Perineal Lesion Research Articles

Vulval Aggressive Angiomyxoma: A Giant Tumour Arising from Hidradenitis Suppurativa Scars

Abstract Aggressive angiomyxoma (AA) is a very rare tumour arising from the vulvovaginal mesenchymal tissue. The literature has not reported its co-existence with hidradenitis suppurativa (HS). A 30-year-old female presented with a giant pedunculated mass arising from a scarred and disfigured perineum for 3 years. On examination, a giant mass of size 20 × 20 cm was hanging over the scarred and disfigured vulva. The clinical possibilities of AA, leiomyoma or angiomyofibroblastoma over the scars of HS were considered. The histopathological examination of the mass revealed the features of AA, and perineal lesion biopsy was suggestive of HS. The patient was managed with surgical excision of the AA along with oral antibiotics for HS.

A Rare Congenital Perineal Groove

Perineal groove is a rare congenital anomaly characterized by nonepithelialized mucous membrane that appears as an erythematous sulcus in the perineal midline, extending from the posterior vaginal fourchette to the anterior anal orifice. It is one of the uncommon anomalies of anogenital region that is unknown to many clinicians, and it is usually misdiagnosed as an anal fissure, perineal trauma, diaper dermatitis, infection, or sexual abuse. Case Presentation. Seven-day-old female neonate was brought by her parents after they observe reddish discoloration of her genitalia. Upon examination, there was a vertical perineal wet groove-like unkeratinized erythematous lesion with no bleeding, sign of infection, or inflammation that extends from the posterior vaginal fourchette to the anal rim. The newborn was sent home after counseling with a reassessment plan in case of complications. Recognition of the congenital perineal groove at birth is important for the health care providers to deliver an appropriate parental counseling and appropriate follow-up.

Modifiable and non-modifiable risk factors for obstetric anal sphincter injury in a Norwegian Region: a case\u2013control study

BackgroundObstetric anal sphincter injury (OASI) is a common and severe complication of vaginal delivery and may have short- and long-term consequences, including anal incontinence, sexual dysfunction and reduced quality of life. The rate of OASI varies substantially between studies and national birth statistics, and a recent meta-analysis concluded that there is a need to identify unrecognized risk factors. Our aim was therefore to explore both potential modifiable and non-modifiable risk factors for OASI.MethodsWe performed a case–control study in a single center maternity clinic in South-Eastern Norway. Data were extracted retrospectively from an institutional birth registry. The main outcome measure was the occurrence of the woman’s first-time 3rd or 4th degree perineal lesion (OASI) following singleton vaginal birth after 30 weeks’ gestation. For each woman with OASI the first subsequent vaginal singleton delivery matched for parity was elected as control. The study population included 421 women with OASI and 421 matched controls who gave birth during 1990–2002. Potential risk factors for OASI were assessed by conditional logistic regression analyses.ResultsThe mean incidence of OASI was 3.4% of vaginal deliveries, but it increased from 1.9% to 5.8% during the study period. In the final multivariate regression model, higher maternal age and birthweight for primiparous women, and higher birthweight for the multiparous women, were the only non-modifiable variables associated with OASI. Amniotomy was the strongest modifiable risk factor for OASI in both primi- (odds ratio [OR] 4.84; 95% confidence interval [CI] 2.60–9.02) and multiparous (OR 3.76; 95% CI 1.45–9.76) women, followed by augmentation with oxytocin (primiparous: OR 1.63; 95% CI 1.08–2.46, multiparous: OR 3.70; 95% CI 1.79–7.67). Vacuum extraction and forceps delivery were only significant risk factors in primiparous women (vacuum: OR 1.91; 95% CI 1.03–3.57, forceps: OR 2.37; 95% CI 1.14–4.92), and episiotomy in multiparous women (OR 2.64; 95% CI 1.36–5.14).ConclusionsAmniotomy may be an unrecognized independent modifiable risk factor for OASI and should be further investigated for its potential role in preventive strategies.

