Anal sex experts on how to prevent and treat bottoming pain

What is anodyspareunia?

Anodyspareunia is the technical medical term for recurrent or persistent anal pain during anal intercourse or other types of anal play that includes penetration.

“It’s basically a fancy and more medically accurate way we call any pain felt during or after anal penetration — whether by a penis or a toy — that is persistent and recurring,” says Dr. Maria Knobel, medical director at Medical Cert UK. “I say any because we don’t actually have an official way to diagnose it, on what kind of pain or how severe it has to be to be considered anodyspareunia. Says a lot about the state of research about LGBTQ+ sexual health, to be honest.”

Nationally renowned anal surgeon Dr. Evan Goldstein tells Out that one of the biggest myths about bottoming is that pain is normal during anal sex. Goldstein, who owns Bespoke Surgical, became one of the leading experts in LGBTQ+ sexual health after coming out as gay himself, and now focuses on making anal sex safe and pain-free.

“That is so far from the truth, and it was the huge impetus for me writing Butt Seriously: The Definitive Guide to Anal Health, Pleasure, and Everything in Between,” he says. “Pain that interferes with anal play, limiting our bottoming potential and pleasure, should be thoroughly evaluated in and out — literally — by experienced anal sexual wellness experts. The ass and its potential are paramount.”

What causes anodyspareunia?

Anodyspareunia is more common than you think, but the causes can be a complex combination of physical ailments, neurological issues, and even psychological factors. While underlying medical conditions can be at play, don’t discount the way anal penetration is approached, says Good Vibes Sexologist Carol Queen, who has been teaching classes on anal sex and fisting with her partner Dr. Robert Morgan Lawrence since the ‘90s.

“The essential basics are relaxation, lubrication, and communication,” she says. “The receptive partner needs to be sufficiently relaxed, have enough lubrication, and feel comfortable communicating boundaries or asking their partner to slow down or stop. The penetrating partner needs to take those requests completely seriously.”

On top of the basics of lubrication — keep in mind that the anus does not naturally lubricate during sex — and the fact that the anal canal is highly muscular so relaxing is key, there is a laundry list of physical problems that could be causing the pain you’re experiencing while bottoming, Goldstein says. This can include everything from hemorrhoids, rectal prolapse, and anal fissures to anal sphincter spasms, an inability to relax the sphincter, or pelvic floor dysfunction, as well as irritable bowel syndrome, or problems with the prostate.

“Oh, and rule out STDs, y’all,” he continues. “So many people come to me with an STD that may also be the reason for painful sex. Swab for chlamydia and gonorrhea, as well as herpes, and we also do stool studies to make sure we test for all possibilities.”

The issue could also be about the mind-body connection, Goldstein says. “Neurologically, we think of how the entire hole and pelvic floor are connected to the brain, and of the overt wiring that may cause what's called paradoxical motion,” he explains. “Meaning you attempt to neurologically contract your ass and it relaxes, and vice versa. You can see how that can affect everything from defecation to anal intercourse.”

Can the problem be psychological?

According to a 2005 study of men who have sex with men by Dr. Simon Rosser, a psychologist who specializes in gay men’s health, “Men with anodyspareunia reported that psychological factors were the primary contributing cause of their pain.”

“A study by Rosser actually linked anodyspareunia with gay men being closeted, citing that social comfort in their sexuality is a factor as well,” Knobel says. “Researchers also list internalized homophobia and performance anxiety among suggested factors.”

Goldstein has found this to be true in his own practice as well. “Psychology plays a major role, from prior traumas to physical and neurological issues that then create apprehension, anxiety, and fear,” he says. “With any one of these, anal contraction and spasm go hand in hand. ‘Oh shit, I may have pain,' or ‘I may bleed,’ which leads to contraction of the anal muscle, elevated pressures in the space, tension, and then reinjury or pain, etc. It becomes a cycle, for sure. The key is to first get a full diagnosis of any overt ailment or pathology, as we cannot improve the psychological component until we rectify the underlying issues at hand—or at ass.”

The mental and emotional factors can be just as important as any underlying medical conditions causing anodyspareunia. The person bottoming needs to feel comfortable communicating and advocating for their needs. “Anxiety, shame, trauma, or low self-esteem” can keep someone from asking to stop or for more lube and instead will push through pain or discomfort, Queen says.

“Many people simply aren't taught the basics of comfortable anal sex,” she says. “Pornography and erotic media also frequently portray anal penetration as something that initially hurts but eventually becomes pleasurable. While that may describe some people's experiences, anal sex does not inherently have to hurt.”

How can you treat anodyspareunia?

The first step is determining what is causing the pain by having a full evaluation with a medical professional, including taking a detailed sexual history, doing an anoscopic examination, and performing full anal manometry. “Pain comes from something. It comes from a culprit,” Goldstein says. “We need to find that source through detailed analytics and diagnosis. We define the primary problem and then any subsequent ramifications.”

Depending on what is causing the underlying pain, Goldstein says that you may need in-office treatments like physical therapy or anal Botox or surgery to fix hemorrhoids, anal fissures, or skin tags that are causing friction. “The asshole is a pipe that should have nothing blocking or obstructing it,” he says. “If that alignment is off, we need to fix that first. Sometimes the anal spasm is so great that we need to partially cut the muscle as well, all to offset those elevated pressures. So the ass is not crazy complicated, but you can see how so many potential causes may be behind painful intercourse.”

Since the problem is often emotional or psychological, Queen says that you don’t need to think of it as something that needs to be “cured,” but you may need to change the way you have sex. “If penetration becomes painful, stop and allow the receptive partner to relax,” she says. “Continuing while someone is bracing against pain is likely to make the problem worse.”

Knobel agrees and says that because the anus has two rings of muscles — the outer one that can be controlled voluntarily and an inner ring that works on its own — relaxing, arousal, and feeling safe will help prevent pain. “With enough lube and prep, and with the right state of mind during sex, anal sex can be pain free and fulfilling not just for the top, but the bottom as well,” she says.

How can you get back to bottoming?

This probably isn’t the advice you want to hear, but if you are experiencing anodyspareunia, you need to stop having sex — at least for a little while. Once you’ve had a medical evaluation and gotten treatment, Goldstein says you can use internal and external anal creams like Preparation H for three to five days to improve symptoms before using anal dilators to do a “test run for sex before jumping right back on the big D.”

“See how it feels,” he says. “Test the waters, and it should be smooth sailing to then enter the full anal arena again.”

You also need to start communicating openly with the person topping you so that if pain pops up during sex, you can address it. “Pain during anal penetration is a signal that something needs to change,” Queen says. “Both partners should learn how to prevent pain and how to respond immediately if it begins. Continuing painful penetration can cause injury and may increase the risk of other complications, including STI transmission.”

Some people turn to chemsex to avoid pain from bottoming and increase their pleasure, but there are plenty of safer ways to manage your symptoms and get back to anal sex, including reevaluating the way you have sex

Sofie Roos, a licensed sexologist and relationship therapist, says that you may also need to change the way you have sex so that you can bottom without pain. “When you know what causes the bottoming pain, you can change the sex you’re having accordingly, and then carefully experiment with what types of sex that works for you,” she says. “When doing so, have a clear and ongoing communication with your partner, use more lube than you think you’ll need, start out with very careful penetration — both when it comes to the tempo, depth and the size of what penetrates — and invest at least 30 minutes in the foreplay.”

Can I still have rough sex?

After you’ve taken a break from bottoming to allow your body to heal, ask yourself if anything went wrong while you were having anal sex so that you can get back to getting drilled through the mattress the way you are craving. "Was it a one-off — wrong positioning, not enough lube, or just too big a dick that you need to gradually work up to?” Goldstein says. “Or is there some true anal pathology that will continue to limit your anal play without appropriate evaluation and treatment? Once that is defined and treated, in whatever capacity, then it's the slow lead back into the anal play we love. It ain't a race. Slow and steady always wins the anal game.”

If you want to be able to bottom for a well-endowed top, or have rough sex, treat any underlying conditions and then use anal dilators to work back up to it. “The people who get hurt are the ones who just shove it in, or advance too fast or too girthy,” he says. “It’s muscles and skin connected to our brains. How do we get the muscles to fully relax, the skin to absorb the overt pressures of anal sex, and the brain mechanics to not only allow everything to happen but also let the pleasure centers fully first — getting you off in all the ways you want? Now that's a plan.”

Roos also recommends slowing your roll before you jump back into vigorous, rough anal sex because “you won’t be able to go from having bottoming pain to joyful rough sex in just a few sessions.”

Make sure you have open communication, stop if there is pain, set clear boundaries about what kind of sex you’re up for, and make sure anal aftercare is part of the equation. Roos continues, “I’d like to end with an important rule of thumb — intense anal sex should always be consensual and pleasurable, and pain is not a part of rough anal, so if it hurts, then cool down and try to find the reason for the pain.”