[Article to be found in the summer issue of the Têtu magazine] And if, among your back-to-school resolutions, you were thinking of finally booking an appointment with a proctologist? Off you go, on Doctolib, your anal health won’t wait!
Everyone has a butt hole, it’s proof that God loves us. “But everyone will, at least once in their life, have an anus problem”, warns Dr. Laurent Abramowitz, proctologist and gastroenterologist at Bichat-Claude-Bernard Hospital in Paris. He wants to remind us: having pain in the anus is neither rare nor shameful, and it does not concern only men who have sex with men (MSM). That said, these men may be more exposed to certain infections or diseases, sometimes simply embarrassing, sometimes more serious. “From the moment you have pain, bleeding, a lump or itching that persists, you should consult”, insists the practitioner. Besides, we don’t ask ourselves as many questions when we have a sore throat or a nose… So we take care of our butt, and we go see the proctologist!
Moreover, you should not wait to have symptoms, or to need screening, to consult one. “If you’re wondering ‘why does it hurt during sex?’, ‘what are the risks of this or that practice?’, ‘should I do enemas?’, make an appointment,” advises Dr. Aurélien Garros, proctologist and gastroenterologist in Lyon. “It’s important to open the discussion on these topics.”
The first time, it’s like for anything else—you may be nervous. To find a proctologist you can trust, start by word of mouth. “I asked my PrEP doctor and gay friends if they knew one, recounts Louis, 39, with two consultations under his belt. Like this, you’re sure he understands the specifics of a gay sexuality.” And if the chosen doctor isn’t satisfactory, don’t hesitate to change to find someone who will ensure regular follow-up.
Hemorrhoids and fistulas
The anus isn’t just a palace of delights, far from it… The proctologist will be able to spot in yours several fairly classic causes of discomfort or pain. First, there are the classic hemorrhoids. Everyone has them at some point. They are small pockets of blood inside or around the anus that can swell, become painful, and sometimes bleed. The anal fissure, on the other hand, is a small cut in the skin at the entrance of the anus: it’s benign, but very painful, especially when passing stool or during anal intercourse. Finally, the fistula (for a bit of history, Louis XIV had one in 1686) or the anal abscess are infections that cause pain, redness, and sometimes pus or discharge.
That, of course, is for everyone, but anal sexual practices expose MSM to certain infections or diseases of the anal canal more. Thus, gonorrhea (gonococcal infection), syphilis or chlamydia can cause false urges to defecate, or discharges from the anus with blood or mucus. Uncontrolled anal practices can also cause incontinence (fecal or gas leakage). “It’s sometimes taboo, and patients don’t dare to bring it up”, regrets Dr. Garros.
HPV: from condylomas to precancerous lesions
And then there are human papillomaviruses (HPV). There are many strains. Some are responsible for the very unsightly condylomas, or “cauliflower-like warts.” These small growths, white, pink or gray in color, are benign but unpleasant and contagious. They must be treated quickly, warns Dr. Aurélien Garros, “because they can proliferate, and the more numerous they are, the more painful the treatment is.”
More worrying, some HPV strains are the cause of anal cancer, which presents as small bleeds, mild pains, and sometimes a small lump. While this type of cancer is rare – “two patients out of 100,000 per year”, notes Dr. Abramowitz – gay men with multiple partners are more exposed than other populations less sexually active. It is also the third most common cancer among men living with HIV, even when effectively treated. This is why it is recommended for these individuals, from age 30, to undergo HPV 16 screening every five years in the absence of symptoms – unfortunately not covered by the national health insurance. If the test is positive, additional examinations and follow-up are proposed to catch any cancer as early as possible. Dr. Aurélien Garros believes this recommendation could be extended to all people on immunosuppressive therapy.
Very early, anal cancer causes precancerous lesions called dysplasias. “Only 0.8% of precancerous lesions progress to cancer and they can also regress on their own”, reassures Dr. Abramowitz. Doctors nevertheless recommend regular screening, every year or every two years, even for HIV-negative gay men. This clinical examination, simple and quick, by the proctologist, will allow treating lesions rapidly so they do not evolve into cancer.
“In the twenty minutes that a consultation lasts, I spend more than three-quarters of it asking questions about symptoms, about the environment, about bowel habits, etc.”, explains Dr. Laurent Abramowitz. After several appointments with a proctologist, Thibault, 45, has this advice: “You really have to speak frankly to the doctor, don’t beat around the bush, say exactly what you do, what brings you in, don’t be ashamed.”
A simple exam…
Then comes the examination, which can be intimidating. “Patients sometimes fear confronting the doctor with the presence of stool. But on the one hand, it’s rarely dirty, and on the other hand, a small trace will never bother any proctologist, reassures Dr. Aurélien Garros. There is thus no need to do an enema before the consultation! To perform the examination, the patient is usually asked to lie on the table in the genu-pectoral position, i.e., on all fours with the knees and elbows—you’re used to it. “I find that we see some things better, which is why I propose this position,” notes Dr. Garros. “But I always explain why, while noting that it is also possible to lie on your side.”
Of course, the first time, it can be surprising – imagine the look on heterosexuals… “Me, this position doesn’t bother me, especially since it doesn’t require taking off your pants but just lowering them a little, and thus not exposing the genital parts,” reports Franck, 44, who is regularly followed because of his seropositivity and recurring condylomas. “And then my doctor talks about other things during the exam, which helps demystify it.” All specialists indeed have their technique for easing the atmosphere and making the patient comfortable. “One day I came across a doctor who used humor during the exam, which significantly dissipated my awkwardness”, recalls Sylvain, 45, with five consultations to his name.
… and quick
Next – a good doctor should explain to you step by step what he will do, ensuring your consent – the proctologist parts the buttocks by a few millimeters. Sometimes this is enough to establish a diagnosis. Otherwise, he inserts a finger and finally a small tube called an anoscope, lubricated and sized to each person’s morphology and potential pathology. “It’s smaller than an erect penis”, states Dr. Abramowitz.
This gesture, normally gentle and painless, allows inspecting the inside of the anus and to identify notably internal condylomas, a small fissure, secretions in the rectum, internal hemorrhoidal pathology, an anal fissure, or an opening of a fistula. After the proctologist carefully removes the instrument, the examination is over! “It’s done in five minutes, and without any pain. You come out reassured or knowing what you have and how to treat it, that’s the essential thing”, concludes Fabrice, 30, who recently experienced his first time at the proctologist. So, fellas, let’s be honest with ourselves: the proctor is like the gynecologist for women; you find one you’ll see regularly, without making a fuss.
