Diverticular disease is an umbrella term for three conditions that affect the lining of the fist chute: diverticulosis, diverticulitis, and diverticular bleeding. The defining characteristic of these diverticular diseases is the development of diverticula. Diverticula are small, protruding pouches (sacs) that appear along the intestinal walls of the upper fist chute. The status of the diverticula determines the diagnosis:

• Diverticulosis | Manifestation of the pouches along the intestinal wall, usually in the sigmoid colon.
• Diverticulitis | Inflammation of the pouches, which is often very painful.
• Diverticular Bleeding | Rupture of blood vessels within the pouches that results in moderate to heavy bleeding (typically beyond pink).

The precise cause of diverticular disease is not well understood. Scientists have theorized that it is related to changes in the strength and elasticity of the colon wall as well as changes in the diet and lifestyle of the individual.

Diverticulosis is usually asymptomatic. As such, it is often undiagnosed or only diagnosed during examinations for other issues.

The symptoms of diverticulitis include severe left-sided abdominal pain, nausea, fever, constipation or diarrhea. The pain may start slowly or appear suddenly. If rupture occurs, a hospitalization is typically necessary to prevent serious illness or death.

Bloody stool or passing blood are signs of diverticular bleeding and require immediate medical attention to avoid severe, life-threatening shock.

While it is true that fisting can thicken the intestinal walls, this thickening is usually limited to the rectum. Since diverticula appear in the upper fist chute, this thickening has little effect on the development of diverticula. No studies exist regarding the long-term effects of fisting on the colon; however, regular agitation of tissues often speeds up disease processes with age.

The following are non-modifiable risk factors for developing diverticular disease:

• Genetics | In men below age 40, the appearance of diverticula is likely related to genetic factors.
• Age | Diverticula typically develop mid-life (40-50). By age 80, most individuals have some diverticula present in the colon.

There are several modifiable risk factors for developing diverticular diseases:

• Diminished Physical Fitness | Lack of exercise and obesity create additional strain on the colon.
• Drugs and Chems | Smoking, steroids, anti-inflammatories (ibuprofen, aspirin, etc.), certain lubricants, and booty bumps weaken or erode tissue lining.
• Diet | Low-fiber, high-fat diets affect passage of stool and increase pressure on the colon walls.
• Excessive Douching | Repeated flushing and disruption of healthy gut flora allow unhealthy bacteria to agitate the intestines, disrupting normal immune responses.
• Pressure | Heavy ass play triggers mucosal sloughing, exposing the colon to irritants such as chems, drugs, and intrusive gut flora.

Preventative measures for these conditions include high fiber diet, exercise, hydration, and probiotics. Specific details are discussed in Diet, Nutrition and Supplements (below).

Treatment of diverticulitis depends on the severity of symptoms. In mild cases, a low fiber diet may be prescribed to allow the colon to rest, followed by a gradual transition to a high fiber diet once healed. For more severe cases, treatment may involve antibiotics to prevent sepsis, and hospitalization may be required to rule out perforation. During hospitalization, intravenous fluids may be given while oral fluids and food are withheld to allow the colon to rest. Anti-diarrheal medications such as Lomotil and Imodium AD are not advised.

Diverticular bleeding can be—but is not always—indicative of perforation. Abdominal x-ray, CT scanning, and lab tests may be required to rule out perforation. Once symptoms subside, a colorectal surgeon may conduct a sigmoidoscopy and perform endoscopic procedures to remove diverticula or seal up problematic vessels. In severe cases of diverticular bleeding and diverticulitis, portions of the colon may need to be removed.

Fisting is permissible when asymptomatic. During flare-ups of diverticulitis or diverticular bleeding, do not fist. Wait six weeks from the last date of symptoms before returning to bottom. The six-week waiting period is based on the logic and rationale followed by gastroenterological surgeons. It is medically prohibited to perform endoscopies and sigmoidoscopies for four-to-six week period following flare-ups.

Risk Mitigation

@nate_stetsonx

Diverticula are typically located in the upper fist chute, so traditional fisting has minimal effect on the disease. As a reminder, traditional fisting:

• Remains confined to the lower fist chute (no attempts at depth fisting),
• Minimizes extreme movements in the lower fist chute that can agitate the upper fist chute (no rapid pistoning, extreme back-and-forth motions, or prolapsing attempts), and
• Avoids pumping air into the sigmoid (no punch fisting or gape development/training).

