COMPLETE PERINEAL

TEAR
BY
Dr.D.V.RATNAM

Perineum
Diamond shaped area between the thighs.
It is bounded by the pubic symphysis anteriorly,
ischiopubic rami and ischial tuberosities anterolaterally,
sacrotuberous ligaments posterolaterally, and coccyx
posteriorly.

An arbitrary line joining the ischial tuberosities divides the

perineum into an anterior triangle, also called the urogenital
triangle, and a posterior triangle, termed the anal triangle.

The perineal body is a fibromuscular mass found in the

midline at the junction between these anterior and posterior
Triangles.
Also called the central tendon of the perineum.
It measures 2 cm tall and wide and 1.5 cm thick.

 It serves as the junction for several structures

and provides significant perineal support .
Superficially, the bulbocavernosus, superficial
transverse perineal, and external anal sphincter
muscles converge on the central tendon.
More deeply, the perineal membrane, portions of
the pubococcygeus muscle, and internal anal
sphincter contribute .
The perineal body is incised by an episiotomy
incision and is torn with 2nd-, 3rd-, and 4thdegree lacerations.

Anterior Triangle

This triangle is bounded by the pubic rami superiorly, the

ischial tuberosities laterally, and the superficial transverse
perineal muscles posteriorly.
It is divided into superficial and deep spaces by the perineal
membrane.
This membranous partition is a dense fibrous sheet that was
previously known as the inferior fascia of the urogenital
diaphragm.

Superficial Space of the Anterior

Triangle
The superficial space of the anterior
triangle is bounded deeply by the
perineal membrane and superficially
by Colles fascia.
closed compartment infection or
bleeding within it remains contained.

This superficial
pouch contains
several
important
structures, which
include the
Bartholin glands,
vestibular bulbs,
clitoral body and
crura, branches
of the pudendal
vessels and
nerve, and the
ischiocavernosus
,
bulbocavernosus,

Deep Space of the Anterior Triangle

This space lies deep to the perineal membrane and extends up
into the pelvis .
In contrast to the superficial perineal space, the deep space
is continuous superiorly with the pelvic cavity .
It contains portions of urethra and vagina, certain portions of
internal pudendal artery branches, and the compressor urethrae
and urethrovaginal sphincter muscles, which comprise part of
the striated urogenital sphincter complex.

Posterior Triangle
This triangle contains the ischioanal
fossae, anal canal, and anal sphincter
complex, which consists of the
internal anal sphincter, external anal
sphincter, and puborectalis muscle.
Branches of the pudendal nerve and
internal pudendal vessels are also
found within this triangle.

Ischioanal Fossae
Also known as ischiorectal fossae,
These two fat-filled wedge-shaped spaces are found on
either side of the anal canal and comprise the bulk of the
posterior triangle.

 Each fossa has skin as its superficial base,

whereas its deep apex is formed by the junction
of the levator ani and obturator internus muscle.
Other borders include: laterally, the obturator
internus muscle fascia and ischial tuberosity;
inferomedially, the anal canal and sphincter
complex; superomedially, the inferior fascia of
the downwardly sloping levator ani; posteriorly,
the gluteus maximus muscle and sacrotuberous
ligament; and anteriorly, the inferior border of
the anterior triangle.

 The fat found within each fossa provides support to

surrounding organs yet allows rectal distention during
defecation and vaginal stretching during delivery.
Clinically, injury to vessels in the posterior triangle
can lead to hematoma formation in the ischioanal
fossa, and the potential for large accumulation in
these easily distensible spaces.
Moreover, the two fossae communicate dorsally,
behind the anal canal.
This can be especially important because an
episiotomy infection or hematoma may extend from
one fossa into the other.

Anal Sphincter Complex

Two sphincters surround the anal
canal to provide fecal continence
the external and internal anal
sphincters.
Both lie proximate to the vagina, and
one or both may be torn during
vaginal delivery.

The internal anal sphincter (IAS) is a distal continuation of the

rectal circular smooth muscle layer.
It receives predominantly parasympathetic fibers, which pass
through the pelvic splanchnic nerves.
Along its length, this sphincter is supplied by the superior,
middle, and inferior rectal arteries.

