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February 2016

The Sex Series – Part Seven: Mast cell activation and anal penetration

So far in this series, we have talked a lot about vaginally penetrating sex.  But that’s not the only way to have sex so for now, let’s move on.

Anally penetrating sex can be safe, painless and pleasurable for many people.  It is enjoyed by many partners of various sexual orientations.  The anus is an inherently different environment than the vagina and as such, preparation for and participation in anally penetrating sex is a bit different.

An obvious difference is that the anus does not self-lubricate in preparation for sex.  Use of external lubricant is HUGELY important.  Silicone based lubes are often used for anally penetrating sex because it is slicker and is not broken down as quickly by your body as water based lubricants. When selecting a lubricant, be sure to research whether components can irritate the anus and rectum.  In particular, many spermicides are very irritating to rectal tissue. Of course, in the same way that a person can react to lubricant in the vagina, you can react to lubricant in the rectum and anus.  Contact dermatitis or other types of allergic reaction can occur.

Though “vigorous anal penetration” is often considered a risk factor for anal or rectal injury, the actual incidence of these injuries is low and mostly occurs in sexual assault situations.  Injury to the sphincter musculature is unusual.  Large patient groups of gay men who engage in anal sex have been surveyed regarding issues or injuries associated with receiving anal penetration over a long period of time.  Some patients reported infrequent or “slight” incontinence, attributed by medical professionals to the inability of the anal sphincter to close as tightly in the immediate time after penetration.  However, in other studies, no patients have reported this issue.  The most frequent problem, as also seen in vaginal intercourse, is the transmission of sexually transmitted infections.  This can be mitigated by using condoms.

Anal penetration should not hurt.  The person receiving and giving should take steps to relax the anal sphincter, use adequate lubrication, and be sensitive to any pain.  Painful penetration can indicate a problem and should be taken seriously by both partners. Regardless of how an injury was acquired, anal sex can irritate any condition that affects the rectum or anus.

Hemorrhoids are blood vessels that become distended.  They can occur internally or externally, and are often painless.  The first indication of hemorrhoid is often bright red blood on toilet paper.  If a blood clot forms in the hemorrhoid, it can become very painful and swollen.  It is not entirely understood how hemorrhoids form, but straining to stool, increased pressure in the abdominal cavity, obesity and pelvic floor dysfunction are often linked to formation.

Mast cells are increased in hemorrhoid associated tissue and may affect hemorrhoid formation and resolution through release of mediators like tryptase, chymase and platelet activating factor. One study found that the number of mast cells in acute and chronic hemorrhoids is not different, indicating that mast cells can be associated throughout the lifecycle.

Fissures are tears in the anal or rectal tissue.  Fissures can be very painful, especially during and after defecation.  Fissures also cause bright red blood on the toilet paper or stool.  Patients who have fissures often have increased resting pressure when tested with anorectal manometry, meaning their muscles are more tense than usual.  Fissures can also be mast cell activating, as mast cells are active in wound healing.  Tears in the rectum and anus do not heal as quickly as those in the vagina.

Rectal itching is not unusual in allergy/mast cell patients.  Mast cells are natively present in the rectum and can degranulate in response to stimuli just like mast cells anywhere else.  Mediators released can also cause pain.  Care should be taken to reduce friction as much as possible to try to prevent degranulation from pressure.  Itching and pain can also be signs of reacting to condoms or lubricants used.

Pelvic floor dysfunction can also make anal sex painful, as the rectum and anus may not be properly supported by connective tissue.  Patients with pelvic floor dysfunction or connective tissue defects should be cautious to observe any pain or discomfort when receiving anal penetration. Pelvic floor dysfunction, and the other conditions mentioned above, can be irritated by anal penetration.

As described earlier in the series, it is possible to have an allergic reaction to semen, either due to the presence of allergens or to the composition of the semen itself. If semen enters the body during anally penetrating sex, it is possible to have an allergic reaction.  Condoms can prevent these reactions, and are also recommended to decrease risk of infection due to contact with GI flora.



