Perineoplasty is a surgical repair of the perineum, the area between the vaginal opening and the anus, usually performed when childbirth tears or an episiotomy have healed poorly. It aims to rebuild the perineal body, reduce gaping of the vaginal opening and relieve scar pain. It is typically considered after pelvic floor therapy and only once tissues have fully recovered from birth.
What is the perineum and why does it matter?
The perineum is the area of skin and muscle between the vaginal opening and the anus. Beneath the skin lies the perineal body, a fibromuscular centre where several pelvic floor muscles meet, including the bulbospongiosus, the superficial transverse perineal muscles and fibres of the external anal sphincter. This central structure supports the lower vagina and helps maintain the shape of the vaginal opening. Anatomical studies, including classic work by DeLancey on pelvic support, highlight the perineal body's role in the overall support of the pelvic floor.
How childbirth damages the perineum
Most women who have a vaginal birth experience some degree of perineal trauma. Tears are classified by depth:
- First-degree: injury to the skin only
- Second-degree: injury to perineal muscles but not the anal sphincter
- Third-degree: injury involving the anal sphincter complex
- Fourth-degree: injury extending through the sphincter into the lining of the rectum
An episiotomy is a deliberate cut to enlarge the vaginal opening during delivery. Most tears and episiotomies are repaired immediately after birth and heal well. However, some heal with a thin, separated or scarred perineal body, particularly after infection, wound breakdown or large tears.
Symptoms that may lead to perineoplasty
Women considering perineoplasty commonly report one or more of the following:
- A feeling that the vaginal opening is wide or gaping
- Reduced friction or sensation during intercourse
- Pain or tightness at a scar, especially with sex (dyspareunia)
- Visible scar tissue, skin tags or an irregular perineum
- Air or water entering the vagina during exercise or bathing
- Difficulty keeping tampons in place
Bowel symptoms such as urgency, leakage of gas or stool may indicate an anal sphincter injury. These need specialist assessment, sometimes with endoanal ultrasound, and may require a sphincter repair rather than, or in addition to, perineoplasty.
How is the perineum assessed?
- The doctor takes a detailed history of births, tears, repairs and current bladder, bowel and sexual symptoms.
- An examination evaluates the perineal body, scar tissue, the size of the vaginal opening and pelvic floor muscle strength.
- The pelvic floor is checked for prolapse, since a weak back wall of the vagina (rectocele) often coexists with perineal damage.
- If bowel symptoms are present, anal sphincter testing or imaging may be arranged.
- Non-surgical options are discussed and a plan is agreed based on symptoms, goals and future pregnancy plans.
First-line treatment: pelvic floor physiotherapy
For many women, symptoms improve with conservative care. Pelvic floor muscle training supervised by a specialist physiotherapist is recommended as first-line treatment for many pelvic floor problems, and the evidence base is supported by Cochrane reviews. Physiotherapy may also include scar massage, biofeedback and help with painful intercourse. Lubricants and, for breastfeeding or menopausal women with dryness, vaginal moisturisers or low-dose vaginal estrogen can improve comfort. Most clinicians recommend at least several months of conservative management before surgery.
How is perineoplasty performed?
The operation is usually performed under general or regional anesthesia, or sometimes local anesthesia with sedation, and generally takes about an hour.
The surgeon typically removes scarred or excess skin in a diamond or triangular shape at the back of the vaginal opening. The separated perineal muscles are then identified and brought back together in the midline to rebuild the perineal body. The vaginal lining and skin are closed with dissolvable stitches. If a rectocele is present, a posterior vaginal wall repair may be performed at the same time.
A key surgical principle is to avoid over-tightening. Making the vaginal opening too narrow is a recognised cause of long-term pain with intercourse, so the aim is to restore normal anatomy rather than to create a very tight opening.
Who is a suitable candidate?
Perineoplasty is generally considered for women who have persistent symptoms despite an adequate trial of physiotherapy, whose examination confirms a damaged or scarred perineal body, and who are in good general health. Ideally, the woman has completed her family or understands the effect of future births. It is less suitable when the main problem is pain without structural damage, because conditions such as vestibulodynia or pelvic floor muscle overactivity are better treated without surgery. Smoking, uncontrolled diabetes and active infection increase the risk of poor wound healing and should be addressed first. A clear discussion of goals is essential, because surgery can restore anatomy but cannot guarantee changes in sensation or sexual satisfaction.
Recovery after perineoplasty
Recovery usually involves:
- Pain and swelling for the first one to two weeks, managed with pain relief and cold packs
- Keeping stools soft with fluids, fibre and sometimes laxatives to avoid straining
- Rinsing the area after using the toilet and patting dry
- Avoiding heavy lifting and strenuous exercise for around six weeks
- Avoiding intercourse and tampons for six to eight weeks, or until a doctor confirms healing
Many women return to office work within one to two weeks. The scar continues to soften for several months.
Risks and limitations
Possible complications include bleeding, infection, wound breakdown, painful scarring, narrowing of the vaginal opening, persistent or new pain with intercourse, and in rare cases injury to the rectum. Results are generally reported positively in the literature, but studies are mostly small and observational. Future vaginal births may cause new perineal injury, so many surgeons recommend postponing elective perineoplasty until a woman has completed her family.
Frequently asked questions
Is perineoplasty the same as vaginoplasty?
Not exactly. Perineoplasty repairs the perineum and the entrance of the vagina, while vaginoplasty typically tightens the vaginal canal itself. The two are often combined after childbirth.
How soon after birth can I have perineoplasty?
Most surgeons recommend waiting at least six to twelve months after birth and after breastfeeding, to allow natural healing and a trial of physiotherapy.
Will perineoplasty improve sex?
For women whose symptoms come from scar pain or a gaping vaginal opening, many report improved comfort and satisfaction. However, results vary and sexual function depends on many factors beyond anatomy.
Can I have another vaginal birth after perineoplasty?
It is usually possible, but a later vaginal birth can cause new tears. Discuss delivery options with your obstetrician, especially if you previously had a severe tear.
Does a third- or fourth-degree tear need different treatment?
Yes. These involve the anal sphincter and need specialist assessment of bowel control. Treatment may include physiotherapy or sphincter repair in addition to perineal reconstruction.
References
- Royal College of Obstetricians and Gynaecologists. Green-top Guideline No. 29: The Management of Third- and Fourth-Degree Perineal Tears, 2015.
- American College of Obstetricians and Gynecologists. Practice Bulletin No. 198: Prevention and Management of Obstetric Lacerations at Vaginal Delivery, 2018.
- DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. American Journal of Obstetrics and Gynecology, 1992.
- Cochrane Database of Systematic Reviews. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women, Woodley SJ et al.
This article is for general education and does not replace an examination by a qualified gynecologist. Individual results vary, and every procedure carries risks.
