Surgery for female dyspareunia after perineal trauma

Abstract

Perineal trauma during labor and vulvo-vaginal surgery is common and entails pain, dyspareunia, and other quality of life issues. Herein we describe common pitfalls, reconstruction problems and considerations illustrated by two cases. Diagnosis: A thorough conversation with the woman about her history concerning trauma and present symptoms including sex life before the trauma. Examination: Visual traces of the trauma and palpation for persisting trigger points in accordance with the history. CASE 1: Had previously had two operations for Bartholinitis and two operations for vulvo-vaginal fistulas. She had severe external dyspareunia and not been able to engage in intercourse for 1 ½ year when referred. CASE 2: Suffered a total obstetric anal sphincter rupture during first delivery. Primary suturing was performed in the delivery room. The patient suffered from severe dysparunia and soiling during intercourse three months after the delivery. A low perineum and a low rectocele were seen. By 3D ultrasound a very short external anal sphincter was seen. The transverse perineal and bulbocavernose muscle were still torn. Surgery: Removal of scar tissue. Identifying affected anatomical structures. Usually, the superficial and deep transverse perineal muscle, the bulbocavernosus muscle and the rectovaginal fascia are traumatized. Examples of anatomical correct reconstruction are presented. Postoperative: Weekly Low Level Laser therapy (LLLT) for three weeks was applied, and pain killers were used. Scar tissue massage after four weeks. Recommendation of no intercourse for six weeks. After a longer period with dyspareunia, sex is usually connected with an expectation of pain even when the trigger is removed. This is partially caused by strong pelvic muscle contractions. Supportive consultations about sexual issues are usually necessary to obtain a complete recovery with a healed body and mind. Anatomical correct reconstructive surgery after long term dyspareunia is best treated in a bio-psycho-social frame. No conflict of interest