Roger-Luc Chayer (Image : AI / Gay Globe)

Anal Fissures: A Little-Known Problem That Deserves More Attention

Today, I want to address a subject that is rarely discussed, either in gay media or in mainstream media. Partly because it involves anatomical areas that people are often uncomfortable talking about, and partly because it has become a source of stigma for many people, widely exploited by homophobes and hate-driven individuals on social media, even though the claims they make are far too often false.

The subject is anal fissures, an injury that occurs more frequently than one might think, among both men and women who enjoy this part of their anatomy as part of their intimate relationships. I think that’s a rather elegant way of putting it, don’t you?

Some people, men and women alike, whether homosexual or heterosexual, discover sensations in this part of their anatomy that are quite different from those associated with more conventional forms of sensuality. The latter generally involve the genitals, caresses, kisses, massages, cuddling, and other forms of intimate contact.

Yet, although some homophobes and hateful individuals who present themselves as heterosexual claim, using vulgar language that I will refrain from reproducing here, that all gay men systematically use their number two in their intimate relationships, the reality is quite different.

Anal Intercourse Among Gay Men: What Do the Numbers Really Tell Us?

When discussing anal fissures, we quickly encounter another subject that is even less openly discussed: the actual role of anal penetration in the sexuality of gay men. For years, I have heard the same crude assertions, often repeated by people who know absolutely nothing about the subject or who are simply looking for an opportunity to demean others. Everyone does it. Most gay men are bottoms. These statements continue to circulate far too easily, as though they were established facts.

Yet, when we look at serious research, the picture is considerably more nuanced.

First, one essential point: not all gay men engage in or enjoy anal intercourse. According to several surveys, approximately 15 to 20% report never having anal penetration or doing so very rarely. They prefer other forms of sexual activity, including oral sex, caressing, mutual masturbation, and so on. Anal penetration is therefore not a universal practice within the community.

Among those who have experienced it, preferences are distributed in a much more complex way than stereotypes would suggest. Studies generally distinguish three broad categories: tops (insertive partners), bottoms (receptive partners), and versatile men (those who enjoy both roles).

Figures vary depending on the country and the period studied, but several trends emerge:

• Exclusive or predominantly top men generally account for between 15 and 25% of gay men.
• Exclusive or predominantly bottom men most often represent between 25 and 40%.
• Versatile men make up the largest group, often representing between 35 and 55%.

In France, a 2018 IFOP survey of men attracted to other men provides some interesting insight. Among those who were already sexually experienced, 75% had been both insertive and receptive at some point in their lives. At the time of the survey, approximately 41% identified as predominantly bottom, 28% as predominantly top, and 31% as strictly versatile.

These figures directly contradict the idea that virtually all gay men are bottoms. On the contrary, they demonstrate a wide diversity of preferences and, above all, a strong presence of versatility. Many men who identify as tops or bottoms have already experimented with the other role, and some occasionally enjoy it depending on their partner or the circumstances.

It is also worth remembering that preferences can evolve with age, experience, and the nature of a relationship. What may appear to be a fixed sexual identity is often much more flexible in practice than people imagine.

Despite the Pleasure, Accidents Can Happen

Even though many people engage in this form of sexual activity without experiencing any problems, accidents can occur. The most common is an anal fissure, which can be extremely painful and often takes a long time to heal. Once it develops, it can recur even after healing because the affected mucous membrane remains fragile.

What Exactly Is an Anal Fissure?

An anal fissure is a small tear in the mucous membrane lining the anus. Nothing more, nothing less. Imagine a fine cut, like a piece of paper tearing, just inside the anal canal.

The problem is that this area is extremely sensitive. Once it tears, every bowel movement, and sometimes every sexual encounter, can become painful, often intensely so. The pain can last for several hours after passing stool. A small amount of bright red blood may also appear on toilet paper or in the toilet bowl.

Most fissures occur at the back of the anus (the posterior midline). They may remain acute and heal within a few weeks, or become chronic, lasting for months and recurring easily because the mucous membrane remains weakened.

It is not a serious disease in itself, but it is one of the most common causes of anal pain among men who engage in anal intercourse. When it becomes persistent, it can seriously interfere with both sexual activity and everyday life.

Anal Fissures: Understanding Treatment Options and Knowing When to Seek Medical Advice

An anal fissure may seem like a relatively minor health problem. However, this small tear in the mucous membrane at the entrance to the anus can cause considerable pain, particularly during bowel movements and sometimes for several hours afterward. Fortunately, several treatments can generally resolve the problem without the need for surgery.

The first step is to promote healing while preventing the wound from reopening every time the bowels are emptied. To achieve this, doctors primarily recommend regulating bowel movements.

Simple Measures That Can Make a Big Difference

Diet plays an essential role in treatment. Eating enough fiber, particularly from fruits, vegetables, and whole grains, helps produce softer stools that are easier to pass. It is also important to drink enough water, generally between 1.5 and 2 liters per day, depending on individual needs and any medical restrictions.

When dietary changes are not sufficient, mild laxatives may be prescribed or recommended. Macrogol, lactulose, and certain fiber-based products can help regulate bowel movements and reduce straining. These measures may need to be maintained for several weeks or even months, including after symptoms have disappeared, in order to reduce the risk of recurrence.

