What is the management for a perineal cut?

Management of Perineal Cuts/Lacerations

For perineal cuts or lacerations, management should follow a structured approach based on the severity of the injury, with continuous non-locking suturing techniques preferred for repair to minimize pain and optimize healing. 1

Classification and Assessment

• Perineal lacerations are classified by depth:
  • Second-degree: Involves vaginal epithelium, muscularis, perineal body, and skin
  • Third-degree: Extends to anal sphincter (OASIS - obstetrical anal sphincter injuries)
  • Fourth-degree: Extends through anal sphincter into rectal mucosa

Surgical Environment and Preparation

Environment Requirements

• Adequate anesthesia (regional or general preferred)
• Good visualization and exposure
• Proper counting of surgical instruments, sponges, and sutures 1

Preoperative Preparation

• Antimicrobial preparation:
  • Vaginal preparation with povidone-iodine (or chlorhexidine if iodine allergy) 1, 2
  • Prophylactic antibiotics for complex lacerations:
    • First-generation cephalosporin (cefazolin 2g)
    • Second-generation cephalosporin (cefoxitin 2g)
    • For penicillin allergy: gentamicin 5 mg/kg plus clindamycin 900 mg or metronidazole 500 mg 1, 2

Repair Technique for Second-Degree Lacerations/Episiotomies

1. Anchor suture above apex of laceration in vaginal epithelium
2. Use continuous, non-locking suture to close vaginal epithelium, muscularis, and rectovaginal fascia to hymenal ring
3. Transition to axial plane, parallel to perineal muscles
4. Reapproximate bulbocavernosus and transverse perineal muscles in running, continuous, non-locking fashion
5. Reapproximate perineal skin using continuous, non-locking, subcuticular technique 1

Important technique considerations:

• Continuous non-locking suturing distributes tension evenly
• Avoid locking sutures which can cause tissue edema and necrosis
• For perineal skin, subcutaneous suturing is preferred over transcutaneous to avoid nerve damage 1
• Consider leaving skin unsutured or using skin adhesive to reduce pain and dyspareunia 1, 2

Management of Complex Lacerations (Third and Fourth-Degree)

• Requires repair in operating room under regional/general anesthesia
• Sequential repair from deep to superficial structures:
  1. Anorectal mucosa repair with interrupted or continuous non-locked absorbable sutures
  2. Internal anal sphincter repair using end-to-end technique
  3. External anal sphincter repair (end-to-end or overlapping technique)
  4. Rectovaginal fascia repair and perineal body reconstruction
  5. Vaginal mucosa and perineal skin closure 2

Postoperative Care

• Pain management:

  • Acetaminophen and NSAIDs as first-line
  • Ice packs for local relief
  • Opiates only if necessary 1, 2

• Wound care:

  • Sitz baths twice daily until first wound check
  • Daily cleaning under running water, especially after bowel movements 1, 2

• Bowel management:

  • Stool softeners (polyethylene glycol 4450 or mineral oil twice daily) for six weeks to achieve soft stool consistency 1, 2

• Documentation and follow-up:

  • Clear documentation of laceration type and repair technique
  • Early follow-up within two weeks, ideally in specialized postpartum perineal clinic
  • Patient education on degree of injury
  • Consider endoanal ultrasound if concern for anal sphincter compromise 1, 2

Common Pitfalls to Avoid

1. Using interrupted transcutaneous sutures for skin closure (increases pain)
2. Using locking sutures (causes tissue edema)
3. Inadequate antibiotic prophylaxis for complex lacerations
4. Insufficient bowel management postoperatively
5. Inadequate follow-up, especially for complex lacerations 1, 2

For simple perineal cuts with minimal tissue damage, basic wound care principles apply, including cleaning the wound and applying appropriate dressings. However, most perineal lacerations require proper anatomical repair to ensure optimal functional outcomes and minimize complications such as pain, infection, and incontinence.

Special Considerations

For chronic or complex wounds that fail to heal with standard approaches, vacuum-assisted closure (VAC) therapy may be considered as it promotes granulation and accelerates wound healing in difficult perineal wounds 3.