LEARN ABOUT ANAL FISSURES FROM THE EXPERTS AT BESPOKE SURGICAL
What is an anal fissure?
An anal fissure is a small tear in the external skin of the lining of the anal canal. It usually manifests in the two weakest spots of anyone’s anus: posterior (to the back/tailbone) or anterior (towards the penis/testicular region). The tear exposes the underlying muscle, which, in turn, leads to the manifestation of symptoms (mostly pain). The majority of acute fissures can heal without anal fissure surgery. Instead, an appropriate bowel regimen, as well as with the use of topical creams, suppositories, and refraining from anal intercourse can work effectively.
Unfortunately, many anal fissures that become chronic and non-healing will require surgical intervention. This is because this area of the body is still considered taboo by most and many refrain from seeking attention and/or the physicians treating them have limited knowledge, specifically of our queer community. A complete understanding of one’s ultimate sexual goals is imperative to the success of any intervention, with the treating physician being well-versed in not only the common ailments that affect our community, but also the appropriate treatments before, during, and, more importantly, post-surgery. Without this knowledge, the outcomes will be subpar.
What causes an anal fissure?
Anal fissures may develop from passing hard stools and/or the trauma associated with anal sex. It’s all about pressures and one must understand that elevated pressure from both defecation and intercourse can be quite high. With that, the skin and the underlying muscle have only a maximal capacity to withstand that stress. Either the skin is the limiting factor or it’s the underlying muscle or a combination of both. But regardless, if that pressure goes beyond its limit, it splits.
Anal Sex and Anal Fissures
Anal sex makes an enormous impact on one’s susceptibility to tears, known as anal fissures. These cuts are commonplace for anyone who engages in this type of intercourse. Anal sex tears stem from the localized trauma that can occur from the elevated pressures of anal play. The asshole is truly simple and basically has two elements of potential injury: the overlying skin and underlying muscle. If one or both are placed under undue stress and are stretched beyond its normal capacity, a fissure with ensue. It doesn’t have to be from forceful, aggressive sex and/or double penetration, though clearly the more stress and strain, the higher the chances of ripping. It’s so multifactorial as it relates to positioning, lubricity, pelvis size, diameter and length of item inserted, etc. It even happens from defecating!
As stated above, there are two specific locations that are the weakest—the back and the front of the anus opening—and the majority of anal fissures from sex will occur here. It’s purely a pressure issue, especially during anal play. As you can imagine, when you graduate to larger toys and/or fisting, these pressures get exacerbated.
The key is to understand your own anatomy prior to anal play in order to mitigate your risk. We speak all the time of using toys to explore safely and to develop an understanding of your own capacity to accept things anally. With gradual dilation, both the skin and the muscle can open to the appropriate diameters. Remember: even though they are stacked on top of one another, the muscle and skin that is, they function independently. You may be fully able to open the skin to a fist size, though the underlying muscle simply cannot accommodate or vice versa.
Successful engagements (more so minimizing anal fissures) stem from your mastery of not only your own anatomy, but also being able to analyze both successful and not so successful play routines. It’s totally a sport and in order to get better, it requires practice, practice, practice! And through this play, your overlying skin gets tougher, allowing also better elasticity, and the underlying muscle to accommodate whichever size you desire. It’s not a hard concept–it just needs to be learned.
Full evaluation with the knowledge above leads to fruitful solutions and future engagements, whatever they may be.
What are the symptoms of an anal fissure?
Symptoms vary from bleeding, discharge, pain, and/or the development of a localized skin tag. Since the anal tear is overlying exposed muscle, you may also develop sphincter spasms as well. These, in turn, can make defecation (and the time following defecation), quite painful and difficult. Also, there may be mucus, discharge, and mild seepage that may present itself and become persisting, affecting overall cleanliness.
Anal intercourse in and of itself can be quite painful, which may limit the pleasure one experiences or prevent one from engaging in the act altogether, with bleeding being another possible symptom. One may not have any issues with defecation, though sex is limited due to the development of some of the previously mentioned anal fissure symptoms. Some clients even just comment on a persisting burning in a specific location. For some, it’s just the nagging, localized irritation and discomfort that limits their quality of life.
How are anal fissures diagnosed?
Most anal fissures can be diagnosed by a medical professional through visual inspection. While anoscopy is the preferred method, since it allows for a thorough evaluation, pain is the limiting factor and this exam may require the client to be placed under anesthesia or defer the evaluation until it has had sufficient time to heal. The key component is to differentiate between acute and chronic fissures, as this changes the initial treatment pathways. Chronic tearing is actually quite easy to ascertain because an old scar and extra tissue is usually present.
