LONG TERM IMPLICATIONS OF SURGICAL LACERATION OF THE PERINEUM AND ANAL SPHINCTER

by Christine Kent on April 21, 2007

At least three generations of women in the United States are aging into the reality of having had the bulky, elastic core of their pelvic organ support system severely compromised by perineal laceration. Our mothers and grandmothers, damaged in just the same way, never became fully conscious of the connections between their hospital births and later hysterectomies, sphincterplasties, and incontinence procedures.

Primary pelvic organ support derives from the shape of the spine and the integrity of soft tissue connections to the skeletal frame. The pelvic diaphragm provides primary muscular support and is made up of a group of paired muscles that include the levator ani and coccygeus muscles. The levator ani are composed of horseshoe-shaped bands of muscle that span from pubic bone to coccyx. The inner most band is called the puborectalis, which surrounds the vagina and rectum like a sling. The puborectalis muscles maintain continence of solid stool by pulling sharply forward and creating an acute angle between the anus and rectum. This mechanism forces stool back up into the rectum where it is stored until evacuation.

Tough, membranous connective tissue surrounds the entire vaginal tube and is fused to the underside of the posterior vaginal wall. The rectovaginal fascia extends downward from the posterior aspect of the cervix and uterosacral ligaments to attach onto the upper margin of the perineal body. From there it extends laterally to blend with the fascia over the levator ani muscles. The uterosacral ligaments pull the vagina toward the sacrum, suspending it in front of the rectum.

The perineal body is located between the vaginal opening and anus. It is the attachment for the superficial muscles of the perineum, a portion of the levator ani, the external anal sphincter, and the rectovaginal fascia. Through its attachments to the uterosacral ligaments, the rectovaginal fascia stabilizes the perineal body, which is essentially suspended from the sacrum. The perineal body is further stabilized through indirect attachments to the pubic bones. In turn, the perineal body stabilizes all soft tissue structures of the pelvic interior. Its trampoline-like quality allows the pelvis to distend backward with sudden increases in intraabdominal pressure.

The combined internal and external anal sphincter complex maintains continence of flatus and liquid stool below the level of the puborectalis. The internal anal sphincter is a thickened continuation of the smooth muscle lining of the colon. Unlike the external anal sphincter and puborectalis muscles, the internal anal sphincter is not under voluntary control. The internal anal sphincter is responsible for most of the resting pressure of the anus. Therefore, continence at rest (particularly of liquid stool and flatus) is maintained by the internal sphincter. Continence during sudden rectal distension is provided by the external anal sphincter and puborectalis muscles.

A woman’s symptoms are often suggestive of what elements of the anal continence mechanism are not functioning properly. “For example, fecal urgency (defined as the inability to delay defecation) is a hallmark of injury to the external anal sphincter, whose primary responsibility is emergency control of impending leakage. Fecal soiling can occur with disruption of the external anal sphincter, hemorrhoids, or rectal prolapse. Incontinence of flatus and liquid stool is typically related to internal anal sphincter dysfunction or a rectovaginal fistula. Incontinence of solid stool is usually related to dysfunction of the puborectalis muscle and/or the external anal sphincter.”

Perineal lacerations from vagina to anus are graded according to depth. First-degree injuries include the skin and connective tissue; second-degree injuries cut into and through the perineal body; third-degree injuries extend into but not through the anal sphincter; and fourth-degree injuries go completely through the anal sphincter. By definition, an episiotomy makes a second-degree wound. Damage to the perineal body and anal sphincters results from the practice of episiotomy.

Throughout the history of obstetrics and gynecology the primary argument in favor of episiotomy was that it prevented genital prolapse and urinary incontinence. This framework came under careful scrutiny during the last decades of the 20th century and today it would be difficult to find a representative of medical science who seriously believes episiotomy prevents prolapse. Researchers now understand that destruction of the perineal body and alteration of the puborectalis muscles comprise the first pathophysiologic events in the development of pelvic organ prolapse.

