Anatomy
Anal intercourse differs from vaginal intercourse in several significant ways. First and foremost, a hole is not just a hole, and a woman’s vagina is anatomically very different from your anus. The colon’s purpose, as we all know, is to transport digestive waste from your small intestine to your anal opening where it’s excreted. As part of this task, the colon’s lining, or mucosa, is specially equipped to absorb water from the liquid waste of your small intestines and turn it into solid feces. When your colonic mucosa doesn’t work properly, diarrhea results. Your colon’s heightened absorption capability makes it a particularly susceptible entryway for many infections; HIV, of course, is one of the most deadly. Your colon is approximately six feet long, and unless your partner is something of a “giant” among men, anal intercourse affects only the last few inches. This area includes your anus and rectum; although they both are regions of your colon, they are, in actuality, two very distinct anatomic sites. Your anus is lined by squamous cells, which are closely related to skin. Your rectum resembles the rest of your colon. Importantly, your anus has nerve endings capable of experiencing pain while your rectum does not.
Hygiene
Before moving on, I must write a few words about hygiene. Most men who enjoy anal sex or anal stimulation are fastidious about keeping this area clean, and, in fact, they can be too fastidious. I remember a patient who came to me for treatment of pain and bleeding with his bowel movements. When I examined him, I noticed deep cuts in the skin surrounding his anus. Upon questioning, I discovered that he wiped so hard with toilet paper to get clean before anal sex that he was quite literally wiping away his skin. Well, I am sorry to report that no matter how hard you try, an anus is still an anus, and it will never be the silk purse you’ve dreamed of. Before sex, I recommend that you gently wipe away any fecal residue from your outer skin with a moist tissue. Wet cotton balls or Tucks do an excellent job, but stay away from those baby-wipe-type towels. Most contain perfumes that can irritate your sensitive skin. An enema or douching prior to sex is not advised, as this can force a large volume of fluid into your rectum, which you may not fully evacuate before sex. The in-and-out motion of your partner’s penis or fingers stimulates colonic contractions, and any residual enema will spill out, creating more of a mess. Chronic enema use also can produce severe constipation. In worst cases, men become so dependent on enemas that they cannot move their bowels without them. If you worry that feces remain in your colon and you cannot have a bowel movement before sex, try a gentle wash-out with an ear syringe. (When you were a baby, your mother used them to clean your ears, but now that you’re a big boy…) Ear syringes, available in most pharmacies, come in two styles: a blunt, wide tip meant only to cover the hole in your ear, and a slender, tapered style for insertion into your ear canal. Be sure to purchase the slender, tapered style and fill it with warm water. Lubricate the tip, insert it into your rectum, and gently squeeze the bulb several times. This will instill much less liquid than an enema. Also, you are more likely to expel the water and any fecal residue fully.Foreplay
Foreplay is as important in anal sex as it is in vaginal intercourse. Although your anus does not self-lubricate as a vagina does during foreplay, this stage is critical if you want to achieve eventual sphincter relaxation. It also helps you judge whether your partner will follow your wishes. For penetration to occur without injury, your partner must wait until you are able to receive. Most injuries during anal sex occur when penetration is rushed or when the receiving partner has not consented or is not relaxed. You must incorporate safe-sex practices into your foreplay. In other words, condoms are not just for fucking. Quite often during foreplay your partner rubs his penis against your buttocks and anal opening. Although HIV is rarely spread without ejaculation, it can be. (Precum carries HIV and can seep inside.) Moreover, numerous other infections, including herpes, anal warts, molluscum, and syphilis, can spread between partners from rubbing without penetration. You can catch most of these nasties with skin-to-skin contact alone. And although these infections are not lethal, they can make you miserable and may be incurable. Therefore, place a condom on your partner’s penis as soon as you anticipate any contact with your anal area. If he complains, remind him that infections travel both ways. You’re protecting him from anything you might be carrying. Pleasure awaits when you stimulate the many nerve endings buried in your anal skin.Some men enjoy light rubbing, while others prefer a heavier touch. Avoid anything that can tear or cut the skin, because feces contain many bacteria that can easily infect a wound. Touching the anus during foreplay is purely for pleasure’s sake. Although it may heighten desire for anal sex, it does not cause lubrication or direct relaxation of the sphincter. In fact, the sphincter responds by twitching closed momentarily with each touch. Some men enjoy anilingus as another way to stimulate their partners, but beware of STDs. Many men insert fingers or sex toys into their anus as part of foreplay or masturbation, but this is not without risk. Fingers can be more dangerous than a partner’s penis if sharp nails, dangling cuticles, diamond rings (you get the idea) cut the delicate lining of the anus. Men with HIV need to pay particular attention to anal hygiene and avoid injury, because their ability to fight infection is impaired. Your rectum lacks nerves responsive to touch, so most tactile pleasure comes from rubbing your anus and surrounding skin, not from penetration. Penetration stimulates pelvic muscle contractions, which can heighten an orgasm. Before inserting a finger into your anus, be sure that your nails (or your partner’s) are free of sharp or jagged edges and cuts that transmit infection. Remember: Any cut on a finger also can become infected with bacteria normally present in the anus. A latex glove or finger cot helps protect you from your partner’s fingers acting as a conduit for STDs. Do not insert more than one finger into your anus to stretch it in anticipation of anal sex. Stretching with several fingers can cause a dangerous tear and plunge your sphincter into painful spasm, which will prevent penetration. Sphincter injury may weaken the muscle so that it cannot contract adequately. Loss of bowel control may result.
