Perineoplasty (Repair of the Perineum)

What is the perineum, and how is it affected by childbirth?

The perineum is the area between the vaginal entrance and the anus. The muscles and fascia (the sheet of connective tissue that wraps the muscles) in this area support the lower wall of the vagina and the pelvic floor (the layer of muscle at the base of the pelvis).

In a vaginal birth the perineal tissues are stretched greatly as the baby's head is born. At this point the tissue may tear, or an episiotomy (a cut made at delivery) may be performed to make the birth easier. Tears are graded from first degree to fourth degree according to their depth.

The sources list the following problems that can persist after childbirth:

• A poorly healed scar from the cut made at delivery: a hypertrophic (thickened, raised) or atrophic (thinned, sunken) scar.
• A wide, gaping vaginal entrance because the perineal muscles and the fascia have separated from each other in the midline.
• Pain during intercourse because of firm scar tissue — medically called dyspareunia (pain during intercourse) — and repeated small tears of the tissue in the same area.
• Air escaping from the vagina, with a sound, during intercourse because the vaginal entrance has become lax.

Who is it considered for?

Perineoplasty is regarded as an operation for function and complaints. The main situations described in the sources are:

• Women with a painful, irregular or raised scar from the cut made at delivery.
• Women who feel a clear gaping of the vaginal entrance and muscle weakness after childbirth.
• Women who notice air or sound escaping from the vagina during intercourse.
• Women who have stinging and pain during intercourse caused by firm scar tissue.
• Women with excess skin folds or skin tags extending from the perineum towards the anus.

Having these complaints does not by itself mean a decision to operate; the decision is made according to the examination findings and the cause of the complaint.

When may it not be suitable, or be postponed?

• If 3–6 months have not yet passed since childbirth: surgery is not planned before the tissues have finished healing.
• If another vaginal birth is planned in the near future: postponing the operation until after all planned births is recommended.
• If the cause of pain during intercourse is not scar tissue: if the pain comes from involuntary tightening of the muscles around the vagina or from excessive tension in the pelvic floor muscles, surgery may not relieve the complaint.
• If the laxity is not only at the entrance but also deeper in the vaginal canal: perineoplasty alone may not be enough; a different or additional procedure may be needed.

How does it differ from vaginoplasty?

The two procedures are often confused, but their scope is different:

• Perineoplasty covers only the outer area: the vaginal entrance, the perineal body (the central point where the perineal muscles meet), the superficial muscles around the entrance and the perineal skin. The deep part of the vaginal canal is not operated on.
• Vaginoplasty, by contrast, narrows the vaginal canal along its length by repairing the supporting tissue and the deep muscles, especially in the back wall. For details, see the Vaginoplasty page.

When needed, the two procedures can be done together in the same operation; this combined procedure is called colpoperineoplasty (repair of the vaginal canal and the perineum together).

Reducing the inner lips is a separate procedure and is described on the Labiaplasty page. For the overall picture of surgical and non-surgical genital procedures, see the Genital Aesthetics page.

Assessment and expectations

The aim of the assessment before surgery is to find out whether the complaint really comes from the perineum. The sources highlight three points:

• Checking for prolapse: the examination looks carefully for pelvic organ prolapse such as a cystocele (the bladder bulging into the vagina) or a rectocele (the last part of the bowel bulging into the vagina).
• Establishing what is really needed: if the laxity is also deeper in the vaginal canal, perineoplasty alone may not relieve the complaint. In that case vaginoplasty may need to be added to the plan.
• Telling apart the causes of pain: in someone who has pain during intercourse, it must be established whether the pain comes from firm scar tissue, or from vaginismus (involuntary tightening of the muscles around the vagina) or excessive tension in the pelvic floor muscles. In the second case surgery may not be the right solution.

Expectations are also discussed openly at the consultation. Unrealistic expectations are addressed as part of this process; results vary from person to person, and the operation may not relieve every complaint.

Assessment for perineal repair is carried out at the practice in Muratpaşa, Antalya.

How is the procedure done?

The technique is planned according to each woman's findings. The basic steps described in the sources are:

• Removing the problematic tissue: irregular scar tissue and excess skin and mucosa (the thin tissue lining the inside of the vagina) are removed through an incision planned in a diamond, ellipse, triangle or Z shape.
• Rejoining the muscles: the superficial perineal muscles that separated in the midline during childbirth are brought back together in the midline with stitches that dissolve in the body on their own. The aim is to strengthen the perineal body.
• Closure: the skin and mucosa are closed with stitches that run under the skin and cannot be seen from the outside.

Anaesthesia: the procedure can be done under local anaesthetic (numbing of the area), local anaesthetic with sedation (a light sleep-like state produced by medicine) or general anaesthetic (being fully asleep).

Duration: when perineoplasty is done on its own, the procedure takes about 30–45 minutes. It is a day procedure; an overnight hospital stay is usually not needed and you go home the same day.

Recovery and waiting times

• Pain and swelling: swelling and mild to moderate pain in the area are expected in the first 24–48 hours. They are usually controlled with intermittent cold application and painkillers taken by mouth.
• Stitches: because dissolving stitches are used, they do not need to be removed.
• Sitting: in the first days, sitting directly on a hard surface can put pressure on the stitch line; a ring cushion with a hollow centre can be used when sitting and breastfeeding.
• Returning to work: most women can return to desk work within 3–7 days.
• Intercourse and tampons: wait at least 6–8 weeks so that the tissue can knit together and the stitches do not open.
• Activity: gentle walking can start straight away. Wait 4 weeks for heavy exercise, Pilates and yoga, and at least 6–8 weeks for activities that put direct pressure on the perineum, such as cycling, motorcycling or horse riding.
• Hygiene: after using the toilet, the area is rinsed gently with lukewarm water and patted dry lightly without spreading the legs too wide; a hair dryer on a lukewarm setting can also be used.
• Bathing: for the first 4–6 weeks, avoid baths, hot tubs, swimming pools, the sea, steam baths and saunas; a lukewarm shower while standing is preferred.

Risks and possible problems

As with any surgical procedure, perineoplasty has risks:

• Over-narrowing and painful intercourse: stitching the muscles too tightly or narrowing the entrance more than necessary can cause severe pain during intercourse or vaginismus developing later. This is why the degree of narrowing matters.
• Wound separation: the perineum is an area highly exposed to tension. Partial opening of the stitches in the early period because of spreading the legs too wide, constipation or coughing is among the most common problems.
• Infection: can develop through contamination after using the toilet or when hygiene is inadequate.
• Bleeding and haematoma (a collection of blood under the tissue): large collections of blood may need to be drained.
• Inclusion cyst (a small sac that develops from a tiny piece of tissue left under the skin): can form later from islands of mucosa buried under the skin during the operation.

When should it be done?

After childbirth: the operation should be planned at least 3–6 months after childbirth, so that the tissues have finished healing, the swelling has gone down and lochia (the discharge that lasts for weeks after childbirth) has stopped.

Plans for future births: in women planning another vaginal birth in the near future, postponing the operation until after all planned births is recommended. The sources state that in women who have had perineoplasty or vaginoplasty, a later vaginal birth can undo the repair, and birth by caesarean section is recommended. The decision about how to give birth should be made during pregnancy together with the doctor looking after the birth.

What is the level of evidence?

Published studies report improvement in painful scars from the cut made at delivery and in sex life. However, a large share of these publications are based on case series (reports of groups of patients followed at a single centre) and on expert experience. The number of prospective, multicentre randomised controlled (comparative studies in which participants are assigned to groups by lot) studies is still limited.