perianal injuries for postgraduates

1. PERINEAL INJURIES
Dr. Joysree Saha
Associate Professor
OBGYN,PMC

2. Perineum:
Perineum is a diamond-shaped space that lies below the pelvic floor.
it is bounded by:
 Superiorly: pelvic floor
 Laterally: the pelvic outlet consisting of subpubic angle, ischiopubic rami,
ischial tuerosities, sacrotuberous ligaments and coccyx
 Inferiorly: skin and fascia

3. This area is divided into two triangles by transverse muscles of perineum and base
of urogenital diaphragm:
Anteriorly- Urogenital triangle.
Posteriorly- Anal triangle
Most of the support of perineum is provided by
pelvic and urogenital diaphragms.

5. Perineal Body:
• The median raphe of levator ani between the anus and vagina, is
reinforced by the central tendon of the perineum.
• Bulbocavernosus, superficial transverse perineal and external anal
sphincter muscles also converge on the central tendon.
• These muscles contribute to perineal body, which provides much
support to perineum.

6. • Blood supply to perineum:
Major blood supply is by
internal pudental artery and
its branches- inferior rectal
artery and posterior labial
artery.

7. • Nerve Supply is primarily via
pudendal nerve (S2,S3,S4)
and its branches.

8. Perineal Tears

9. Causes and Predisposing Factors:
• Lacerations of perineum are the result of overstreching or too rapid streching
of the tissues, especially if they are poorly extensile and rigid.
• Perineal injuries are more common in primigravida than multigravida.
• Obstetric injuries:
Malpresentations such as breech
Contracted pelvic outlet
spontaneous labour
operative vaginal deliveries( forceps or vaccum)
Macrosomic babies
• Non-obstetric injuries: rape, molestation, fall, accidental injuries like RTA,
bull horn injuries etc.

10. Degrees of Perineal tear
First degree- limited to vaginal mucosa and skin of the introitus.
Second degree- extends to the fascia and muscles of the perineal body.
Third degree- trauma involves the anal sphincter.
Fourth degree - extends into the rectal lumen, through the rectal
mucosa.
• A rare type of tear is central tear of the perineum when the head penetrates
first through the posterior vaginal wall, then through the perineal body and
appears through the skin of the perineum. It usually occurs in patients with
contracted outlet.

11. FIRST DEGREE PERINEAL TEAR
 Involve the fourchette, perineal
skin, and vaginal mucous
membrane but not the underlying
fascia and muscle.
 These included periurethral
lacerations

12. SECOND DEGREE PERINEAL TEAR
• Involve, in addition, the fascia
and muscles of the perineal
body but not the anal sphincter.
These tears usually extend
upward on one or both sides of
the vagina, forming an
irregular triangular injury

13. THIRD DEGREE PERINEAL TEAR:
• Extend farther to
involve the anal
sphincter

14. FOURTH DEGREE PERINEAL TEAR:
• Extends through the rectum's mucosa to expose its lumen

15. Symptomatology:
• Immediate:
• Bleeding Traumatic PPH - hemorrhagic shock.
• Perineal Pain
• Perineal hematoma
• Urinary retention due to painful perineum
• Urinary incontinence
• Anorectal dysfunctions like fecal incontinence
• Delayed:
1. Infected perineum- perineal abscess
2. Uterovaginal prolapse
3. Urinary incontinence (stress and urinary fistula)
4. Fecal incontinence ( rectovaginal fistula)
5. Dyspareunia
6. Feeling of slack vagina during coitus
• Bleeding
• Disruption of anatomical continuity

16. How to recognize:
• Put the patient in extended lithotomy position.
• Arrange proper spottless bright light.
• Arrange for vaginal pads instruments like ant. and post. vaginal retractors , urinary cathter,
sponge holders, curved and straight artery clamps.
• Vulva should be examined stepwise right from clitoris to the anus downwards, laterally
paraclitoral, paraurethral, paravaginal and pararectal skin and muscles in every case after
delivery.
• Perineal tears may be associated with high vaginal circular tears and tears in the fornix and
cervix.
• One should suspect traumatic PPH due to perineal tears when continuous bleeding p/v
persisting even after delivery of placenta when uterus is contracted and retracted.
• All lacerations exceeding half inch in depth should be immediately repaired and individual
bleeder should be ligated separately.

17. PERINEAL TEARS (1st
& 2nd
degree)&
EPISIOTOMY (induced 2nd
degree) REPAIR
Prerequisites:
Should be repaired immediately after delivery of the placenta (if not possible, within 24 hours of
delivery.)
per light with good exposure
Good analgesia
Good assistance
Prefer blunt needle
Chromic catgut 2-0
polyglactin 910
First step is to define the limits of the lacerations, which includes vagina as well as
perineum.

