Bottoming and IBD

Having a Pleasurable Bottoming Experience

With IBD

Fiber: Decreases your need to douche, BUT in IBD, fiber can be a touchy subject. It may help to ask your doctor about increasing fiber in your diet (you don’t have to say it’s for the purposes of anal sex.)

•  Companies market fiber supplements to bottoms - DON’T FALL FOR IT! 

• They are soooo overpriced, and the same thing as any fiber supplement you get at the pharmacy or grocery store. Just get a psyllium husk supplement and don’t buy something that is marked up 500%. 

• Douching: There are no increases in STI transmission associated with douching. See here - specifically, rectal douching was not associated with increased rates of anorectal chlamydia and gonorrhoea.

• Isotonic saline does not damage the epithelium. Fleet enemas are HYPERtonic/Hyperosmolar and can lead to epithelium damage after too much use and dehydration if used too much or if you are already dehydrated. Everything in moderation!

• DO NOT USE those jet stream super powerful douches like shower douches. The tissue walls/lining of your rectum/anus needs more time to heal and adapt to high pressure force and that can hurt it.

• See more information below about douching including how to douche, what to use, and the do’s and don’ts.

• Lubricant: Silicone lubricant is ideal ONLY if not using a silicone based toy. If you think you’ve got enough lube, use some more. Iso-osmolar lubricants (typically silicone based) might be preferred for bottoming as hyperosmolar lubricants (typically water based) can cause epithelial damage and increase risk of bleeding and infection if used too frequently. Because of our IBD, we might (and usually) need to use more lube. If you love it, lube it.

• HOWEVER, when using silicone lubricant with silicone objects (for example, a dildo), be careful, as combining silicone + silicone will lead to material breaking down.

• Poppers: Don’t combine these with PDE5 inhibitors (medication for erectile dysfunction and pulmonary hypertension including Cialis and Viagra). Poppers should be used with a lot of caution as they can cause significant cardiac events, and if you are on certain meds to manage IBD side effects or other conditions, you may need to check that.

• Here is the interaction checker for medications that interact with poppers:

• Foreplay: Getting aroused/turned on will not only relax you, but make the muscles around your butt relax and blood flow increase (all the happy chemicals do that) It never hurts to throw in some foreplay to loosen things up!

• You don’t need a partner for this, either - fingers are a good place to start, because you can start with a pinky and work your way up, or you can use sex toys like vibrators, dildos, anal/rectal dilators,etc  https://www.drugs.com/drug-interact

  Consent: Open communication, respect, and honesty all are super important to having a pleasurable experience. Consent is sexy!

• Communication: Having a pleasurable time bottoming (and being a top!) should involve open communication, regardless if you have IBD. Communicating what feels good, what doesn’t, what you are comfortable with, what you aren’t, etc, is essential to having the most pleasure.

  Safe Sex: Condoms and dental dams if you are with a new partner and good hygiene ALWAYS! Brush your teeth and wash your booty!

• Medication: Some people are prescribed hydrocortisone cream by their PCP (there are also OTC options) for use the day before and day after to soothe and “calm down” the anus area. Some people’s IBD specialist also recommend using Uceris foam the day before and day after to handle any residual inflammation as well.

If It Hurts:

Recurrent or persistent pain that occurs before, during or after bottoming/anal

When/How Does Painful Bottoming Happen?

• Painful bottoming/receptive anal intercourse of any kind) is referred to as anodyspareunia

• Painful bottoming/anal sex typically occurs at the anus during initial entry or during entry and/or thrusting.

• In people with IBD and dyspareunia, the missionary position can cause penetration pain during sex, so you may consider modifying positions.

• Internal anal sphincter hypertonicity and sphincter spasms can result in difficulty with anal entry/penetration and painful anal sex.

• Sharp pain might additionally be experienced during entry/penetration or thrusting if a penetrating object pushes on the rectosigmoid junction causing mesenteric stretching (refer to the diagram below!)