Effect of New Peripudendal Block (PPB) in the Second Stage of Labour on Perineal Relaxation and on the Reduction of Episiotomy Rate: A Randomized Control Trial

Methods In a prospective randomized study, we examined the extent to which the PPB we developed changed the rate of episiotomies, injury rates. Results A total of 333 primiparas and 324 multiparas were included in the study. In the case of primiparas, we used the PPD procedure in 133 cases, while in the case of multiparas, we used it in 103 cases. The rate of episiotomy in primiparas was 89/133 (66.9%) with PPD and 181/200 (90.5%) without PPD (p < 0.02). In multiparas, the episiotomy rate was 30/103 (29.1%) with PPD and 140/221 (63.3%) without PPD (p < 0.02). In the case of primiparas, the rate of perineal injury and lesion was 33/133 (24.8%) with PPD, while without PPD it was 12/200 (6.0%). Examining the need for all surgical care (due to episiotomy and/or injury), a total of 103/133 cases of operative surgery were required with PPD (77/4%) while 183/200 cases were required without PPD (91.5%)(p < 0.02). In the case of multiparas, the rate of perineal injury and lesion was 11/103 (10.7%) with PPD, while without PPD it was 9/221 (4.1%). In the case of multiparas, a total of 41/103 cases required surgical care with PPD (39.8%), while without PPD, 147/221 cases required surgical care (66.5%)(p < 0.02). Conclusion The PPB is simpler, requires less medication, can be easily mastered, and perineal relaxation can also be observed, reducing the need for an episiotomy.

Preterm Infant of Diabetic Mother with a Retrorectal Mass: A Troubling Tail Tale.

Preterm Infant of Diabetic Mother with a Retrorectal Mass: A Troubling Tail Tale.

Treatment of a Chronic Vulvar Wound by Hyperbaric Oxygen Therapy (HBOT)

We hereby report the case of a 66-year-old obese patient (BMI 30) with type 2 diabetes, who presented a chronic vulvar lesion on the left labia majora following surgical drainage of an abscess. After multiple unsuccessful treatments by antibiotics and local wound care, we proposed a trial of hyperbaric oxygen therapy (HBOT). The patient fully recovered after 54 sessions at 2.5 ATA, 95 minutes each. HBOT has been studied for perineal lesion such as skin atrophy or necrosis caused by irradiation but not for vulvar nonhealing chronic lesions in the case of impaired vascularization caused by diabetes. This case is, to our knowledge, one of the first publications about the healing boost of HBOT in chronic vulvar wounds due to vascular impairment.

Perineal groove: A rare congenital malformation

A 40 + 3-week-old female newborn weighing 2910 g was delivered by cesarean section (CS) due to a previous CS. Apgar score was 9 and 10 at 1 min and 5 min, respectively. Pregnancy history was unremarkable. All prenatal tests were negative, and there was no family history of congenital malformations. During the first physical examination, a perineal lesion characterized by an erythematous midline sulcus with a mucous membrane was noticed, extending from the posterior vaginal fourchette to the anterior anal margin.

Image-guided confirmation of a precision pull-through procedure during laparoscopically assisted anorectoplasty in an open MRI operating theater: first application in an infantile case with anorectal malformation

BackgroundImage-guided surgery with an open magnetic resonance imaging (MRI) system is applied for brain tumors in the neurosurgery field, but has rarely been reported in pediatric surgery. We report our initial experience of intraoperative confirmation of precision rectal pull-through during laparoscopically assisted anorectoplasty (LAARP) in an open MRI operating theater for pediatric patients with anorectal malformation (ARM).Case presentationA 3.0 kg term male neonate was delivered with anorectal malformation. An invertogram revealed the intermediate type. Transverse colostomy was made on the left upper abdomen. The recto-bulbar urethral fistula (RBUF) was diagnosed by a distal colostogram and voiding cystourethrogram. LAARP was planned at 6 months of age. Because this was the first procedure in which the pediatric abdomen had been scanned in an open MRI operating theater in our institution, we scanned his pelvic floor under sedation 3 weeks before the operation using the open MRI system in our operation room. We performed the operation with 4 trocars. The peritoneal reflection was carefully incised and the rectum was dissected. The RBUF was resected. The center of the muscle complex was detected at the perineal skin with an electrical nerve stimulator, and a 7-mm longitudinal skin incision was made on the perineal lesion for anoplasty. The muscle complex and the pubo-rectal sling were confirmed laparoscopically using a 3.5-mm bipolar forceps connected to the electrical nerve stimulator. Anoplasty was performed between the rectal stump and perineal skin. After anoplasty, the patient was scanned with open MRI under general anesthesia. We attached the quadrature-detection (QD) head coil around the patient’s pelvis and inserted him in the gantry. A 0.45-T open MRI clearly revealed that the pulled through rectum was located in the center of the muscle complex on T2-weighted images. The postoperative course was uneventful. Oral intake was started on post-operative day 1. Postoperative dynamic urography showed no complication (e.g., leakage or residual fistula).ConclusionsWe successfully performed LAARP for ARM, with intraoperative confirmation of precision rectal pull-through in an open MRI operating theater. Further cases are required to evaluate the application of open MRI systems in pediatric surgery.

Hemiscrotal agenesis: a novel phenotype of a rare malformation

BackgroundHemiscrotal agenesis (HSA) is an exceedingly rare congenital anomaly in scrotal development. It is characterized by unilateral absence of scrotal skin with intact midline raphe. In the English literature, only seven patients were diagnosed with HSA. Herein, we report a 14-month-old boy with HSA, unilateral cryptorchidism and a perineal skin tag. Additionally, the patient had a monodactylous limb, unilateral cerebellar hypoplasia, and a cardiac septal defect.Case presentationA 14-month-old boy presented with right HSA and ectopic scrotal skin in the right perineal region. Extra-genital examination showed right monodactylous lower limb, without dysmorphic facial features or any other skeletal anomalies. His karyotype was 46, XY, while his hormonal profile showed prepubertal LH and FSH. Skeletal survey showed right monodactylous lower limb (with only a big toe which had 2 phalanges) and normal spine alignment. A previous echocardiography was done and showed a small muscular ventricular septal defect (VSD) that closed on follow-up. Magnetic resonance imaging of the brain showed posterior fossa malformation. The patient had his right testis fixed in the right scrotum. The pathological examination of the perineal lesion showed fibro-epithelial polyp (skin tag), with no testicular tissue or atypia.ConclusionWe believe that this is the first case to be reported with hemiscrotal agenesis and ipsilateral cryptorchidism, associated with a perineal skin tag, unilateral monodactylous lower limb on the same side, unilateral cerebellar hypoplasia, and VSD. Interestingly, further genetic analysis is required to reach a final diagnosis. However, regrettably, advanced molecular diagnostic studies for this patient is not available in our country.

Evaluation of Suzor forceps training by studying obstetric anal sphincter injuries: a retrospective study

BackgroundInstrumental deliveries are an unavoidable part of obstetric practice. Dedicated training is needed for each instrument. To identify when a trainee resident can be entrusted with instrumental deliveries by Suzor forceps by studying obstetric anal sphincter injuries.MethodsA French retrospective observational study of obstetric anal sphincter injuries due to Suzor forceps deliveries performed by trainee residents was conducted from November 2008 to November 2016 at Limoges University Hospital. Perineal lesion risk factors were studied. Sequential use of a vacuum extractor and then forceps was also analyzed.ResultsTwenty-one residents performed 1530 instrumental deliveries, which included 1164 (76.1%) using forceps and 89 (5.8%) with sequential use of a vacuum extractor and then forceps. Third and fourth degree perineal tears were diagnosed in 82 patients (6.5%). Residents caused fewer obstetric anal sphincter injuries after 23.82 (+/− 0.8) deliveries by forceps (p = 0.0041), or after 2.36 (+/− 0.7) semesters of obstetrical experience (p = 0.0007). No obese patient (body mass index> 30) presented obstetric anal sphincter injuries (p = 0.0013). There were significantly fewer obstetric anal sphincter injuries after performance of episiotomy (p < 0.0001), and more lesions in the case of the occipito-sacral position (p = 0.028). Analysis of sequential instrumentation did not find any additional associated risk.ConclusionTraining in the use of Suzor forceps requires extended mentoring in order to reduce obstetric anal sphincter injuries. A stable level of competence was found after the execution of at least 24 forceps deliveries or after 3 semesters (18 months) of obstetrical experience.

