10/1/2009

Postpartum Perineal Pain

Author: Frank W. Ling, MD

Editor: Sangini Sheth, MD

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The diagnosis and management of postpartum perineal pain depends on history and physical examination. Because pain is rarely an isolated symptom, additional symptoms by history may also include bleeding, discharge, or irritation. Some perineal pain is common with normal postpartum physiologic changes or with healing of a perineal wound and is typically managed with oral pain medications and Sitz baths.

Severe pain should raise suspicion for perineal wound complications. In the first 6 weeks postpartum after an obstetric anal sphincter injury (OASIS), approximately 25% of women experience wound breakdown and 20% experience wound infection. Risk factors for OASIS include operative vaginal deliveries, midline episiotomy, increased fetal birthweight, primiparity, labor induction, labor augmentation, epidural anesthesia, and persistent occiput posterior position. 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.

Early postpartum fever and worsening perineal pain suggest an infected episiotomy or laceration repair. The site typically appears erythematous, edematous, and may have purulent drainage. Leukocytosis would likely be present. Treatment options include antibiotics, possible incision and drainage in the setting of an abscess, and wound debridement. Mild discomfort with malodorous discharge 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 drainage and packing. If conservative management fails, surgical exploration is warranted.

Vulvar edema can be managed with ice packs and pain medication. Granulation tissue at the site of a laceration can be treated with silver nitrate, topical estrogen, and potentially excision.

Bladder infection, diverticulum, hemorrhoids, or anal fissures should also be considered in the differential. Scarring, suture abscess, and granuloma are potential later causes of discomfort. Necrotizing fasciitis can occur in rare cases and warrants prompt evaluation and treatment, which includes antibiotics and debridement.

Dyspareunia, especially when accompanied by vaginal dryness and post-coital bleeding, 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 (OASIS). 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.

Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 198: Prevention and Management of Obstetric Lacerations at Vaginal Delivery. Obstet Gynecol. 2018 Sep;132(3):e87-e102. doi: 10.1097/AOG.0000000000002841.

Initially approval October 2009; Reviewed July 2016, Revised November 2017, Reaffirmed May 2019, Minor Revision November 2020, Revised May 2022

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