• The rectosigmoid junction is roughly 6 to 9 inches (15-17 cm) up from the anus.

• Some people really enjoy this area and it can feel really good! (colloquially known as the “second hole”/"second ring" etc.)

• If that is your thing/you enjoy that or it feels good to you, ensuring you are maximally prepared and relaxed is a good idea.

• Follow the tips above and work with your partner(s) to make sure you are ready, and don't be afraid to try things out yourself beforehand to "test the waters" - i.e, self play with a dildo at home, fingers, etc.

• If you have active inflammation in this area (rectosigmoid junction/second hole) things may not feel as good and the tissue may be more prone to friability/easier to damage/bleed. If you are in a flare that is affecting this region, it may not feel as good since the area and mucosa is inflamed.

• There is no research or evidence regarding sexual intimacy and effects during active IBD involving the rectosigmoid junction and how pleasure is affected in this area, but from conventional wisdom and connecting the dots, one can assume it would be less pleasurable and the tissue would be more friable/sensitive/inflamed and pain would be more likely rather than pleasure. I have no idea though!

• If this is the case, take everything slow and be smart about what you do.

• Trust your intuition/gut feeling (even if your guts are a little different)

  Anatomical, Physiological and Psychosocial Factors That Can Contribute to Painful Bottoming

  • Inadequate anorectum lubrication (aka - not enough lube)

  • The anorectal angle (the angle of a line from the anal canal tangent to the posterior rectal wall, the angle increases after evacuation (fancy word for pooping, important in anal continence and how your sphincter functions)

  • More about the anorectal angle below!

  • Anal sphincter tightness

  • There are two rings of muscles in your butt.

  • External muscles you can control and relax on your own, but the internal sphincter only loosens up if it senses pressure.

  • Tip: To help relax these muscles, you can take a finger, lube it up, loosen up your butt before you try to push anything up there.

  • Size of the penetrating object (whether that’s a dildo, toy, penis, finger, etc) - if it is too big (length wise or width/girth wise) you may be a bit uncomfortable. I promise your partner will understand and not be offended if you need to slow down because size is an issue.

  • Lack of relaxation and foreplay!

  • It’s so important for not only loosening things up but dilating the blood vessels and everything down there.

  • Proctitis (inflammation of the rectum) may be associated with rectal pain, tenesmus and bleeding.

  • For us with IBD engaging in RAI/bottoming, increased bleeding from proctitis might not be life-threating, but could create anxiety for yourself (and partner(s) if present) from concern as well as confusion regarding the underlying source of the bleeding.

  • For individuals with prostates affected by IBD with rectal involvement, local inflammation can cause persistent prostatic inflammation (inflamed prostate area), likely affecting bottomming/RAI. This would also decrease the pleasure and enjoyment experienced by prostatic stimulation/prostate orgasms.

    Psychosocial Factors That Can Make Bottoming Unpleasant

    • All of these things (listed below) can increase sympathetic nervous system activity that then leads to increased anal sphincter hypertonicity (AKA when you get nervous and wound up, your butthole gets too wound up and nervous too)

    • Generalized or conditioned anxiety (which is more prevalent in individuals with IBD, and in minority populations and LGBTQ+ individuals)

    • Trauma history (unfortunately, prevalent in people from sexual and gender minority communities).

    • Internalized homophobia.

    • Fear of STI transmission (including HIV).

    • Fear and/or phobia of engaging in a stigmatized act (related to internalized homophobia).

    • Defecation concerns, including defecation during RAI - these are often associated with anodyspareunia (painful bottoming/receptive intercourse)

    • This is all the more reason why it’s important to stay in tune with your mental wellbeing and mental health, and check in with a therapist/psychologist/psychiatrist/mental health professional of whatever flavor to make sure everything is good.

      IBD Systemic Inflammation and Bottoming

      • Widespread/systemic inflammation in IBD can also make bottoming not the best.

