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Anal health is important for men who have sex with men (MSM). Most MSM engage in anal sexual practices, but stigma can contribute to a reluctance to discuss anal health with healthcare providers. Anal pathology, receptive anal practices and sexually transmitted infections (STIs) may contribute to anal symptoms. MSM, especially those living with HIV, are at substantially elevated risk of anal human papillomavirus (HPV)-related high-grade intraepithelial lesions (HSIL) and squamous cell carcinoma.The Study of the Prevention of Anal Cancer (SPANC) was a prospective cohort study of HPV and related anal lesions among community-recruited MSM age ≥35 years, in Sydney, Australia. Participants completed computer-assisted self-interviews and underwent STI testing, anal cytology and high-resolution anoscopy. Systematic data collection provided a unique opportunity to investigate a range of anal health issues among community-recruited older MSM.Chapters 2–6 explore aspects of anal health among SPANC participants. Chapter 2 explores associations with change in self-reported anal health. Chapter 3 investigates the association of anal symptoms with pathology, sexual behaviours and STIs. Chapters 4 and 5 evaluate whether HSIL is associated with anal symptoms and/or anal warts. Chapter 6 investigates the prevalence, incidence and predictors of anal STIs and syphilis. Worsening of self-reported anal health was associated with physical, psychological and sexual factors. Anal symptoms were common. Two-thirds of participants were diagnosed with anal pathology, but most were asymptomatic. There was no significant association between HSIL and any anal symptom. Anal warts were common and significantly associated with HSIL. HSIL was detected within one in seven biopsies from clinically diagnosed warts. There was a high incidence of STIs, independent of age. The high prevalence of anal symptoms and pathology in this cohort suggests that clinicians should prioritise anal health during consult