What are the causes of perineal pain (pain in the perineum)?

From the Guidelines

Perineal pain can be effectively managed through a combination of medication and self-care measures, prioritizing the most recent and highest quality study available, which emphasizes the importance of early recognition and treatment of underlying conditions such as anorectal abscesses and Fournier’s gangrene (1). For immediate relief, take acetaminophen (Tylenol) 650-1000mg every 6 hours or ibuprofen (Advil, Motrin) 400-600mg every 6-8 hours as needed. Some key points to consider in managing perineal pain include:

• Apply cold packs to the perineal area for 10-20 minutes several times daily during the first 24-48 hours to reduce swelling and numb the area.
• After 48 hours, switch to warm sitz baths for 10-15 minutes, 2-3 times daily to improve blood flow and promote healing.
• Keep the area clean by gently washing with warm water after urination or bowel movements and pat dry rather than rubbing.
• Topical anesthetics like lidocaine gel 2% can be applied to the perineal area up to 4 times daily.
• Avoid prolonged sitting, use a donut cushion if necessary, and wear loose cotton underwear to reduce friction.
• Increase fiber and fluid intake to prevent constipation, which can worsen perineal pain.
• If pain is severe or persists beyond 1-2 weeks, or if you develop fever, increasing swelling, or discharge, seek medical attention as these may indicate infection or other complications requiring prescription medications or further evaluation, as highlighted in the management of anorectal emergencies (1) and Fournier’s gangrene (1). It is crucial to prioritize the patient’s history and physical examination to identify potential underlying conditions that may be causing the perineal pain, such as anorectal abscesses or Fournier’s gangrene, and to seek medical attention promptly if symptoms worsen or do not improve with self-care measures (1).

From the Research

Perineal Pain Management

Perineal pain is a common issue after childbirth, especially for women who have experienced perineal trauma. The management of perineal pain is an essential part of postnatal care.

• Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for the management of postpartum pain, and their effectiveness and safety have been assessed in several studies 2, 3.
• Aspirin has also been used in the management of postpartum perineal pain, and its effectiveness and safety have been evaluated in a Cochrane review 4.
• A systematic review of randomized controlled trials and systematic reviews assessed pain management after vaginal delivery with perineal tears or episiotomy, and recommended acetaminophen and NSAIDs as first-line treatment 5.
• A randomized controlled trial compared the efficacy of ibuprofen and acetaminophen for the relief of perineal pain after childbirth, and found that ibuprofen was consistently better than acetaminophen at 1 hour after treatment 6.

Effectiveness of NSAIDs

The effectiveness of NSAIDs in relieving perineal pain has been demonstrated in several studies.

• A Cochrane review found that NSAIDs were more effective than placebo in relieving perineal pain at 4 and 6 hours after administration 2, 3.
• The review also found that NSAIDs were more effective than paracetamol in relieving perineal pain at 4 hours, but the evidence was less certain at 6 hours 2, 3.
• A systematic review recommended NSAIDs as first-line treatment for perineal pain after vaginal delivery with perineal tears or episiotomy 5.

Safety of NSAIDs

The safety of NSAIDs in the postpartum period has also been evaluated.

• A Cochrane review found that the risk of maternal adverse effects was generally low, but the evidence was often unclear due to poor reporting 2, 3.
• The review also found that neonatal adverse effects were not assessed in any of the included studies 2, 3.
• A randomized controlled trial found that ibuprofen was well-tolerated and had no significant side effects compared to acetaminophen 6.

Recommendations

Based on the available evidence, the following recommendations can be made:

• NSAIDs, such as ibuprofen, can be used for the relief of perineal pain after childbirth 2, 3, 6.
• Acetaminophen can also be used, but may be less effective than NSAIDs at 1 hour after treatment 6.
• Aspirin may be considered for use in non-breastfeeding women with post-episiotomy perineal pain, but the evidence is less certain 4.
• Epidural morphine may be reserved for severe perineal tears, with adequate respiratory monitoring 5.
• Ice or chemical cold packs can be used as a simple and effective first-line treatment for postpartum pain 5.