      • Systemic inflammation from IBD can cause side effects with negative impacts on things in the bedroom, including:

      • Fatigue

      • Increased fecal urgency (a very common and disruptive symptom)

      • Fecal incontinence

      • Bloody diarrhea

      • Abdominal pain and malnutrition

      • The fear of having diarrhea can also contributing to issues with intimacy, so make sure this is something you talk to your doctor about if it’s an issue important to you, and communicate to your partner as a concern (but NOTHING to be insecure or worried about - everybody poops!)

      • Although RAI/bottoming might initially be painful, over time, the pain generally diminishes and pleasure increases - practice and getting more comfortable with bottoming can make things go easier. This goes for everyone - IBD or not.

      And most importantly, don’t let the haters (or very misinformed people) get you down! You can, in fact, bottom with IBD.

Detailed anatomy of the anus and rectum - the anorectal junction (“second hole” is circled) If your IBD is active in this area, you may not have as much pleasure here.

Basics of Bottoming: Anatomy and Physiology 101

a rudimentary overview of the A&P

What Happens Anatomically?

• During anal sex, the penis (or dildo, toy, or whatever you chose) is inserted into the anus, past the external and internal sphincter muscles, and into the rectum.

• The rectum is connected to the sigmoid colon, which is where poop is collected and stored by your body before you are ready to use the bathroom.

• It can take 2-10 hours until it fills up after you eat and you have to defecate -meaning there’s quite a bit of time in between when you eat and when your colon fills

• Although there are several factors that may affect this including IBD or IBS or if you have altered colonic transit times due to gut dysmotility conditions, etc) these are just the textbook numbers.

  What is an External and Internal Anal Sphincter?

• When talking about stretching the muscles for anal sex… what muscles are we talking about?

• The external and internal sphincters need to stretch open, or relax, to allow entry (for a penis, a dildo, whatever the situation is).

• You can control your external sphincter (skeletal muscle) consciously, while the internal sphincter (smooth muscle) is not under voluntary control.

• As a result, the internal sphincter may need some additional coaxing to relax.

• Think about it - when you have to poop sometimes it just comes automatically, and sometimes you have to push it out!

• This is one difference between smooth muscle versus a skeletal muscle (there are a lot more, but let’s not rehash A&P)

• When people experience pain during anal sex, a simplified reason may be that the external sphincter is not relaxed before their partner’s penis goes in (or dildo, or toy, etc).

  Nerve Endings

• Nerve endings produce sensations through even light touch or pressure by transmitting information from an external stimulus to your brain - we have these all over our body, from our skin to our colon and rectum.

• In the anus, there are nerve endings that produce pleasure (or pain) - which is what we are aiming to avoid!

• Foreplay can help you begin enjoying the sensations around your anus, and also help to relax your sphincter.

• If you are having trouble relaxing around there, you can try exercises to help.

• When you’re alone, or with a partner if comfortable doing so, use light touch around your anus to help relax, different types of touch, different types of pressure, and explore what feels good.

• Keep going for as long as you enjoy it.

• Some people can be overly sensitive around their anus, and can benefit from desensitization exercises.

• To help desensitize, apply deep, broad pressure, such as a flat hand, around your anus to help calm your nerve endings down first.  

• Lighten up the touch and see if you can ease your mind and learn to enjoy the touch around your anus.

• If you are recovering from a flare or perianal disease, you may be more sensitive in this area, so things may take more time! And that’s okay.

Pelvic Floor

• People with IBD and GI disease may already be familiar with the term pelvic floor (muscles that support the pelvis) or be referred to pelvic floor PT, due to how the disease can impact our pelvic floor muscles and continence and the like.

• Everyone has a pelvic floor, and it is intricately linked with how you pee, how you poop, your “core stability,” and erectile function (for people with a penis).

• Will most people feel the muscles in the pelvic floor? Probably not.

• But just as you feel the motion of your knee extending (this sense of your body moving (proprioception) and can identify your quadriceps performing that motion, you can become aware of the muscles of the pelvic floor.