 The external anal sphincter (EAS) is a striated

muscle ring that anteriorly attaches to the
perineal body and that posteriorly connects to
the coccyx via the anococcygeal ligament.
The EAS maintains a constant resting
contraction to aid continence, provides
additional squeeze pressure when continence is
threatened, yet relaxes for defecation.
Traditionally, the EAS has been described as
three parts, which include the subcutaneous,
superficial, and deep portions.

 The external sphincter receives blood

supply from the inferior rectal artery, which
is a branch of the internal pudendal artery.
Somatic motor fibers from the inferior
rectal branch of the pudendal nerve supply
innervation.
Clinically, the IAS and EAS may be
involved in 4th-degree laceration during
vaginal delivery, and reunion of these rings
is integral to defect repair.

PERINEAL TEARS
The following classification described
by Sultan has been adopted by the
International Consultation on
Incontinence and the RCOG:

First-degree tear: Injury to perineal

skin and/or vaginal mucosa.

Second-degree tear: Injury to perineum

involving perineal muscles but not
involving the anal sphincter

Bulbocavernos
us m.
Superficial
transverse
perineal m.

Third-degree tear: Injury to perineum involving

the anal sphincter complex.

Grade 3a tear: Less than 50% of external anal

sphincter (EAS) thickness torn.
Grade 3b tear: More than 50% of EAS thickness
torn.
Grade 3c tear: Both EAS and internal anal
sphincter (IAS) torn .

External
anal
sphincter

Fourth-degree tear: Injury to perineum

involving the anal sphincter complex (EAS
and IAS) and anorectal mucosa.

External
anal
sphincter

Internal anal
sphincter

Rectal
mucosa

Rectal buttonhole tear;

If the tear involves the rectal mucosa
with an intact anal sphincter
complex, it is by definition not a
fourth-degree tear. This has to be
documented as a rectal buttonhole
tear.
If not recognised and repaired, this
type of tear may lead to a
rectovaginal fistula.

 Third- and fourth-degree lacerations

are considered higher-order
lacerations.
The incidence of higher-order
lacerations varies from 0.25 to 6 %.

RCOG GREEN TOP GUIDELINE

June 2015

Risk factors

1. BW > 4.0 kg
2. Persistent OP position
3. Nulliparity

4. Asian ethnicity
5.
6.
7.
8.
9.

Epidural analgesia
Prolonged second stage ( > 1 hour)
Shoulder dystocia
Midline episiotomy
Forceps delivery

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

Identification of obstetric anal

sphincter injuries
All women having a vaginal delivery
are at risk of sustaining OASIS or
isolated rectal buttonhole tears.
They should therefore be examined
systematically, including a digital
rectal examination, to assess the
severity of damage, particularly prior
to suturing.

 According to NICE perineal care guidance,

before assessing for genital trauma,
healthcare professionals should:
Explain to the woman what they plan to do
and why
offer inhalational analgesia
Ensure good lighting
position the woman so that she is
comfortable and so that the genital
structures can be seen clearly.

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.

 A rectal examination to assess whether there has

been any damage to the external or internal anal
sphincter if there is any suspicion that the perineal
muscles are damaged .
Since the introduction of endoanal ultrasound,
sonographic abnormalities of the anal sphincter
(occult injuries) have been identified in 33% of
women following vaginal delivery.
However, when endoanal ultrasound was
performed immediately following delivery, the
detection rate of OASIS was not significantly
increased compared with clinical examination alone.

Repair of complete perineal

tear
Two methods are used to repair a
laceration involving the anal
sphincter and rectal mucosa.
The first is the end-to-end technique,
and the second is the overlapping
technique.

