Anal fistulas 101: How bottoms can treat and prevent this painful condition

What are anal fistulas? What are the symptoms?

Not to be confused with an anal fissure, which is a tear in the lining of the anal canal, an anal fistula is an infected wound inside the anus that becomes an abnormal tunnel connecting the anal canal to the skin outside the anus.

“Most of them start the same way, inside the anal canal are small glands that can get blocked and infected, and the infection collects into an abscess, which is a pocket of pus,” renowned anal surgeon Dr. Evan Goldstein tells Out. “When the abscess drains, either on its own or because a doctor opens it, it sometimes leaves behind a tract that never fully closes. That leftover tunnel is the fistula.”

The classic symptoms of an anal fistula are oozing pus, smelly discharge, blood, swelling, and irritation of the skin surrounding the anus, usually accompanied by pain. “A lot of patients describe a cycle: pressure and pain build up, then it drains and they feel better, and a few weeks later it all happens again,” explains Goldstein, who owns Bespoke Surgical, which caters to gay men's sexual health. “You might also notice discomfort during bowel movements or staining even when you’re resting.”

According to Dr. Michelle Forcier, a clinician for the LGBTQ+ telehealth company FOLX Health, anal fistulas are “idiopathic,” meaning that “they occur in otherwise healthy persons often after the development of an anal abscess.” Anal fistulas are also “one of the most common proctological (anorectal) conditions experienced,” she says. While healthy people can get them, your risk factor is higher if you have inflammatory bowel disease, Crohn’s disease, cancer, have gone through radiation therapy, have certain STIs, or have had trauma to that area.

Are anal fistulas common for gay men who like to bottom?

For people who love to bottom, you can unintentionally start the process of an anal fistula by irritating the anal canal during sex or inflaming the anal glands by over-douching or using the wrong products.

“What I see at my practice is that friction, tiny tears, and especially aggressive or frequent douching, especially with tap water or store-bought enemas, can irritate the anal glands and the lining of the canal, which makes infection and abscess more likely,” Goldstein says. “Some STIs that are more common for bottoms, like chlamydia (including the LGV strains), can cause serious inflammation in the rectum and anal canal, and that inflammation can also lead to abscesses and fistulas.”

Goldstein says that while there “haven’t been enough studies that focus on how common fistulas are specifically among gay men who bottom," the condition is “more common in men than in women.” According to the Cleveland Clinic, anal fistulas are “twice as common in males,” and an infected gland that forms an abscess “causes 75 percent of anal fistulas.”

Regardless of what led to your anal fistula, Goldstein says that the important thing to remember is that if you are having symptoms, you should get them checked out by a medical professional right away.

“The key here is waiting too long to get it checked out,” he says. “Whether you’re embarrassed or you simply think this is just another pain in the ass (no pun intended) that will go away on its own, don’t leave it to chance. See a specialist and get it treated before it turns into something bigger.”

What treatment options are available for anal fistulas?

If you can catch the abscessed anal gland before it becomes a full-blown fistula, Forcier says that the first-line treatment is surgical drainage. “The abscess needs to drain so that the abscess does not progress into a fistula or expanding tract,” she says. “More than one-third of abscesses already have fistulas at time of presentation for medical care. Usually, when there is a fistula, that requires surgical closure and repair.”

In Goldstein’s experience, you only have a “50/50 shot of medical management being successful versus needing surgical interventions for anal abscesses,” because they almost never heal on their own and antibiotics alone aren’t enough. “Surgery is usually the answer, and something I do quite often at my practice,” he says. “The main thing that I look at is: how much of the sphincter muscle does the tunnel runs through?”

For simple anal fistulas with little to no damage to the sphincter muscle, Goldstein has a high success rate doing a fistulotomy, which is a surgical procedure where the anal tract is opened along its length so that the fistula can heal from the inside out. But complex fistulas that pass through a large portion of the sphincter muscle require other surgical techniques. “That's where the surgeon needs to be much more careful, because cutting through that muscle can affect continence and ultimately bottoming, too,” he says.