While this has been a crucial step in the right direction, it has only halted or slowed down the rate of “routine” episiotomy. The injurious procedure is still being performed in hospitals throughout much of the developed world. I would argue that modern obstetrics could not exist independently of episiotomy because the cascade of obstetric interventions often necessitates enlarging the vaginal opening. Obstetric practice that anticipated the needs of the laboring woman without drugs or instrumentation would be midwifery.

Just as there has been much confusion and contradiction regarding the usefulness of episiotomy, the information existing in the medical literature on how best to manage old perineal lacerations is misleading at best. Perineorrhaphy is very commonly performed as part of “posterior repair”. The procedure attempts to reconstruct the perineal body by either pulling together the puborectalis muscles or reapproximating the more superficial muscles of the perineum. Surgeons describing the common results of this procedure tell us that “Most so-called levator stitches result only in increased approximation of thinned or separated layers of the perineal body and do not usually result in a buildup of the levator itself…if placed directly into the belly of the levator muscle, these sutures may actually destroy portions of the muscle, eventually resulting in a shelf-like ridge of nonelastic fibrous tissue within the introitus (vaginal opening) and immediately beneath the posterior vaginal wall.”

Many women believe their vagina to be “gaping” after episiotomy, but few understand either the reason for or long term implications of such an injury. “Any perineal laceration which permits the labia minora to retract laterally and expose a gaping vagina harbors the divided and retracted origin of the bulbocavernosus muscle. Such a lesion lowers the efficiency of the voluntary urethral sphincter and should be considered as an etiologic basis for stress incontinence in the female.”

Anal incontinence in the female almost always results from extension of a midline episiotomy into or through the sphincters. Researcher and childbirth educator Henci Gore tells us, “Without exception, the medical literature shows that anal injuries almost never occur except as extensions of an episiotomy.” Given that structural damage to the anal sphincters occurs in about one-third of women following hospital vaginal delivery and 50% of these will experience persistent problems, there are a staggering number of women alive today with symptoms of anal incontinence. These symptoms range from inability to control flatus to incontinence of solid and liquid stool.

Damage to the external anal sphincter is almost always anterior in location and results in a visible loss of the radial folds comprising the sphincter. In fourth degree lacerations, the perineum completely disappears and the vaginal and anal linings come into contact with each other. Women with third degree lacerations generally form a band of perineal scar tissue covering the top of the external anal sphincter. This results in the classic “dovetail” sign due to loss of the anterior radial folds in the sphincter.

Although anal sphincter repair operations are simple in concept, they are fraught with wound complication, tissue breakdown, and failure. Surgeons approach the repair by either approximating the severed muscles end to end or by overlapping them, the former having been generally replaced by the latter because of better outcomes. Reconstruction aims to restore continuity to the external and internal sphincters. However, “There is controversy among surgeons as to whether damage to the internal anal sphincter can be effectively repaired and function restored.”

Analysis of functional results following direct repair of the external anal sphincter reveals the percentage of women remaining incontinent of liquid and solid stool to be approximately 50%. “Correlation of the mechanism of sphincter injury with the functional outcome after repair reveals a diminished likelihood for rendering patients continent for liquid and solid stool after operative injury to the anal sphincter.” Women describe recovery from the operation as extremely painful and difficult. Because of the risk of fistula development from enclosed bacterial contamination, the wound is left open to heal and this requires a high level of post-operative care.

Due to the great degree of uncertainty accompanying these operations surgeons often counsel that not all individuals who are symptomatic require operative repair. “The decision to proceed with repair of anal sphincter injuries is in large measure determined by the extent of disability experienced by the patient. True fecal incontinence should be distinguished from urgency and seepage.” The following questions are helpful in making that distinction.

• Are you able to differentiate flatus from stool?

• Do you have incontinence of flatus only or of stool and flatus?

• Does stool escape from the anal canal or does seepage occur only at the time of a bout of diarrhea?

• Is the material that escapes from the anus truly feces or mucus secretion?

• Are you aware when stool escapes from the anal canal or does the presence of the stool go unnoticed for long periods of time?

• Do you have an urgency to evacuate and, if so, how long can you wait once the urge appears before the actual need to reach the bathroom?