Is directed open-glottis pushing more effective than directed closed-glottis pushing during the second stage of labor? A pragmatic randomized trial – the EOLE study

ObjectiveTo compare the effectiveness of directed open-glottis and directed closed-glottis pushing. DesignPragmatic, randomised, controlled, non-blinded superiority study. SettingsFour French hospitals between July 2015 and June 2017 (2 academic hospitals and 2 general hospitals). Participants250 women in labour who had undergone standardised training in the two types of pushing with a singleton fetus in cephalic presentation at term (≥37 weeks) were included by midwives and randomised; 125 were allocated to each group. The exclusion criteria were previous caesarean birth or fetal heart rate anomaly. Participants were randomised during labour, after a cervical dilation ≥ 7 cm. InterventionsIn the intervention group, open-glottis pushing was defined as a prolonged exhalation contracting the abdominal muscles (pulling the stomach in) to help move the fetus down the birth canal. Closed-glottis pushing was defined as Valsalva pushing. MeasurementsThe principal outcome was “effectiveness of pushing” defined as a spontaneous birth without any episiotomy, second-, third-, or fourth-degree perineal lesion. The results in our intention-to-treat analysis are reported as crude relative risks (RR) with their 95% confidence intervals. A multivariable analysis was used to take the relevant prognostic and confounding factors into account and obtain an adjusted relative risk (aRR). FindingsIn our intention-to-treat analysis, most characteristics were similar across groups including epidural analgesia (>95% in each group). The mean duration of the expulsion phase was longer among the open-glottis group (24.4 min ± 17.4 vs. 18.0 min ± 15.0, p=0.002). The two groups did not appear to differ in the effectiveness of their pushing (48.0% in the open-glottis group versus 55.2% in the closed-glottis group, for an adjusted relative risk (aRR) of 0.92, 95% confidence interval (CI) 0.74–1.14) or in their risk of instrumental birth (aRR 0.97, 95%CI 0.85–1.10). Key conclusionsIn maternity units with a high rate of epidural analgesia, the effectiveness of the type of directed pushing does not appear to differ between the open- and closed-glottis groups. Implications for practiceIf directed pushing is necessary, women should be able to choose the type of directed pushing they prefer to use during birth. Professionals must therefore be trained in both types so that they can adequately support women as they give birth.

Hypertrophic genital herpes in an HIV-infected female patient: Imiquimod as an alternative treatment

Herpes Simplex Virus (HSV) is the leading cause of genital ulcers worldwide. In Human Immunodeficiency Virus (HIV) co-infected individuals, rare hypertrophic pseudo-tumoral forms have been described as simulating squamous cell carcinoma or other viral infections such as those caused by Varicella zoster, Molluscum contagiosum and HPV induced lesions. Here, we report a case of hypertrophic genital herpes in an HIV-infected patient effectively treated with surgery and topical 5% imiquimod after the recurrence of lesions. A 45-year-old woman, HIV-positive for 17 years and on regular antiretroviral therapy, presented with a painful 2cm vulvar sessile lesion, a 1cm ulcerated lesion on the clitoral hood, and a slightly elevated lesion in the middle third of the tongue. Excisional biopsy and surgical removal of lesion were performed for histopathological exam. Histopathology of genital lesions showed evidence of chronic lymphoplasmacytic inflammation, intense ulcerated plasmacytosis, and squamous cells displaying HSV cytopathogenic effect. After three months, the patient presented with a new ulcerated perineal lesion. Histopathology showed evidence of chronic ulcerative-vegetative herpetic dermatitis. Consequently, topical 5% imiquimod was administered with successful results. Relapsing character and atypical genital disease evolution with an exophytic pseudotumoral injury have been noted in patients co-infected with HIV and HSV, necessitating anatomopathological recognition for diagnostic confirmation and exclusion of malignancy. Local immunotherapy should be considered as treatment approach.

Comparison of clear cell carcinoma and benign endometriosis in episiotomy scar - two cases report and literature review

BackgroundMalignant endometriosis in an episiotomy scar is rare; only seven cases have been reported previously. Here, we compare two cases of benign endometriosis and clear cell carcinoma.Case presentationThe first case was a 54-year-old woman who presented with a large perineal lesion in her episiotomy scar with high 18F-fluorodeoxyglucose uptake. This location had a history of endometriosis many years ago. She underwent radical excision of the mass and bilateral inguinal lymph node dissection. Histological and immunohistochemical analysis confirmed the presence of clear cell carcinoma arising from endometriosis. Assisted radiotherapy was performed after surgery due to a positive lymph node. No recurrence was detected over a 1-year follow-up period. The second case deals with a 3 × 2 cm mass in the episiotomy scar of a 33-year-old woman. Part of the anal sphincter was resected because of the close proximity of the lesion. Because the disease lay very close to the anus, she received anal sphincter reconstruction combined with mass excision. Pathology result showed typical endometrial glands and interstitial tissues.ConclusionsDeleterious change only happens in patients experiencing perineal endometriosis. Complete excision is crucial for this form of disease; sometimes impairment of the anal sphincter is also necessary. Patients with malignancy required a combination of treatments in order to improve their prognosis.

Une histoire de fesse: cas d'une tuberculose gommeuse de la fesse chez un adulte immunocompétent

La tuberculose est une maladie endémique au Sénégal. Les formes cutanées sont rares et se caractérisent par leur polymorphisme clinique. Elles représentent 2% des localisations extra pulmonaires de la tuberculose. Nous rapportons l'observation d'une gomme tuberculeuse de la fesse révélant une localisation pulmonaire active chez un adulte immunocompétent. Un homme âgé de 47 ans fut admis pour une tuméfaction douloureuse de la fesse droite évoluant depuis quatre ans. L'examen physique notait un placard induré et polyfistulisé fait de nodules confluents avec une émission de pus jaunâtre, siégeant à la face inférointerne de la fesse droite, associé à des adénopathies inguinales bilatérales d'allure inflammatoire. Une tuberculose cutanée était retenue devant l'histologie qui montrait un granulome tuberculoïde et la recherche de BAAR dans le liquide de tubage gastrique qui était positif. La tomodensitométrie thoraco-abdominopelvienne avait montré de multiples micronodules pulmonaires acinaires basals bilatéraux. Les sérologies VIH et VHB étaient négatives. Une guérison était obtenue six mois après un traitement antituberculeux. La tuberculose cutanée se caractérise par son polymorphisme clinique en zone d'endémie. Elle doit aussi être cherchée devant tout placard d’abcès du périnée.

P199 Hidradenitis suppurativa associated with Crohn’s disease: An increased risk of permanent stoma

Hidradenitis Suppurativa (HS) is a chronic cutaneous, inflammatory disease with strong impact on quality of life. Perineal lesions in Crohn’s disease (CD) are frequently observed and may resemble to perineal HS. CD and HS both share an inadequate immune response, to commensal bacteria, in genetically predisposed subjects. The association between these two diseases is more and more described and it appears that HS could negatively influence the prognosis of CD. The aim of our study was to evaluate the impact of HS on CD outcomes. We performed a case–control with 1 on 4 ratio from a mono-centric tertiary centre where 4645 CD were seen between 2003 and 2016. Patients with both CD and HS were matched to CD patients without HS on sex, date of birth (±2.5 years), date of CD diagnosis (±2.5 years), presence of perineal lesion at the time of diagnosis and follow-up quality. HS cases were confirmed after reviewing the medical charts and by a dedicated clinical examination. Each case of HS was characterised by its location and Hurley’s classification. The prevalence of HS was 0.95% through 44 cases identified from the 4645 CD. Of these, 64% had active smoking habits. HS was severe with 80% of patients with Hurley II and III, and was mainly localised in axillary (72%) and perineal (50%) areas. HS was diagnosed after CD in 70% of cases, with a 9 years median between the two diagnosis (IQR 5.25–12.75). In the case–control comparison, HS-associated CD was more active (56% vs. 40% years with active disease, p <0.001) and required more TNF antagonists (39% vs. 23% years spent under anti-TNF, p <0.001) than CD alone. HS-associated CD was also associated with a higher risk of permanent stoma, 16.8% (IQR 7.5–33.3) vs. 2.5% (IQR 0.8–7.4) in the control group (p = 0.002). The univariate and multivariate analysis confirmed HS as an independent risk factor for permanent stoma with a Hazard Ratio of 6.29 [95% CI (2.30–38.33) p <0.001]. Our study shows that HS has a negative effect on CD outcomes with a more active disease and an increased risk of permanent stoma, despite a higher use of anti-TNF antagonists.

