I said what I said.
It might be common, but it is NOT normal.
That doesn’t mean it is for everyone or that it is going to be great every time. There can be some discomfort with anal sex (physical, mental, and/or emotional), but pain is not normal.
Pain is telling us that something is wrong.
My patients are surprised when I tell them that the overwhelming majority of cases of pain with anal sex that I treat stem from our day-to-day bowel movements and hygiene! And while many of my tips are simple, some are totally counterintuitive.
Even when there is a more complicated cause (and we’ll get into those), improving bowel function and gentle hygiene almost always improves symptoms with anal sex.
I encourage everyone to explore pain with anal sex with their healthcare team. While many licensed providers might shy away from pain with anal sex, it is actually one of my favorite things to treat. It literally changes my patients’ lives, relationships, self-esteem, and sometimes changes their relationship with healthcare. I realize that not all healthcare teams have my unique experience and knowledge; my goal for this guide is self-help in the capable hands of your healthcare team. Don’t sit on anal pain, bleeding, discharge, fever, lesions (like a lump or bump), get them checked by a licensed provider.
We will explore together:
The most common factors: It’s (probably) your poop, not the sex
If you follow me, these aren’t a surprise and if you’re already doing all this, don’t worry, we’ll get into the more complicated parts in a minute:
- Dietary fiber, supplemental fiber- both bulking like Psyllium(Metamucil)/methylcellulose (Citrucel), and non-bulking like dextrin (Benefiber) plus lots of hydration. We need 25-38 grams of fiber, most of us fall short. Follow my fiber supplement guide.
- Limit time on the toilet to 1-2 minutes and avoid pushing or straining with bowel movements.
- Be gentle with hygiene and wiping. And for the love of your anus, don’t use wet wipes!
Common medical causes: Rule out the usual suspects including hemorrhoids, fissures, dermatitis, and STIs
Next step, we need to rule out medical problems: the common causes of pain with anal sex I see are hemorrhoids, fissures, and dermatitis. These typically cause symptoms with bowel movements as well, but not always. It is common for bowel function, bowel habits, and hygiene to be the main contributing factors to each of these (see above). During sex there is often more friction than during bowel movements, so sometimes we feel these more during sex than with bowel movements, even though the cause usually relates back to the bowel movements.
I cover hemorrhoids and dermatitis, and I will cover fissures, but the one really important thing to know now is that among my patients, anal fissures are almost always caused by what is happening with bowel movements rather than due to sex
The other common medical cause of pain with anal sex is STIs. A rectal swab is the only way to test for rectal gonorrhea and Chlamydia.
I remember one patient well who had scheduled a surgery with another surgeon because of months of pain with bottoming; the patient saw me for a second opinion. The diagnosis was gonorrhea and treatment with a single antibiotic shot spared the patient from a major anal surgery. Even when someone considers their relationship monogamous, I always recommend STI screening in the workup of symptoms with anal sex.
Other less common STI causes of pain with anal sex can include:
- Syphilis – which is tested for in the blood but is only detected weeks to months after the infection starts
- Herpes or HSV – which is exceedingly common, severely under diagnosed, and often recurrent. both HSV-2 (the genital herpes virus) and HSV-1 (the cold sore virus) can affect the anal area. Blood testing for HSV only indicates if someone has the virus but now when or where. A PCR swab during active symptoms is the most reliable test.
- HPV is the most common sexually transmitted infection and can cause warts (though most people with it will never develop warts). HPV typically does not cause pain with anal sex, but it can. An internal exam with a small anoscope can evaluate for these types of lesions.
- MPOX can also cause painful lesions in the anus, and while the lesions typically resolve in a few weeks, I’ve seen many cases of prolonged issues like difficult to treat fissures following MPOX infections.
You know I always recommend getting checked, so seeing if these common issues are causing pain with anal sex is your next step. I recommend seeing a colorectal expert, and you can use the LGBTQ+ Health Directory as a way to find someone culturally sensitive.
Less common medical causes: don’t miss these
There are a few less common causes we don’t want to miss, because with these, waiting makes things worse. One thing they share: they usually don’t only show up during sex. If any of these sound familiar, that’s your cue to share that with your care team ASAP.
- An abscess is a pocket of infection near the anus that is painful, swollen, and typically needs to be drained by a professional. They are closely related to a fistula which is a little tunnel connecting the inside of the anus to the skin. This often seems like a pimple near the anus that keeps draining and coming back. Fistulas can be elusive and often make anal sex more uncomfortable than it should be or even painful.
- Proctitis is inflammation of the rectal lining, and it can feel like urgency, mucus, blood, or a constant need to go with little result. Ulcerative colitis can cause it, and so can certain STIs, which is why testing comes first.
- Crohn’s disease can also cause fissures, skin tags, abscesses, and fistulas around the anus, sometimes before anyone realizes Crohn’s is the issue. An already inflamed rectum plus anal sex feels like “sex is the problem,” when really it’s just where the pain is the most obvious. Red flags I take seriously: blood or mucus, diarrhea that won’t quit, unexplained weight loss, and fissures that are off-center, multiple, or just won’t heal.
