It is common, it is not much studied, and most people who have it never raise it. What follows is what is known about the causes, what can be done, and where the limits are.
What causes it
The factors that are not structural
The research consistently identifies non-structural contributors, and in several studies they predict pain more strongly than anything anatomical.
- Anxiety and difficulty relaxing, which are the most consistently reported across studies. The pelvic floor responds to anticipated pain by tightening, which produces more pain.
- Insufficient lubrication. The rectum produces none of its own.
- Inadequate arousal and preparation before penetration.
- Depth and rate of penetration, and lack of communication about both.
- Comfort with one's own sexuality. Studies in men who have sex with men have found this associated with pain, which is worth knowing rather than a judgment about anyone.
None of this means the pain is imagined. A muscle held in involuntary spasm produces real pain by an entirely physical mechanism, whatever set it off.
How common, and how little is known
Reported prevalence varies with how the question is asked. A 2024 review in Archives of Sexual Behavior put pain during receptive anal intercourse at around 15 percent of men. A 2022 systematic review found 14 percent in a United States sample and 18 percent in a Belgian one, with one Argentine study reporting that 89 percent had experienced some degree of pain. The 1998 paper that first named the condition found 12 percent describing it as too painful to continue.
That same 2022 systematic review found seven studies in total on this condition, published across twenty-four years. None of them evaluated a treatment. There are no randomized trials, no standardized assessment tool, and no research at all in intersex, transgender or gender non-conforming people. The authors noted that psychosexual services have developed treatment for pain with vaginal penetration while this condition has had far less attention.
What exists instead is a well understood set of causes, several of which are identifiable on examination and treatable.
What helps
The first step is finding out which of the causes above is in play, because several of them have specific treatments and none of those treatments is the same. A fissure, hemorrhoids, proctitis and inflammatory bowel disease all present as pain here and all need different things. Examination comes before anything else.
Where the problem is muscular, the approaches with the most support behind them are not injections. Pelvic floor rehabilitation, biofeedback, graded dilation and changes to lubrication, preparation and positioning are what the literature describes, and for a meaningful number of people that is sufficient.
Where botulinum toxin fits
Injection into the internal anal sphincter lowers resting pressure. That effect is well established, and it is the basis of an accepted treatment for chronic anal fissure, where the same spasm prevents healing.
Applying it to pain with receptive sex is reasoning from that mechanism rather than from a trial in this population. The muscle that will not relax is relaxed for three to four months, which for some people is enough time to break the cycle where pain drives tightening and tightening drives pain. That is the rationale.
There is one thing to settle first. Fecal incontinence is more common in men who have frequent receptive anal intercourse, with reported prevalence between 8 and 30 percent depending on frequency and population. Botulinum toxin deliberately lowers sphincter tone. If your continence is already marginal, that matters, and it is a question worth answering before an injection rather than after. Dosing here is conservative for the same reason.
What an assessment is like
- History first
- Direct questions about pain, bowel habits, bleeding and continence.
- Examination
- External and digital, with lubricant and topical anesthetic.
- If it hurts too much
- The examination stops. It is not pushed through.
- Testing
- Where infection or inflammatory disease is a possibility.
- Visit length
- 45 minutes. This is not a five minute appointment.
- Treatment
- Not the same day. A plan comes out of the assessment.
- Performed by
- Dr. Mundluru.
- Privacy
- Scheduled so you are not waiting in a shared area.
You will be asked plainly what you do, how often, and what specifically hurts and when. Those answers change the differential. Nothing you say is unusual to hear.
Before, during and after
Open any of these to read before booking, or again after your visit.
Common questions
Is it normal for it to hurt?
Common is not the same as normal, and the two get confused here. Something like one in seven men who have receptive anal sex report pain, so you are far from unusual. That does not mean pain is the expected state or that you should work around it indefinitely. Persistent pain has causes, several of which are identifiable on examination, and some of those causes are conditions that need treating for reasons beyond sex.
What is anodyspareunia?
The clinical term for painful receptive anal intercourse. It was named in 1998, in a study that proposed diagnostic criteria similar to those used for other sexual pain conditions. Having a name matters, because a condition without one tends not to get assessed, studied or treated.
Do I need an examination?
Yes, because the causes are not distinguishable by history alone. A fissure, hemorrhoids, proctitis from a sexually transmitted infection, and inflammatory bowel disease can all present this way and are treated very differently. The examination is external and digital, done with lubricant and topical anesthetic, and it stops if it is too painful. It is not pushed through.
Will I need an injection?
Often not. Where a fissure, hemorrhoids or an infection is found, treating that is the answer. Where the problem is muscular, the approaches with the most support are pelvic floor rehabilitation, graded dilation, and changes to lubrication, preparation and positioning. Botulinum toxin is one option among several, not the default, and it is discussed when the assessment supports it.
Does botulinum toxin work for this?
It reliably lowers resting pressure in the internal anal sphincter, which is well established and is the basis of an accepted treatment for chronic anal fissure. Whether that translates into less pain with receptive sex has not been tested in a trial. The reasoning is mechanistic: relax the muscle that will not relax and give the cycle of pain and tightening a few months to break. That is a rationale rather than proof, and it is discussed as such at consultation.
Could it affect my continence?
Temporary difficulty controlling gas is the most commonly reported effect after sphincter injection, and it resolves as the botulinum toxin wears off. Temporary leakage of stool is less common. Separately, fecal incontinence is more common in men who have frequent receptive anal intercourse, between 8 and 30 percent depending on frequency and population, so your baseline is worth establishing before adding anything that lowers sphincter tone. That question gets asked here before treatment, not after.
Is this psychological?
Anxiety and difficulty relaxing are among the most consistently reported contributors in the research, and that does not make the pain imaginary. A pelvic floor that tightens in anticipation of pain produces real pain through an entirely physical mechanism. It also means the loop runs both ways, and that treatments aimed at the muscle and at the anticipation can both be worth doing.
Is bleeding a concern?
Small amounts of bright red blood are common with a fissure or hemorrhoids and are worth having looked at rather than ignored. Bleeding that is heavy, dark, persistent, or accompanied by weight loss, fever or a change in bowel habit needs assessment promptly and should not wait, because those features point away from the simple explanations.
This page is for general education and is not medical advice. It does not establish a physician-patient relationship, and it cannot account for your individual history, medications or skin. Suitability for treatment is decided at consultation following examination.