That scarring leads to a bump in the region or a tag called a sentinel pile. This is the normal way in which scarring occurs in the region, due to the need to continue to defecate. If this is present, surgical treatment is warranted, since that new scarred tissue that is laid down is beyond weak. Take that weakness and add the pressures of defecating and anal play, and you can see the chronic tearing occurring. Lastly, sometimes on visual inspection, there are no issues that are found; however, through discussion, a client will say that once they engage anally, a tear is noted.
With this, we either tell one to have anal engagement the night before we inspect, for the best diagnosis, or we schedule an operation under anesthesia to dilate, simulating anal intercourse. This will definitely show the hang-points of friction and, of course, the subsequent tearing. With this new knowledge, it can be treated appropriately. Mostly, this last category is more a history taking diagnosis, which is missing from far too many other surgical evaluations through other surgeons. The use of diagnostic anoscopy is essential in our community, specifically as it relates to the way in which we all engage.
How do I know if I have a hemorrhoid or a fissure?
It’s sometimes not an easy distinction between a hemorrhoid and a fissure, even for some professionals. Pain with defecation, plus or minus bleeding, may be present with both. Also, some extra skin in the region is another common occurrence. Now, with fissures, many describe the defecating as “shitting razors” and you feel a significant anal muscle spasm along with this sensation. This can last for a considerable amount of time after each bowel movement and even debilitate you enough that you have to lie down.
As for external hemorrhoids, it’s pressure and you can feel a clot from the size of pea all the way up to a walnut protruding externally. Most hemorrhoids, geographically, are noted on either the left or the right side, whereas a fissure is more posterior towards the tailbone.
You can usually take an anal selfie and send it to us. We get them all the time. From there, we can diagnosis and place you on an appropriate treatment plan.
The reality is, the treatment for both of these in the acute phase is very similar.
How are anal fissures treated at Bespoke Surgical?
Non-Surgical Treatment for Anal Fissures (Initial Regimen)
The appropriate initial regimen to treat an anal fissure consists of:
Over-the-counter stool softeners, such as Colace, three times daily
Over-the-counter fiber supplements, such as Metamucil
Calmol 4 suppositories twice a day, found at small local pharmacies such as C.O. Bigelow, New London Pharmacy, or Capsule Pharmacy.
Sitz baths, utilizing over-the-counter epsom salts
A small pea-size drop of Lidocaine 2%/Anusol 2.5%/Cardizem 2% topical ointment should be gently applied by fingertip to the anal opening before bed, in the morning, and after each bowel movement. This compound can be obtained solely by prescription at Capsule Pharmacy in NY.
Boosting your fiber intake with choices such as grains and whole-grain products, fruits, vegetables, legumes, nuts, and seeds
Increasing your overall water intake to 8-12 ten ounce glasses per day
Refraining from caffeinated beverages, as they tend to cause dehydration
Keeping the anal area clean and dry. Wash gently with warm soapy water, and hairblow dry.
Limiting the use of toilet paper, as wiping causes local inflammation. Please refrain from using baby wipes or medicated pads since this prevents healing from its harmful chemicals.
Anal pathology takes time to heal. You can imagine that every time it is attempting to improve, another local trauma/bowel movement occurs. Do not try to avoid having bowel movements, and try not to get frustrated as you work on the above regimen.
Anal Fissure Surgical Treatment
The most commonly used surgery is a fissurectomy, in which the chronic scar tissue and skin tag is completely excised or cauterized to encourage closure. This allows for new healthy tissue to form, while using the above medical management. A lateral internal sphincterotomy is not advised in clients who engage in anal intercourse, as this procedure can cause future complications limiting sex, as well as incontinence. In the anal intercourse world, most fissures are more from trauma related injuries, then actual muscular tightness.
During the procedure the muscle is dilated with surgical dilators and depending on the clients, anal botox is used to improve healing. Botulinum is injected into both the fissure line, as well as the internal sphincter to allow for just enough relaxation during the healing process. This will also help post anal fissure surgery, making sure this relaxation is utilized to our advantage when you start dilating with butt plugs post-surgery; all in the hopes of returning to anal engagement if one desires.
