What is the cause of increased perineal pain in a postpartum woman with a history of spontaneous vaginal delivery, second-degree perineal laceration repair, and current symptoms of perineal tenderness, edema, and dysuria, with vital signs indicating normothermia, mild hypertension, and tachycardia?

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Differential Diagnosis for Postpartum Perineal Pain

  • Single most likely diagnosis
    • Urinary Retention: The patient's increasing perineal pain, particularly with voiding, suggests urinary retention, which is a common issue postpartum, especially after a prolonged second stage of labor and perineal trauma. The edema of the perineum and labia majora could also contribute to discomfort and difficulty in urinating.
  • Other Likely diagnoses
    • Perineal Hematoma: Given the patient's recent perineal laceration and repair, a perineal hematoma is a possible cause of her increasing pain. Although the laceration repair appears intact, a hematoma could have formed beneath the repair site.
    • Infection (Early Signs): While the patient does not have a fever or purulent drainage, early signs of infection could manifest as increased pain and tenderness at the site of the laceration repair.
    • Urethral Trauma: The patient's pain with voiding could also suggest urethral trauma, which might have occurred during the delivery or as a complication of the perineal laceration.
  • Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
    • Septic Pelvic Thrombophlebitis: Although rare, this condition is life-threatening and can present with nonspecific symptoms such as pain. It's crucial to consider in the differential diagnosis of postpartum pain.
    • Necrotizing Fasciitis: This is a rare but deadly infection that can occur after perineal trauma. Early recognition and treatment are critical for survival.
  • Rare diagnoses
    • Vesicovaginal Fistula: While more commonly associated with prolonged labor or obstetric trauma, a vesicovaginal fistula could present with pain and urinary symptoms, although it would be less likely to present so early postpartum.
    • Pudendal Nerve Injury: Injury to the pudendal nerve during delivery could result in perineal pain and urinary retention, although this would be a less common cause of the patient's symptoms.

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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