Tales From the Tail — The Dangers of Lateral Internal Sphincterotomies

Dr. Evan Goldstein
5 min readJun 2, 2021


Client’s Tale.

Ten years ago, with a rougher-than-usual partner and a thicker-than-usual cock, my asshole split. A literal tear occurred and holy shit did it fucking hurt. The scene was bloody and painful, and I would never wish it on my worst enemy. Even worse, it fucked up my relationship because I could no longer bottom. Crazy, right?

At that time, I saw a local surgeon and was placed on pretty standard creams, but they didn’t do much. I finally went in for surgery and had a lateral internal sphincterotomy. That’s where they cut the muscle inside your hole to try and relax the anal pressures, in hopes of healing the cuts. It definitely helped to stop shitting blood every day whenever I had a bowel movement. However, it didn’t even come close to allowing me to truly bottom. Toys and cock were just not in the cards. I experienced pain and irritation every time.

What else could be done? I was super frustrated and eventually found myself Googling the sphincterotomy I had years prior. Up popped Bespoke Surgical, which had a lot of information on alternative treatments for those who engage in anal play. I then booked an appointment to see Dr. Goldstein to examine my anal pressures — the ones that were supposed to be minimized by my prior surgery. To no real surprise, he discovered not only were they still elevated, but also my fissure and skin tag was still present. We discussed the implications of everything and how because of the elevated pressures needed for bottoming, everything fails and causes local problems. Great, I thought to myself. I guess at least I finally had an explanation for why I still couldn’t bottom.

Dr. Goldstein removed the old tear and any extra tissue that had formed and he also injected Botox throughout the internal sphincter. Healing went well and we are getting into the dilating phase with toys to help develop scar tissue. I’m hopeful that I’m finally on the right track, but I’m still cautious and anxious to get back on the horse again. My mental psyche has been totally fucked from all these years of issues. When you are a total bottom and then have your asshole taken away from you, it becomes a disaster. That’s why I’m so fortunate I found Dr. Goldstein.

My Discussion.

Another client, another fissure. It’s the most common ailment I see as a consequence of anal intercourse. And yet, when using PubMed to research all the topics associated with anal fissures, there’s not a single one that mentions and/or studies those who engage in anal sex. Every discussion on its treatments applies to — you guessed it — having a bowel movement.

I know I sound like a broken record, but this is bullshit. I also know that we need to get to work at Bespoke Surgical to correct this. It just goes to show you the data that physicians are using is incomplete. Let’s just look into lateral internal sphincterotomy. That’s when a surgeon cuts a portion of the muscle (usually the lateral side, left or right) with the intent of decreasing the anal pressures. The theory is that lowering these pressures will allow the fissure and scar tissue to heal. It definitely decreases the pressure initially, but in 6 to 12 months, the pressures creep back up. For most people who have a shitting issue, this window gives them time to heal. However, for those who engage in anal play, the elevated pressures of sex need to be absorbed, so it’s a vicious cycle where high pressures continue to create issues over time.

When surgeons cut the sphincter in one position, it doesn’t render the entire muscle useless. The remaining muscle fibers in the sphincter still contract. When Botox is given correctly and at the right dosage, it actually takes out that muscle uniformly. We give 4 shots — into all the regions of the muscle — and therefore it provides complete relaxation. Another thing to think about is the use of toys to help continue reducing pressure in the long run. We will also use Botox again, after the initial healing period, to continue decreasing this pressure, which will allow you the pleasures of anal play. Most surgeons who perform sphincterotomies do not cut enough muscle and, again, it’s only in one location. Clearly that’s not the right approach. On the other hand, some can go above and beyond and transect way too much, which can lead to other issues that we discuss in other blog posts.

We haven’t even gotten to talking about removal of the scar tissue that so many clinicians fail to take into account. You can read my other blog posts on anal fissures to learn more about the important implications of not doing this correctly. The key to this blog post was to make you aware of how important it is to lower your anal pressures to allow continued and more successful bottoming.

I’ll leave you with one more thing: anal sex has the potential to be traumatic. Many people are successful at fully relaxing their muscle mechanism, taking all those pressures, absorbing them, and having great sex. Other people just aren’t blessed in that regard. While they can definitely try on their own with toys and pelvic floor therapy directed toward this reducing these pressures. That, in and of itself can be enough for some people, which is why we are pushing for better sexual education as it relates to anal play. And then, lastly, there’s the group of people who just can’t do it on their own. The elevated pressures and the discomfort are just too much to handle. Some people’s asses split and tear and require a surgical approach for correction. The good news is that it’s possible to stop before this happens and we can augment with Botox to once again bring those pressures into a much more manageable level. Fortunately, Botox is only temporary and is meant to assist through the healing process, getting you to where you want (and need) to be. Some people need continual injections to augment the constant elevated pressures, but that’s few and far between. The continued use of dilation and the understanding of your pelvic floor anatomy and approaches — if successful bottoming is what you’re after — is what will give you long-term results

Anal sex ain’t hard and we deserve the scientific rationale for better bottoming. The old school methodology and literature just doesn’t apply to our community. It not only has to be taken into account, but also studied for future generations to be successful. We at Bespoke Surgical are committed to these long overdue changes. The pleasures of anal sex shouldn’t be a privilege for only a lucky few. They should be a right for everyone with an asshole.

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