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Postpartum Perineal Pain

10/1/2009 - Frank W. Ling, MD

Editor:  Pamela D. Berens, MD

REVISED PEARL - February 2015

The diagnosis and management of postpartum perineal pain depends more on physical examination than history alone.  Because pain is rarely an isolated symptom, the history may also include bleeding, discharge, and or irritation.  Patients are often unable to specify the origin of pain.  Some perineal pain is common with normal postpartum physiologic changes, and is typically managed with oral pain medications and Sitz baths.

Severe pain should raise suspicion for perineal wound complications which occur in approximately 7% of women who have had an obstetric anal sphincter injury.  Smoking, increased body mass index, fourth degree laceration, and operative vaginal delivery increase the risk.  Risk factors for perineal wound breakdown include prolonged second stage, mediolateral episiotomy, third or fourth degree laceration, operative vaginal delivery, meconium stained fluid and lack of prior vaginal delivery.

Physical examination should include thorough inspection and palpation.  Concerning features include significant leukocytosis, left shift and fever.

Early postpartum fever and worsening perineal pain suggest an infected episiotomy or laceration repair.  The site typically appears erythematous and swollen, and may have purulent drainage.  Treatment includes antibiotics and possible drainage and debridement.  Mild discomfort with odor may occur from a retained sponge, bacterial vaginosis, gonorrhea or chlamydia.

A hematoma may be evident on examination.  Small hematomas may be observed. Large hematomas may require packing, and if conservative management fails, surgical exploration.

Vulvar edema can be managed with ice packs and pain medication.  Necrotizing fasciitis should be considered in the differential, as should bladder infection, diverticulum, hemorrhoids or anal fissures.  Scarring, suture abscess and granuloma are potential later causes of discomfort.

Dyspareunia may result from delivery-related conditions, but is less likely outside of the immediate postpartum period.  When accompanied by vaginal dryness and post-coital bleeding, pain with intercourse may be related to vaginal atrophy due to breastfeeding and hormonal changes.  Water soluble lubricants and topical estrogen may be beneficial.  Counseling helps to reassure the patient and her partner that reduced lubrication is a temporary physiologic phenomenon.

Further Reading:

Stock L, Basham E, Gossett DR, Lewicky-Gaupp C. Factors associated with wound complications in women with obstetric anal sphincter injuries. Am J Obstet Gynecol. 2013 Apr;208(4):327.e1-6. doi: 10.1016/j.ajog.2012.12.025. Epub 2012 Dec 19.

Williams MK, Chames MC. Risk factors for the breakdown of perineal laceration repair after vaginal delivery. Am J Obstet Gynecol. 2006 Sep;195(3):755-9.

Dudley LM, Kettle C, Ismail KM. Secondary suturing compared to non-suturing for broken down perineal wounds following childbirth. Cochrane Database Syst Rev. 2013 Sep 25;9:CD008977. doi: 10.1002/14651858.CD008977.pub2.

Initially approval 10/2009; Revised 2/2015; Reaffirmed 7/2016

 

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