Pelvis Problems: Anodyspareunia (aka: Pain with Butt Stuff)

Hello again, Scarleteen readers! Caitlyn the pelvic health PT here again with another installment of Pelvis Problems.

This time, I’m here to shine some light on anodyspareunia, a fancy name for anal sex being painful. While the traditional definition of this condition typically refers to pain experienced with the insertion of a penis (or a penis-shaped toy) into the anus, I’m going to take a broader view and include persistent pain with any sort of anal play in our discussion today. Let’s dive in!

What exactly is anodyspa-whoosie-whatsit??

While anal sex and other types of anal play are increasingly common forms of sexual expression for many people of all genders and orientations, the scientific and medical research on problems related to this type of sex is scarce.

It is therefore difficult to pin down a consistent “official” definition for anodyspareunia. Some researchers consider people who report any pain with any anal sexual encounter to have anodyspareunia, whereas others only diagnose someone with anodyspareunia if they report severe or unbearable pain with every single attempt at anal sex. Additionally, every research article on anodyspareunia I could find strictly investigated penis-in-anus (P-in-A or PIA) intercourse, and did not take into account people who engaged in other forms of anal sex, such the use of fingers, tongues, or toys in the anus. Additionally, it’s important to note that all the current medical research on anodyspareunia is exclusively focused on the pain experienced by a receptive partner – that’s a person whose anus is receiving a finger/tongue/penis/toy from another partner (or via masturbation). In cases in which a penis is being inserted into an anus, it is certainly possible that a person with a penis who is doing the inserting may experience some pain. This is different type of issue, however, and wouldn’t be classified as anodyspareunia. In the interest of being inclusive of the many forms that anal sexuality can take, I’ll use the terms “anal sex” and “anal play” to encompass any type of sexual activity that involves direct contact with the anus, regardless of whether anything actually goes inside.

The word anodyspareunia is a combination of the prefix “ano-”, referring to the anus, and “dyspareunia”, a term that has traditionally referred to persistent pain experienced by a female partner in a cisgender heterosexual couple during penis-in-vagina (P-in-V or PIV) sex. While anodyspareunia was first discussed and researched in populations of cisgender men who have sex with men (MSM), it turns out that folks of all orientations engage in and can enjoy anal sex in many forms. And since nearly every human on earth has a butthole, the information in this article is for everyone!

If you're here because you or your partner(s) have experienced pain with anal sex, you’re in the right place, regardless of whether the pain has happened multiple times or just once.

What if it was only painful the first time, or it only hurts sometimes? Do I or my partner(s) have anodyspareunia?

What a tricky and important question! It's generally accepted in the medical community that pain with vaginal sex should never, ever, ever (one more time for the people in the back!), ever be considered normal or something to just “put up with” – if vaginal sex hurts, then it’s important to reach out to a healthcare provider for help. However, when it comes to anal intercourse, it's not as clear whether or not some amount of discomfort should be considered “normal”. Survey studies indicate that a large proportion of folks who engage in anal sex are likely to experience some degree of discomfort during or after intercourse. A study of more than 1,700 MSM in Belgium found that 59% of them reported some level of pain with anal sex in the last month, but only 6% of them ranked the pain intensity as moderate or severe. A survey of over more than 1,200 heterosexual women aged 18-30 who had engaged in anal sex found that nearly half reported pain with their first encounter that required them to stop the activity, but only 3% of them reported severe pain with every attempt at anal intercourse thereafter.

Do these statistics mean every person who engages in anal sex will experience pain during or afterwards? Definitely not! Many people in those studies did not report pain with any of their recent experiences with anal sex/play. Those numbers simply demonstrate that having some pain with anal sex is a relatively common occurrence, and not something to feel embarrassed about. Just because you or a partner have experienced pain with anal, it doesn’t mean that it will necessarily happen with every attempt, especially if everyone involved is communicative, enthusiastically consenting to the activity, and undertakes proper preparation. However, if all these preparatory requirements are met and a receptive partner is still experiencing pain with each attempt at anal sex, it may be worth considering anodyspareunia as a cause.

Tell me more about those preparatory steps!

1) Lube is your friend.

Anal sex is different from vaginal sex. I’ll say it again: anal sex is different from vaginal sex. For this reason, it’s really important to learn some helpful ways to prepare for anal play of any type, whether or not you’re planning to even attempt to insert a penis into an anus.

For those who’ve had experience with vaginas in a sexual context, you may have noticed that the vagina, when stimulated and aroused, will often (though not always!) make at least some of its own lubricant in preparation for sexual activity. (Note: some vaginas naturally make less lubricant than others, and that’s still totally normal! Some folks will need to add more lubricant from a tube to make sexy-times more comfortable and enjoyable, and there’s not a darn thing wrong with that.) The anus and rectum (the “tube” just inside the anal opening), however, do NOT make their own lubricant. They need some sort of external lubrication to help ease the passage of a penis or toy. (More on lube here!)

Please note: many people who want to engage in anal play have no interest in or experience with vaginas, and that’s cool, too. The fact remains that pretty much all anuses are going to appreciate it if lube is applied to them prior to sexual activity.

