Dressing Removal
Unless otherwise instructed, you may remove your dressing within 6-8 hours after surgery and then take your first shower. To remove the dressing, we recommend submerging in a bathtub and then removing the tape and gauze. If there is any internal packing, it will generally come out on its own. Do not worry if it doesn’t, as it often times degrades internally all by itself.
Many people feel the urge to defecate (and/or urinate) within this period. Often times, this feeling is just pressure from the surgery itself and you don’t actually need to go. However, if you do have to use the bathroom, please first remove the dressing using the method described above. Most people are fine wiping gently and then making their way into the shower and bath to clean the area thoroughly, being sure to place a new, fresh gauze dressing up against the wounds. It’s important to remember that you may still be numb in the area and therefore you may not feel everything entirely. Because of this, please refrain from being overly aggressive and/or pushing hard during your bowel movement, at least beyond your usual strength.
Understanding Your Procedure
There are two types of incisions or wounds that may arise during and after your surgery. We’re going to review both since many people will have a combination of incisions and/or wounds.
Closed incisions are sutured with absorbable stitches (and usually several of them) to keep everything intact, especially because of the pressures of daily living, like going to the bathroom and moving around. When we use stitches, we usually do not recommend using suppositories until later in the healing process to allow the tissues to align. With that said, since we must defecate and there is innate pressure when doing so, sometimes these stitches can open up. I urge you not to be alarmed if and when this happens. This is perfectly normal. While we obviously don’t want this to occur, we anticipate some of the stitches will rip open. That’s why we place many rows of stitches. There may be some bleeding and localized pain, especially if the underlying muscle becomes exposed. But don’t worry! The tissue in this region heals well and will come together nicely. In the office, we will administer localized treatments to aid the healing process. The key here is to keep everything as clean as possible and get increasingly more aggressive with exfoliating cleansers or bars of soap in the area. This will help the mucus, discharge, and/or bleeding improve. Additionally, please keep placing gauze directly on the wound to catch any of the excrement and be sure to switch out to a new piece of gauze every few hours as this will also help heal the local tissue. Do not be alarmed if it’s still draining for 6-8 weeks post-surgery. This, again, is normal and expected. With proper hygiene and following the steps we take in the office, we will get the area to fully and functionally heal.
Open wounds are just that left open specifically due to their location and/or to encourage better healing for our long-term goals and will take 6-8 weeks to heal. With that said, mucus, discharge, bleeding, and, of course, an open wound are completely normal. One may see worsening over the first two weeks or so and the same thing with potentially more bleeding. The scabs will start falling off, causing significant localized changes and, once again, this is normal and expected. We advise people, once they feel somewhat in a better space, to decrease their use of external lotions and increase their use of abrasive soaps. We suggest using a bar of soap or exfoliating cleansers and don’t be afraid to be aggressive. While it shouldn’t be a painful cleanse, exfoliation will help get rid of the mucus discharge and keep the wound healthy and healing. With a combination of you being diligent with cleaning and keeping the gauze properly placed on top of the wounds (and changing them every few hours), and me administering local treatments in the office, we will get the tissue to fully heal.
One thing to note: I find taking selfies (or photos of your anus) complicates the process. They tend to provide a distorted picture of the healing process, which ends up causing more stress than it should. Of course we encourage you to reach out to us if questions arise, but most people really do undergo a 6-8 week healing process. By following the protocols laid out in this guide and any other instructions we may provide to you, we will get you to the finish line. The anus is finicky and takes time to fully heal, so it’s important to be patient and trust our process. At the 4-week follow-up, most people are about 70% healed, 85-90% healed at the 8-week follow-up, and then finally 100% after we start our dilation protocol, using toys and finally back to sex if that’s what you desire. Consider adding a scar therapy gel to your routine as you heal.
Process
Once you’ve read the above, now we can talk about the healing process in more detail. First off, I’m not going to lie to you, the initial pain sucks. Hence why we provide you with pain medication and lotions. Please follow the instructions and use them. Most people need narcotics for the first 3-5 days and then they can start weaning off and introducing ibuprofen and/or Tylenol. Make sure your bowel movements are easy, your stool is soft, and you’re keeping the area clean. The gauze that’s placed against the wound is key to absorbing the normal discharge or mucus and local bleeding in the area. This may get worse a week after your surgery, but it’s all normal and expected. Once you feel like you are in a better place, slowly start to decrease your use of the external lotions. About one to two weeks after your surgery, you can get more aggressive with cleaning. Please don’t forget to keep the gauze in place and frequently switch to a new piece of gauze as the goal is to dry out the wound to get it fully healed. I am fine with Depends and/or underwear liners, but it’s important to also keep gauze right up against the actual incisions because if it’s not, then it will sit on your butt cheeks for prolonged periods of time, leading to potential skin irritation. You will drain for 6-8 weeks, but after the first few weeks, it will slowly diminish. The more hygienic you are, the faster this will occur.