RECOVERY FROM ANAL FISSURE SURGERY
Most importantly, the majority of clients tell us they should have undergone this surgery much sooner, since the recovery is no different than the usual recovery one goes through when they get their anal fissures. The standard course post-surgery is 2-3 days of more constant pain and irritation. Prescription pain pills are utilized, along with lotions, suppositories, epsom salt baths, and stool softeners. The use of a bidet for cleaning purposes can also be beneficial. Honestly, the use of non-steroidal medications, like Advil or Ibuprofen are the best for diminishing this kind of pain.
Most clients will use these meds more religiously the first few days post-surgery. It then becomes more so during bowel movements over the subsequent 1-2 weeks. At this point, the Botox is fully on board, decreasing the overall pressures during defecation, which leads to diminishment of this painful process. Finally, by the 2-3 week mark, we have entered a really great healing phase. Now, the initial postoperative visit is 3-4 weeks post surgery. During this visit, a chemical called silver nitrate is placed to encourage appropriate cleaning of the wound and allow for appropriate scar to be laid down.
This will give us that tough scarring to withstand all pressures in the subsequent weeks. We then switch from using all lotions and suppositories to using nothing other than exfoliating soaps. Now that one feels more comfortable in the region, we can start to get more aggressive with the cleaning to encourage appropriate closure. We should mention that during all the time leading up to this, most people place a gauze in the anal region to catch some mucus and discharge. Though it lessens as time marches on, it’s common to still have some mild drainage up until you see us for the first visit.
Once the chemical is placed in the office, this clears up to allow full internal evaluation during the second postoperative visit. A full internal evaluation is performed and another round of this chemical is applied, if it is deemed necessary. During this inspection, we go over the next steps of using at home butt plugs to help us get over the finish line. These are imperative as it will allow strong, yet distensible, scar growth. This key exercise is what other surgeons are missing.
The post-operative dilation and work we do is imperative to success of this operation. It takes two to tango here and we want our clients to make sure they understand this a symbiotic relationship. Of note, most are about 80-95% healed by the 6-8 week mark. This then brings us into the final stretch, literally. The next month is all about anal play with a set of butt plugs. There isn’t a huge time commitment, but it does require 2-3 nights a week with a 3-5 minute session each time, either mechanically or sexually, to get friction across our scar line.
This encourages strengthening, distention, and forming aesthetics. The best part of all is the Botox, which is so helpful for getting one back into the bottoming world—not only quickly, but efficiently. Finally, by the end of the second month, one is back and beyond where they want to be on the defecation and sexual front. Of course, fisting and larger toys will take a little longer. During this entire process, Bespoke Surgical now has an in-house physical therapist who specializes in the pelvic floor, which will help one achieve all these milestones and goals. It’s a long, but necessary process to set the stage for successful engagements and planning for the longevity of the future.
How long do anal fissures take to heal?
This depends on the severity and if it’s a recurring issue. If it’s an acute fissure and it’s treated within a short period of time, you should start healing in about five days. The full resolution can take up to two weeks. If no improvement is noted or if it’s persisting longer than what’s stated above, a thorough re-evaluation should be performed by a doctor.
With chronic issues and repeat offenders, the likelihood of improvement diminishes the more times a fissure develops. This should be noted on the initial examination and may sway the treatment directly to surgical options.
“Four months ago, my partner and I were engaging in anal intercourse with me on the receiving end. Typically, I’m more top/verse so with him being rather girthy, we embarked on an amazing session… until it wasn’t. At some point after him entering me from behind, I don’t know if it was our position or because he was not lubricated enough, but I felt an extremely painful tearing that was accompanied with bright red blood.
Of course we stopped right away and I tended to it for a few weeks with some creams. However, I haven’t really felt normal since then and have had on and off issues with pain and spotting during bowel movements. Without question, this has limited my bottoming experience — i.e. no bottoming at all. I have become so frustrated and finally did some investigating on seeking advice for corrective action. Sex is so integral to our relationship and because of this, we both have felt the strain.”
Dr. Evan Goldstein is the Founder and CEO of Bespoke Surgical, NYC’s leading sexual health private practice. He received his osteopathic doctorate from the University of Medicine and Dentistry School in 2002 and completed his residency in General Surgery at Maimonides Medical Center. In 2020, he was named one of NYC’s top LGBTQ+ business leaders by Crain’s New York and he is involved with GLSEN, ACRIA, HRC, and Callen-Lorde’s Howard J. Brown Society. All of these experiences and affiliations have shaped his whole-life approach towards the practice of private surgical care and sexual wellness.