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Anal pain is common. Talking about it isn't — especially for people dealing with anal fissures or pain during receptive anal sex. Tightness, tearing, bleeding, or just dreading penetration can wear you down fast, and it tends to happen in silence. Most patients have already been told to relax more, use more lube, or "just take it slow." Often it isn't the solution, because the internal anal sphincter is simply too tight — hypertonic, in medical terms — and no amount of mental relaxation changes that on its own.
Botulinum toxin (commonly known as Botox or other brand names like Dysport and Jeuveau) has been used for years in colorectal medicine to relax an overactive internal sphincter and treat chronic anal fissures. More recently, the same mechanism has picked up a second use that gets a lot less clinical attention: making receptive anal sex more comfortable, safer, and more pleasurable. Online it's sometimes called "anal Botox" or "holetox." The nickname is new; the underlying medicine isn't.
You have two anal sphincter muscles doing very different jobs. The external sphincter is voluntary — it's the one you consciously clench and release. The internal sphincter isn't. It's smooth muscle, running on autopilot, and you can't simply will it to relax.
That distinction is why so many people get stuck. You can be mentally relaxed, well-lubricated, and communicating well with a partner, and still hit real, physical resistance if the internal sphincter is hypertonic. It also explains a frustrating pattern a lot of patients describe: tightness causes pain, pain triggers guarding, guarding increases spasm, and spasm makes the next fissure or tear more likely. The American Society of Colon and Rectal Surgeons (ASCRS) describes this exact mechanism in chronic fissures — internal sphincter hypertonicity leading to local ischemia that keeps the tissue from healing.
A fissure is a small tear in the lining of the anal canal, and it hurts — sharp pain, burning, bleeding, spasm that lingers well after a bowel movement. If you're on the receiving end of anal sex, an active fissure usually takes sex off the table until it heals.
First-line treatment is usually dietary fiber, hydration, sitz baths, topical nitroglycerin, diltiazem, or nifedipine. When a fissure won't quit despite that, the sphincter spasm itself often needs direct treatment. Botulinum toxin relaxes the internal sphincter, which improves blood flow, reduces spasm, and allows the tissue heal — with a lot less commitment than a lateral internal sphincterotomy, the surgical option that permanently cuts part of the muscle. A 2025 systematic review and meta-analysis of randomized trials confirmed botulinum toxin's place in the current fissure treatment lineup alongside topical nitrites, calcium-channel blockers, and sphincterotomy, and ASCRS guidelines list it as a legitimate option — noting that some patients need more than one round of treatment.
For the right patient, that's the appeal: real relaxation of an overly tight sphincter, without permanently cutting muscle.
The same mechanism that helps a fissure heal is what helps with pain during anal sex — and this isn't a lesser concern than the medical one. Bottoming is part of sexual identity, intimacy, and pleasure for a lot of people, and when it's consistently painful, it chips away at confidence and relationships, not just comfort. Most patients don't bring this up with their doctor, and honestly, most doctors aren't trained to ask about it directly or usefully.
Anal Botox works here the same way it works for fissures: it relaxes the internal sphincter and reduces the involuntary resistance that makes penetration painful. The point isn't numbness — it's less spasm, less tearing, and an experience that doesn't require pushing through pain to get there.
This use has gotten more visible in cities with large LGBTQ+ communities — New York, LA, Miami. GQ covered it in 2025, describing rising interest in anal Botox among men seeking more comfortable receptive sex, and tracing its roots back to fissure treatment before it got adapted for sexual comfort. That kind of mainstream coverage makes it a little easier to bring up something people have been quietly living with for years.
Good candidates are people with signs of internal sphincter tightness or spasm: pain with attempted penetration, an inability to relax even with arousal and enough lubrication, recurrent fissures, tearing during sex, burning after bowel movements, or that sense of involuntary clamping down. It's also a solid option for anyone with a diagnosed hypertonic sphincter or chronic fissure who'd rather avoid surgery.
This isn't for everyone. Active infection, unexplained rectal bleeding, severe diarrhea, uncontrolled IBD, significant fecal incontinence, a complex history of anorectal surgery, concern for anorectal cancer, serious hemorrhoid complications, or unexplained anal pain all need a careful workup before anyone considers treatment.
If you have Crohn's disease or ulcerative colitis, extra caution applies. Anal sex may be fine during remission for some patients, but it should generally be off the table during an active flare, with bleeding, ulceration, or significant inflammation.
Bleeding, a persistent lump, severe pain, drainage, fever, unexplained weight loss, or a sore that won't heal all need to be seen by an experienced physician before considering treatment.
The procedure itself is small injections of botulinum toxin into the internal anal sphincter, typically at the 3 and 9 o'clock positions. The target is a sweet spot — enough reduction in sphincter tone to ease pain and fissures, while keeping enough tone that continence isn't affected. Effects build over a few weeks and generally last a few months.
For fissures, that usually means less spasm, less pain with bowel movements, and better healing. For sexual comfort, it usually means less involuntary tightness, easier dilation, less pain with penetration, and less fear of tearing going in.
The procedure itself is quick, but it needs to be done by someone who actually understands anorectal anatomy, sphincter physiology, sexual health, and dosing — not picked up casually from an unqualified injector.
The main risk worth knowing about is temporary weakening of continence — some patients can notice more gas leakage, urgency, or minor seepage than usual. It's temporary, which is exactly why conservative dosing and careful patient selection matter so much. Other possible effects include injection discomfort, bruising, bleeding, infection, an underwhelming response, or tightness returning as the toxin wears off. People already dealing with fecal incontinence generally aren't good candidates.
Compared to surgery, the appeal of botulinum toxin is that it's non-invasive and reversible by nature — if it's too strong, it wears off; if it works, it can be repeated to maintain the benefit.
For fissures, results are better when bowel habits are dialed in — hard stools, constipation, diarrhea, straining, and aggressive wiping all keep a fissure going, so fiber, hydration, stool management, and topicals still matter alongside the injections.
For sexual comfort, pairing treatment with gradual dilation, real lubrication, honest communication, and skipping sex during active pain or tearing makes a substantial difference. And for some patients, pelvic floor physical therapy is worth adding, particularly when external sphincter tension or anxiety-driven guarding is part of the picture.
Talk to Someone Who Won't Make It Awkward
At Longevity Health Clinic, we treat sexual health as health. If you're dealing with painful bottoming, recurrent fissures, tightness, tearing, or a hypertonic anal sphincter, you deserve a physician who'll talk about it directly, without judgment, and help you figure out whether botulinum toxin treatment makes sense for you.