Toys
If you enjoy sex toys or dildos, don’t pass them back and forth between you and your partner unless they’re covered in a condom that is changed between each insertion. Avoid toys with sharp or pointed edges; instead use ones with tapered ends. Your rectal canal is not a straight line; rather, it curves back toward your tailbone. Thus, insertion of any object should be directed a little posterior (toward your back) and not toward the front. Approximately eight inches from the anal opening, the colon takes a sharp turn to the left. You must know this if you insert a long object into your rectum. Stiff dildos or other objects may not be able to negotiate the turn and may pass right through your colon wall. A colon rupture is a surgical emergency, because bacteria can spread quickly throughout your abdomen or pelvis. When shopping for a new toy, choose one made of soft latex. Harder materials are less giving (and forgiving) and offer greater risk of rupturing your colon. Besides choosing a soft dildo or sex toy, find one with a blunt, tapered end so that your sphincter gradually stretches as penetration occurs. A wide base or flange at the opposite end prevents its escape into your rectum if you lose your grip. (Toys can become quite slippery.) Should this occur, your sphincter will close. Don’t try to “dig” the object out. (You aren’t drilling for oil.) Most often you’ll pass it like a bowel movement if you squat down and wait. If it’s still inside after an hour, see a doctor. Failure to remove a foreign object can lead to colon perforation. Attempts to wash it out with enemas or a shower spray (as my patient did) will only push it farther up into the colon. Usually a doctor can retrieve it in his office or an emergency room with special instruments. In extreme circumstances, a trip to the operating room with anesthesia may be necessary, but only to dilate your rectum so the toy can be grabbed. Horror stories of men needing extensive abdominal surgery usually are not based in fact—unless they have ruptured their colon. As always, common sense is the rule. Learn to be sensitive with your hand when inserting anything into your rectum. If there is any resistance or pain, change the angle of penetration or pull it out. Never persist. Communicate any discomfort to your partner, and be sure he is responsive to your complaints.Anal Sex Technique
With a little understanding of physiology, anal intercourse can be performed safely. Like any muscle, your internal sphincter can contract for only so long before it fatigues and must relax. When it relaxes, your partner can safely insert his penis without causing you pain. How do you make your muscle fatigue? Easy. Unroll a latex condom over your partner’s penis. Natural—membrane condoms don’t protect you from HIV, and ultra-sheer styles can break during sex. Lubricate the condom well with a watersoluble solution (Eros, Foreplay, and Wet are just a few of the available brands), because it won’t harm latex condoms, and it is readily broken down by your body after intercourse. Besides weakening condoms, oil-based lubricants occlude your very sensitive anal glands and can cause infection. Read labels carefully before buying. Many lubricants, including Elbow Grease and hand creams, are oil based. The lubricant is very important; don’t trust the choice to a partner grabbing whatever is handy from his nightstand. Many lubricants (even water-soluble ones) contain dyes and perfumes that can be especially irritating to your sensitive skin and anal lining. I have seen men who developed terrible skin allergies and colitis from lubricants. So find a brand you like, but remember that what works for you may not work for your partner.
