An episiotomy is a surgical incision into the perineum, the area between the bottom of the vaginal opening and the anus, in order to increase the size of the vaginal opening during childbirth. If it is done as part of gynecologic surgery, it's called a perineorrhaphy. As discussed in recent threads on this forum, episiotomy is controversial. However, it's sometimes necessary, and, in any event, sometimes a tear (also called a perineal laceration) will occur during childbirth regardless of whether an episiotomy is cut.
After an episiotomy or tear, the doctor or midwife should inspect the vagina, cervix, perineum, and anus to make sure there are no other damaged areas. If pain is a problem, the area should be injected with novocaine, or, if necessary, the patient should be offered an IV shot of strong painkillers. In some cases a large tear of the cervix and/or vagina requires repair under epidural or general anesthesia in the operating room. Most women, however, have a 2nd-degree tear of the vagina, which can be repaired right in the delivery room. A 1st-degree tear is a thin line through the perineal tissue. This is less common than a 2nd-degree tear, which goes a little deeper. 3rd-degree tears actually cut into or through the round sphincter muscle that surrounds the anus. This muscle helps "hold it in" so identification and repair of injuries to this muscle may prevent fecal incontinence. A 4th-degree tear goes into the rectal tissue, and must be repaired correctly to prevent a hole forming between the vagina and rectum, called a fistula, where gas and feces can pass into the vagina. I have seen women who delivered at home or in an otherwise unattended setting who have a cloaca, where the rectum and vagina are essentially one opening! This can be repaired surgically even years later. Despite what some may say, even the best doctors and midwives will encounter 3rd- and 4th-degree tears, as childbirth is a traumatic event to the tissues of the vagina and perineum.
Repair of an episiotomy is generally straightforward. Do a good exam, identify the tissue edges, then sew with suture that lasts at least a few weeks. (Chromic catgut is a common episiotomy suture that lasts about 2-3 weeks). Errors can be made by doing a hasty repair, or, more commonly, not having good enough visualization of the area to be repaired. Poor lighting, excessive bleeding, a moving target, or, in some, cases, an uncooperative patient (i.e. someone high on crack cocaine who doesn't want to sit still) can all make it hard to repair the area. If the area is not approximated correctly, or even if a stitch pulls through later, the edges of the wound may not heal correctly. Some women heal "too well" and form granulation tissue, which can create spotting and pain. In other cases a trigger point is formed, usually right at the 6 o'clock position at the bottom of the vagina, which can cause extreme pain with insertion of a tampon, finger, or penis.
Sadly, many women do not report this to their doctors. Maybe they are concerned about hurting their doctor's feelings, or maybe they are embarrassed, or busy with their newborn. Regardless, episiotomy pain can almost always be fixed. If it's a fistula, surgical repair will solve the problem. If it's a slightly tender episiotomy, ice packs, numbing cream, sitz baths, and wearing loose clothing may help. Breastfeeding moms may benefit from a low-dose estrogen cream, as breastfeeding decreases the amount of estrogen in the vaginal tissues. In cases where there is a bunching up of tissue, or there are knots or other abnormalities, outpatient surgical revision of the area may help. Most patients feel it's better to go through more surgery and have a 6-8 week recovery than have a lifetime of painful intercourse. In cases where trigger points are identified, injections may be helpful. In some cases a combination approach may help, such as removing the excess tissue, the doing injections later if necessary. Again, however, this is often not that hard to fix for an experienced gynecologist. If someone has not obtained relief from the basic treatments, then more intensive treatment is often indicated. Gynecologists are used to dealing with patients with painful intercourse, so you should get attention to this problem from your doctor. If not, find another.
D. Ashley Hill, M.D.
Department of Obstetrics and Gynecology
Florida Hospital Family Practice Residency