The Ins and Outs of Gay Sex (9 page)

I apologized for hurting him, but he said, “It’ll be worth it if you can just help me.”

My heart sank.
I felt his fissure, and I also felt the cancer that caused it.

As a gay man with HIV, you may find yourself faced with a chronic, debilitating anal ulcer and a surgeon who refuses to operate on you.
Oftentimes the medical community cites poor healing in HIV-positive patients as a reason for not treating their ulcers.
Although this may be the case, if your immune status is relatively good, you should heal after surgery.
Whenever faced with a physician who says “Sorry, but you’ll have to live with it,” get another opinion.
You’ll probably find someone who’ll help you.
I caution you, however, not to be too optimistic.
Many times, even though your ulcer is removed and studied under a microscope, no cause for it is ever identified.
However, simple
removal may be enough to cure it.
Of course, if something treatable turns up (such as a tumor or virus), you will no doubt require further therapy.

An abscess in your anal region is potentially very dangerous, yet often gay men ignore it until it progresses to a critical stage.
An abscess begins as a painful sensation in your anal area, which gay men often wrongly attribute to a prior sexual experience.
Embarrassment keeps them from seeing a physician while their infection is still in its early stages.
Although the infection certainly could be caused by injury during sex, most often it results from a piece of stool getting caught in your anal crypts (glands).
(See
Figure 2.
1
.
) This earliest painful stage is called a
cryptitis.
As infection progresses, it can spread into sphincter muscles and fatty tissue around the anus and rectum.
The infection forms a cavity and pus accumulates.
At this point you have what is commonly called a perirectal abscess.

Once an abscess develops, it burrows toward the skin, slowly destroying more and more tissue.
Your skin reddens, is warm to the touch, and may feel like a water balloon if you gently push on it.
Of course, any pressure to the area is very painful.
If a doctor does not intervene, eventually your abscess will break through the skin and pus will pour out.
Although you’ll feel better immediately, your problem won’t be solved, because the hole is not large enough to drain the cavity fully.
Pus reaccumulates until it drains again, but the unabated infection destroys more and more surrounding tissue, including, occasionally, the sphincters.
I have treated patients whose infection left them unable to control their bowels.

Proper treatment for a perirectal abscess is surgical and is called an I&D (incision and drainage).
While antibiotics
often are necessary, by themselves they are not enough.
Local anesthesia for surgery won’t provide adequate relief.
Ask to either go to sleep (general anesthesia) or have regional anesthesia that numbs your lower body.
Most people feel much better after their surgery.

I treated a young man who noticed severe rectal pressure several days after anal sex.
He assumed that his problem was related to something that happened during sex and put off seeing a physician until he had a high fever and could barely walk.
In his case, the abscess had traveled upward along his colon rather than out toward his skin.
His abscess required multiple surgeries over more than two years until it was completely cured.

A fistula-in-ano can result from a prior abscess but is more often caused by a milder infection that never formed a full-blown cavity.
Instead, the infection burrowed to your skin and popped open like a pimple.
(See
Figure 2.
1
.
) Again, it is
rarely
related to a previous sexual experience.
Most men complain of a tiny painful pimple or boil beside their anal opening that swells until it drains a bit of pus.
Symptoms are rarely severe enough to see a doctor and may go away for days to months at a time until the cycle begins again.

A fistula-in-ano should be treated.
If it blocks up and cannot drain, an abscess will develop.
Some men have fistulas that form side tracks that spread around their anus making multiple holes (commonly called a watering-can anus).
I have seen men with holes so large that stool came out of them when they moved their bowels.
Not a pretty sight.

Surgery is the best treatment and involves opening the fistula (performing a fistulotomy) and removing debris so it can heal from the inside out.
Usually discomfort after surgery is minimal.
If the fistula is large and travels through sphincter muscles, incontinence is possible after surgery.
In
these cases, the surgery is much more complicated and done in stages.
Occasionally, if faced with a very difficult fistula, a surgeon might recommend that it be left alone.
Fortunately these extreme conditions are rare.

Advertisements for hemorrhoid remedies teach us that hemorrhoids itch.
In fact, however, hemorrhoids often are the
result
of the itch, not the cause.
Sure, huge internal hemorrhoids that hang out of your anus secreting mucus will itch.
But these cases are rare.
Most often chronic irritation causes the external tags you feel at your anal opening when you scratch.
If a surgeon performs a hemorrhoidectomy, the tags may be gone temporarily, but your itch will remain.
You continue to scratch and tags blossom once again.

Anal pruritis (itch) most often results from chronic skin irritation.
Although the itch may be from psoriasis or an infection (see
Chapters 3
and
4
), a contact or allergic dermatitis is the most frequent cause.
In other words, something your anal skin contacts irritates the hell out of it.
Contact can come in the form of creams or perfumes applied before sex, scented or harsh soaps used for bathing or laundry, or an irritating food product coming out in your stool.
When I mention this, most patients say, “It’s never given me any problem before, so why should it now?”
Most often something your body tolerated in the past has suddenly sensitized your skin and an allergy results.

With anal pruritis, the skin around the anus appears reddened and cracked.
Over time, the skin thickens and takes on a more callused appearance.
The itch worsens at night, and often cuts and scabs appear from scratching during sleep.

While steroid creams (prescription strength) will stop the
itch, long-term use weakens the skin.
Suppositories have little effect since they travel up too far and bypass the problem.
Instead, determine what caused your itch and eliminate it.
The following are a few steps that can go a long way in resolving your problem.
While some of them are quite difficult, if you can follow these procedures for just one month, you’ll be well on your way to solving the problem.

Eliminate any oils, creams, lotions, lubricants, and caustic soaps that come in contact with your anal region.
This means changing your bath and laundry detergents.
(If you use a laundry service, check to see what they wash your clothes in.
)


Don’t use toilet paper.
Toilet tissues contain bleaches and perfumes that can irritate skin.
Try using Tucks, which are perfume-free pads containing witch hazel and can be purchased in most drugstores and supermarkets.
In addition to removing fecal residue, they soothe the skin.
Do not use the baby-wipe-type pads, as many contain irritating perfumes and alcohol.


After you thoroughly cleanse the area, apply a thin layer of Balneol lotion.
It soothes and lubricates the skin.
If you sweat a lot, place a small piece of fluffed-up cotton against your anal opening to absorb moisture.


Wipe with Tucks and apply Balneol in the morning when you awaken, just before bed, and after every bowel movement.
And yes, you will have to take the wipes and lotion to work if that is where you have a bowel movement.


Now comes the hard part.
Eliminate all foods that can irritate your skin when they come out in your stool.
The following is a list of the most common offenders: