20 Kind of Invasive Questions With Anal Surgeon Evan Goldstein
Dr. Evan Goldstein had no idea he wanted to become an anal surgeon. In medical school, he was actually training to be a cardiothoracic surgeon. But after coming out as gay, he wanted to give back to the queer community.
“I realized my surgical skills could help the LGBTQ+ community,” he says.
He went on to found Bespoke Surgical, an anal surgery practice that’s well known among the queer male community in New York City.
“Most anal surgeons treat hemorrhoids … or anal cancers with a very narrow lens: eradicate the pathology at hand,” Goldstein says. “But for many, the anus is used for more than just defecation. It serves a cosmetic and sexual functional purpose, too. Bespoke Surgical provides medical services to treat all the common anal ailments, such as hemorrhoids, skin tags, and fissures, in addition to cosmetic procedures like Botox and tightening services. We also have an in-house physical therapist to address sexual problems that can be treated with anal dilation (stretching our your anus with toys) and pelvic floor therapy.”
Over the years, Goldstein has worked with countless patients to give them the assholes they so desperately crave. We asked the surgeon 20 questions so you can learn more about the world of anal health and gain a better understanding of what anal reconstructive surgery actually entails.
1) What is anal reconstructive surgery?
Anal reconstructive surgery is a type of plastic surgery that focuses on restoring the form, function, and cosmetic appearance of the anus. It is designed to help you regain muscle definition and tone (a.k.a. help tighten the sphincter muscles if they’ve become too loose) and create an aesthetically pleasing exterior in the hopes of enhancement, both physical and mental.
2) Why do people get it? Is it for cosmetic or medical reasons?
People get it done for cosmetic or medical reasons, but most often, it’s a combination of both. We recommend it to people who experience dissatisfaction with how their asshole looks, loss of pleasurable sensations during sex, loss of control during defecation, overuse of the anal muscles (like in the case of frequent extreme anal play over extended periods), as well as injuries like anal tearing (fissures), hemorrhoids, and skin tags.
3) If they get it for cosmetic reasons, what are they hoping to achieve? What does an “ideal anus” look, feel like, and do for them?
As you can imagine, the concept of an “ideal anus” is entirely subjective. Some people have a tiny skin tag or mole that makes them feel extremely self-conscious and want them removed, while others aren’t bothered by bulging hemorrhoids and dangling skin tags. My job is not to tell someone what is and isn’t beautiful or perfect; I’m there to talk with my clients about what their goals are and what will give them more confidence and pleasure in and out of the bedroom.
Things like skin tags can often affect someone both cosmetically and physically, causing irritation during sex. In extreme cases, they can cause tearing and bleeding. Now, some— usually those who have lost muscle strength—want that tight pucker that porn makes us believe is the “ideal anus.” Regardless of the reason, I will talk through what is realistic and how we can go about achieving their desires.
4) But is there an ideal, physical anus size when it comes to functionality?
There is an optimal pressure in the sphincters that allows people the luxury of defecating and engaging without pain or injury. However, if that optimal pressure sways one way or another for prolonged periods, negative consequences may develop that need reconstructive procedures to restore them to the ideal state.
5) Who do you typically see getting anal reconstructive surgery? Porn stars? People with big sexual appetites? Someone else?
I see assholes from around the world. There is a range, from a seasoned pro who has a more elastic hole to someone who is too tight.
6) How does a patient prep for anal reconstructive surgery?
It’s actually quite simple. I usually tell people to go number two the morning of their surgery. If it makes my patients feel more comfortable, they can clean themselves out with an enema, but it’s unnecessary. The ass is, for the most part, clean and devoid of any stool and since we are just working on the distal end, I am usually in the clear (no pun intended).
7) What does anal reconstructive surgery entail on your end?
Do you mean what I do to to surgical increase tightness? It gets a little complicated here, but in short, what I do is remove what’s called an anal column, which is a cluster of hemorrhoids. Hemorrhoids are just when the veins in the anus become dilated and enlarged, but when when these hemorrhoids swell, I can, during surgery, remove the column of hemorrhoids. After the column of hemorrhoids gets removed, the booty hole gets pulled in, decreasing circumference and increasing tightness.