A Word for You Tops
I know you’ve read it already, but it’s so important you’re going to read it again: Your partner must be in control. Your penis can hurt him seriously if he isn’t ready to take it. Foreplay is great. While it may heighten his desire for anal sex, physiologically it doesn’t do anything to relax his sphincter. So when you’re ready to put it in, do whatever he asks. If he wants you to wait or take it out, listen to him. By persisting, you’ll cause more damage, and he may never let you back in again. Many men, even with proper sphincter relaxation, still experience some pain when you first get all the way in. Some find it tolerable, while others will ask you to pull out and let them rest. Your penis has just acted like a dilator, and coming out prevents his sphincter from going into spasm. No doubt he’ll let you back in, and because his muscle is already stretched, you’ll both have an easier and more enjoyable time. If your penis is especially long, you may come to a point in penetration that gives your partner pain. Your partner feels the head of your penis stretching the curve in his colon. While you probably won’t push through, you can injure him and cause bleeding. If those last few inches make him uncomfortable, hold back. Always use a condom. STDs pass both ways, and an anus is the highest-risk place for STDs. He can easily infect you with anything lurking in and around his anus. I caution you to assess your risk of catching something from each new partner before sticking it in. You may decide that something less risky (masturbation or even oral sex) might be a wiser choice. Some men abandon condoms if both partners are HIV positive. Again, I strongly advise against this. There are plenty of other STDs to catch that you may not already have. By not using a condom you also increase your chances of picking up a more resistant strain of HIV than what you already have. As soon as you ejaculate, withdraw your penis while keeping a firm grip on the end of the condom. If you wait to pull out, you will start to lose your erection and semen can seep through gaps in the condom at the base of your shaft. This allows STDs out or in, depending on who has what. By holding on to the condom as you withdraw, you prevent it from being left inside. What if your partner says no to anal sex? That is always his prerogative. Certainly talk about it, exploring feelings as you try to discover reasons for his objection. If he says it hurts, try a course of dilators. Always be mindful of nonverbal cues. (Gritting his teeth while you’re poised to enter is not a good sign.) He may be afraid to tell you he doesn’t want to do it, and persisting can ruin a good relationship. If he refuses, find other ways to satisfy yourself or move on. If the relationship is important, sex therapy and couples therapy are often beneficial and may solve your problem. And last, just because you’re the top doesn’t mean that someday your partner won’t ask you to be the bottom. Again, you can always refuse, but you might just like it.Complications
Gay men who practice anal sex or stimulation tend to assume erroneously that all analrelated problems are caused by their sexual practices. This could not be further from the truth. If you do develop an anorectal problem, I urge you to contact your physician, for although it may be related to sex, it probably isn’t. Besides mentioning your symptoms, tell your doctor that you’ve had anal sex. If you cannot admit this without embarrassment, find a different doctor! There are numerous, though thankfully infrequent, complications related to anal sex, but most are infectious and will be covered in subsequent chapters. Several complications do need to be discussed now.BLEEDIND
Bleeding is probably the most common complication you’ll experience during or after anal intercourse. Of course, if you notice it during sex, your partner should immediately withdraw his penis and terminate intercourse. Bleeding also occurs prior to anal sex from finger manipulation, and anal sex should not be attempted until you heal. Painless bleeding most often results from hemorrhoid trauma and stops on its own. Most men know if they have hemorrhoids, but if your bleeding persists for more than a day, see your physician. Bleeding associated with pain is more significant and usually signifies a tear (fissure) in the lining of your anus. This tear usually sends your sphincter into spasm, which may not subside until the fissure heals fully. Persisting in anal sex can deepen the tear, causing injury to your sphincter muscle. Fortunately, tears usually heal on their own with stool softeners (medications that lubricate your stool for easy passage) and temporary abstinence from anal sex.PAIN
Pain is a very nonspecific symptom after anal sex and is often the first sign of infection (most notably herpes and gonorrhea). Typically, pain begins a few days after intercourse, once the infection has had time to incubate and take hold. Although you may notice a discharge or blisters around your anal opening, most often you will notice nothing at all. Severe pain, with or without bleeding, during intercourse or immediately after may signify damage to your sphincter muscles. These muscles can tear when stretched too much or too quickly. Injured muscle bleeds, but the blood can remain trapped where you won’t see it. Instead, you might notice swelling and pressure accompanying the pain—similar to a bruise from a torn muscle in any other part of your body. Treatment includes muscle relaxants, pain relievers, stool softeners, and sitz baths (bathing the area in warm water). Although most muscle injuries are minor and resolve without long-term complications, some doctors