• The pelvic floor has two states of motion: it can be in a contracted state of motion (a Kegel) or relaxed state of motion.

• These are also associated with different states of mind: very relaxed, normal day-to-day, and high stress or anxiety.

• Pelvic floor therapy has been shown to decrease sexual dysfunction, erectile dysfunction, and chronic pelvic pain as well.

• See here for more information on pelvic floor physical therapy.

• When preparing for anal sex and bottoming, it’s best to be relaxed, and to also begin to play with constriction, relaxation and bearing down with the pelvic floor muscles.  

  The Unique Shape of Your Rectum!

• Your rectum isn’t a straight tube, there’s a bend in your rectum called the “anorectal angle.”

• Imagine a long balloon that is twisted at a 90-degree angle about 10 centimeters from the end of it.

• This is the shape of your rectum, that allows poop to be held back until you’re ready to go to the bathroom.

• (This is also a rudimentary definition of anorectal angle)

• During anal sex, it’s best if the anorectal angle relaxes slightly so that the rectum becomes more linear.

• You can make this happen/relax it more by using your pelvic floor muscles to “bear down” during sex (hear me out - there is a scientific reason)

• Bearing down or pushing out, like the feeling when you’re pooping, as the person topping is inserting whatever object (penis, dildo, etc). (aka, push out as the person topping pushes in) helps straighten out the anorectal angle

• This works by bearing down through your pelvis without tightening your external sphincter (this is where the pelvic floor muscle control comes into play)

• This will allow your anorectal angle to be more linear because your pelvic floor muscles will be relaxed.

• This allows the muscles to elongate and adapt to changing sizes.

• The person topping will feel less resistance/ it will be easier for them upon entry.

  Your rectum: Is there poop in it?

• Generally, No! Unless you have special circumstances (like, you have diarrhea or steatorrhea (excess fat in your stool, could be caused by things like medications, malabsorption, bile acid malabsorption, exocrine pancreatic insufficiency, or simply just eating a high fat meal.

• People generally assume is that there is feces (poop) just inside their internal sphincter/ in their rectum (their butt). This is a fair assumption!

• As with everything, some exceptions do apply, but for the most part, poop does not stay in your rectum.

• Poop is stored in your colon until you’re ready to use the bathroom.

• Right before you have to poop, there will be poop/feces there, but otherwise, there isn’t just poop lurking in your rectum.

• Unless you are reaaaaally constipated (then please let your doctor know, and you would have to be really, really constipated)

• When you’re sitting on a toilet, poop travels from your colon through the rectum and out your anus.

• Some people still prefer to douche their rectum before anal sex (more on this below), but you should know that even if you don’t douche there may not be any poop (depending on the consistency) in your rectum.

• There may be some fecal matter residue if you recently pooped and didn’t wipe very well (or use a bidet, seriously, try them out!) but you really don’t have to worry about poop in your rectum.

• Be comfortable with the idea that sometimes poop comes out of your butt.

• If you have IBD, there is a good chance you have come to terms with that, but it can be embarrassing regardless.

• If you’re afraid of that idea, you can stick with oral sex or you can work on getting comfortable with the idea that it might happen.

• If you’re overly worried about poop showing up during sex, you’re going to shock your system into an anxiety-ridden state that can negatively affect the sex you’re having and you won’t have a good time.

•  Keep in mind that caffeine and foods high in fiber can accelerate mobility to the lower bowels, though.

• Leave some time before sex (maybe an hour or so) if you’re going to douche.

  Mindset

• In everyone, IBD or IBS, or no IBD or IBS, digestive disease or not, anal control consists of both voluntary and involuntary muscles.

• It’s used as an analogy in things like sports (and debate team and apparently LinkedIn…), but I think it works here too - mindset is 80% of the challenge. The other 20% is skill, strategy, and what you know and can do. Your mindset influences your response emotionally and psychologically and if you are in a bad mindset, you will probably have a bad time.

