Perineal tear

Disease Description (Causes and Symptoms)

• Definition: Perineal laceration is a condition in which the pressure or stretching force exerted on the perineum by the fetal head or body during delivery exceeds the elasticity of the perineal tissue, causing the back of the vaginal opening and adjacent tissues to tear.
• Causes and risk factors: Difficult labor, large fetus (macrosomia), rapid delivery, first delivery, lithotomy position (extreme positioning), instrumental delivery such as forceps or vacuum delivery, weakening of the perineal tissue, use of local anesthetics, inappropriate delivery assistance, and episiotomy (such as a midline incision).
• Pathophysiology: Tearing occurs in layers, including the perineal skin, subcutaneous tissue, muscles, anal sphincter, and rectal mucosa. It is classified from first to fourth degree according to the extent of injury. The higher the grade, the greater the risk of complications such as incontinence, bowel dysfunction, and rectovaginal fistula because the injury may extend to the anal sphincter and rectal mucosa.
  • First degree: Skin and subcutaneous tissue only
  • Second degree: Includes the vaginal sphincter and perineal fascia (without involvement of the anal sphincter)
  • Third degree: Involvement of the internal and external anal sphincters
  • Fourth degree: Extends to the anal and rectal mucosa
• Main symptoms: Tearing pain in the perineum, bleeding, swelling, difficulty urinating or defecating, and in severe cases, fecal or gas incontinence or discharge and fever (if infected)

Treatment Methods

• Initial treatment
  • Control of bleeding (pressure and, if necessary, hemostasis before suturing), and pain control (pain relievers and local cold compresses)
  • Drainage and hemostasis if there is a severe hematoma
• Suturing and surgery
  • Lacerations of second degree or higher are sutured under appropriate sterile conditions (using absorbable sutures)—usually by an obstetrician-gynecologist or the responsible clinician qualified to perform surgery
  • Third- and fourth-degree lacerations are treated by an experienced operator, including anal sphincter repair (usually performed in an operating room under local or spinal anesthesia)
  • In severe cases or when suturing fails, reoperation or specialized colorectal surgery/pelvic floor reconstruction may be needed
• Medications
  • Pain relievers (such as nonsteroidal anti-inflammatory drugs)
  • Antibiotics if necessary: They are not routinely administered to all patients, but are used for high-risk cases (extensive injury, contamination of the sutured area, immunosuppression, etc.) or when infection is suspected
  • Medications to prevent constipation (stool softeners and laxatives)
• Conservative treatment and rehabilitation
  • Apply cold compresses during the first 24 hours to reduce swelling, followed by sitz baths to promote blood flow and relieve pain
  • Wound hygiene: Wash with clean water and keep the area dry; rinse with water after urination
  • Bowel management: Increase fiber intake, maintain adequate fluid intake, and use stool softeners if necessary
  • Pelvic floor (Kegel) exercises: Helpful for rehabilitation after anal sphincter injury
  • Sexual activity: Avoid until the period specified after suturing (usually 4–6 weeks after suturing or as determined by the responsible physician) has passed
• Follow-up and reassessment
  • Monitor wound healing, signs of infection, and recovery of bowel and sexual function
  • If anal sphincter injury is suspected, consider additional tests (anal reflex testing, anorectal manometry, anal ultrasonography, etc.) and pelvic floor physical therapy or surgical correction
• Precautions (risk of complications and self-care)
  • Infection: Seek medical attention immediately if fever, severe pain, foul-smelling discharge, or separation of the sutured area occurs
  • Long-term complications such as hematoma, wound dehiscence, rectovaginal fistula (connection between the rectum and vagina), fecal incontinence, chronic pain, and dyspareunia may occur
  • Avoid lifting heavy objects and limit excessive exercise during the wound healing period

Outpatient Visit Checklist (Including Preparation Items and Sample Questions)

• Items to prepare / things to confirm
  • Date of delivery and type of delivery (vaginal delivery/C-section/vacuum or forceps delivery, etc.), and whether an episiotomy was performed (and the type of incision, if so)
  • Laceration grade (if known), and whether suturing was performed and when
  • Current symptoms (pain severity, bleeding or discharge, fever, urination or bowel problems, and gas or fecal incontinence)
  • List of medications currently being taken (including anticoagulants, immunosuppressants, etc.)
  • Allergies and history of previous surgery
  • Recent temperature and wound photographs (if possible), and records of bowel movements (including whether constipation is present)
• Symptoms that should be reported immediately during an outpatient visit
  • Fever (>38°C), foul-smelling discharge from the wound, severe pain, separation of the sutured area, heavy bleeding, inability to pass stool, or urinary retention
• Sample questions for the patient to prepare and ask the medical staff
  • "What degree is my laceration, and what does it mean?"
  • "Are my current pain and bleeding within the normal range?"

General Sample Questions to Ask the Doctor

• "What pain-control methods and medication side effects should I expect?"
• "How long is the expected recovery period, and when can I return to daily activities, work, and sexual activity?"
• "What should I do immediately if I suspect an infection or separation of the sutured area?"
• "What dietary or medication regimen do you recommend for bowel management?"

Sample Questions Tailored to This Condition

• "What degree (first to fourth) is my perineal laceration? How can we determine whether the anal sphincter was injured?"
• "If I have a third- or fourth-degree laceration (involving the anal sphincter), how likely is additional rehabilitation or reoperation? Do I need pelvic floor physical therapy?"