Leflunomide in the Treatment of a Pseudotumoral Genital Herpes Simplex Virus Infection in an HIV Patient

The patient is a 52-year-old African American man with a past medical history of HIV infection (on antiretroviral therapy, CD4 count 399 cells/µL, and undetectable HIV viral load) and recurrent genital herpes. While on valacyclovir, the patient presented with four tumorous lesions on the perineum and scrotum. A biopsy specimen stained positively with HSV-1 and HSV-2 immunostains and displayed a lymphoplasmacytic infiltrate. The patient received foscarnet and imiquimod for two weeks with minimal improvement. Based on the previous activity of leflunomide, which has both antiviral and immunomodulatory properties, in cytomegalovirus and herpes simplex infections, leflunomide 20 mg orally twice daily was started. The patient received 23 days of foscarnet, 14 days of topical imiquimod, and 11 days of leflunomide with approximately 80% reduction in the size of the perineal lesion. After nine months on leflunomide there was complete regression of the large perineal lesion and only two small ulcerations remained on the scrotum. Pseudotumoral herpes lesions in HIV patients represent an immune reconstitution event and are poorly responsive to the usual anti-herpes agents. This report demonstrates the successful use of leflunomide in the treatment of an HIV patient with pseudotumoral herpes. Thalidomide has also been used with some success.

Effect of the type of maternal pushing during the second stage of labour on obstetric and neonatal outcome: a multicentre randomised trial—the EOLE study protocol

IntroductionThe scientific data currently available do not allow any definitive conclusion to be reached about what type of pushing should be recommended to women during the second stage of labour....

Perineal Pain Management with Cryotherapy after Vaginal Delivery: A Randomized Clinical Trial.

Introduction Systematic reviews that evaluate the perineal cryotherapy to reduce pain in the vaginal postpartum are inconclusive. Purpose To evaluate clinical effectiveness of cryotherapy in the management of humanized postpartum perineal pain and vaginal edema. Methods A double-bind randomized controlled clinical trial (UTN number: U1111-1131-8433) was conducted in a hospital in Northeastern, Brazil. Women were included following humanized childbirth. All had vaginal deliveries of a single, full-term pregnancy with cephalic presentation. Exclusion criteria included previous perineal lesion, episiotomy during the current delivery, instrumental delivery, uterine curettage and postpartum hemorrhage. In the experimental group, an ice pack was applied six times on the perineum for 20 minutes, reducing the temperature between 10 and 15 ° C, then 60 minutes without exposure to cold. In the non-cryotherapy, a water bag unable to reduce the temperature to this extent was used, compliance with the same application protocol of the first group. Perineal temperature was monitored at zero, 10 and 20 minutes for application in both groups. Evaluations were made immediately before and after the applications and 24 hours after delivery spontaneous, to determine the association between variables. Results A total of 80 women were included in the study, 40 in each group. There was no significant difference in scores of perineal pain and edema between the groups with or without cryotherapy until 24 hours after childbirth. There was no difference between groups when accomplished repeated measures analysis over the 24 hours after delivery, considering the median perineal pain (p = 0.3) and edema (p = 0.9). Perineal cryotherapy did not influence the amount of analgesics used (p = 0.07) and no adverse effect was registered. Conclusion The use of cryotherapy following normal vaginal delivery within the concept of humanized minimally interventionist childbirth had no effect on perineal pain and edema, since it was already substantially lower, nor the need for pain medicaments.