• How much staining do you experience? Is it enough to require the use of a pad or do you have to wear some sort of absorbent underwear?

• “In patients in whom the diagnosis is in doubt, the ability to retain an enema argues strongly against any clinically significant incontinence.”

I would venture a guess that almost all women in the United States who gave birth in hospitals to at least two children before 1983 experience symptoms resulting from gross disruption of the perineum and loss of the ano-rectal angle. This sequela would include some or all of the following: vaginal prolapse, urinary incontinence, extremely thin tissues and little area between vagina and rectum, and for some percentage of women, varying degrees of fecal incontinence.

I would also suggest that the best way to address the damage is by supporting that area naturally through posture and lifestyle, and if necessary external support garments. A huge body of literature reflects extremely high morbidity and failure rates for all the prolapse surgeries, the sphincterplasties and the incontinence procedures.

Although it is very difficult to tell a young mother to live with the terrible rectal pressure that has resulted because her perineum is no longer elastic and distensible, the best person to tell her is the woman whose prolapse ultimately “required” a hysterectomy, four cystocele repairs, five rectocele repairs, a colostomy, colon resection, and more reconstruction of her perineum than she cares to remember.

“I must be careful each day to take just the right amount of bulking agent to control my fecal incontinence. It’s hit and miss so I make sure I’m always wearing adult protection. I manage the pain as best I can with low doses of valium, but when my rectum gets full I must immediately empty it or else my legs become numb.”

I leave the final words to Michel Odent, M.D:

“I have never had to repair the perineum after a real undisturbed foetus ejection reflex. One of the many reasons probably is that in such a context the mother is more often than not bending forward, for example, on hands and knees. In such postures, the mechanism of vulva opening is different from that of other postures. First the anterior part of the vulva opens more quickly; then the deflexion of the head tends to be delayed and, when the face is coming out, the chin is more lateral. I use this opportunity to mention that, if by chance there is a benign tear (usually because there has been no authentic foetus ejection reflex) I do not stitch it. If the mother does not spread her legs at all during the first two weeks (avoiding looking at the perineum, avoiding the lotus posture, etc) the cicatrisation will be perfect.”

Sources:

Dargent et al. Vaginal and Laparoscopic Vaginal Surgery 2004
Brubaker L Saclarides T The Female Pelvic Floor 1996
Rock J Thompson J TeLinde’s Operative Gynecology 1997
Weber et al. Office Urogynecology 2004
Goer H A Thinking Woman’s Guide to a Better Birth 1999
Nichols D Randall C Vaginal Surgery 1989
Benson Female Pelvic Floor Disorders 1992
Odent M The Caesarean 2004

{ 12 comments… read them below or add one }

mamaoftwo May 4, 2014 at 10:25 pm

Hi there,
My story sounds much like some of this article… I had an episiotomy 10 years ago at the tender age of 17.. becoming a mommy so young was hard enough but dealing with a broken sphincter and a recto-vaginal fistula on top of everything has been more difficult over the years. The fistula healed over time but I always have problems with urgency and holding gas. Being a young woman makes the “not much you can do about it” hard to swallow.. I have thought about the surgery to repaìr the sphincter many times but the odds just dont sit well with me.. not at this age.. some days I am totally fine and others are scary.. not being able to travel long distances because of the need for a nearby washroom or going places without washrooms (boats, subways, beaches etc.) Im not even sure what type of diet to try or what would help.. but something would be nice since ive been dealing with this for 10 years and it doesnt seem any better…
Any thoughts would be nice.. this is the most similar article, website etc to my situation.. I haven’t been able to find anything else in all my attempts to search this topic…

Judi January 29, 2013 at 8:23 am

I’ve had a puborectalis repair several times (late ’70s and again in 1996). It completely resolved all my fecal incontinence problems. However, it broke down again when doing extremely heavy work in Sept. 2011. I felt it when it ripped. I know exactly where it is (it was detached from the ischium so one doctor stated). Had mesh installed to no avail. Pain became so bad had to have the mesh removed several month later. I cannot find any physician who will attempt to repair the puborectalis since it has been repaired twice. I cannot discount the 15 years of no pain, no incontinence, complete and total pain free. Please help me find a doctor who will attempt the repair. I have lots of scar tissue from previous surgeries so I’ve been told. I’ve also been told there is a doctor in New Mexico who repairs puborectalis. HELP me find him. would go to the ends of the earth to find relief. Thank you for any help.