• If you’re afraid, anxious, worried or fearful, your sympathetic (fight or flight) nervous system takes over, which can result in a very negative experience your body will remember.

• Unfortunately, people with IBD and minority populations tend to report higher levels of anxiety and worry, which probably leads to more of this “fight or flight” system in action.

• The mind body connection is vital in creating positive experiences, so being aware of what state your mind is in will express how your body reacts!

• It’s best if you are fully relaxed, and that includes your anus!

• Taking deep breaths can help, but mostly, trust with your partner is paramount.

• This is why it’s important to take time to relax, prepare yourself, and get into the right frame of mind so that you’ll enjoy the sex you have and ensure you have healthy communication with your partner(s) and trust them.

  Benefits of Intimacy/Bottoming (other than the obvious)

  Benefits of Intimacy/Bottoming (other than the obvious)

  • Sex is good for you!

  • Sexual activity is a fundamental human function with short-term and long-term emotional, social, and physical benefits. (but it’s also important to keep in mind that while good sex promotes good health, good health also favors good sex.)

    Short Term Benefits

  • Many of these occur immediately following sex.

  • One example is the increased pain threshold after direct genital stimulation 

  • Associated phenomena with intimacy, such as affectionate touch is also known to have powerful beneficial effects on its own, such as cardiovascular relaxation

  • Interpersonal touch not only promotes well-being and emotion-regulation but also facilitates neurocognitive processes underlying flexible goal-directed behavior (i.e., cognitive control)

  • Positive sexual experiences has a lot of overlapping beneficial outcomes!

  • This includes pleasure, pain reduction, sleep improvement, and improved function of the immune system (the last one with also intermediate-term benefits).

  • Pleasure, pain reduction, and increased mental health quality of life is attributed to the production of three of the major intervening hormones: oxytocin, testosterone, and cortisol.

    Pleasure (Happy Chemicals)

  • The most obvious and distinctive short-term benefit of sexual activity is sexual pleasure.

  • This may include solo or partnered behavior as well as cognitive experiences of sex, such as fantasies.

  • Non-penetrative sexual acts, such as oral and manual stimulation are quite common, especially among sexually diverse and gender-diverse individuals and may be more pleasurable than penetrative sexual activities.

  • While it is subjectively rewarding, it has been linked to overall well-being 

  • Sexual pleasure and its associated positive emotions functioned to reinforce sexual behavior and to enhance self-esteem, resulting in a beneficial cycle.

    Pain Relief

  • Sexual activity can be used as a strategy for reducing pain as well.

  • In migraine patients, 60% reported an improvement of their migraine during sexual activity (within 70% of them moderate to complete relief).

  • Sexual intimacy might alleviate pain by providing a source of distraction as well as other pathways.

  • One study found that pressure stimulation of the anterior vaginal wall and self-stimulation of the clitoris had an analgesic effect, reaching maximum effect with orgasm.

  • Endorphins and oxytocin might also explain the pain-reducing effect of sexual activity.

  • Higher oxytocin levels are correlated with a higher pain threshold , with muscle relaxation contributing to the pain-reducing effects of sexual activity.

  • In patients with multiple sclerosis and spinal cord injury, sexual vibration and orgasm can produce reductions in spasm and muscle relaxation that last for several hours.

    Sleep Improvement

  • Sex may promote health through sleep-related pathways!

  • Studies have found links between good sex and good sleep, but the causal direction is unclear. (correlation doesn’t always directly equal causation, etc. etc.)

  • The physiological after-effects of sexual activity may promote high-quality sleep (physical activity followed by muscle relaxation; elevated oxytocin level and consequent stress-reduction; elevated prolactin level after orgasm; lowered cortisol after orgasm).

  • Empirical evidence (and conventional wisdom) suggests that sexual activity followed by orgasm facilitates sleep, although laboratory studies have not verified this causal hypothesis

  • Masturbation also seems to help assist in inducing sleep.

  • In an Australian study among >750 individuals, more than 50% indicated improved sleep quality after masturbation to orgasm, with no gender difference.

