• Perianal fistulas are little tunnels that occur between the rectum or anal canal and perianal skin

• This might also contribute to problematic RAI/bottoming for a few reasons.

• The relative position of the fistula (intersphincteric, transphincteric, suprasphincteric or extrasphincteric) might influence:

• sphincter function

• treatment type (surgical, setons) vs medical, antibiotics or different biologics)

• resultant sphincter tonicity (how tight your butthole is)

• and therefore RAI/bottoming pleasure.

• They might damage other surrounding structures involved in pleasurable RAI

• May cause scarring that might make the area feel dry or tight

• May cause pain during penetration, especially if the fistula is filled with fluid.

• Perianal fistulas are also frequently associated with anorectal strictures causing anorectal narrowing

• This could limit the ability to engage in RAI/bottoming the way you feel best

• This potentially could make penetrative anal sex impossible (POTENTIALLY, not definitely - in rare cases!).

• Rectovaginal and colourethral fistulas can lead to unintentional leakage, causing anxiety and self-consciousness surrounding bottoming/RAI

Perianal Setons in Situ and Bottoming

• Setons in situ can cause pain and discomfort as well as frustration due to decreased sexual spontaneity and difficulties explaining setons to sexual partners if they are not familiar with IBD/don’t have IBD themselves.

• Knotless setons are associated with significantly less pain than their counterparts (traditional knotted setons) possibly enabling more pleasurable RAI/bottoming.

• Fistulotomy, typically used for low intersphincteric fistulas that have failed medical management may carry more risks than setons alone including:

• Scar formation (which could reduce anorectal elasticity

• Decreased ability to accommodate an objects such as dildos or penises for RAI/bottoming) (i.e, things may be a little tighter than before)

• Sphincter weakening (which could cause decreased arousal).

  Alternatives to Setons

• For people who bottom/engage in RAI and are candidates, mucosal advancement flaps and fistula ligation might be preferred options over seton placement.

• OBVIOUSLY DISCUSS WITH YOUR GI DOCTOR AND COLORECTAL SURGEON FIRST, EVERYONE IS DIFFERENT!!

• Mucosal advancement flaps involve mobilizing rectal tissue to cover fistula tracts and preserve the sphincter

•  The procedure can only be performed in patients without active proctitis and reoperation occurs in up to 50% of patients.

• Ligation of intersphincteric fistulas (which has a low risk of fecal incontinence) is another treatment option that might preserve sphincter function compared to other surgical treatments.

Skin Tag Excision and Bottoming

• Anal skin tags (perianal skin tags/rectal skin tags/superficial skin tags) are benign little folds of anal tissue that can arise from several sources, including (but not limited to)

• Anal tears (fissures)

• Dilated veins (hemorrhoids)

• Anal abscesses/infections.

• Anal gland tunnels (fistulas)

• Anoreceptive intercourse (this does NOT mean bottoming = destined to get a skin tag)

• Irritation and friction near the anus (including from things like excessive diarrhea causing a really moist and irritated anus area)

• Intense exercise, like weightlifting.

• Blood clots around the anus

What do I do if I have a skin tag?

• First off, please GO TO YOUR DOCTOR (if it is bothering you)!

• If you have one that is small enough to be treated non surgically, these are some non-surgical treatments:

• Some smaller tags may resolve on their own over time.

• Sitz baths

• Sitz baths can provide relief by soothing the area, reducing inflammation and shrinking the skin tag)

• Proctozone 2.5%

•  Proctozone 2.5% is a prescription topical ointment that reduces itching and discomfort while easing irritation around the tag. 

• While these treatments can be helpful in some cases, it’s important to consult with a healthcare professional to determine the best approach for your specific situation.

• If you do have to have surgery to remove it (most times it is an in-office procedure done under local anesthetic)

• Anal skin tag removal is typically done through a minor surgical procedure where the tag is carefully excised using a scalpel or local anesthesia (they numb the area using lidocaine, you won’t feel anything at all but you will be awake). The procedure is quick and minimally invasive.

• The first 3-5 days will be the most difficult, with a a sense of local spasm in your butt area/the area it was removed from.

• Pain can be controlled with and prescribed pain medication (if prescribed) acetaminophen/Tylenol, combined with suppositories, lotions, and daily Epsom salt baths.

• Using a bidet during this time can be a gentler method of cleansing the area. (I’m a big bidet fan anyway)

• After this period comes 1-2 weeks of more localized pain during bowel movements.

• This time, using non-narcotic pain meds (Tylenol!) and continuing with the other aforementioned remedies will aid in recovery and minimize discomfort.

• After another 2-3 weeks, the pain should be mostly resolved

• Full healing will come after roughly 6-8 weeks post-surgery.

• You can start exercising after 5 days and begin topping or engaging in non-anal play after one week.

• At the eight-week mark, some surgeon’s office start using anal dilators to assist in healing and restoring the anal architecture.

•  This fully allows people to achieve their anal desires (bottoming, anal play, etc), if that’s part of their goal.

• There is no written guideline on the best time to resume bottoming/anal sex after skin tag removal, so this will be a discussion to have with your doctor if you can and your partner.

• It is essential that the wounds and the surgical site has healed properly before resuming intercourse and bottoming, so that the skin can regain its elasticity without the danger of the wound opening.

•  It should be noted that the dilation of the anus may be less than it was before the procedure, so the first time you have anal sex after surgery, it is advisable to take your time and proceed slowly, without forcing and with good lubrication. 

• Generally, the best practice is like above - avoid bottoming for at least 6-8 weeks (or until your surgeons office explicitly says so) to make sure everything heals well.

• Make sure you are following all of the post-op care from your doctors office and everything is healing well.

• When you do start back up, start back up slow and gentle and with plenty of lube (I need a sponsorship or something). Start slowly and gently, don’t rush anything and listen to your body.

• Protection/a condom may be a good idea to consider here, to minimize infection risk since you just had surgery.

• Use plenty of water-based lube to minimize friction and potential irritation of the skin tag area and perianal/rectal (or where it was)

• COMMUNICATE! Have open and frequent communication with your partner about your comfort level and know it’s okay to stop any time.

  Stay tuned: more information is coming!