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PSA: Say “No” to a Lateral Internal Sphincterotomy!

October 02, 2018 by Dr. Evan Goldstein

Over and over we write a tale of someone who is way too fucking tight. Too tight to even take a shit, let alone think about getting a dick up the ass. And the reason we started this blog was to educate each and everyone of you, some of whom do not have the appropriate resources or access to the specialized care we provide here at Bespoke Surgical. So, here we go.

Several times every week, I get DM’s or emails about not only a misdiagnosis of an anal tear (called a fissure), but also people telling me their surgeon recommends to cut the anal sphincter muscles (called a lateral internal sphincterotomy). It’s gotten to a point that I feel as if we should forgo this week’s tale and go directly to the appropriate treatment of your tail. But before we dive in real deep, remember that this can happen to any one of us, it even happened to me 20 years ago. The commonality is a chronic tear that’s painful, bleeds, irritates, and prevents us from any sort of anal engagement. It totally fucking sucks and for sure needs treatment, just not the one most surgeons are proposing.

Warning: please beware of surgeons who want to cut your anal muscle to treat anal tears. The medical and technical terms thrown around and used are a lateral internal sphincterotomy for treating a chronic anal fissure. And I hope with you Googling around, that you stumbled upon this article as a reference for the appropriate treatment for our specialized community. To put it into context, in the ten years of surgical practice, specifically treating the gay community, I can count on one hand how many times a sphincterotomy has been required. And in the bigger picture, every week I see and treat a ton of ass, so that means it’s beyond rare.

Anal tears in the gay community have a different patho-physiology and should be approached and treated completely differently.

Complications & Side Effects of Lateral Internal Sphincterotomies

Why the fuss about performing a lateral internal sphincterotomy or cutting the anal sphincter? The first and most important reason is incontinence. What’s incontinence, you ask? Drumroll please… You may not be able to hold in your farts and/or you may shit yourself, not to mention you may also be too loose to enjoy anal intercourse–two unfortunate side effects. Now, this may not be immediate, but remember that as a hole and an essential part of the bottoming community, the more we fuck, the looser we get. So now take an already loose asshole with a the sphincterotomy and put it to the test of withstanding years of bottoming. What do you think happens? Yep, you guessed it: a looser hole in an even shorter period of time. Not favorable for you and your partner’s pleasure. It totally sucks, but it’s also totally avoidable if you come with the necessary knowledge when undergoing treatment for an anal fissure. We need all the muscle we can get in order to stay in the game for as long as possible. Don’t cut the muscle! Just say “no” to performing a lateral internal sphincterotomy.

Now, let’s break it down into subsets.

Traumatic tear from anal sex

Lots of people are able to fully relax their muscles, accepting whatever cock is in front of (or behind) them, but their overlying skin, being quite friable, is susceptible to tearing. It doesn’t necessarily have to be from particularly rough sex for this to occur and can also stem from awkward positioning. So in this case, why would one even think about performing the cutting of any muscle (lateral internal sphincterotomy), when indeed the muscles are not the culprit to the anal tear? Understanding how we engage is critical to prescribing treatments, specifically detrimental ones.

Way too tight

Take for instance the “too tight” scenario. The top who wants to bottom, but just can’t fully relax. Most of the time the muscle is reacting to the actual anal tear and it becomes this cyclical scenario. The muscle knows nothing more than to stay ridiculously tight when an anal cut is present. The reality is that after we surgically clean out the tear and dilate, setting the stage for healing, the irritated muscle usually calms down. To make sure this occurs, Botox is utilized for temporary paralysis. This approach spares the permanent cutting after a lateral internal sphincterotomy, all the while allowing full and complete restoration. The Botox is simply a temporary cutting of the muscle. Why would anyone permanently alter their asshole when simpler non-permanent solutions are readily available?

Botox first and dilating second

As you can see, I am a huge proponent of Botox as a first initial treatment. One loses nothing, but gains an enormous potential of healing. The upside is huge. Now, I will let you in on a little secret. Bottoming is hard work, with the best of bottoms having to train their asshole. And with this, the muscles are in complete full control. This is the difference with the straight proctologist you just saw. They have no understanding of how critical post-surgical anal dilation with butt plugs is. With the Botox on board, one can embrace and engage to give one the relaxation needed for success. This is beyond crucial not only for healing the primary anal fissure, but also as the impetus to start fucking. And when I mean fucking, I mean full acceptance with the pleasures we all strive for. All the straight doctors care about is that are you capable of defecating normally. Most don’t even ask if your a homo, let alone if you take it up the ass.

And if you find yourself in that exact scenario, run away fast!

OK, OK. So now you say, “Dude, I am super fucking tight and nothing has ever gone in my hole. This shit is not gonna work.” I beg to differ, dude. As stated prior, by undergoing the appropriate surgical intervention and staying diligent about the anal dilation and post-operative follow ups and treatment, the success is in the pudding. And when that pudding is in your ass, the complete uncut one, and you’re moaning and groaning in pleasure, you will remember my name. Actually, probably best not to remember my name at the very moment of orgasm. Maybe just after.


Fuck the sphincterotomy. We, as a community, do not need it. Period. One can test the true understanding of their anal surgeon if it’s even brought up as a possible solution. Talk about this. Blog about this. Tweet about it. Demand access to the appropriate care we all so deserve. And if they do not bring up your sexuality and sexual desires, then you should do two things immediately: (1) mention it to them, attempting to educate them on the sensitivities of our community and (2) walk the fuck out. We at Bespoke Surgical are here for guidance. We are here for everyone who wants what we want. It’s time to open up, literally and figuratively!

Stay in touch on Instagram: me and Bespoke Surgical.

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About the Author

Dr. Evan Goldstein is the Founder and CEO of Bespoke Surgical. Dr. Goldstein has extensive experience educating and shedding light on health care issues relating to the gay community, and has been published in several national publications including The Advocate, OUT Magazine, Vice, Refinery 29, NY Mag and more.

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