Because diverticular disease manifests differently in every individual, some fisters may be able to include depth, punch, girth or piston play in their sessions. Several sessions with a trusted friend can help identify allowable practices.

Tactics that help decrease your chance of injury with diverticular disease include:

• Learning About Your Condition | Apart from knowing the information here, speak with your primary healthcare provider and gastroenterologist to ascertain the scope and severity of your condition. Minor cases generally require less behavioral modification.
• Enhancing Topping Skills | Improve your topping skills while your hole is off limits.
• Eliminating Extreme Fisting Practices | Punching and pistoning put additional stress on diverticula. Eliminate deep punching and pistoning and decrease shallow punching. Avoid extremely firm and extremely textured toys that are longer than 20 cm (8 inches).
• Monitoring Bleeding | Halt any fisting with the appearance of blood, especially darker blood that indicates more than just capillary damage.
• Allowing Time for Healing | Fisting causes inflammation of the colon. Increase the number of days between sessions to allow the fist chute to rebound.
• Making Lifestyle Changes | Begin regular exercise and eat a high fiber diet supplemented with prebiotics and probiotics.
• Discontinuing Contraindicated Medications | Oral and topical steroids decrease the production of collagen, which is an essential component in the lining of the fist chute. Use should be limited for prescribed purposes only. NSAIDs, such as Ibuprofen, can erode the lining of the intestine and should be used sparingly. See Table 2.1 for medications that should be avoided.

  Topical Steroids

  Examples:

  • Lidocaine/Hydrocortisone Cream
  • Hydrocortisone Cream
  • Fluticasone Cream
  • Triamcinolone Foam

  Typical Suffix: -sone

  Purpose: Alleviates itching and swelling

  Anabolic Steroids

  Examples:

  • Testosterone
  • Nandrolone
  • Stanozolol
  • Oxandrolone

  Typical Suffix: -olone

  Purpose: Build muscle mass

  Oral Steroids

  Examples:

  • Prednisone
  • Hydrocortisone
  • Methylprednisolone
  • Dexamethasone

  Typical Suffix: -sone

  Purpose: Alleviate inflammation

  NSAIDs / ASAs

  Examples:

  • Ibuprofen
  • Naproxen
  • Voltaren Cream
  • Aspirin

  Typical Suffix: None

  Purpose: Pain relief, decrease swelling

  Table 2.1: Contraindicated Medications

  Various medications can weaken the lining of the intestinal tract and increase perforation and bleeding risk. For those with diverticular disease, long-term use of these medications can increase risk of perforation.

Diet, Nutrition, and Supplements

Diet for diverticulosis, the benign stage of diverticular disease, corresponds with the fisting clean-out diet. It is high in fiber and potassium rich fruits and vegetables, which help maintain bulk, healthy gut bacteria, and electrolyte balances.

VOCABULARY

Probiotics

1. Noun Foods or supplements such as yogurt that contain live microorganisms that will improve or maintain the normal, healthy gut microflora.

Prebiotics

1. Noun High fiber foods that feed existing microflora, such as bananas, greens, and artichokes.

During diverticulitis, fisters should switch to low fiber diets to prevent excess pressure on the colon walls or blockage of individual diverticula. If severe diverticular bleeding is present, a hospitalist may recommend a liquid diet until the colon has rested and recovered. Maintaining full hydration also decreases constipation that can lead to diverticulosis.

Prebiotics and probiotics should be used on a daily basis to maintain a healthy colony of gut bacteria. Once a healthy colony is established, non-digestible fibers, such as raisins, apple with skins, corn, and mushrooms play a restorative role in lower intestinal colonization. Undigested items help transport healthy bacteria to lower areas of the digestive tract.

Clean-out

Douching routines vary based on the severity of diverticular disease. During a flare-up of diverticulitis or diverticular bleeding, anyone should avoid douching to allow the colon to rest. With diverticulosis, douching is allowed but may require some modification.

Lubrication

Play Modifications

Because each person reacts differently to the disease, restrictions and modifications can vary substantially. Once your diverticular disease is under control, some modifications may be necessary. Minor cases of diverticulosis often require little, if any changes to play.

Restricted Activities

The location of diverticula, the quantity of diverticula, and the colon's response to stimulation will restrict your play.

Keep a diet and activity journal so that you can identify activities and foods that irritate your colon. Because diverticulitis may not manifest immediately, it is important to have a record of food consumption and activities that occurred in the days prior to the flare-up. This helps you identify activities that should be eliminated.

Suggested guidelines include the following:

• Restrict bottoming during a flare-up of diverticulitis or diverticular bleeding.
• Avoid depth play and direct manipulation of diverticula.
• Eliminate activities that introduce air into the sigmoid colon, such as punch fisting. Pressure from air can inflate diverticula and increase the risk of rupture.

	Diverticulosis	Proceed with Caution
	Diverticulitis	Abstain until abdominal pain resolved for two weeks
	Diverticular Bleeding	Abstain for eight weeks after bleeding ceases

Table 2.2: General Guidelines

Standard wait times for stages of diverticular disease. Your diet and activity journal may indicate shorter or longer abstention periods.

Modified Techniques

Many men with diverticulosis continue fisting without issues after making lifestyle changes.

As mentioned previously, record details about your session for future reference. If you have issues after you play, you can refer to your journal and modify behaviors during your next session.

Consider the following modifications to your fisting sessions:

• Limit your play to elementary activities in the lower fist chute. Do not attempt to penetrate the second ring. Balling the fist once it has penetrated the anal canal helps prevent unintended probing into the sigmoid colon.
• Truncate the length of your session. The longer the session, the more likely tissue swelling along the entire course of the fist chute will occur, even if no depth play occurred.
• Reduce extreme girth play. Choose the least taxing activities for your fist chute. For example, a focus on doubles is likely to result in systemic inflammation of the entire colon.

Toy Considerations

Because diverticulitis almost always occurs in the upper fist chute, you should limit your toys to plugs and realistic sizes. Exclude toys that are longer than 20 cm (8 inches) and always purchase softer toys.

SquarePegToys offers a large variety of toys in this range in Supersoft Bronze™. Increased pressure in the rectum can stimulate the sigmoid. This stimulation may trigger inflammation in the upper fist chute. Consider borrowing large girth toys from friends to determine if use is detrimental to your condition.

Any health condition that affects the fist chute can cause anxiety and significant mental distress. Learning that a core element of one's sexual identity may be limited is difficult and often requires the help of mental health professionals. They can help you develop coping mechanisms and explore options that allow you to live your best life, including how to successfully abstain from activities that trigger flare-ups.

If your diverticular disease is severe and requires abandoning bottoming altogether, a counselor is often needed to process grief, develop new identities (as a top, for example), and decrease anxiety.

Some bottoms find it difficult to express their needs due to a fear of being labelled "bossy" or overbearing. A majority of bottoms assume that the top is intuitive enough to ascertain discomfort or assess abnormalities within the fist chute and then alter fisting techniques to accommodate variances or pain. These assumptions and aversions can lead to discomfort, disconnection, and even injury.

With a diverticular disease diagnosis, always start your session with a discussion of your hole. A good top will usually start a session with the request "tell me about your hole." If he does not ask, then volunteer the information. Let him know that you have diverticulosis that can be exacerbated into diverticulitis if he goes "apeshit" on your hole. This will lead into conversations about what makes you feel good, what puts you at ease, and how he can make your hole (and you) happy.

Fisters with diverticular disease typically have a primary healthcare provider and a gastroenterologist. Frank conversations about your fisting habits can help them keep you healthy. Do not withhold information from them if you intend to continue fisting after your initial diagnosis.

These following points should be discussed with your healthcare team to ensure the best health outcomes.

Show Detailed Medical Rationale for Each Point

• General proclivities including type of and intensity of play, such as:
  • Depth Play | Including details about how deep, pistoning stroke, and pace of depth movement

    Rationale

    Diverticula are primarily located in the sigmoid and pressure from a firm foreign body (such as an arm) can agitate them and trigger a case of diverticulitis.

  • Punch Play | Including details about style (open/closed fist), extraction (full/partial), pace (fast/slow), and rate (number of consecutive or near-consecutive punches)

    Rationale

    Punching typically forces air into the upper fist chute. Pressure from this air can agitate the diverticula and trigger a case of diverticulitis.

  • Width/Girth Play | Including circumference, depth, and punch practices (doubles is the same as jack-in-the-box)

    Rationale

    Simultaneous insertion of multiple hands (either fully or partially) into the rectum and occasionally the sigmoid colon allows air to inflate the fist chute. As mentioned previously, pressure is a significant factor in exacerbation of diverticulosis.