Chond PS, Bartolo DCC. Hemorrhoids and fissure in ano. Gastroenterol Clin N Am 2008, 37: 627-644.

Cawich SO, et al. Complete anal sphincter complex disruption from intercourse: A case report and literature review. International Journal of Surgery Case Reports 2012: 3, 565-568.

Zamvar V, et al. Severe anal pain caused by food allergy?: A case report. European e-Journal of Clinical Nutrition and Metabolism 2010, 5: e144-e145.

Taweevisit M, et al. Increased mast cell density in haemorrhoid venous blood vessels suggests a role in pathogenesis. Singapore Med J 2008; 49 (12): 977-979.

The Sex Series – Part Six: Male pelvic dysfunction and mast cells

Chronic pelvic pain syndrome (CPPS) affects about 15% of male patients and 90% of patients with chronic prostatitis. Patients with these conditions experience pain in the pelvis, abdomen and genitalia, as well as urinary tract symptoms without evidence of infection. Pain can be intermittent or constant, and can interfere with daily activities including sitting, standing, urination and defecation.

CPPS also causes sexual symptoms. Painful ejaculation, erectile dysfunction, and other types of ejaculation dysfunction are all common in this patient group.  In one study, 40% of patients with CPPS were found to have erectile dysfunction.  In another, 72% of patients reported either erectile dysfunction or difficulty with ejaculation.

Pelvic floor dysfunction is a component of CPPS. Many of these patients have abnormally tense pelvic floor muscles, which can cause muscle spasm and obstruct bloodflow. CPPS patients are more likely than healthy controls to have vascular dysfunction associated with nitric oxide level. In a group of 146 patients with CPPS and verified pelvic floor spasm, 56% experienced painful ejaculation.  Visceral and myofascial pain and spasm of the muscles in the pelvic floor contribute to CPPS.  While pelvic floor dysfunction has been well researched for female patients, there are far fewer studies on pelvic floor dysfunction in men.  Biofeedback and pelvic floor physical therapy can resolve issues with erectile dysfunction and other sexual issues.

IL-17, expressed by special T cells called Th17 cells, is required to develop CPPS-like conditions in animal models. IL-17 triggers mast cell degranulation and secretion of many inflammatory molecules.  A number of mast cell mediators are elevated in patients with CPPS. IL-1b, TNF, IL-6 and IL-8 are higher in seminal fluid of these patients.  CCL2 and CCL3 expression is also increased. In the prostate of animals with a CPPS model, TNF, IL-17a, IFN-γ and IL-1b are all increased.

Tryptase has been found to induce pelvic pain. Levels of tryptase and carboxypeptidase A3 are higher in CPPS patients than in healthy controls.  Tryptase binds to a receptor called PAR2.  When tryptase binds to this PAR2 receptor, it is thought that it makes nerves oversensitive. If the PAR2 receptor is blocked, pelvic pain is mitigated.  In animal models where they cannot make tryptase-like products, pelvic pain does not develop in CPPS.

Nerve growth factor (NGF) is a mast cell mediator that has been implicated in CPPS. It is elevated in seminal plasma of CPPS patients and directly correlates with pain level. It is thought that NGF makes the peripheral nerves oversensitive and causes more nerve cells than usual to be present. NGF and tryptase were elevated in prostate secretions of most CPPS patients in a small patient group. Of note, NGF release occurs and increases weeks after initial symptoms.

In animal models, injecting cetirizine (H1 antihistamine) into the peritoneal cavity decreased pain by about 13.8%; ranitidine (H2 antihistamine), 6.1%; cromolyn, 31.4%. A combination of all three decreased pain by 69.3%. When cromolyn and cetirizine were used together, larger pain relief was achieved than when used individually, but this was not seen when using ranitidine and cromolyn together.  These data suggest that H2 signaling is not a major contributor in chronic pelvic pain in male patients.

Pelvic floor dysfunction is also common in heritable connective tissue diseases and is often present in hypermobile patients.


Done JD, et al. Role of mast cells in male chronic pelvic pain. Journal of Urology 2012: 187, 1473-1482.