8) How long does it take to complete?
Most surgeries take about 45 minutes depending on the extent of the work. People arrive about an hour and a half before to fill out the usual paperwork and receive introductions. We then place them under sedation with local anesthesia for the duration of the procedure. Afterward, they stay in the recovery room for about an hour before being discharged home.
9) What’s the recovery time after? How long do you need to wait until you put something inside your anus?
Full recovery averages from six to eight weeks, though it’s broken out into phases. I typically tell people they will hate me the first few days, actually up to two weeks, immediately following the procedure. I prescribe painkillers for the first few days and then recommend that clients switch to Advil, Calmol-4 suppositories, Epsom salt baths, and exfoliating soaps, which help speed along the healing process while minimizing discomfort. Clients should avoid stressful activities for about a week but can resume exercise (except butt workouts) and sex (as the insertive partner only) after that. We provide a full dilation protocol to help minimize scarring and get people back into receptive anal sex starting at six weeks.
10) Is any additional aftercare needed?
Yes, the process takes three months to heal fully. I see each patient once a month for those three months to make sure the healing process is progressing as it should. It’s the ass. We shit and move and groove, so we need to constantly check the surgical sites. Sometimes tweaks need to be done in the office while everything is settling.
We start recommending the use of toys for both dilation and contraction at the two-month mark. This helps strengthen the scar line and allows for more accommodations (like anal sex). This process takes roughly four weeks. We also have clients see our in-house physical therapist to continue the upward trajectory during this healing process. It’s indeed a process. I tell everyone to keep their eye on the prize throughout because it’s worth it in the end, pun intended.
11) How do people feel about their new anus post-surgery?
It depends on what they started with and what the desired outcomes are. We tailor the procedure to what they want. However, if someone addressed elasticity or looseness, the tightness is noticeable and appreciated. Once the healing process is complete, I often receive emails from clients and their partners overjoyed with how much better sex feels and their anuses look, which is always a great reminder of why I love doing what I do.
12) Obviously, the anus stretches to accommodate bigger…things. But how much dick would you have to take for your butthole to end up permanently loose?
Believe it or not, quantity isn’t always the culprit. I have seen people who take small dicks or toys at weird angles and end up causing severe permanent damage to the sphincter. On the other hand, people can handle big things and be fine, so it depends on how you’re having anal sex and whether you’re contracting and working your pelvis correctly, both when having sex and outside the bedroom.
One important test that we offer at our office is an anal manometry exam. This test measures a person’s anal pressures, and we can follow it through time to see if someone is becoming looser or maintaining the same ability to contract. Suppose we notice decreased contractility, which is the medical way of saying that they’re getting looser. In that case, we can do physical therapy or have someone do sessions on the EMSELLA (a chair with magnetic rays that simulates Kegels) that can improve about 20% in contractility. And it’s all noninvasive.
13) What are some common cosmetic surgeries people get for their assholes?
Common cosmetic surgeries include skin tag removal from tears (anal fissures) or dilated veins (hemorrhoids) that cause excess tissue and/or swelling in the anal region. That said, some people love having a prolapsing anus (aka rose buds). When that’s the case, I must be super precise in approaching their treatment, as we want to give them exactly what they want.
14) For what reason should someone see an anal surgeon?
Most clients come to see me because of an anal issue that limits their life, whether inside or out of the bedroom. The most common problems are fissures, hemorrhoids, and skin tags, which can make bowel movements difficult and receptive anal sex painful. Of course, any anal surgeon can handle physical issues, but what’s rarer is finding one with an acute understanding of maintaining ideal aesthetic and long-term functional needs around sexual engagement.
15) You spoke a little bit about anal Botox. Is that for someone who’s “too tight?”
Yes, if someone is too tight, we have the option of administering Botox to help relax muscles in the area. We then follow up with our standard dilation protocol, were you insert a small toy and slowly work your way up to larger toys to stretch and strengthen the skin and muscle. This has proven to be quite successful in getting people to where they want to be. We may also pair this with an anal manometry exam to monitor the muscle strength and see if the Botox and dilation exercises are working. If not, we adjust accordingly.