Your first post-op follow-up exam will be at 4 weeks. I will perform treatments in the office to assist the wound in closing by placing what’s called silver nitrate into the wound. This will be painful for the some time after your office visit, and I may clean the wound under local anesthesia to speed up the healing process. After 6-8 weeks, you will be almost 85-90% healed. At your next follow-up exam, I will administer the silver nitrate one more time and take a complete look both inside and out with a small anoscope to make sure everything is healing as it should. This time, it will definitely be less painful, as the wounds should be almost fully healed. You will be introduced to anal dilators and instructed on how to properly use them to get you past the finish line. Their role is to create friction in the area to complete the healing process and also allow the tissues to not only get strong, but also distensible for both defecating and anal play, if that’s your goal. Finally, we may do another round of Botox at 4 months in the office to further enhance your ability to defecate and/or bottom without discomfort.
Pain Medication
We typically prescribe either Percocet or Hydromorphone, and people can take 1-2 tablets every 4-6 hours, if needed. Please make sure you stay hydrated and also take your medication with food, as some people can feel lightheaded or dizzy. Also, be careful when standing up and/or using the bathroom. Believe it or not, urinating and defecating may cause you to become lightheaded. Some people even prefer sitting down when urinating, which I encourage, as well as taking your time, especially with the first few bowel movements. I usually recommend Advil or Motrin to help with the pain and inflammation and will instruct you personally if that is suitable. If you need a refill or you feel as if these are not providing you with the relief you need, please let us know as we have others that can be prescribed. One important thing to note is that your level of pain will never be zero. That’s, unfortunately, part of the healing process and in due time, the pain will subside and you will be fully healed. We need to stay positive and on the right course.
Bleeding
Bleeding is perfectly normal and may actually get worse before it gets better. My first bit of advice is: don’t sit down on the toilet if you’re bleeding. The open cuts are quite superficial, so you standing up and/or squeezing will contract the tissue causing it to stop. Pressure is key and you can place plenty of gauze in the area and hold pressure in the region. If you’re taking Advil or Motrin, please stop, as these may make the bleeding more substantial. My second bit of advice is you can purchase Afrin spray, which is available over the counter, to help with the bleeding. Simply place copious amounts of Afrin onto the gauze, as well as onto and into the wounds with pressure. Then, lie down and try to relax. Most of the bleeding should stop. However, if these don’t help stop the bleeding, please let us know. There are things we can do in the office or we’ll advise on a possible urgent care or emergency visit if needed. The latter is very rare if you’re following our instructions.
Constipation
It’s perfectly normal for people to not defecate for 2-3 days after surgery. Please continue to take stool softeners and Milk of Magnesia as needed. Sometimes, we will add a gentle laxative called Miralax to your post-op protocol. If you are still bloated and/or cannot go to the bathroom, half a bottle of magnesium citrate and/or adding a glycerin suppository should do the trick. Also, walk around, drink lots of water, and, if you’d like, you can even add prunes and other high fiber foods to your diet. You will definitely need to jump start your bowels after surgery and while it’s going to hurt, the key is to keep the process moving along. We don’t want diarrhea, but we do need to keep your pipes open and flowing. These steps should help get you there.
What are my immediate limitations after surgery?
For the first 24 hours after surgery, you should not drive, operate machinery, make important decisions, or sign legal documentation. Also during the first 24-hours please refrain from both alcohol use and large or heavy meals.
How will my diet be limited?
Unless instructed otherwise, advance as tolerated to a regular diet. In the beginning, it’s important to avoid heavy meals, spicy foods, and red meat. It’s common to not have a bowel movement for 2-3 days after your procedure, so we recommend staying well hydrated and eating fruits and vegetables daily to help this process along.
How will my activities be limited?
Gradually increase your activities, but be careful not to overexert yourself to the point of fatigue. You will need to avoid stress to the operative site (such as lifting, pushing, and pulling) for 3-5 days. After this period, you will be able to return to your fitness routine per usual, avoiding focus on the operative site until you feel ready. Mild discomfort at the operative site is not uncommon, so be sure to listen to your body and progress at a rate where you won’t feel pain. Anal intercourse should be avoided until after your first post-operative visit.
How long until I’m back to normal?
While everyone’s healing process is different, the overall healing timeline is approximately 1-2 weeks. You may need to use painkillers for the first 3-5 days after surgery, switching to Tylenol or Ibuprofen after day 5 or so (at the latest). Bouts of pain and/or bleeding up to 2 weeks post-surgery are not uncommon, especially towards the end of the first week, but most patients will have a positive trajectory onwards. You will improve over time, with residual symptoms possibly occurring for as long as 4-6 weeks.
Summary
We get it, the recovery process is long, with lots of ups and downs while you wait to be fully healed. This isn’t meant to discourage you, but rather to frame the post-operative course so as to make sure you completely understand what you’re going to experience, how best to prepare yourself for it, and the importance of staying on course. Of course, there can be complications like with any surgery you may undergo, but if you notice things are deviating from the above framework, please do not hesitate to reach out to us. Email is the preferred method. While easier said than done, constantly looking (and even taking anal selfies), analyzing your wounds, and worrying about bleeding and discharge will only provide unnecessary stress to an already stressful situation. If we adhere to this post-op guide, it should make for a quicker and easier recovery. If you have a fever over 101 degrees or shaking/chills, you should reach out immediately.