18. TECHNIQUE
• All tears that are bleeding should be
identified and ligated separately.
• The stitching starts from the apex of
vaginal mucosa using polyglactin
stitch with continuous or interrupted
sutures.
• The muscles are stitched using the
same stitch taking full thickness of the
muscle and achieving hemostasis.
• The skin is stitched with interrupted
sutures.

19. THIRD AND FOURTH DEGREE REPAIR:
OBSTETRICALANAL SPHINCTER INJURIES(OASIS)
Prerequisites:
 Written consent
 General anesthesia/spinal anesthesia/epidural analgesia
 Operation theatre
 Trained obstetrician
 Good light, Good assistance
 Proper instrument and sutures

20. REPAIR:(RCOG)
Immediately (within 24 hours)
If >24 hours then repair at 6 weeks.
As accurate an approximation as possible of all the tissues should be
secured and no dead spaces are left.

21. Equipment for Repair:
• Sterile drapes & gloves
• Needle holder
• Suture scissors
• Forceps with teeth
• Allis forceps
• 10ml syringe with 22 guage needle
• 1% lidocaine
• 3-0 polyglactin 901 (Vicryl) suture for Vaginal mucosa, perineal muscle, skin
sutures
• 2-0 polydiaxone sulfate (PDS) suture (external sphincter sutures)

22. Surgical strategy
• Identification of additional birth injuries and exact classification of the
perineal tear by means of speculum inspection and digital rectal
examination.
• If necessary, first management of cervical and high vaginal tears (from
the top down), and then management of the perineal tear is done.
• For 4th degree tears: repair anorectal epithelium with atraumatic, 3–0,
end-to-end sutures
• If the edges of the torn internal anal sphincter can be identified
approximate the edges with atraumatic interrupted mattress sutures,
preferably 3–0.

23. CONT.
• Identification of the edges of the external anal sphincter muscle and
gripping them with Allis clamps.
• Suture of the external anal sphincter muscle with atraumatic U sutures
– preferably with thread size 2–0. (two methods: Overlapping
technique and the end-to-end technique.)
• When obstetric anal sphincter repairs are being performed, the burying
of surgical knots beneath the superficial perineal muscles is
recommended to minimise the risk of knot and suture migration to the
skin.
• Layer-by-layer management of the perineum.

25. END TO END teqnique Overlapping technique

27. CHOICE OF SUTURE MATERIAL:
• When repair of EAS muscle is being performed either monofilament
sutures such as polydiaxonone or modern braided sutures such as
vicryl used.
• When repair of IAS muscle is being performed,PDS 3-0 and 2-0 vicryl
causes less irritation and discomfort.

28. POSTOPERATIVE MANAGEMENT:
• Use of broad spectrum antibiotics is recommended following
repair of OASIS to reduce the risk of postoperative infection
and wound dehiscence.
• Postoperative laxatives
• Seitz bath BD.
• Analgesics
• Bulking agents should not be give with laxatives
• Physiotherapy and pelvic floor exercises 6-12 weeks after
repair.

29. Follow-up
• history of symptoms of anal incontinence.
• inspection of the perineum
• vaginal and rectal palpation
• Information about a possibly long latency onset/worsening of the
symptoms of anal incontinence
• discussion regarding subsequent pregnancies and births
• If patient is experiencing incontinence or pain on follow up refer
to a special gynaecologists or colorectal surgeon and anorectal
manometryshould be considered.

30. Sequel of obstetric perineal laceration:
Chronic perineal pain
Dyspareunia
Urinary & fecal incontinence

31. Prevention
• Timely episiotomy should be given in all primigravida, vacuum and
forceps delivery, breech delivery and breech extraction done after IPV,
rigid perineum in multigravida or previous cases with history of
perineal tears.
• Proper support of perineum at the time of crowning and expulsion of
head.

32. Conclusion
• More common in Primigravida than Multigravida.
• Gross injury is due to mismanaged 2nd
stage of labor.
• After vaginal birth a 3rd or 4th degree perineal tear must
be excluded.
• Perineal tear should be repaired immediately after
delivery of the placenta.
• Clinicians should be aware, however, that risk factors do
not allow the accurate prediction of OASIS.

36. Complications if left untreated
• Infection
• Hemorrhagic Shock
• Cosmetic disadvantage
• 3rd
and 4th
degree tears if left untreated may lead to fecal
incontinence.