2) Warm up before the big game.

You’ve probably heard that it’s smart to warm up and stretch your muscles a bit before you exercise. It turns out that the muscles in of the rear end also appreciate a little preparatory attention before you get busy at the backdoor.

Let’s pause here for a quick anatomy lesson. The anus, the rectum, and the internal muscles and nerves that surround them are the primary structures that are affected during anal play. The anus is the name for the actual opening of the butthole. It consists of two muscular layers: the internal and external anal sphincters. You can learn a bunch more about the anatomy of this region here.

The rectum is the last portion of the intestines and begins just inside the anus itself. Like the internal anal sphincter, the rectum is made of smooth muscle and is controlled subconsciously. As the rectum fills with stool (another name for poop), it gradually stretches. Special nerve endings in the muscle of the rectum sense this stretching, and eventually signal the brain that it is time to empty the rectum via a bowel movement. These stretch signals trigger another automatic response, the defecation reflex. This reflex causes the internal anal sphincter to relax to allow stool to move closer to the anal opening; at the same time, the external anal sphincter contracts to prevent stool from leaving the body until you are ready.

If it’s not a convenient time to go to the bathroom, your brain can help you consciously suppress the urge to poop by signaling the anal sphincters to contract more firmly. This moves the feces in the rectum backward slightly, decreases the stretch on the smooth muscle, and therefore decreases the urge to poop until a more appropriate time. These sphincters are assisted by a few neighboring muscles, the puborectalis and the levator ani group, that form part of your pelvic floor. Don’t worry, I won’t quiz you on those names!

Once you’re able to make it to the bathroom and it is time to have the bowel movement, both sets of sphincter muscles and the neighboring pelvic floor muscles have to relax to allow stool to leave the body. If any of them can’t relax fully, pooping can become difficult and sometimes painful. As you might imagine, muscles that have a hard time relaxing during a bowel movement might also struggle to relax when something is trying to enter from the outside…more on that later.

So what does all this anatomy gobbledegook mean for your tush? Think about the last time you saw an athlete warm up and stretch before competing in a sporting event – they do this so that their muscles feel ready to contract and relax smoothly as they run, throw, dance, etc. Similarly, gently warming up and stretching the muscles of the anus and surrounding pelvic floor can go a long way to help them relax fully during insertion of a penis or toy. In fact, the study of Belgian men who have sex with men found that massage of the anal sphincter prior to penile insertion reduced the likelihood that a receptive partner would experience pain.

Here are some suggestions to help your warm-up routine:

  • Start by TALKING. Being sure that everyone is on the same page and truly enthusiastic about trying anal play will go a long way to helping your bodies relax. Agree on what words, body language, or other signs you plan to use to communicate if either of you wants to stop at any time – being clear on this helps a receptive partner feel safe and relaxed throughout the encounter.
  • Spend plenty of time on other sexual activity first, like kissing, or touch all around a partner’s body, that doesn’t necessarily focus right on the anus. This helps everyone relax and settle into the moment without feeling rushed into the “main event.”
  • Start with gentle touch around and on the anal opening, before putting anything inside.

Physiologically speaking, the anus and rectum are accustomed to storing and releasing feces from the inside of our bodies to the outside. The sensation of something moving through them from the outside in is less common, and therefore can be a bit confusing for the body, at least at first. When the skin around the anus is stimulated by touch—with a finger, a partner’s penis, or a toy—this triggers a reflex called the “anal wink.” This “wink” is an automatic contraction of the external anal sphincter, the outermost portion of the anal opening, in response to touch. This reflex is short-lived, however, and the sphincter should naturally relax in less than a second. This reflex is one reason that the sensations of a partner stimulating the anus can feel strange the first time (or first several times) you try it. With patient, slow practice, though, the body starts to accommodate to touch in this area, and it starts to feel less weird and more pleasant!

  • Add lube—lots of it!—over the anus. If you’re worried about mess, throw a towel down over the bed or wherever you’re getting busy to make clean-up easier.

With a receptive partner’s (that is, someone whose body orifice something is going inside of) permission, an insertive partner (someone who is the person doing the going into that orifice) can slowly slide a clean, lubricated finger into the anus, and pause there.

Insertive partners: rather than trying to push your finger inside, let the reflexive contraction of the anus “draw” your finger in, sort of like suction. Let your receptive partner set the pace, and follow their lead!

Give a receptive partner a moment to get used to the presence of that finger. Because the anus and rectum are used to being stretched by the presence of stool, they tend to interpret any internal pressure as the feeling of needing to poop. If a receptive partner feels like they are having a bowel movement at this stage, that’s totally normal. That sensation tends to fade after a minute or two of sustained pressure.

It’s helpful for an insertive partner to use their free hand to keep providing some pleasant touch elsewhere on a receptive partner’s body: this helps everyone stay aroused and “in the mood” while you’re each taking your time.

  • If a receptive partner is still feeling good, an insertive partner can slowly and gently press the inside finger against the walls of the anus – from side to side, front to back, or in gentle arcs – to create a comfortable stretch. Experiment to see what feels good for each of you, and again, keep communicating! When you’re ready to remove the finger, slide it out slowly: our backdoors don’t usually like to be surprised by sudden movements!

