A 26 year-old woman delivered her first baby, weighing 7 pounds, 6 ounces, without difficulty after 35 minutes of pushing. Although her doctor used perineal stretching (gentle stretching of the area between the vagina and anus) and lubricants during delivery, there was a small, second-degree tear of the vagina and perineum as the baby's shoulders delivered. A second-degree tear is a laceration (cut) that goes through the skin and into the tissue just below the skin. Therefore, the anal sphincter muscle and rectum were not involved. Her doctor used a standard technique, with stitches that dissolve on their own, to suture the laceration. She was discharged from the hospital uneventfully on the second day after delivery.

At her 6 week postpartum visit, the patient received a clean bill of health from her doctor. The ob/gyn noted that the vagina/perineum had healed nicely, the uterus was back to a normal size, and there was no sign of infection. Since she was breastfeeding, the patient received the “mini pill” (progesterone-only oral contraception).

About 2 weeks later the patient called her doctor to complain of intensely painful intercourse. She was advised to make an appointment. At the appointment, her doctor took a careful history, which revealed that she had “entry” dyspareunia (intercourse pain with entry into the vagina). The pain was so intense that she asked her husband to withdraw after only seconds of penetration. She tried to insert a tampon when her period started, but this was also very painful so she switched to pads. There were no other complaints. A thorough physical exam was undertaken, which revealed a small area of intense pain just at the entrance to the vagina, at the “6 o'clock position, at the introitus (entrance to the vagina). This was just before the hymenal remnants. It corresponded to the area where the knot was tied after the episiotomy repair. There was no evidence of a> fistula (hole between the vagina and rectum), and the patient denied passing any gas or feces through the vagina, as one might expect with a fistula. The area of tenderness was only about 5mm wide, and was only noticeable when touched with a Q-tip or the examining finger. The vagina, cervix, uterus, ovaries, labia, and anus were nontender. There was no sign of infection or vaginal dryness.

Discussion:

Painful intercourse, called dyspareunia, is a common condition that at one time or another can occur in 45% of women. There are many causes, including vaginal dryness (especially with breastfeeding), an exposed suture, a rectovaginal fistula, an incompletely healed episiotomy, and vaginal scar tissue. In the patient presented here, the most likely cause is scar tissue of the vaginal tissue. Scar tissue can develop after vaginal surgery, such as episiotomy repair. The area of scarring can be quite small, but can cause intense pain when irritated. It is important to note that this can occur even with the best surgical technique. For reasons that are poorly understood, scar tissue tends to develop in women quite often after gynecologic surgery.

There are a number of possible treatment options for this patient. Her doctor could prescribe an estrogen cream to apply to the tender area each night for a month or so. In my experience, this usually does not alleviate the pain. Another method is to excise the area, either in the office under local anesthesia or in the operating room. This removes the scar tissue. However, in some cases the scar tissue will recur in the area of excision, creating even more scar tissue. There is really no way to prevent this. Finally, I have had excellent success with “trigger point” injections using a combination of steroids and marcaine, which is a local anesthetic. (For doctors reading this, mix 9cc of 0.5% marcaine with 1cc of depo-medrol, 40mg/cc, and shake well. It's a white mixture that is injected, using a 22-gauge needle, into the area of tenderness to form a wheal. A smaller needle is not as helpful, as the injection should “break up” the scar tissue). Although this injection can be briefly painful, it quickly numbs the area. Most patients find complete relief with one injection (study protocol results thus far: D A Hill).

For the patient presented, an injection of marcaine/steroids as described was performed. The patient noted complete relief of her symptoms, and has a nonpainful, satisfying sexual relationship with her husband.

D. Ashley Hill, M.D.
Associate Director
Department of Obstetrics and Gynecology
Florida Hospital Family Practice Residency Program
Orlando, Florida