After vaginal delivery, the vagina, perineum, and anorectum are examined to identify and repair significant injuries. In particular, occult injury to the anal sphincter complex occurs frequently at the time of an otherwise uncomplicated delivery and, if neglected, can contribute to anal and fecal incontinence . Even when recognized and repaired, persistent sphincter dysfunction is considered to be the most common cause of postpartum anal incontinence [2,3].
Evaluation and repair of episiotomy incisions and perineal lacerations associated with childbirth will be reviewed here. Evaluation and management of vaginal lacerations are discussed separately. (See "Evaluation and management of lower genital tract trauma in women", section on 'Vagina'.)
The muscles of the female pelvic floor and perineum are shown in the following figures (figure 1 and figure 2). The anorectal sphincter complex is comprised of two structures with different, but overlapping, roles for maintaining continence (figure 3). The external anal sphincter (EAS) is a thick, circular, predominantly striated muscle that surrounds the anal orifice, and is responsible for continence of solid and liquid stool, as well as flatus, both at rest and at times of rectal distension. The internal anal sphincter (IAS) lies between the external sphincter and the anal canal and represents a thin condensation of the longitudinal smooth muscle fibers of the colon submucosa (figure 3). The IAS extends more than a centimeter above the cephalad margin of the external sphincter . It is entirely under involuntary control and contributes to maintaining anal continence at rest . The puborectalis portion of the levator ani complex also plays an important role in continence of solid stool. An intact pudendal nerve appears to be important, as well.
In 1999, Sultan proposed refining the traditional classification system for obstetric perineal lacerations . The revised system provided a subclassification for third degree lacerations:
- First degree lacerations involve injury to the perineal skin and vaginal epithelium only. The perineal muscles remain intact.
- Second degree lacerations extend into the fascia and musculature of the perineal body, which includes the deep and superficial transverse perineal muscles and fibers of the pubococcygeus and bulbocavernosus muscles. The anal sphincter muscles remain intact.
- Third degree lacerations extend through the fascia and musculature of the perineal body and involve some or all of the fibers of the EAS and/or the IAS.
Third degree lacerations are subclassified as follows: