Pain with receptive anal sex, whether you call it bottoming, pegging, or anal, medically called anodyspareunia. It is common, often distressing, and many of its causes respond well to physiotherapy and psychologically-informed strategies.
Whether you call it bottoming, pegging, or anal, it all involves the same process: anal penetration, with the all-encompassing term being receptive anal intercourse. Just like vaginal intercourse, it can be painful for some people at times. Anodyspareunia is the term for painful anal sex, and between 50 and 65% of men who engage in receptive anal, bottoming or pegging experience pain during or after (and this pain can be severe in 7 to 15% of them).
Anal sex is often thought of as primarily between men, but around a quarter of sexually active women engage in anal sex monthly, with significant pain reported in about 10%, though there is less research into the statistics for women. Painful anal sex can be distressing and hard to manage alone, especially when so many people experience it and do not know where to ask for help, but many of its causes can be remedied through physiotherapy and psychologically-informed strategies.
Some people are more predisposed to anodyspareunia if they have had recurrent constipation or painful bowel motions, or IBS and similar conditions like diverticulitis and ulcerative colitis. Most causes, though, are a combination of physical preparedness (muscle tightness or overactivity, and not being able to relax the anorectal muscles enough for comfortable penetration) and psychological factors, including the expectation or anticipation of pain, fear of passing a bowel movement or "painting" the penetrative partner, and the social stigma historically attached to anal sex. Some of these are more easily addressed than others, and some need input from a few different professionals, but many cases can be remedied through physiotherapy and psycho-physiotherapeutic strategies.
During your first visit, I'll go through what has brought you in, the history and timeline, and the contributing factors, both lifestyle and medical or surgical, and anything you have already tried that did or did not help. I'll also ask about your sexual habits, preferences, and goals. Having your partner present can be meaningful in the first appointment, so goals are set together and everyone is on the same wavelength.
To diagnose accurately and build a treatment plan when there is pain in or around the back door, I'll assess the muscles around the perineum (gooch) and those surrounding the anal ring. This is done externally for generally all presentations, and in many cases where there is pain with penetration, an internal rectal assessment is recommended, as the muscles are most accurately examined about one knuckle's depth inside the rectum, along with the tolerance to stretch of the mucous membranes that make up the anal ring and sphincter. External examination only is an option if you are not comfortable with an internal one, along with ultrasound to view the deeper tissues and how they move and work in different positions and activities.
After the examination, treatment usually begins in the same session and often involves manual therapy in some form - sometimes soft tissue techniques to relax or desensitise muscle or tissue that is sensitive to touch or stretch, and sometimes relaxation or down-training, activation or co-ordination of the pelvic floor if the muscles are hard to feel working. Depending on the structures involved, there can be strategies to reduce sensitivity at the anal ring (whether muscle, skin, or the stretchy tissue near the anus), along with how to resume some activities at home and how to modify them to make them more tolerable as you recover. If I find other contributing factors during our initial discussion, I can talk you through exercises to continue at home, along with what to keep doing, what to modify, and what to temporarily avoid in the early stage of your recovery, as well as whether you would benefit from dilators or other devices to complement the exercises.
All of this is packaged into a plan to continue at home between sessions, where I continue or adapt the hands-on techniques as you improve, monitor your progress, and increase the intensity or complexity of the exercises as needed.
Consent is ongoing, specific, and yours to withdraw at any time.
There are a few reasons anal sex can hurt. One of the most common I see in the clinic is muscle overactivity and guarding around the anal sphincter, which creates a barrier to entry and causes pain when the muscles are asked to stretch while unable to relax. That can also tear the elastic skin around the anal ring or increase the risk of fissures, which becomes a vicious cycle: stretch causes pain, and pain makes stretch harder. Painful anal sex can be remedied with a few different strategies depending on the main factors involved, but it does take a bit of time, since these are muscles like any other - you can't learn the splits in a week, and in many cases you can't train your back door to accommodate penetration in the snap of your fingers.
Internal assessment gives the most useful information about muscle tone, skin and sphincter stretch, and tolerance to pressure. Some people can't tolerate that much stretch at the start, so an external examination can be done first, and then, as your tolerance to stretch and pressure improves, an internal one can be performed more accurately and comfortably to work out whether different approaches are needed to progress your recovery.
Of course. I see people from all walks of life with all sorts of sexual proclivities. Whether you are a gay or bisexual man engaging in regular anal sex, a woman who enjoys semi-regular anal, or a straight-identifying man who enjoys prostate stimulation, anyone can run into these problems and benefit from physiotherapy if they are having trouble enjoying what they used to. In the same vein, people who are more sexually adventurous with toys or fisting can also experience pain around the back passage if they are out of practice or go beyond what they usually tolerate, and they are just as welcome, whether for pain management, retraining, or pelvic floor strengthening and co-ordination to make sure the increased elasticity of the rectum does not put them at risk of prolapse.
Not sure if I'm who you need? Ask me and I'll let you know if physiotherapy is the right fit, or point you to who is.