- Endometriosis may be considered in someone with a uterus, as it can involve the rectum or the tissue between the rectum and vagina causing deep pain with anal sex (and typically with vaginal sex). Clues include pain (with sex or bowel movements) that’s worse around the time of a period.
- Prostate problems might appear with deep, hard to explain pain and are often associated with urinary symptoms. There is much overlap with prostate issues and pelvic floor issues, so check out that section as well.
In anyone with a history of medical conditions in the pelvis, gut, or prior radiation or pelvic surgery these all need to be considered and discussed with your care team.
It’s very common that a complicated case of hard to solve pain with anal sex involves the patient and myself working with many other specialists: gastroenterology, physical therapy, gynecology, etc.
Skip the home remedies and get seen soon if you have: fever, a swollen or hard lump, ongoing drainage, blood or mucus, unexplained weight loss, or pain that’s getting worse or hanging on after a few weeks of the basics. Don’t sit on it, see a licensed provider.
Only hurts during sex? Check the cleanup, the lube, and the condom.
Cleaning out too much before sex (colloquially “Over-Douching”) is the biggest offender here. We know adequate fiber reduces the need to clean out and a small bulb syringe with about a half cup of tap water 2-3 times should do. And definitely don’t push it out, just release the water. Checkout my guide on cleaning out.
Allergies can play a role here as well: allergies to condoms if they’re being used (especially latex) but also sensitivity to components of lubricant. And it’s not always as black and white as allergies, some people have a minor sensitivity to common preservatives in lube (parabens, methylparabens being among the most common). Using non-latex condoms (polyisoprene, polyurethane, nitrile) and finding a lube that works better for you is the next step. Water-based lubes can dry out quickly and cause friction, so they need to be reapplied frequently and generously. Water-based lube often include glycerin which can be irritating, and they are often hyperosmolar which impact the intestines negatively (though unclear how much this impacts sex). Silicone lubes last longer, but can’t be used with silicone toys, and they are sometimes too long lasting- scrubbing the silicone off your skin later can cause dermatitis. Oil-based lubes used to be the black sheep as they aren’t compatible with latex or polyisoprene condoms, but if these aren’t being used they’re a long-acting option (Elbow Grease or something simple like coconut oil).
Small tweaks, big difference: slow down, breathe, change positions
There’s a few simple things to understand that can also help reduce tension during anal sex:
1. The receptive partner can control the rate of insertion. If the insertive partner lays flat and the receptive partner gets on top, it puts them in control.
2. Bulbocavernosus reflex (such a great word) occurs when the genitals are stimulated, the anus contracts. So limiting genital stimulation of the receptive partner during insertion can reduce tension.
3. When the anal opening (“verge”) is stimulated, the sphincter contracts. Give it a second then it will relax and ease insertion. (FYI this anocutaneous reflex is also called the “anal wink”)
4. Breathe. And I cannot stress this enough! It is helpful for relaxation, it is helpful to reduce involuntary anal sphincter tension, and because the diaphragm moves in sync with the pelvic floor, breathing keeps the muscles around the sphincter moving, flexible, and dynamic.
5. Being bent at the waist (think squatting, laying in a fetal position, or any number of creative poses) helps relax the puborectalis sling and straightens out the rectum to reduce resistance.
6. Communication between partners is key, ensuring both partners are moving at a comfortable pace, not rushing, and know when to stop. An agreed-upon stop signal or “safe word” can be helpful to know when to stop, especially when everyone is excited in the moment.
7. The “butt clock” technique (See the next section where I cover this along with the pelvic floor!)
What’s not the solution, numbing agents. Pain is telling your brain that something is wrong and trying to cover that up rather than finding the solution can actually be dangerous. Numbing agents may dull the sensation that something is tearing. I strongly recommend against these.
“I’m too tight” usually isn’t it. When it is, “just relax” isn’t the answer.
My patients often say “I’m too tight” and they’re surprised when I tell them that’s not likely the case. Much of what we’ve discussed above are commonly perceived as “too tight.”
The anal sphincter is strong and it takes some time for it to learn to be both an exit AND an entrance. This can be challenging for someone who hasn’t or doesn’t regularly engage in receptive anal sex. With time and practice this can improve, especially when treating the anus compassionately and avoiding ambitious expectations.
A simplistic description of the sphincter muscle (the round muscle which opens and closes for sex and bowel movements) identifies an external sphincter which we control (squeeze your hole right now, that’s your external sphincter) and that cuffs around the internal sphincter which we don’t control. I compare this internal sphincter to the muscle of the heart because they are muscles which we don’t control and because many of the things that relax the heart muscle also relax the internal anal sphincter. Think when you feel safe, relaxed, content, your heart rate slows and your internal anal sphincter relaxes. When you feel unsafe, worried, scared, your heart rate increases and your internal anal sphincter tenses.