bluemama March 14, 2010 at 8:31 pm

Second degree tears
Submitted by bluemama on January 29, 2008 – 4:59am.
Hi-
I’ve recently bought your book (still waiting for it to arrive)- I had a second degree tear when delivering my son at a birth centre 4 years ago- I had his head out underwater in the bath and no midwife in sight to help, just my poor DH who I promptly sent out for a midwife. The only info I got once it was all over, was that I had a second degree tear and that someone would be in to sew it up!

I’m assuming the info above on episiotomy, relates to ‘natural’ tears? I saw a bottom specialist after the birth and there was also no mention of a relationship of splits, hemis, prolapse issues to perineal tearing. In the last 12 months I’ve noticed that toilet trouble has become ‘normal’- that I always have to watch my diet, not strain and push, that more often than not there is blood passing stools, that I hold my breath after to see if the heavy feeling and irritation starts up with my cystourethele. Is this fairly typical?

A diet change, exercise and drinking a lot of water has helped a lot- but sex makes it worse. Does your book cover all of this stuff as well? I had no idea how many of the problems I’ve been experiencing have all been related to the whole pelvic floor area. I saw doctors for IBS symptoms and none of them linked it to the hemis/sphincter problems etc. Some women I’ve talked to have said how they had midwives or nurses tell them to go straight to physio after birth etc- noone ever talked to me about anything other than PND issues! Its so crazy that women are left in the dark about all of this.

My burning question is, have women using these techniques and exercises in your program ever shown signs of these kinds of problems improving even to a slight degree, or is it a case of once the elasticity in the sphincter is gone its gone? Can you stop it from worsening, or as my gyno foretold, does a life of complete incontinence await me down the track?
The hardest part of all this is the not knowing, and the fear that comes with a bad day. And not knowing my body well enough in the first place to understand what it is I’ve lost?! Crazy crazy crazy! Thank you for doing this, putting this site together.
Enormous hugs
bluemama xxoo

Christine March 14, 2010 at 8:31 pm

if men…
Submitted by Christine on November 18, 2007 – 10:21pm.
Dear Hazel,

I’m sorry to hear your story and I understand how frustrated you must feel. Our medical system is in great need of change – particularly in the area of women’s health.

However, I’ve noticed a common thread amongst women who’ve had prolapse surgery that I would like to bring attention to.

It’s very common for women who’ve had one or two or three surgeries, and are still having problems, to curse the condition of prolapse when in fact their chronic and debilitating problems are not prolapse related at all. Rather, they are the result of damaging surgeries (including violent birthing practices) that changed simple prolapse – the same prolapse that women here are learning to live very well with – to disabling conditions that, as you describe, change the course of women’s lives forever.

Please feel free to vent all you want, but it helps all women when we keep things in perspective.

Big hugs,

Christine

Christine March 14, 2010 at 8:31 pm

To Havigotaproblem
Submitted by Christine on November 18, 2007 – 10:10pm.
Dear Haveigotaproblem,

I am so sorry no one ever responded to you! I never saw your message until reading Hazel’s just now. Although I, and our wonderful moderators, try to keep up with all the posts, sometimes one will slip by unnoticed – especially here in my blog section.

In any event, I am sorry I don’t have answers for you. I do know there are wonderful nurse specialists in wound care and long term management of paralysis. I can only wish you well and hope by now you have found help.