Early pelvic floor muscle training after obstetrical anal sphincter injuries for the reduction of anal incontinence

ObjectivesBetween 0.5 and 5% of vaginal deliveries involve obstetrical anal sphincter injuries (OASIS). Thirty to forty percent of patients with OASIS will suffer from anal incontinence in the subacute postpartum period.The aim of the present study was to assess the effectiveness of early pelvic floor muscle training (PFMT) combined with standard rehabilitation on anal incontinence after vaginal deliveries complicated by OASIS. Study designThe present work was a retrospective quantitative study performed in a tertiary-level maternity hospital. Women with 3rd or 4th degree obstetric tears were included. Women who gave birth between January 1st, 2011 and December 31st, 2012 underwent standard pelvic-perineal rehabilitation within 6–8 weeks postpartum. Women who gave birth between January 1st, 2013 and July 1st, 2014 had early rehabilitation (within 30 days after delivery) followed by the same standard rehabilitation received by the other group. Rehabilitation was performed by physiotherapists specialized in perineology. No electrostimulation was done in early rehabilitation. An in-house-validated modification of the Jorge and Wexner questionnaire was sent by mail to the patients to assess symptoms. The main judgment criterion was anal incontinence to gas, loose stools and/or solid stool. ResultsTwo hundred and thirty patients were diagnosed with OASIS. Nineteen women (8.3%) were lost to follow-up. The intention-to-treat analysis included 211 patients, 109 of whom underwent standard rehabilitation and 102 early rehabilitation plus standard rehabilitation. The two groups were comparable in terms of parity, birth weight, assisted delivery, epidural anesthesia and rates of mediolateral episiotomy. Multivariate analyses adjusted for type of perineal lesion were performed. Early rehabilitation significantly reduced gas leakage: OR 0.51 [0.29–0.90] (p=0.02), liquid stool leakage: OR 0.22 [0.08–0.58] (p=0.02) and urinary stress incontinence: OR 0.43 [0.24–0.77] (p=0.004). ConclusionsWe recommend early (during the first month postpartum) PFMT after vaginal deliveries associated with OASIS. Rehabilitation should be carried out by a physiotherapist specialized in perineology in order to prevent medium-term functional consequences. A longer follow-up may be necessary to confirm the stability of results.

Cryotherapy for the Control of Perineal Pain Following Vaginal Delivery

INTRODUCTION: Perineal pain after vaginal delivery is a common problem reported for many women. Cryotherapy can have a role to prevent or relieve perineal pain. OBJECTIVE: To evaluate the clinical efficacy of cryotherapy in controlling perineal pain and edema after vaginal delivery. METHODS: A sham-controlled, randomized clinical trial conducted in a maternity hospital in Brazil. Women were included after humanized childbirth. All had vaginal deliveries of a single, full-term pregnancy with cephalic presentation. Exclusion criteria were previous perineal lesion, episiotomy during the current delivery, instrumental delivery, uterine curettage, and postpartum hemorrhage. In the experimental group, a crushed ice pack was applied to the perineal region, reducing skin temperature to 10–15°C. In the sham group, a bag of water incapable of reducing skin temperature to this extent was used. Pearson's χ2 test and Fisher's exact test were used, as appropriate, to determine the association between cryotherapy and perineal pain and edema, the use of analgesics, and adverse reactions to the cold therapy. Risk ratios were calculated, together with their 95% confidence intervals, as a measure of relative risk. RESULTS: The groups did not differ significantly regarding perineal pain (P=.33) and edema scores (P=.89) or in the amount of analgesics used. No adverse effect was registered with the use of perineal cryotherapy. CONCLUSION: The use of cryotherapy after normal vaginal delivery within the concept of humanized childbirth had no effect on perineal pain or edema. This study did not include women submitted to common obstetric interventions under the conventional obstetric care model.