The “butt clock” technique can coax the internal anal sphincter into relaxing: insert a finger to put pressure on the sphincter in 4 different positions. Imagining the tailbone as 12:00 on a clock. Press your finger toward the right side (3:00) and hold for 30 seconds. Move toward the perineum (6:00) and hold for 30 seconds. Then move to the left side (9:00) and hold for 30 seconds. Finally move toward the tailbone (12:00) and hold for 30 seconds. (Credit to Dr. Carlton and my pelvic PT colleagues) Ensure nails are trimmed and adequate lubricant is used. I commonly use this technique with patients who are struggling to tolerate an anal exam in the office. If there is any sharp pain stop, and if there is increased discomfort at 12:00 or 6:00, these are the common locations of anal fissures. Don’t sit on it, get it checked out!
The anal sphincter is part of the pelvic floor which I’ll simplify as a bowl of intertwining and interacting muscles that support the anus and rectum as well as the genital and urinary organs. These muscles connect to the tailbone, hips, and pelvic bones.
When my patients have symptoms which overlap with these organ systems (i.e. rectal pain with urinary symptoms, recurrent prostatitis, genital symptoms, or even sometimes tailbone pain, lower back pain, etc.), I often refer them to a physical therapist who focuses on the pelvic floor. These specialist PTs are more accessible than most people imagine. When helping a patient who doesn’t live in NYC locate a PT who specializes in the pelvic floor, I always share with them that one of the primary focuses of pelvic floor PT is pregnancy, so you may find someone who seems to specialize in pregnancy but could actually be the right fit in these cases.
Stretching works, but only after other causes are ruled out.
When someone really is too tight, I share with them my dilation protocol. This is something I’ve developed over the last 2 decades from experiences working with patients and expert opinion of some of my current and past colleagues. It is essential that we’ve ruled out a pathology before we try to stretch things.
Dilation protocol: Use of a dilator at least 3 times a week for at least 6+ weeks.
o A dilator set or something similar, like a dildo with a wide base can be used. Do not use a plug as its shape is not ideal.
o Each session should last about 15-20 minutes.
o Start with a small size (small dilator, small dildo, or maybe a finger), gently insert it, and hold it in place. Do not stimulate the genitals during insertion, but they can be stimulated after insertion has occurred successfully.
o Especially early on in the dilation process, a warm bath for 10-20 minutes prior to dilation will relax the surrounding muscles first.
o Once insertion is more cortable, moving the dilator in and out helps simulate sex.
o Gradually increase the size, but progress will NOT be linear. Meaning that some days will go better then others (this will depend on diet, stress, and other factors). Progress will vary; and periods where there is no increase in size are still helpful, still progress.
o Stop immediately if you feel pain or see bleeding. If this happens, get evaluated.
o Butt clock technique can be helpful in increasing size.
o As comfort progresses, pairing dilation with genital stimulation and with partners helps reconnect anal stimulation to sex. (I tell my patients that it might begin like a chore, but should move toward being sexy)
o Commercial options (which I don’t specifically endorse) include: https://www.soulsource.com/collections/silicone-pelvic-trainers (do NOT use silicone lubricant with silicone dilators) or https://futuremethod.com/products/glass-anal-dilator-set (always check dilators before any use for chips, cracks, breaks, etc.)
This dilation protocol comes from clinical experience, not clinical trials. I always work with my patients to personalize their plan.
Yes, your brain is involved. No, it’s not “all in your head.”
There is ALWAYS a psychological component to pain with anal sex, but I don’t mean that this is all in your head. Sometimes it is the primary cause, sometimes it is an outcome of the pain, and sometimes it adds complicated layers. Pain with something that is meant to be pleasurable messes with our brains, and our brains are closely connected with our gut and our pelvic floors.
It’s not uncommon for my patients to say something like “sex isn’t quite painful, but I don’t enjoy it the way I see in porn.” And I always remind my patients that porn is ACTING. I have the utmost respect for the entertainment industry, but it is not a helpful comparison. It’s also probably not helpful that most of us learn about anal sex through porn. This definitely impacts our view of what successful sex should look like.
Trigger warning– I’m going to discuss sexual trauma and abuse. (Please call or text 988 or use another local crisis line if needed). A history of sexual trauma or abuse can have a lasting, complicated impact on sex. It can show up without a conscious understanding, and it can show up in a way that doesn’t make sense to us. Working with a mental health profession is essential.
But we also have to recognize that pain with sex itself is somewhat traumatic, especially when it’s not understood, it’s lasting a long time, and impacting relationships – romantic, friendships, even just losing the confidence to discuss sex with friends because of symptoms we don’t understand.
This stress, anxiety, trauma actually impacts our bowel function and pelvic floor (including the sphincter muscle) and that starts a common, vicious cycle. What may begin as a simple cause of pain with anal sex (maybe wiping too much) can actually cycle into a complicated picture of bowel irregularities and pelvic tension due to this. I always call this out with my patients. I recognize this trauma (big or small), we name it, we recognize it, and we work toward breaking that cycle. Which is often easier said than done.
Discussing Pain with Anal Sex with Your Care Team Checklist
Use this guide with your key team to consider what may be going on.
Last reviewed by Jonathan Baker, MPAS, PA-C, DFAAPA 11/10/2026