    Width play may include the depth insertion of two arms, which creates a huge amount of pressure.

  • Toy Play | Including firmness, width, depth, pace, and rate

    Rationale

    Toy play may involve multiple factors that can trigger diverticulosis:

    • Firm objects penetrating the second ring press against the intestinal wall of the upper fist chute. This results in extreme pressure in the sigmoid colon.
    • Rapid pistoning creates drag and in some cases, a vacuum that tugs the sigmoid down. The tension can irritate diverticula and trigger inflammation responses.
    • Fast extraction and reinsertion into the hole pump air into the rectum and sigmoid.
• Lubrication details including type and characteristics, such as:
  • Category | Specifically lipid, PEO, gums, obstetrical, petroleum distillate, or silicone (tip: physicians may recognize PEO lubrication as obstetrical lube or veterinary lube)

    Rationale

    Certain types of lube clog diverticula or trigger natural immune responses (which includes inflammation)

  • Additives | Specifically analgesics (such as lidocaine, witch hazel), cooling agents, warming agents, or sugars (in the case of J-lube)

    Rationale

    Additives can easily irritate the mucosal lining of the entire fist chute.

  • Quantity | How much and how frequent of application, including any injection practices

    Rationale

    Excessive amounts of lube can be absorbed by the body and can trigger unwanted immune responses, including diverticulosis.

  • Communal Lube / Contamination Practices | Such as lube sharing, BYOL, hygienic practices between multiple partners

    Rationale

    Communal lube can introduce sexually transmitted infections as well as harmful bacteria into the fist chute. The resulting immune response triggers inflammation and diverticulitis.

  • Post Play Lube Douche | Practices to internally rinse and expel excess lube

    Rationale

    Removal of excess lube may mitigate some of the aforementioned triggers of inflammation.

• Clean-out routines, including duration, water-flow intensity, laxatives use, and fiber intake

  Rationale

  Water from douching can result in unnecessary pressure on existing diverticula and may inflate them triggering painful nerve stimuli. Electrolyte imbalances may cause other physiological processes that agitate the diverticula.

  Fiber mitigates constipation—which can trigger pressure related or infection related swelling and inflammation.

  Laxatives trigger muscle responses that tax the intestine and prevent it from resting.

• Frequency of play

  Rationale

  Rest is the primary treatment option. Multiple sessions a week do not allow enough time for recovery.

• Discomfort during or after play (any)

  Rationale

  Enduring pain is an indication of something more severe, possibly indicating rupture or perforation.

• Medication and chem usage, such as:
  • Anabolic Steroids | For muscle gain or hormone replacement
  • Corticosteroids | Typically prescribed for other illnesses
  • Topical Steroids | Treatments for inflammation and swelling, especially if used inside the hole
  • Oral Anti-inflammatories and Pain Relief | Specifically NSAIDs (ibuprofen, naproxen) and aspirin including frequency of use
  • Topical Analgesics | Including Voltaren cream or Lidocaine or any substance inside the hole

  Rationale

  These medications decrease the strength of the mucosal lining, resulting in increased perforation risk at the site of diverticula.

• Quantity and location of diverticula

  Rationale

  Having this knowledge from your doctor may provide you with more incentive to temporarily alter your behaviors until you have full recovery.

• Screening tools and frequencies (including colonoscopies)

  Rationale

  Discussing diagnostic tools and scheduling checkups puts your mind at ease and ensures your chart is updated appropriately for your annual physical.

• Value and importance of fisting in your life

  Rationale

  Many practitioners do not understand the Fister's Brain and offer only one solution: total abstinence. Relaying its relevance may alert your practitioners to your inability to comply with abstinence protocols. Your healthcare team may then implement harm reduction options in your care plan.

QUICK REFERENCE

• Healthcare Providers

Your fisting revelations to your healthcare providers are important. Without covering the information above, they may not diagnose you correctly, they may prescribe unnecessary medications and testing, and they may not offer sound medical advice for you. Their focus may be on abstinence only—especially with providers who aren't familiar with fisting culture.

You can help improve your provider's knowledge by supplying them with the following data sheet:

050404122-01 Diverticular Disease and Fisting - Data Sheet