16) What about people who are struggling from looseness?
Unfortunately, a loose anal sphincter is a real possibility, especially if people push their sphincter’s limits. Most people who experience a loss of function tend to like bigger toys, penises, or engage in fisting. Over time, all of these factors can cause the anus to loosen itself beyond repair and result in issues that require anal tightening. The muscles in our anuses are just like any other muscle in our body, and there’s a real possibility that they can lose their ability to recoil. The key is to maximize medical management before we even think of surgical treatment. If a client has any function remaining in the muscles, we first try to work through physical therapy and stimulation to try and improve both muscular and neurological control. This can be accomplished by doing Kegels [exercises where you contract and release your pelvic floor muscles] while using butt plugs.
Butt plugs are a great way to stretch and strengthen the skin to have comfortable anal sex, but you can also use them to keep your sphincter muscles at a comfortable laxity (the medical term for looseness). You’ll want to do these exercises every other day, where you insert a butt plug (preferably the smallest one in a set of three) and then contract, holding it for five seconds at a time. Doing this 15 to 20 times during the session and adding pelvic floor work, like kettlebells and squats, can help get one to a better place.
17) Can you explain how, exactly, Kegel exercises improve your tightness?
The pelvic floor muscles are like a hammock between the pubic bone and coccyx bone and form a bowl shape of muscles that control urination, defecation, internal organ support, core support, and help with sexual function. Kegel exercises are designed to increase awareness, strength, endurance, and fine control of the pelvic floor muscles so they can be functionally integrated into daily life to help support your core and protect against sexual dysfunction and incontinence. Therefore, Kegels are crucial for maintaining and improving a healthy, fully functioning pelvic floor, as both bottoming and aging can reduce pelvic floor control. Stronger erections and orgasms can also come from doing Kegels. Typically, it takes four to six weeks to see a real increase in strength, endurance, and control when working with muscles.
18) What’s the best way to prevent anal fissures?
If you enjoy receptive anal sex, it’s important to first understand your anatomy. Anal dilation exercises are the best way to do this because it allows you to explore what feels good (and what doesn’t) and helps strengthen both the skin and the muscle so that they can open to the appropriate diameters. Even though muscle and skin are stacked on top of one another, they function independently.
Take this example: You may be fully able to open the skin to the size of a fist. However, the underlying muscle may not accommodate or vice versa. Anal sex takes patience, copious amounts of lube, and practice to maximize pleasure and minimize the risk of injury.
I am a huge fan of lube shooters, also known as lube applicators, which help distribute lube throughout the anal canal and into the rectum to ensure adequate lubrication in all the spots that matter. This will help decrease the chance of tearing.
19) What’s the best way to treat anal fissures?
Most acute fissures can heal with at-home remedies, including over-the-counter stool softeners, fiber supplements, suppositories, Epsom salt baths, avoiding wet wipes and wiping aggressively, and drinking plenty of water. These remedies will help make bowel movements easier, putting less strain on your sphincters. Of course, refraining from anal play will also help.
Sometimes, if caught and addressed early enough, in-office Botox is beneficial to prevent the fissure from becoming a chronic issue. If after three to five days, you are not noticing much of an improvement, then a fissurectomy might be necessary, which involves excising or cauterizing the chronic scar tissue and skin tag.
20) How do anal fissures differ from hemorrhoids?
Sometimes it’s difficult to tell the difference between a hemorrhoid and a fissure, even for some doctors. Pain with defecation, plus or minus bleeding, may be present. Also, some extra skin in the region is another common occurrence. With fissures, many people describe the sensation as paper cuts while going to the bathroom, and you may also feel a significant anal muscle spasm along with this sensation. This can last for a considerable amount of time after each bowel movement and even debilitate you enough that you must lie down. On the other hand, with external hemorrhoids, there’s immense pressure, and you can feel a clot from the size of a pea all the way up to a walnut protruding externally from your asshole.
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