  • After sex with a partner, the sleep benefits were higher.

    Allergies/Immune System

  • Studies focusing specifically on other forms of sexual activity have found that masturbation was followed by a transient increase in the absolute number of leucocytes, in particular killer cells, that can be seen as a “boost” of the immune system.

  • Kissing, which remains a nearly ubiquitous part of sexual expression, appears to alleviate allergic symptoms by decreasing allergen-specific IgE production.

  • This does not mean you should stop taking Claritin and substitute that for a kiss. Integrative medicine is the new thing - complimenting your traditional treatments with others :)

    Intermediate Term Benefits

  • Ejaculate contains many substances that are easily absorbed by the epithelium, especially in highly aroused individuals and associated with decreases in depression and anxiety (testosterone,DHEA, and zinc

  • The free testosterone level (i.e., testosterone’s bioavailable fraction) in seminal plasma is 3 - 4× higher than in the blood , potentially increasing the antidepressant properties of the hormone

  • Engaging in sex appeared to create mood-driven positive outcomes the following day as well.

  • One study found that physical affection or sexual behavior in couples significantly predicted next-day reductions in negative mood and stress, and next-day increases in a positive mood.

    Long Term Benefits

    Pelvic Floor Health

  • Masturbation actually more effective than Kegels in strengthening the pelvic floor! (Penis-root masturbation)

  • Masturbation is positive outcomes in pelvic floor health for people assigned female at birth as well as male at birth - decreasing urinary incontinence issues and fecal incontinence issues and strengthening the muscles in the pelvis

    Physical Exercise

  • The more physically active forms of solo or joint sexuality can indeed be seen as exercise and accordingly have the potency to positively influence cardiovascular and cerebrovascular health.

  • The typical energy expenditure during penetrative intercourse is ∼85 cal or 3.6 cal/min when at a moderate intensity

  • Even without muscular activity, sexual arousal activates circulation and can be accompanied by changes in heart rate, blood pressure, and peripheral vascular responses.

  • Orgasm is always accompanied by a rise in heart rate (20–80 beats/min), systolic blood pressure (25–120 mmHg), and diastolic pressure (25–50 mmHg)

  • As physical activity is recognized as an important lifestyle factor delaying the development of atherosclerosis and cognitive decline, and sexual activity through both arousal and intercourse achieves this.

  • it may be appropriate and beneficial to include regular sexual activity in health recommendations, since it is hitting all of the benchmarks of exercise (rise in heart rate, circulation, etc)

    Longevity

  • A large, longitudinal US study found that sexual activity, quality of sexual life, and interest in sex were positively associated with health in middle age and later life

  • The English Longitudinal Study of Aging also explored associations between sexual activity and cognition in adults aged 50–89, finding that regular sexual activity was linked to slower cognitive decline, memory and executive function.

  • It’s not exactly clear from these studies whether intercourse is singularly beneficial, or whether it is the overall experience of arousal and orgasm that is beneficial (in which case solo masturbation could convey the same effects)

  • More research is needed to clarify a causal relationship direction though (correlation doesn’t necessarily mean causation :)

    Protective Factors Against Disease

  • With respect to prostate cancer, studies have found that frequent ejaculation is associated with reduced prostate cancer risk and plays a beneficial role in the etiology of prostate cancer.

  • Regular ejaculation appears a preventive factor in the development of chronic non-bacterial prostatitis.

  • The overall impression is that an increasing amount of elements of sexual action and intimacy and interaction appears to favor physical and mental health - good sexual health favors good physical health, and vice versa!

  • So in the words of Marvin Gaye (with protection when needed and following guidelines from your healthcare team) … get it on! It’s good for you!

  • This DOES NOT mean to stop taking your medicine and substitute Entyvio (or Stelara, or any of the other IBD meds) or Zyrtec for any of the above.

  • Sometimes a little integrative medicine is key and makes the difference - combining different healing practices is a fairly effective strategy!