What are the treatment options for persistent perineal pain after an episiotomy (perineal incision), that occurred about a year ago, with new tenderness to touch and no signs of infection?

Persistent Perineal Pain After Episiotomy: Treatment Approach

For persistent perineal pain one year post-episiotomy with new tenderness and no infection, perform a thorough examination to identify specific causes (neuroma, scar tissue, or occult sphincter injury), then initiate multimodal pain management with NSAIDs and consider referral to a specialized perineal clinic for potential surgical revision if conservative measures fail.

Initial Assessment

A systematic evaluation is essential to identify the underlying cause of persistent pain:

• Perform a detailed visual inspection and digital examination of the perineal area to assess for scar tissue, neuromas, or areas of tenderness 1
• Conduct a digital rectal examination to evaluate for occult anal sphincter injury that may have been missed during initial repair, as rectal exams improve detection rates of sphincter injuries 1
• Consider endoanal ultrasound if there is any concern for anal sphincter compromise, as this can reveal the full extent of damage to the anal sphincter complex that may be contributing to pain 1
• Ensure adequate lighting and visualization during examination to avoid missing subtle pathology 2

The new onset of tenderness after a year suggests either scar tissue formation, nerve entrapment (neuroma), or delayed wound complications rather than acute infection.

Conservative Pain Management

Begin with non-invasive approaches as first-line therapy:

• Prescribe ibuprofen as the primary analgesic agent, which has demonstrated efficacy for episiotomy pain and possesses both analgesic and anti-inflammatory properties 1, 3
• Add acetaminophen for additional pain control if ibuprofen alone is insufficient 1, 4
• Recommend sitz baths twice daily to promote comfort and tissue healing 1, 4
• Apply ice packs to the perineum for acute pain episodes 1

Research evidence shows that dry heat application (infrared lamp therapy at 45 cm distance for 10 minutes twice daily) significantly reduces perineal pain and improves wound healing compared to moist heat 5, 6. This can be considered as an adjunctive therapy.

Specialized Interventions

If conservative measures fail after 2-4 weeks:

• Refer to a specialized postpartum perineal clinic for expert evaluation, as early follow-up in these specialized settings is recommended for complex perineal issues 1
• Consider acupressure to points LV4 and LI4 for 10 minutes, which has shown significant pain reduction maintained for up to 120 minutes in research studies 7
• Evaluate for surgical revision if examination reveals specific anatomical problems such as:
  • Excessive scar tissue causing tethering
  • Palpable neuromas at the repair site
  • Improperly healed tissue with poor approximation 1

Surgical Considerations for Revision

If surgical revision is indicated based on examination findings:

• Perform repair under regional or general anesthesia for adequate pain control and muscle relaxation 1, 8
• Use continuous non-locking subcuticular sutures rather than interrupted transcutaneous sutures, as this technique avoids damage to nerve endings on the skin surface and reduces pain 1
• Consider leaving skin unsutured or using skin adhesive during revision, as these approaches reduce pain and dyspareunia compared to traditional suturing 1, 4
• Administer prophylactic antibiotics (first-generation cephalosporin such as cefazolin 2g, or gentamicin 5 mg/kg plus clindamycin 900 mg for penicillin allergy) to reduce wound complications 1, 2

Post-Treatment Management

Regardless of the intervention chosen:

• Prescribe stool softeners (polyethylene glycol 4450 or mineral oil twice daily) to prevent straining that could compromise healing 1, 8, 4
• Schedule follow-up within 2 weeks to assess response to treatment 1, 4
• Provide clear documentation of findings and treatment plan 1, 2

Critical Pitfalls to Avoid

• Do not assume all persistent pain is normal healing—new tenderness after a year warrants thorough investigation for specific pathology 1
• Avoid inadequate examination with poor lighting, which can lead to missed diagnoses of neuromas or scar tissue 2
• Do not overlook occult sphincter injury, as failure to identify and address this can lead to persistent symptoms 1
• Avoid using locked sutures if revision is needed, as these create excessive tension leading to tissue necrosis and pain 1, 8

Note that low-level laser therapy showed no benefit for perineal pain or healing in a randomized controlled trial 9, so this modality should not be recommended despite its theoretical appeal.