A note to insertive partners: as someone who has performed a lot of rectal examinations in my clinical practice, I can tell you that the muscles of the anus and rectum are strong. They don’t tend to “give” or stretch the same way that the muscles of the vaginal walls do. If you feel your finger fatiguing or falling asleep during these warm-up steps, communicate with your partner and take a break! You wouldn’t want your partner to be uncomfortable during any of this, so don’t force yourself to be either.

Spend as long as you need to at each of these steps before progressing to the next. There is also no reason that you ever have to progress past any particular stage if anyone doesn’t feel ready and excited to do so.

So, is it gametime?...

If the warm-up goes well and everyone involved is comfortable and enjoying themselves, then and only then should you attempt to progress to inserting something larger, like a toy or penis. This is where communication and moving slowly become even more critical.

Insertive partners shouldn’t expect to be able to thrust hard and fast once they are inside a receptive partner: although some receptive partners do come to enjoy that type of movement with time and experience, it’s not for everyone, and it definitely isn’t a great first-time move. Instead, use this as an opportunity to slow down and listen to your partner (both the words they use and their body language) and Take. It. Slow.

*A safety note: If you’re planning on putting a penis into an anus, covering said penis with a lubricated condom helps protect both partners from infections that can be transmitted during anal sex.

*An additional note for folks with vaginas: A penis that has been inside your backside should never go directly into your vagina afterwards. If you want to switch to P-in-V after anal, you'll need to remove the condom (and replace it with a fresh one if necessary) to decrease the risk of a urinary tract or bacterial infection.

During the encounter, if anyone expresses the need to stop (verbally or nonverbally), all the action should stop immediately, and then you can decide together if another attempt is appropriate at a later time. Having a negative or painful experience is a surefire way to make a subsequent attempt feel more daunting and scary. However, this also doesn’t mean that one negative experience with anal play means you’re doomed to never enjoy it. A recent interview-based study of 20 heterosexual women who had had anal intercourse found that even though many of them had negative or painful experiences with their initial attempt at anal sex, many also report that they came to enjoy it with subsequent encounters.

Sex Toys in Anal Play

Many folks find that starting with the use of an anal-specific sex toy is a great introduction to anal play and helps them feel more confident about eventually trying with their partner’s penis. This also helps teach the muscles we’ve been discussing how to relax with a more gradual amount of stretch. Here are two great articles -- one and two! -- on safe DIY sex toys.

One important note: if you’re planning to use a toy, make sure that it is specifically designed for anal use. It should have a base at least twice as wide as the width of the shaft that goes inside: this ensures that the reflexive contractions of the anus and pelvic floor can’t draw the toy too far inside. Remember when I said those muscles are strong?!?

We’ve tried all that stuff, and it still hurts!

So you’ve taken all my advice, and anal sex just doesn’t feel good. Never fear: for some folks, anal play just isn’t their cup of tea. There are as many different sexual preferences and bodies in the world as there are people in it, and not everyone is going to enjoy every type of sexual activity. If this is the case for you or your partner(s), there is absolutely nothing wrong with that: you do you!

If getting busy in the booty is still your goal, however, there are plenty of other things that can help. Let’s talk options!

You can see a pelvic health physical therapist:

As pelvic PTs, we are trained to help you determine what else might be causing anal play to hurt. Sometimes sex is painful when the muscles of the pelvic floor, like the puborectalis and levator ani muscles I mentioned earlier, are chronically tight. If those muscles can’t relax fully on their own, they will be resistant to stretching when you or a partner attempts to place something inside the anus, and this resistance can cause pain.

If it turns out that your pelvic floor muscles aren’t relaxing fully, your pelvic PT can help you learn how to correct this. Sometimes this involves retraining the muscles using specific exercises. Your therapist might have you try a biofeedback device which can track what your muscles are doing and cue you when you aren’t fully relaxing them. Your PT may also suggest other hands-on techniques such as massage and manual soft tissue stretching to help the pelvic muscles learn to relax, and they can teach you how to perform some of these techniques yourself with your hands, your partner’s hands, or even a specialized tool designed for this type of use.

If you also struggle with other type of pelvic health problems, such as chronic constipation, difficulty fully emptying your bladder, and/or pain with other types of sexual activity, then it is even more likely that you could benefit from specialized help from a pelvic PT. Here’s a site that may help you find a pelvic health PT near you.

You can work with a counselor to determine what else might be getting in the way:

For some folks, prior negative experiences with sex play a big role in making subsequent encounters unpleasant or uncomfortable. Many people may not even be aware of the connection between such previous experiences and their current pain problem: this is where a mental health professional can be extremely helpful.

Even for those who haven’t had what they would classify as bad or traumatic sexual experiences, the experience of even one or two “failed attempts” at anal sex can cause significant distress and lead to fear and avoidance of the act in the future. A mental health provider can also help in the process of working through this type of roadblock.

If anal sex of any type hasn’t gone smoothly for you or your partner(s) in the past, don’t lose hope, and seek out help! I hope this primer on pain with anal play has been helpful, and that you feel empowered and excited to explore more in the future!

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