Many blessings,

Christine

Hazel March 14, 2010 at 8:30 pm

If men gave birth
Submitted by Hazel on November 18, 2007 – 9:41pm.
I agree. I so wish men could experience the whole pregnancy and childbirth thing. They just don’t understand what it is like to suffer with prolapse and the effects it has on everyday bodily functions. I dread every morning when I have to defecate. It’s difficult, painful, and I always have to resort to enemas. And I am never comfortable all day because of extreme hemorrhoids from pushing and flatus incontinence. I also hesitate to go out very much(I am a stay-home mom of 21 years – thank god), and I resist going on vacations. I go out as little as possible. I feel so restricted. At 53, I thought my life would be a new beginning, especially with the empty-nest coming soon. I have daughters – 19 & 15 years old. Now I feel cheated. I have suffered with this for 15 years, since my last daughter’s vaginal birth. I highly recommend a c-section. Never had an inkling of a problem following that. Anyway, I know I sound so negative, but I also have pain with intercourse since I had all the surgery for the prolapse. That’s been taken away from me, also. All I do now is try to do some sewing to keep myself pre-occupied. My husband and I don’t have any intimacy anymore either. I wish I was a man so that I wouldn’t have had to endure all of this, and it was a man who decided that I should do the vaginal birth rather than a c-section again. I am a very petite woman 4’11″ – 95 lbs, and he told me that the hysterectomy he performed on me was a CHALLENGE to do from the vagina as opposed to an incision. I think he saw the challenge & dollar signs even before he delivered my daughter. I really despise him to this day. I guess I still hold a grudge against him. Sorry, but I needed to vent.

haveigotaproblem March 14, 2010 at 8:30 pm

can you help with this?
Submitted by haveigotaproblem on September 27, 2007 – 9:20pm.
I have been paralysed for over 30 years following damage to my spine at level thoracic or dorsal 10.(T10 paraplegia) I have been in a wheelchair all this time. I have 3 children. Since 1970 I have worn an in dwelling catheter and am experiecing problems-pain bleeding and urine leakage due to the balloon wearing away the bladder wall.

Surgery to put a catheter in supra pubicly is offerd although I am resisting it as much as possible.
I don’t have good muscle function in my lower abdomen but do not want radical surgery. The most horrible things are offered to our patients on spinal wards a mytroughenough-using bowel to enlarge bladder to me is the stuff horror films are made of.

Can you help me and scores of female patients?

Christine March 14, 2010 at 8:29 pm

Western FGM
Submitted by Christine on June 3, 2007 – 8:13am.
There is no question that ALL prolapse surgeries and virtually all episiotomies are the Western form of FGM. However, because these operations developed within the religion of rationalism instead of theism; are carried out under bright lights and within a sterile environment; and are performed “for our own good”, we as a society do not question the absolute barbarism of surgeries that really, from a whole body perspective, are far more deeply damaging than sub-Saharan FGM.

louiseds March 14, 2010 at 8:29 pm

Genital mutilation?
Submitted by louiseds on June 3, 2007 – 2:19am.
Hi Christine

After reading this entry I can’t help comparing female circumcision in other cultures with routine episiotomy in our culture, for the damage it can do to a woman’s body. We abhor female circumcision under any circumstances but routine episiotomy is no doubt still practised with little questioning in some of our western ‘healthcare’ systems, funded by governments and performed by obstetricians who should know better.

Is this a double standard or what?

I can’t help thinking (with my conspiratorial hat on) that if men gave birth it would all happen very differently.

Cheers

Louise

UKmummy March 14, 2010 at 8:28 pm

And it is surely the very
Submitted by UKmummy on April 22, 2007 – 3:47pm.
And it is surely the very prospect of a life time of uncomfortable rectal pressure for a young woman which then leads them towards the surgeons table for even the slightest hope that something can be done.

This all makes me want to weep for so many having to go through this repeatedly with such ill informed and negligent birthing options.

MeMyselfAndI March 14, 2010 at 8:28 pm

Eeps
Submitted by MeMyselfAndI on April 22, 2007 – 11:55am.
I have had 3 children – 2 episiotomies (One for forceps) and one tear

I wish people actually informed people about things BEFORE the fact – Rather than never…

alemama March 14, 2010 at 8:28 pm

clarifying as always
Submitted by alemama on April 22, 2007 – 11:36am.
every time I read your writing I get a deeper understanding of how my anatomy works. Thank you for the well thought out article.

Of course after reading this I feel damned. Is there no hope for us torn and stitched girls?

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