a physical exam to determine the cause of the bleeding. In some cases, they’ll perform a minor procedure, which involves inserting a scope into the rectum to get a better look. A small scope called an anoscope allows your provider to check if there’s a fissure. To go deeper, a scope called a sigmoidoscope may be used. After getting diagnosed, if you have either a hemorrhoid or fissure, you may receive similar recommendations. Treatment for both conditions is sometimes abbreviated with the word WASH. The letters stand for:

• Warm water: Sitz baths involve sitting in a warm pan of water to soak the painful anal area.
• Analgesic agents: Various creams and ointments can temporarily numb the anal area to provide relief. However, it’s recommended that these aren’t used for more than a few days in a row. Your provider can recommend how long to continue using these treatments.
• Stool softeners: Taking over-the-counter medications can help keep the stool soft until the hemorrhoid or fissure heals. This can help you avoid re-injuring and further irritating the anus while having a bowel movement.
• High-fiber diets: A high-fiber diet will keep stools soft and easy to pass.

It’s critical to follow your health care provider’s recommendation as it helps heal any type of anal injury within a few days. Very rarely, a hemorrhoid or fissure may become infected, develop a clot within, or take longer to heal. If this occurs, your health care provider may recommend that you undergo a surgical procedure or use certain medications to help heal the fissure. It’s worth mentioning that any skin damage in the anal region increases the risk of getting or giving sexually transmitted infections (STI) and HIV. Following safer sex guidelines (such as using condoms) is recommended for all sexual activities where body fluids may be involved (including anal sex). That being said, to prevent a more serious complication, it’s wise to hold off on more anal sex until your current discomfort and bleeding are completely gone. When you resume anal sex, here are some recommendations to help prevent anal troubles in the future:

• Open the lines of communication. It’s helpful to talk with your partner(s) about the need for the inserter to go very slowly and gently and to stop the moment you feel any pain or discomfort. As with any type of sex, consent is key, and a partner can ask to stop at any time. Anal sex doesn’t happen for everyone on the first try and might take some time to get comfortable.
• Progress to anal sex slowly. Before diving into anal sex, some people like to start with a moving a well-trimmed, clean nail finger in the anus, very slowly inside. If there’s pain, stop, wait a moment, and breathe to allow the anal sphincter to relax. If the discomfort stops and you’re enjoying it, you can try inserting additional fingers, other sex toys, or a penis. If you use a dildo, finding one that’s soft and flexible (not stiff) may help to prevent colonic perforation.
• Use lots of water- or silicone-based lube. For all types of sex, lube can help to increase pleasure, decrease risk of injury, and protect against STIs along with a barrier method, such as a condom. You might want to keep in mind that being relaxed and aroused can help the anal sphincter muscles to relax to ease insertion. The face down position for those on the receiving end of anal sex may help to decrease anal pressure during the act.
• Talk with a health care provider. If you're still having pain with anal penetration, talking with a health care provider may provide other options. These could include rectal dilators, which are a set of instruments that get progressively larger. Typically, the smallest diameter dilator is inserted in the anus and when this is completely comfortable, you can move on to the next size, and on through the largest size. They can also help you plan a safe and reasonable schedule of progressing through the different sizes.

Though serious complications don’t often arise from anal sex, speaking with a health care provider can help ensure that you’re getting timely diagnosis and treatment information. Also, being open and honest with your partner(s) about how you’re feeling and if you need to stop can help to avoid injury and allow the experience to be enjoyable for everyone. After trying different ways to make anal sex comfortable and enjoyable for all involved, you may decide that anal sex isn’t what you enjoy. If that’s the case, the lines of communication aren’t just for negotiating anal sex — they can be used for discussing other ways to experience and give pleasure among partners in other ways as well.

Best of luck,