Roman K, et al. Tryptase-PAR2 axis in experimental autoimmune prostatitis, a model for chronic pelvic pain syndrome. Pain 2014: 155 (7), 1328-1338.

Cohen D, et al. The role of pelvic floor muscles in male sexual dysfunction and pelvic pain. Sex Med Rev 2016; 4, 53-62.

Murphy SF, et al. IL17 mediates pelvic pain in experimental autoimmune prostatitis (EAP). PLoS ONE 2015, 10(5) : e0125623.


Degranulation station

Most of my teeth erupted later than they were supposed to, some by years. My last molars came in when I was 25. I had my wisdom teeth and three molars removed around that time. We left the one that wasn’t fully erupted. When it finally emerged, it had a cavity. My first cavity, in a place where I couldn’t brush.

In the last few years, I had more cavities, all in that same tooth. One of them was a pretty straightforward filling. The other was at the gumline and caused by acid rot from vomiting. My dentist patched it up but the placement is awkward and over time, it has fallen out and gotten bigger.

I throw up pretty regularly and take massive antihistamine doses that dry out my mouth. So it was not terribly surprising when last week, my tooth started hurting a lot. I walked down to my dentist’s office and verified that I do in fact have a huge cavity in this same tooth. Given the damage, I would need a crown to fix it, and that requires lots of strange materials in my mouth. In order to have it done by dentists who know me and my disease, it would take multiple procedures as well, and I have to premedicate heavily for each procedure.

“Or we could just pull it,” she said. That was the winner. Take it away.

I react really badly to pain and as long as my pain is managed, I have no problem with procedures. But this requires some frontloading with IV meds and the ability to give more if necessary. My dentist can’t do any anesthesia but local in her office. I called oral surgeons who extracted my teeth before I was diagnosed. They wouldn’t work on me in the office because I’m a high anesthesia risk. (Which, in fairness, I am.)

So I visited the oral surgery office at the Brigham which inexplicably does not do IV sedation unless you are in an OR, and everyone agrees I need twilight sedation so that means I need an OR. First available is in late April. I called all the people and did all the things. Unless I end up in the hospital as a result of this tooth, they can’t move it up. I’m trying to come up with a workable solution, which I expect will be something like temporary filling to get me to the April date. Just ridiculously irritating.

I expect things like having pieces of my GI tract removed or devices implanted in my body to be complicated. It is the complexity of things that should be easy that is difficult. It should not be this hard to get a simple extraction.

I have been having this issue with my vision recently where later in the day, my vision feels darker, but when I turn on more lights, it hurts my eyes. I made an appointment to see an eye doctor at the same practice as my PCP. This guy took one look at me and my port and said I needed to see a specialist to have my eyes dilated because he wasn’t comfortable dilating them. I have my eyes dilated every two years. It’s never a problem. So I had to make another appointment for next month and now wait for that. Stupid.

I am fortunate that I am not particularly sensitive to chemicals, especially given my line of work. But I am very sensitive to certain cleaners. I’m so sensitive to some that everyone who works with me knows about it. I’m so sensitive that when I started telling this story at work today, I said, “You know how I react to bleach?” and my coworkers nodded knowingly, “Yes.”

Anyway, I came home on Tuesday and opened the door to my hallway and in thirty seconds was on my hands and knees on the floor, coughing and spitting out mucous. My landlord had cleaned the hallway with something that triggered a reaction. My respiratory tract was on fire and producing mucous like some gross sci-fi monster and this nasty wet cough and a headache that felt like it was trying to scalp me and I have lived here for three years are you fucking kidding me right now?

My dog got very upset and ran around the apartment barking authoritatively at lights while I lay on the floor coughing and feeling sorry for myself. It took two days to get rid of the smell using an aggressive amount of door opening, haphazardly arranged fans and kitty litter that my dog is scared of.

Some readers sent me messages to make sure I was okay since I just dipped out with no explanation. I’m right here, at Degranulation Station.

*makes choo-choo train noise*