Anal health and sphincter care

Common conditions

Haemorrhoids. Swollen vascular cushions in the anal canal, present in everyone and symptomatic in many. Caused mainly by straining, constipation, prolonged sitting on the toilet, pregnancy and heavy lifting — not by anal sex. Symptoms: painless bright red bleeding, itching, a lump, or a feeling of incomplete emptying. Treatment: fibre, fluid, not straining, a footstool to raise the knees, short courses of topical treatment, and for persistent cases banding or surgery.

Anal fissures. A tear in the anal canal lining, causing sharp pain during and after bowel movements — often described as passing glass — with bright red blood on the paper. Most are caused by hard stool. They can be caused by insufficiently lubricated or rushed penetration. Treatment: stool softening, warm baths, and topical glyceryl trinitrate or diltiazem to relax the internal sphincter and allow healing. Chronic fissures may need botulinum toxin or surgery. Fissures heal slowly because the sphincter keeps re-tearing them, which is why sphincter relaxation is the active ingredient in treatment.

Skin tags. Harmless remnants of previous swelling. No treatment needed unless they interfere with hygiene.

Pruritus ani. Persistent anal itch, most commonly caused by over-cleaning, fragranced products, moisture, or diet. Treatment is usually to stop doing something: no soap, no wipes, no scrubbing, no fragranced products. Pat dry. If it persists, it needs assessment — lichen sclerosus, fungal infection, threadworm and, rarely, anal cancer present this way.

Anal abscess and fistula. Painful swelling with fever needs urgent surgical assessment; abscesses do not resolve with antibiotics alone.

Sex-related care

• Lubricant is the single most protective measure — friction injury is the main mechanism of harm.
• Progressive dilation over minutes, never force.
• Flared base on everything inserted.
• Space sessions to allow healing. Repeated penetration of unhealed micro-tears is how fissures become chronic.
• No numbing products; pain is the protective signal.
• Nitrile gloves for manual play; nail injuries are common and invisible.

Anal sex does not cause faecal incontinence in the absence of injury. Studies examining the question find associations that are small and confounded, and the strongest predictors of incontinence remain obstetric injury, age and neurological disease. Any new incontinence warrants a pelvic floor assessment rather than resignation.

Screening and cancer

Anal cancer is caused mainly by persistent high-risk HPV. Risk is elevated in people living with HIV, people with a history of anogenital HPV disease, immunosuppressed people, and men who have sex with men.

• HPV vaccination protects against the responsible types.
• Anal cytology and high-resolution anoscopy screening is offered to higher-risk groups in some settings. The ANCHOR trial (Palefsky et al., 2022, NEJM) demonstrated that treating anal high-grade squamous intraepithelial lesions reduced progression to anal cancer by 57 percent, which has strengthened the case for screening programmes.
• Any persistent lump, ulcer, bleeding, itch or change in bowel habit needs assessment. Anal cancer is frequently misdiagnosed as haemorrhoids for months.

Red flags

Seek medical assessment for: bleeding that is dark or mixed through the stool rather than bright on the paper; a change in bowel habit lasting more than three weeks; unexplained weight loss; a persistent lump or ulcer; ongoing pain; fever with anal swelling; or any new incontinence. Do not attribute these to sexual activity — bowel cancer presents this way and is highly treatable when found early.

Sphincter and pelvic floor

The anal sphincters are part of the pelvic floor. Both weakness and hypertonicity cause problems: weakness causes urgency and leakage, hypertonicity causes pain, incomplete emptying and difficulty with penetration. A pelvic health physiotherapist assesses which, and the treatments are opposite. Self-directed clenching exercises for a hypertonic sphincter make it worse.

Habits that protect the anus

• Do not strain. Use a footstool so the knees sit above the hips.
• Do not sit on the toilet reading; prolonged sitting engorges the vascular cushions.
• Enough fibre and fluid to keep stool soft.
• Wash with water, pat dry, and avoid soap, wipes and fragrance in the area.
• Treat constipation promptly rather than waiting.

Sources

• Stewart DB et al. "Clinical practice guideline for the management of anal fissures." Diseases of the Colon and Rectum, 2017.
• Davis BR et al. "Clinical practice guidelines for the management of hemorrhoids." Diseases of the Colon and Rectum, 2018.
• Palefsky JM et al. "Treatment of anal high-grade squamous intraepithelial lesions to prevent anal cancer (ANCHOR)." NEJM, 2022.
• BASHH. UK national guideline on the management of anogenital conditions, current edition.
• NICE. Suspected cancer: recognition and referral, NG12.
• Markland AD et al. Studies on anal intercourse and faecal incontinence prevalence and confounding.

Last reviewed: August 2026.