Postpartum Perineal Pain – Oct 2009
The correct diagnosis and management scheme for pain in this anatomic region after a delivery are dependent far more on physical examination than on history. Because pain is not likely to be an isolated symptom, accompanying history may well include bleeding, discharge, and irritation, with none of those necessarily leading to the correct diagnosis. In addition, patients are often not able to specify the origin of pain beyond describing it as being "down there."
The effect of a normal vaginal delivery can create various levels of discomfort, and because postpartum physiologic changes further complicate how an individual patient may interpret her discomfort, the skilled clinician would do well to fully investigate a woman's complaints with thorough inspection and palpation. It is, therefore, incumbent on the physician to have had extensive previous experience evaluating what the normal postpartum perineum is like.
In the first few days after delivery, fever and pain in the perineum certainly suggest an infectious process. Ruling out non-perineal sources of temperature elevation goes without saying, but the focus may potentially be an infected episiotomy or laceration repair. If the patient had a fourth degree laceration repair, the potential contamination of the repair from rectal contents certainly increases the likelihood of infection. Treatment of either would include antibiotics, local care and possible debridement. Repeat repair during this acute phase has been suggested by some and found to be appropriate. Alternatively, an infected hematoma may have developed since the original repair was done. Gentle palpation of the vaginal canal in addition to inspection of the perineum is warranted. Associated findings of the bladder, e.g. UTI, diverticulum, etc. or rectum, e.g hemorrhoids or fissure should be considered if only because the patient may not be aware of where her pain might be coming from.
Vaginal odor accompanied by discharge may be part of an infectious process. These symptoms could also be compatible with a sponge left in the vagina. This is a prime example of why a thorough examination, including evaluation of the vaginal canal, is a necessity. The possibility of a more common cause of vaginal discharge and odor such as bacterial vaginosis should also be investigated with a wet mount and possible cultures of the endocervix for gonorrhea and Chlamydia.
As the time from the vaginal delivery gets longer, the problems are less likely due directly to the delivery and/or repair. There can still be scarring or even a stitch abscess or granuloma. Albeit infrequent, these conditions are best diagnosed using visualization and palpation of the area that the patient points to. The clinician should always check his/her clinical suspicion by asking the patient if the pain on examination is, indeed, the pain that the patient perceives.
Dyspareunia, as a specific complaint, may result from a delivery-related condition such as those listed above, but the more remote from delivery, the less likely this is the case. Particularly when accompanied by complaints of vaginal dryness and post-coital bleeding, pain with intercourse may well be related to breastfeeding. Symptomatic care using either small amounts of topical estrogen cream for the atrophic vaginal epithelium or a water soluble lubricant may be necessary until weaning of the newborn occurs. A full explanation of the physiologic causes of the atrophic vaginitis related to breastfeeding will help to reassure both the patient and her partner that her inability to lubricate is not for lack of interest, but is a normal phenomenon.
An additional etiology of dyspareunia after a delivery can be new onset vulvar vestibulitis, also called vestibulodynia. It is not known what causes this to occur later in life as can happen after delivery for some women, while others present with these symptoms as an adolescent when first trying to insert a tampon or when coitus is attempted for the first time. The pain is primarily on entrance or attempted penetration and is often enough for the patient to cease trying to be intimate with her partner. Needless to say, this can be quite distressing to the new parents.
The diagnosis is best made by listening to the symptoms, ruling out more common causes, then looking specifically for vestibulodynia using a moistened cotton-tipped swab. Gentle pressure is applied to the vestibular glands just external to the hymenal remnants. Specifically, the Bartholin glands and Skene's glands can be found to be exquisitely tender to direct palpation with the swab. As above, the patient should usually be able to verify that the tenderness elicited does recreate her complaint. Treatment of this condition with topical anesthetic agents and neuropathic oral medications, such as selected antidepressants and/or anticonvulsants, can be useful.
In summary, postpartum perineal pain is very distressing to the patient and should be evaluated by the physician with sensitivity and thoroughness in a timely fashion. Having an empathetic and sympathetic approach to the new mother is particularly helpful as the stresses of being a new mother present their own challenges for the patient and her partner.