Still Suffering From that Long-Ago Episiotomy?

December 18, 2011
HealthyWoman from Bottom Line
Dana R. Gossett, MD, MSCI (master of science in clinical investigation)

More than 20 years have passed since my friend Jillian last gave birth, but she still cringes at the thought of her episiotomy, a surgical incision made to widen the vaginal opening during childbirth. Given the embarrassing and painful health problems she has suffered since her episiotomy, she was gratified when I told her that the practice is on the wane.

New report: According to the Agency for Healthcare Research and Quality, there was a 60% decrease in the use of this procedure between 1997 and 2008. Why the change? Although in special circumstances the procedure may be appropriate, recent studies show that routine episiotomy usually has no benefits for mother or baby. In fact, making a cut may increase a mother’s chances of getting a severe tear in the perineum (the tissue between the vaginal opening and anus) during delivery.

The change in routine protocol is good news for today’s new moms. But what about women who had their children—and their then-routine episiotomies—decades ago? For some, episiotomy-related complications have led to ongoing problems with fecal incontinence (impaired bowel control) and/or painful intercourse. A woman may develop symptoms after giving birth and continue to suffer, constantly or intermittently, for years (as Jillian has)… or her symptoms may arise or return in midlife or later, triggered by hormonal changes and/or muscle weakening associated with aging.

I contacted Dana R. Gossett, MD, MSCI, chief of the division of general obstetrics and gynecology at Northwestern University Feinberg School of Medicine in Chicago, to discuss solutions to episiotomy-related health problems.

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Fecal Incontinence

Dr. Gossett explained that a very large tear in the perineum can damage the anal sphincter (the muscle surrounding the anus), compromising bowel control. There are three basic levels of fecal incontinence—when the person can hold in stool but not gas… when she can hold solid stool but not diarrhea… or when she cannot hold in stool at all.

Self-help strategies target the muscles of the anus, perineum and pelvic floor. The muscles of the pelvic floor form a sling to hold pelvic organs in place, allowing the organs—including those that control bowel function—to work properly. Try the following…

Do two types of Kegel exercises daily. You know that Kegels improve urinary control—but they also improve bowel control, Dr. Gossett noted, if in addition to squeezing your pelvic floor muscles (the ones used to halt your urine stream), you also focus your squeeze on the muscles of the anus and buttocks (as if trying to stop stool from passing). Exercise #1: Squeeze your anal and pelvic floor muscles and hold for five seconds… relax. Repeat 10 times. During the course of the day, do 10 sets of 10 squeezes. Exercise #2: Do a chain of 10 quick squeezes, holding for one second and then releasing for one second. Do this 10 times daily. You should start to see improvement after a few weeks, Dr. Gossett said.

Sit, don’t “hover,” in public restrooms. Squatting puts undue pressure on pelvic floor muscles, compromising them further.

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Avoid constipation. You may think that being a bit constipated would aid bowel control, but straining on the toilet puts pressure on pelvic floor muscles. Helpful: Eat more fiber from fruits, vegetables and whole grains… drink plenty of fluids… limit fats and processed foods… and get regular exercise.

If the above steps do not relieve your symptoms…

Consider pelvic floor physical therapy. The effects of this targeted form of physical therapy (PT) can be “quite miraculous,” Dr. Gossett said. (And Jillian told me that pelvic floor PT helped her immensely.) Treatment sessions may include…

  • Instruction in additional exercises that strengthen the pelvic floor and anal sphincter.
  • Biofeedback, which aims to improve the strength and coordination of anal muscles and increase awareness of rectal sensations. A pressure probe placed in the anus or a sensing electrode on the skin is attached to a visual or sound display that tells you when you are succeeding in engaging the right muscles.
  • Percutaneous tibial nerve stimulation, in which a fine needle electrode inserted into the leg sends an electrical pulse through the nerves that affect pelvic floor muscles, improving their function.

To find a practitioner: Visit the Web site of the American Physical Therapy Association at www.apta.org, click on “Find a PT,” then search the “women’s health” practice area.

Talk to your doctor about surgery. If fecal incontinence does not respond to other therapies, options may include surgical repair of the anal sphincter or construction of an internal sling to support pelvic organs that have dropped from their normal position. New: The FDA recently approved an implanted device called InterStim, which uses mild electrical stimulation (like a pacemaker) of the sacral nerves that affect pelvic muscles to improve bowel control.

Referrals: You can find a specialist in urogynecology and female reconstructive surgery through the American Urogynecologic Society (www.augs.org).

Painful Intercourse

Another possible long-term consequence of episiotomy is pain during sex. That’s because scar tissue can form at the incision site… and scar tissue is inflexible. Symptoms often worsen at menopause, when the effects of scarring combine with reduced lubrication due to declining estrogen. Surgery is not the answer because it generally produces more scar tissue, Dr. Gossett said. What can help…

Use a long-lasting nonprescription vaginal moisturizer, such as Replens, several times per week (not just during sex).

Do Kegels. While they do not address the scar tissue problem directly, Kegels may help make sex more pleasurable overall by intensifying orgasms.

Try pelvic floor PT. This therapy can incorporate perineal massage techniques that help soften and release old scar tissue, Dr. Gossett said.

Bottom line: Don’t give up. With the right treatment, you can overcome—at long last—the lingering effects of that long-ago episiotomy.