We Asked a Gay Proctologist to Answer All Your Scariest Questions

Beware: The following article, in which a proctologist answers questions about anal issues, contains a lot of real talk.

Ever wondered why rimming is such an enjoyable act and is so popular among gay men? It’s because anal tissue is so sensitive. In fact, it’s made from the same skin tissue as our lips; and like our lips, it’s also rich in nerve endings. The downside? That same skin tissue is thin and susceptible to injury and blemishes. But while it’s easy to tell if you have a busted lip or cold sore, it’s not so easy to spot anal issues like warts, hemorrhoids and skin tags. Some men may even have them and have no idea without making a trip to their general physician or proctologist.

So we spoke with Dr. Evan Goldstein, CEO and founder of Bespoke Surgical, a private gay proctological and anal surgery practice in New York City and Los Angeles, about the three most common anal issues in gay men and how to detect and treat them.

According to Dr. Goldstein, the three anal issues are very different.

First, the irritating facts about hemorrhoids

Hemorrhoids are veins that engorge with blood due to a buildup of pressure during defecation or anal intercourse. They’re meant to act like cushions to prevent further trauma and can occur both internally and externally. The external ones look like a blueish marble that’s either soft (simply an engorged vein) or hard (a vein with clotted blood) to the touch. 

“When hemorrhoids become symptomatic from repetitive, increased pressure in the veins of the anus, it causes them to bulge and expand, which leads to significant pain, swelling and/or bleeding,” Dr. Goldstein tells Hornet.

Dr. Goldstein says people can avoid painful hemorrhoids in a few ways: by having a high-fiber diet (so that you’re not straining when you go to the bathroom), by avoiding prolonged sitting, by learning how to properly squat at the gym (isolating the glutes and breathing properly in order to lower one’s pressure) and by using butt plugs to help relax during anal play.

He adds that over 90% of hemorrhoids heal without surgery by switching to a high-fiber diet and increasing water intake. He recommends warm Epsom salt baths and topical creams for relief as they heal, though stool softeners can help make bathroom time more bearable.

But Dr. Goldstein warns that chronic hemorrhoids that interfere with normal bathroom and bedroom time may require surgical treatment, usually through cauterization, banding or hemorrhoidectomy — most of which use general anesthesia. He also advises against getting a “stapled hemorrhoidectomy,” as the staple used to close up the wound can cause irritation and pain during sex.

Second: Identifying, preventing and treating anal skin tags

Sometimes when you get a hemorrhoid or a tear in the anal lining (called a “fissure”), the stretched skin can heal in such a way that it develops a loose flap called a skin tag. A lot of people confuse these anal issues with hemorrhoids, but they look and feel different.

“You can flick this or pinch it and it just looks like it sounds,” Dr. Goldstein says. 

Some skin tags can cause localized irritation, discomfort, itching and some people consider them odd-looking. “They may cause hygiene problems and interfere with anal intercourse,” the proctologist adds.

While some skin tags can resolve on their own over time with sitz baths (in which only the butt and hips are immersed in water) and the prescription topical ointment Proctozone 2.5%, in other cases people have anal skin tags removed with laser, electrocautery or surgical excision. The type of surgery depends on the type of skin tag you have and the desired after-appearance. 

“With early treatment or intervention of hemorrhoids and tears, one can avoid or minimize tag development and/or formation,” Dr. Goldstein says.

Third: Understanding anal warts

Anal warts are linked to human papilloma virus (HPV), the most common sexually transmitted infection, transferred primarily by sexual intercourse and skin-to-skin contact through small cuts, abrasions or small tears in the skin’s outer layer.

“Licking, rubbing, playing — all the fun stuff we love to do can lead to its transmission,” Dr. Goldstein says. “Although many people with HPV do not develop symptoms, one can still infect others through sexual contact.”

Anal warts typically look like cauliflower or mushrooms that can be external, along the rim or even deep inside the anus. They grow in an irregular pattern (compared to hemorrhoids or skin tags) and often have a whitish hue. 

One can avoid anal warts with Gardasil, a vaccine that protects against the HPV strains that are most likely to cause anal warts. Also, Dr. Goldstein says using condoms during anal sex and showering after sex can help prevent contraction or transmission of the virus, but those aren’t foolproof solutions. If you have HPV, telling partners and having a full external and internal anal medical evaluation (including an annual anal pap smear) can help limit the spread of these anal issues.

“While there’s no cure for HPV, the infection may clear on its own,” says the proctologist. “If it doesn’t and treatment is needed, there are many options that an HPV doctor can help with. Treatment focuses on wart removal and anal cancer prevention. Warts can be approached with topical creams, acids, infrared coagulation and/or electrocautery. The best course of action is dependent on the extent and location of the disease.

Other thoughts about anal issues

Dr. Goldstein says that anal warts, hemorrhoids and skin tags are just a few of the anal issues people face. Because the anus’s primary function is defecation, anal sex does stretch and put pressure on anal tissues in ways that can stretch out the skin, causing potential injury and loose healing.

But with gradual anal play to help loosen up the sphincter and by following the guidelines above, gay men can minimize wear and injury.

“What’s key is to seek out gay providers who understand all these important issues that surround our community,” Dr. Goldstein says, “with the hopes of prevention and eradication.”

If you’re experiencing any anal issues of your own, consult your general physician or a proctologist.

This article was originally published on April 13, 2018. It has since been updated.