End-to-end technique
Approximation of the
anorectal mucosa and
submucosa in a running or
interrupted fashion using
fine absorbable suture such
as 30 or 40 chromic or
Vicryl.
During this suturing, the
superior
extent of the anterior anal
laceration is identified, and
the sutures are placed
through the submucosa of
the anorectum

 A second layer is placed

through the rectal muscularis
using 30 Vicryl suture in a
running or interrupted fashion.
This reinforcing layer should
incorporate the torn ends of the
internal anal sphincter, which is
identified as the thickening of the
circular smooth muscle layer at
the distal 2 to 3 cm of the anal
canal.
It can be identified as the
glistening white fibrous structure
lying between the anal canal
submucosa and the fibers of the
external anal sphincter (EAS).
In many cases, the internal
sphincter retracts laterally and

In overview, with
traditional end to-end
approximation of the
EAS, a suture is placed
through the EAS
muscle, and four to six
simple interrupted 20
or 30 Vicryl sutures
are placed at the 3, 6,
9, and 12 oclock
positions through the
connective tissue
capsule of the
sphincter.

 The sutures through the inferior and

posterior portions of the sphincter should
be placed first to aid this part of the repair.
To begin this portion of the closure, the
disrupted ends of the striated EAS muscle
and capsule are identified and grasped
with Allis clamps.
Suture is placed through the posterior wall
of the EAS capsule.

Sutures through the

EAS (blue suture)
and inferior capsule
wall.

Sutures to
reapproximate the
anterior and superior
walls of the EAS
capsule.
The remainder of the
repair is similar to that
described for a midline
episiotomy.

 In all techniques that have been described, it is

essential to approximate the torn edges of the rectal
mucosa with sutures placed in the rectal muscularis
approximately 0.5 cm apart.
One suitable choice is 20 or 30 chromic gut.
This muscular layer then is covered by
reapproximation of the internal anal sphincter.
Finally, the cut ends of the external anal sphincter are
isolated, approximated, and sutured together end-toend with three or four interrupted stitches.
The remainder of the repair is the same as for a
midline episiotomy.

 The overlapping technique is an

alternative method to approximate the
external anal sphincter.
Data based on randomized controlled trials
do not support that this method yields
superior anatomical or functional results
compared with those of the traditional
end-to-end method.

Choice of suture materials

3-0 polyglactin should be used to repair the
anorectal mucosa as it may cause less irritation
and discomfort than polydioxanone (PDS) sutures.
When repair of the EAS and/or IAS muscle is being
performed, either monofilament sutures such as 30 PDS or modern braided sutures such as 2-0
polyglactin can be used with equivalent outcomes.
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.

 The use of PDS sutures for repair of the

anorectal mucosa should be avoided as they
take longer to dissolve and may cause
discomfort in the anal canal.
There are no systematic reviews or
randomised studies available to evaluate the
type of suture materials used in the repair of
the IAS. Similar to EAS repair, the use of fine
suture sizes such as 3-0 PDS and 2-0
polyglactin (Vicryl) may cause less irritation
and discomfort.

Postoperative management
The use of broad-spectrum antibiotics is
recommended following repair of OASIS to
reduce the risk of postoperative infections
and wound dehiscence.
A single dose of a second-generation
cephalosporin is suitable, or clindamycin
for penicillin-allergic women.
The use of postoperative laxatives is
recommended to reduce the risk of wound
dehiscence.

 Bulking agents should not be given routinely with

laxatives.
Local protocols should be implemented regarding
the use of antibiotics, laxatives, examination and
follow-up of women with obstetric anal sphincter
repair.
Women should be advised that physiotherapy
following repair of OASIS could be beneficial.
Women who have undergone obstetric anal
sphincter repair should be reviewed at a
convenient time (usually 612 weeks postpartum).

Prognosis
Good prognosis following EAS repair
60 - 80% asymptomatic at 12 months

 Future deliveries (for those who sustained

obstetrics anal sphincter injury):
should be counselled about the risk of developing
anal incontinence or worsening symptoms with
subsequent vaginal delivery

The role of prophylactic episiotomy in

subsequent pregnancies is not known and
therefore an episiotomy should only be
performed if clinically indicated.
Those who are symptomatic or have abnormal
endoanal ultrasonography and/or manometry

should be counselled regarding the option of

Complications if left
untreated:

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

THANK YOU