Perineorrhaphy successful for treatment of poorly healed second-degree perineal laceration

Reference

Bergman I, Westergren Söderberg M, Ek M. Perineorrhaphy compared with pelvic floor muscle therapy in women with late consequences of a poorly healed second-degree perineal tear. Obstet Gynecol 2020;135(2):341-351.

Synopsis

In this randomized controlled trial from a single center in Sweden, the investigators allocated (concealed) 70 women with symptoms of pelvic floor dysfunction to surgical treatment or pelvic floor muscle exercise therapy. Included women had bothersome perineal dysfunction symptoms and a history of childbirth at least 6 months prior to enrollment, with second-degree perineal tear and a "thin perineal body." The latter was defined as less than 2-cm thickness on bidigital palpation of the perineal body adjacent to the anal sphincter. The researchers also used ultrasound with a probe perpendicular to the vaginal wall at the perineal level to confirm that the bulbocavernosus and the superficial perineal muscles were partially or completely detached from the perineal body. Women were excluded for a long list of reasons, including principally, history of more severe perineal trauma or surgery and any conditions that would interfere with healing, such as connective tissue disease or diabetes. Although the study was not masked, a physician other than the surgeon performed the baseline and follow-up assessments. Surgical treatment consisted of perineorrhaphy and distal posterior colporrhaphy. The control condition was referral to a physical therapist for instruction on correct performance of pelvic floor muscle exercises with 1 to 3 follow-up visits. The primary study outcome was the score on the Patient Global Impression of Improvement Scale, a validated questionnaire for assessing outcomes after incontinence and prolapse interventions. Intention-to-treat analysis of the 6-month follow-up assessment showed women in the surgical treatment group responded that their symptoms were "much better" or "very much better" significantly more often than women in the control group (25/35 [71%] vs 4/35 [11%]; odds ratio 19; 95% CI 5 - 69; number needed to treat = 2; 1 - 3). All questionnaire subscale scores were significantly improved in the surgical treatment group (eg, incontinence, sexual function). The only exception was gas incontinence, which was common at baseline (49%) and did not improve in either group.