The Ins and Outs of Gay Sex (8 page)

Last, once you have had anal surgery, some scarring is
unavoidable and can cause tightening.
Usually this is not a problem, and anal sex can resume with a gentle touch without difficulty after healing occurs (four to eight weeks after a standard hemorrhoidectomy).
Occasionally patients who undergo surgery for extensive hemorrhoids will need rectal dilators to stretch their opening to once again accommodate their partner.
(See
Chapter 1
.
) Even if you choose an in-office, nonsurgical method for removing internal hemorrhoids, you still will not be able to have anal sex until the area heals.
This generally occurs within two weeks—unless you require additional treatments to remove multiple hemorrhoids.

An anal fissure is a tear or cut in the anal lining and usually begins as an extremely painful event.
Most men with fissures complain of severe pain during bowel movements and a bright-red streak of blood on their stool.
Pain can persist for hours after each bowel movement and results from spasm in the anal sphincter.
(See
Figure 2.
1
.
) Anal fissures most often result from a hard bowel movement tearing the sensitive lining of the anal canal.
Pain and bleeding often are incorrectly attributed to hemorrhoids, which, unless thrombosed, are rarely painful.
In gay men, other common causes of fissures are trauma from anal intercourse or fingers and toys as well as ulcers related to HIV.
Fissures usually occur in the posterior midline (the side of the anus closest to the coccyx, or tailbone), but if caused by sexual trauma, they can occur anywhere.

When fissures first occur, they look like a small cut at the anal opening and may be covered by a speck of blood.
If untreated, stool rubbing over the cut deepens it and further intensifies the muscle spasm.
Anal sphincter spasm tightens the anal opening, making it even harder to push out a
bowel movement.
The tear deepens, taking on the appearance of a tiny volcanic crater with white edges of callused skin.
The cut can extend right down to the sphincter muscles.
Often just the simple effort of spreading your cheeks apart for a close look can be painful.
When fissures become chronic, the long-standing inflammation can cause a small anal tag (a sentinel pile) to form at your anal opening.
(See
Figure 2.
1
.
) Many men incorrectly attribute their pain and bleeding to the tag, which is the result of the inflammation, not the cause.
Usually the fissure can be seen just inside the anal opening.
As with thrombosed hemorrhoids, constipating yourself or using laxatives only makes the problem worse.

A patient walked into my office demanding surgery for his anal fissure.
He insisted that it still hurt like hell despite stool softeners.
When I questioned him, I discovered he had been taking glasses of milk to keep his bowels soft instead of the medications I had advised.
Obviously he suffered from lactose intolerance and was not digesting milk.
His colonic bacteria worked on the undigested milk sugars, creating acid.
The acid acted like a laxative and burned severely when it passed across his raw fissure.
His fissure healed as soon as he switched to psyllium husk.

As in the treatment of hemorrhoids, initial treatment of an acute fissure is conservative (nonsurgical) and aimed at softening the stool and relaxing sphincter muscles.
Because every hard bowel movement feels like a rock rubbing against your cut, use over-the-counter bulk agents containing psyllium husk and a stool softener like docusate sodium (Colace).
When I tell patients with fissures that they need to have a bulkier stool, they usually look at me in wide-eyed terror.
If it already hurts to move your bowels, why would you want a larger stool?
Although initially painful, a soft, bulky stool conforms to the narrowed size of your anal opening and is less damaging to your healing cut.
More
than half the patients with acute anal fissures heal within several days after instituting appropriate treatment.

Over-the-counter creams, especially those with a steroid component, also may help heal fissures.
Avoid suppositories, because inserting them across your cut through a tight sphincter exacerbates pain.
When you push in the suppository you actually push it above your sphincter and fissure, past the point where it will do any good.
Since fissures are most often right at your anal opening, creams can be applied directly with your fingertip or an applicator.
Many creams include a topical anesthetic that will relieve pain and relax your sphincter.

Pain that is caused by a fissure is not only from the tear but also from muscle spasm.
Therefore, in addition to softening your stool, it is important to relax your sphincter as much as possible.
Obviously, the larger the anal opening, the easier it will be for your stool to pass.
Warm sitz baths act directly on the area and help loosen muscles.
If your spasm is severe, a muscle relaxant like Valium (diazepam) may help, and don’t be afraid to ask your doctor for it.
I do not recommend narcotic pain medications, which are constipating, but prefer topical anesthetics applied directly to the fissure.
In addition to deadening pain, they also relax sphincters.

If a fissure occurs during anal sex, stop immediately.
Avoid any attempt at further intercourse or manipulation of the anus until healing occurs.
If pain is severe or if fever develops, it could mean that a penis (or toy) tore through your sphincter into the delicate tissue surrounding your anus.
Seek medical attention immediately, because infection will usually result and antibiotics and/or surgery will be required.

A chronic fissure is less likely than an acute fissure to heal on its own.
Recent medical studies show that topical nitrates applied to the cut promote healing.
Many people
with heart disease use nitrates applied in patches to their skin to keep their coronary arteries open.
With fissures, nitrates are thought to dilate blood vessels in the area, bringing in more nutrients and oxygen to promote healing.
In doses used for heart disease, nitrates cause severe headaches and other troubling side effects.
Unfortunately, the medication is not yet commercially available in reduced strength, so consult your physician.

Some surgeons promote healing by cauterizing fissures.
Although you may wince at the painful sound of the word, cauterization is performed in your doctor’s office with only a topical anesthetic.
The doctor uses a weak electric current or chemical to burn the area.
Expect to need several treatments over a four- to eight-week period.
Results have been spotty at best.

The sphincterotomy is the mainstay of surgical treatment for anal fissures.
When a fissure becomes chronic, your sphincter muscle, through its spasms, has been in a perpetual workout and is much stronger than it needs to be.
This added strength tightens your anus to the point where any bowel movement is traumatic and the fissure will never heal.
A sphincterotomy cuts a portion of the muscle to weaken it, breaking the spasm and widening your opening.

To better understand the process, try thinking of the anal sphincter as your biceps muscle.
(Just try!
) Before you start weight training, you can press only sixty pounds.
With exercise, your muscle mass increases so that you can lift double the weight.
If a surgeon removed a piece of your biceps, you might be able to lift only sixty pounds once again.
This is exactly what a sphincterotomy accomplishes.

The surgery is performed on an outpatient basis (you go home right after it) and requires only a local anesthetic.
Don’t be frightened, though.
Most surgeons combine local anesthesia with intravenous drugs that relax you and make
you drowsy.
You’ll be high as a kite and not remember anything.

Once you are on the operating table, your internal sphincter muscle is relaxed by cutting away a small portion at its very end.
Most muscle above the fissure is left intact, as is the external sphincter.
You’re probably concerned that incontinence (inability to control your bowels) will result, and rightfully so.
That is indeed one of the risks of the surgery.
You must rely on the skill of your surgeon to cut just enough muscle to break your spasm without causing incontinence.
Thankfully, incontinence is rare because so little muscle is actually cut.
If you do have trouble, usually it is only with controlling flatus (gas) immediately after surgery, and that improves with time.
(Approximately one-third of patients who have had a sphincterotomy complain of incontinence of flatus immediately after surgery.
This drops to less than 5 percent by the second week.
The rate of fecal incontinence is even lower.
) As with any surgery, choose your surgeon carefully.

After any anorectal surgery, many patients report incontinence when the problem really is their inability to hold back a bowel movement because of soreness.
Your rectum stores stool until it is convenient for you to eliminate it.
After surgery your sphincter works well, but when a piece of stool touches the fresh cut, your muscles relax to get out of the way.
You perceive this sudden urge to move your bowels as incontinence, when really it is more like you’re pulling a cut hand away from a rock.

In rare instances, you might find a surgeon who recommends a simple anal dilatation, or “stretch,” to treat your fissure.
Although this procedure is more popular in the United Kingdom, some surgeons in this country prefer it to a sphincterotomy.
In essence, the surgeon stretches your tight sphincter until it partially tears.
Most surgeons frown
on this method because tearing occurs in an uncontrolled manner.
With a sphincterotomy, the surgeon knows exactly how much muscle is cut.
In theory, an anal dilatation should result in a higher incidence of postoperative incontinence, but that hasn’t been shown to be the case.
If a surgeon recommends an anal dilatation, it may be that in
his
hands this is the best way to treat your problem.
Surgeons are best at doing the type of surgery they have experience in.

Gay men who practice anoreceptive intercourse may develop an acute fissure from direct injury.
If treated with stool softeners and abstinence, this type of fissure should heal.
If, however, a chronic fissure develops and surgery is required, then a sphincterotomy or anal dilatation is usually not necessary.
Most often men who have had anal intercourse have already stretched their sphincter (I’m sure you can figure out how) and spasm is rarely present.
The fissure usually will heal if the surgeon removes the scar tissue and closes the tear with a few stitches.
Keep this in mind if a surgeon tells you a sphincterotomy is necessary.
In this instance, you might be placing yourself at a higher risk for incontinence because your sphincter is already loose.
You can always go back for a sphincterotomy if your fissure doesn’t heal after simple closure.

HIV-positive patients often present with many different types of anal fissures that are atypical and quite complicated.
HIV and medications used to treat it may cause diarrhea and subsequent fissure formation.
The constant wet stool macerates the anal lining and promotes breakdown and tearing.
(Think of your mushy skin after you’ve soaked in a tub for too long.
) Bulk agents and medications that control diarrhea (Imodium) often will cure this type of fissure.

Although many times rectal bleeding and pain are the hallmark symptoms of HIV-related fissures, you may notice only a chronic purulent (infected) discharge and foul odor.
Your discharge may appear as a brownish-green stain in your underwear.
This type of HIV-related fissure looks different from typical anal fissures and more closely resembles a broad, shallow ulcer rather than a simple cut.
As with any new symptom, if you have pain and an infected discharge, tell your physician.

If you have HIV and a fissure, first treat it with topical steroid creams, stool softeners, and bulk agents.
If healing does not occur, as is often the case, then the ulcer may need to be biopsied and removed.
In these instances, your ulcer may result from many different HIV-related causes, including the HIV virus itself, tuberculosis, CMV, herpes, fungus infection, syphilis, lymphoma, Kaposi’s sarcoma, or other cancers.

I
saw a young HIV-positive man whose fissures had been treated with creams and suppositories for two years by another doctor.
He gripped the table prepared for pain as I slid my finger into his anus.