Pain relief is another important aspect of treatment. Acetaminophen can be used to reduce discomfort, and certain anti-inflammatory medications may be considered when there are no contraindications. Sitz baths in warm water, lasting approximately 10 to 15 minutes several times a day, particularly after bowel movements, can also provide considerable relief.

Local anesthetic creams or lubricating products may also be recommended by a healthcare professional. Finally, hygiene around the anal area should remain gentle. It is best to avoid irritating soaps, vigorous rubbing, and scented products. Drying should be done carefully by patting rather than rubbing.

In the case of a recent fissure, these measures alone may be sufficient to allow healing within a few weeks. Reported healing rates vary depending on the studies and clinical circumstances.

When a Fissure Persists, Specific Medications Are Available

Some fissures become chronic or cause particularly intense pain. In these situations, the problem may be maintained by excessive contraction of the internal anal sphincter. This contraction reduces blood circulation in the affected area and can prevent the wound from healing normally.

Topical treatments may then be prescribed for a period generally ranging from six to eight weeks.

These include ointments containing nitrate derivatives, such as glyceryl trinitrate. They help relax the sphincter and improve local blood circulation. Their effectiveness is well established, but they can cause side effects, particularly headaches that may sometimes be severe enough to require discontinuation of treatment.

Diltiazem and nifedipine, two medications belonging to the calcium channel blocker family, can also be used in topical preparations. They offer comparable effectiveness in many situations and are often better tolerated.

Another option is to inject botulinum toxin into the anal sphincter. This procedure produces temporary muscle relaxation, generally lasting two to three months, which can give the fissure the time it needs to heal.

Surgery: An Option When Other Treatments Fail

Surgery is generally not considered a first-line treatment. However, it may become necessary when a fissure persists despite properly followed medical treatment for six to eight weeks or longer, or when the pain remains difficult to control.

One of the best-known procedures is a lateral internal sphincterotomy. It involves partially cutting the internal sphincter to reduce tension and promote healing. This technique has a high healing rate, often exceeding 90%. Nevertheless, it carries a risk of continence problems, generally minor, but which should be discussed with the surgeon before the procedure.

Fissurectomy is another possibility. It involves removing the tissue associated with the fissure to allow new tissue to heal. In some cases, this procedure is accompanied by an anoplasty, a technique intended to reconstruct or improve the tissues in the affected area.

The choice of procedure depends on several factors, including the clinical situation, the condition of the sphincter, and the patient’s medical history.

Preventing Recurrence Remains Essential

Even when the pain disappears and the fissure appears to have healed completely, it remains important to maintain good bowel habits. Persistent constipation, excessively hard stools, or repeated straining on the toilet can cause another tear.

It is also important not to dismiss persistent anal pain or bleeding. Not every lesion in this area is necessarily an anal fissure. A medical examination can confirm the diagnosis and rule out other conditions that may require different treatment.

Anal fissures are therefore generally treatable conditions, often without surgery. Regulating bowel movements, local care, and, when necessary, appropriate medication allow the vast majority of patients to regain greater comfort. The essential thing is not to let the pain become established and to seek medical advice when symptoms persist.

Understanding the Risks

During intimate activities involving anal penetration, the tissues must be allowed to adapt gradually. Insufficient preparation, inadequate lubrication, or movements that are too abrupt can cause microtrauma to the mucous membrane.

These small injuries are not always immediately painful, but they can develop into a more significant fissure when the tissues are subjected to further stress before they have had time to recover.

One essential principle should therefore be remembered: no pain should ever be considered normal or necessary during an intimate encounter.

Lubrication: An Essential Precaution

Unlike other parts of the body, the anal mucous membrane does not naturally produce sufficient lubrication to facilitate penetration. Using an appropriate lubricant is therefore particularly important.

It is best to use a generous amount and reapply it as needed during sexual activity. Water-based or silicone-based products may be suitable, taking into account their compatibility with the condoms being used. Oil-based products can damage certain latex condoms.

Scented, warming, or numbing products should also be avoided because they may irritate the tissues or mask pain that could indicate an injury.

Take Your Time and Respect Your Body’s Limits

Progression should be gradual. Penetration that is too rapid or an intensity that does not respect the tissues’ ability to adapt can cause injuries.

Communication between partners plays an essential role here. Everyone must be able to express discomfort immediately, slow down, or stop the encounter without pressure or embarrassment.

Bleeding, persistent pain, or a sensation of tearing must be taken seriously. It is preferable to suspend activities that place stress on the area until symptoms have disappeared and, when necessary, until a medical assessment has been completed.

Prevention is not limited to sexual activity. Chronic constipation, excessively hard stools, or repeated episodes of diarrhea can weaken the anal mucous membrane and increase the risk of fissures.

A fiber-rich diet, adequate hydration, and regular physical activity help maintain balanced bowel function.

Intimate hygiene should also remain gentle. Harsh soaps, scented products, and excessive friction can cause unnecessary irritation.

What Should You Do When a Fissure Appears?

When an anal fissure is suspected, it is important not to continue intimate activities that could worsen the injury. Even if the pain seems to decrease quickly, the tissues may need considerably more time to heal completely.

A medical consultation can confirm the diagnosis and determine whether specific care is necessary. An anal fissure should not be confused with other conditions that can cause pain or bleeding, including certain infections or inflammatory diseases.

Intimate relationships between men can be fully satisfying while still giving an important place to prevention and respect for the body. Lubrication, gradual progression, communication between partners, and attention to the first signs of irritation are simple habits that can prevent many problems.

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