believe they weaken the sphincter muscles. Repeated injuries cause cumulative damage and, in later life, may lead to incontinence (an inability to control your bowel movements or gas). As with all aspects of anal sex, the common-sense rule again applies. If your partner pounds you senseless, then trauma and bleeding are more likely to occur. It is understandable that when you make the decision to have anal sex, your state of sexual arousal is at a feverish pitch. You may have sex several times in a night, and as we all know, the more often you come, the longer it takes to come again. Your partner’s constant pounding places your anal canal at a greater risk for injury, and you should stop the moment sex ceases to be pleasurable. Drug use also increases the risks associated with anal sex. Drugs dull sensation, so something that should hurt doesn’t. They further increase danger by distorting judgment and allowing you to have sex in ways you ordinarily wouldn’t. Drug use fosters unsafe sex.PERFORATION
Although a total (transmural) perforation of your anus or rectum is possible during anal sex, thankfully it is quite rare. Perforation, however, is much more frequent when hands (fisting) or sex toys are inserted into the rectum. These objects tend to be longer, thicker, and less pliable than a penis. If perforation occurs, pain usually is the first symptom. Although it begins immediately, you might barely notice it. The pain progressively worsens as you notice other hallmarks of infection: fever, swelling, and reddening of your buttocks. If the perforation is high up in your rectum, a deadly complication, your buttocks may look normal, and pain, fever, and a sense of pelvic pressure are the only signs. Most often neither you nor your physician can see the actual hole or holes. Typically they are quite small and hidden in the myriad folds in the normal colon lining. Treatment of a transmural perforation often requires emergency hospitalization, intravenous antibiotics, and surgery to clean out the infection. Unfortunately, most men delay treatment for many reasons: embarrassment, an unwillingness to discuss the problem with their doctor, and/ or the unrealistic hope that it will go away on its own. This is an extremely dangerous course to follow as the colon is filled with deadly bacteria that can cause devastating infection once they escape the colon. In extreme situations, ignoring the signs and symptoms of a perforation can cause a colostomy to be needed until the infection heals.INCONTINENCE
Incontinence is the medical term for the inability to control either feces or gas. Doctors describe many degrees of incontinence. In its mildest form, it can be an inability to control gas (which everyone seems to complain of) or a sense of urgency to move your bowels. You feel that if you don’t get to a bathroom immediately, you’ll soil yourself. In severe cases, people lack the ability to sense stool in their rectum and cannot prevent it from escaping. Clearly, an inability to control gas is more embarrassing than debilitating; complete fecal incontinence, however, can be quite devastating. It requires significant lifestyle changes: a diaper and occasionally a colostomy. Most people experience episodes of fecal incontinence at some point in their lives, typically during severe bouts of diarrhea. You can’t control the diarrhea because your sphincter muscles are not strong enough to hold back the sheer volume of liquid or to prevent its watery consistency from slipping out. Although this type of incontinence is normal and infrequent, it presents a problem for HIV-positive men prone to diarrhea or who take diarrhea inducing medications (which many antiviral drugs are). In one medical study of men who practiced anoreceptive intercourse, 25 percent reported at least isolated episodes of fecal incontinence. An age-similar group of heterosexual men had only a 3 percent incontinence rate. When the researchers studied patients with AIDS, the incidence of incontinence rose to 50 percent and probably resulted from a higher rate of frequent loose bowel movements in these individuals. What does this mean to men who enjoy anal sex? Although the threat of incontinence is small, it is present nonetheless. Incontinence in men who practice anal sex is thought to result from repeated injury to their internal spincter muscle, not the external sphincter, which comes under their voluntary control. Again, although a penis is often the size of a large bowel movement, your sphincter involuntarily relaxes to allow the bowel movement to pass and your muscle is not injured. Insertion of a penis, however, causes your muscle to contract involuntarily. Repeated insertion through a contracted internal sphincter muscle may cause cumulative damage so that the muscle loses its ability to seal the anorectal canal tightly. Incontinence from anal sex appears to be rare enough so that you probably won’t have a problem if you protect your internal sphincter as described. Incontinence rates do increase in proportion to the number of sexual partners a man has. Whether this implies that sex with many partners causes more frequent sphincter injury over a longer period of time or that men with more partners are prone to rougher sexual practices causing more injury is unknown. Fisting and insertion of extremely large sex toys into the anus results in a much higher incidence of incontinence and is definitely not recommended. Incontinence in men who practice either of these types of sex is thought to result from increased damage to their internal sphincter muscles by the large-diameter object.dqok.darkq.netdna-cdn.com/wp-content/uploads/2011/04/Stephen-E.-Goldstone-The-Ins-And-Outs-Of-Gay-Sex.pdf