If you find yourself in this situation, your main surgical options are a seton placement where “a soft surgical thread or band placed through the tract,” a LIFT procedure where a surgeon will “tie off the tract in the space between the two sphincter muscles and remove the rest, without cutting the muscle itself,” or fibrin glue or a fistula plug, a less invasive procedure with a lower success rate, but is appropriate for some patients, Goldstein explains.

You and your doctor should decide on the best treatment for you based on your condition, while also taking into account the way you like to have sex. Goldstein also says that a growing number of his patients are bottoms who have a “fistula-like problem” that may need a different approach.

“In a lot of these cases, the gland itself is the problem, or they're fissuring in that same space,” he says. “And it isn't always an infection driving it. Sometimes it's the expansion and accommodation that happens during sex, and many people who bottom feel exactly this. I start with anal Botox and pelvic-floor physical therapy focused on that local area. But if those don't get someone to the point where they can have sex the way they want to, these patients need a surgical approach too.”

Can you prevent an anal fistula?

To prevent an anal fistula — regardless of whether you’ve had one before — you’ll need to make some dietary and lifestyle changes. “You may decrease your risk for fistulas when reducing anal local trauma by using lube, not retaining foreign objects in the anus and rectum, [and] using condoms or PrEP to prevent a variety of infections,” Forcier says. “Reducing trauma with passing hard large stools is good anal health, so fiber, fluids and regular bowel habits are also helpful. If you notice pain or abscess formation, get that evaluated sooner than later — before a fistula has time to form.”

Goldstein also recommends keeping your bowels happy with fiber and hydration, douching smarter, not harder, by using an isoosmolar product, being gentle “before you get rough” during sex, using plenty of lube, and getting tested for STIs regularly.

“Beyond that: don't sit on the toilet scrolling your phone, don't strain, and keep the area clean. I'm a huge fan of bidets and ditching wet wipes. Wipes wreak so much havoc on your hole,” he says.

While you’re healing, can you still bottom?

According to Frocier, your surgeon will give you an idea of how long of an “anal rest” you’ll need to take after any procedure, so that you can “avoid additional trauma to the area and pain” while you heal. “There are more ways to have sex than just anal sex, so try out something new,” she says.

Have a friend who is a side? Ask them what kind of fun they get up to because there is so much more to sex than just penetration.

“I know this isn’t what bottoms want to hear, but you need to take a break from sex,” Goldstein says of people recovering from an anal fistula. “Penetration puts direct pressure and stretch on tissue that's trying to close, and it brings bacteria into an open wound. Bottoming too soon is one of the easiest ways to make the fistula come back, or to end up with a painful fissure on top of it.”

Your body will do most of the healing at the six-to eight-week mark, so Goldstein tells his patients to “start guided anal play with dilators” after a two-month post-op exam. He recommends using a glass dilator set because he finds that “glass really helps build strong calluses in the area, which is exactly what you want for future bottoming success,” but you should only really consider full anal sex after three months. This also means douching should wait, and when you start again, be careful and remember to “keep it gentle and low-volume, like with Future Method’s isotonic and isoosmolar anal douche powder that won’t irritate the area.”

If getting back to bottoming is really important to you, Goldstein also stresses that you find a surgeon who understands what that means, and is willing to work with you to come up with a plan that will allow you to bottom again in the future.

“The vast majority of my patients go back to bottoming exactly the way they did before,” he says. “That’s my goal when someone comes to me with a fistula. Most surgeons don’t ask if their patients bottom, so their only concern is getting rid of the fistula, and not ensuring they do the surgery in a way that gives people back the ability to bottom. That’s why I cannot stress enough how important it is to pick the right surgeon. Any fistula repair leaves scar tissue. If it's a fistulotomy through a meaningful amount of sphincter muscle, there's a serious risk of incontinence and to how well the canal stretches. So when a surgeon doesn't ask whether you bottom, they’re likely to pick the simplest procedure rather than the one that will allow you to bottom again once you’ve recovered.”

Sources cited:

Dr. Evan Goldstein is a renowned anal surgeon who owns Bespoke Surgical and the anal health brand FutureMethod.

Dr. Michelle Forcier is a clinician for the LGBTQ+ telehealth company FOLX Health.