Hypothesis / aims of study
Childbirth related injuries of the pelvic floor may impact on women’s sexual health with symptoms such as dyspareunia. The relationship between obstetric factors and dyspareunia is well studied, however not well understood. Second-degree perineal tears vary widely in the extent of damage to the perineum and a recent meta-analysis highlights the need for a subcategorization of second-degree tears for better understanding of dyspareunia following those tears (1). We have used a reliable subcategorization of second-degree tears based on the percentage of damage (2A, 2B, 2C) to the perineum when studying the impact of second-degree tears in dyspareunia after birth.
The aim of this study was to assess the impact of the severity of second-degree perineal tears on dyspareunia at three and twelve months postpartum.
Study design, materials and methods
This single-center observational cohort study was conducted between January 2021 and July 2022. All nulli- and multiparous women meeting the inclusion criteria, were invited to participate when attending the hospital for routine prenatal ultrasound examinations at 18 weeks of gestation. Inclusion criteria were having a singleton pregnancy and being able to understand the native language. Exclusion criteria were female genital mutilation and additionally for multiparas: previous third- or fourth-degree tear, or previous caesarean section.
Perineal tears were classified according to the College of Obstetricians and Gynecologists’ classification-system, which was extended by the detailed classification in case of second-degree tears. All superficial tears not affecting the perineum were defined as first-degree tears, second-degree tears were subcategorized based on percentage of damage to the perineum (<50% damage= 2A-tear; >50% but not entire perineum= 2B-tear; entire perineum, but anal sphincter not involved= 2C-tear) (2). In cases of multiple perineal tears, the most severe tear was used for analysis. Women with episiotomy were analyzed separately and could have had an additional perineal tear. Hence, none of the perineal tear categories include women with episiotomy. Women with third-and fourth-degree tears and women with cesarean section in the current delivery were excluded from analysis.
The outcome of this study, dyspareunia, was assessed at 18 weeks of gestation, and three and twelve months postpartum by an electronic questionnaire sent out by e-mail. Participants who reported present sex-life over the past four weeks were asked the following question from the ‘Karolinska Symptoms After Perineal Tear Inventory (KAPTAIN)’ questionnaire (3): ‘Are you bothered by pain in the genital area during sex?’ (never; sometimes; often; always). In this study, participants who answered sometimes, often or always were categorized as having dyspareunia. To assess present sex-life the following question from the ‘The International Consultation on Incontinence Questionnaire Vaginal Symptoms Module (ICIQ-VS)’ was used: ‘Do you have sex-life at present?’ (yes; no because of vaginal symptoms; no because of other reasons).
Background and delivery data were collected from the participants medical records and from the electronic questionnaires.
The distribution of dyspareunia is presented as frequencies with percentages, and a Two Proportions Z-test was used for statistical analysis comparing percentages between perineal tear categories. When Two Proportions Z-test was significant, a logistic regression analysis was performed to adjust for the following confounding factors: age, BMI, parity, vaginal operative delivery, length of second stage labor. A power calculation for this analysis was not perfomed.
Results
Out of 857 women eligible for analysis, 803 answered the questionnaire at 18 weeks of gestation, 701 responded at three months and 672 responded at twelve months after birth. Background and obstetric data of the study population is presented in Table 1. In our study, 51.4% of the women were primiparous and 48.6% were multiparous. Twelve percent of the women had an operative vaginal delivery. Perineal tears were distributed as follows: no tear/first-degree tear 52.2%, 2A-tear 15.7%, 2B-tear 8.1%, 2C-tear 5.4% and episiotomy 18.6%.
Eighty-six percent of the women reported present sex-life at 18 weeks of gestation, 62.9% of the women reported present sex-life at three months postpartum and 83.8% reported present sex-life at twelve months postpartum. We found no statistically significant differences between the perineal tear categories and the percentages of women reporting no present sex-life because of vaginal symptoms at any timepoint.
The percentages of women reporting dyspareunia according to the degree of the tear at three months postpartum was: no tear/first-degree tear 59.5%, 2A-tear 60.3%, 2B-tear 52.0%, 2C-tear 76.9% and episiotomy 76.5%, and at twelve months postpartum: no tear/first-degree tear 51.8%, 2A-tear 50.0%, 2B-tear 40.0%, 2C-tear 68.6% and episiotomy 64.4%.
When comparing dyspareunia in women according to the second-degree subcategories, we found a statistically significant higher percentage of women with a 2C-tear reporting dyspareunia compared to women with a 2B-tear (mean difference 28% (95% CI 7, 50), and a nearly statistically significant higher percentage of women with a 2C-tear reporting dyspareunia compared to women with a 2A-tear (mean difference 18% (95% CI 0.3, 37) at twelve months postpartum. After adjustment for confounding factors, the difference in the percentage of the reported dyspareunia between women with 2C-tears and women with 2B-tears, and between women with 2C-tears and women with 2A-tears was no longer statistically significant. There were no statistically significant differences in reported dyspareunia when comparing women with no tear/first-degree tear and women classified to the respective second-degree subcategories at three and twelve months postpartum (Figure 1).
Compared to women with no tear/first-degree tear, women with episiotomies had a statistically significant higher percentage of reporting dyspareunia at three (mean difference 17% (95% CI 6;28)) and twelve months postpartum (mean difference 13% (95% CI 1.7; 23)) (Figure 1). The results did not remain statistically significant after adjustment for confounding factors in the regression analysis.
Interpretation of results
Dyspareunia following childbirth has been studied previously, however the majority of previous studies have assessed dyspareunia in relation to mode of delivery, and perineal tears in general. Our results reveal new knowledge about the reported dyspareunia from pregnancy up to one year after delivery according to the degree of trauma within the second-degree category. In our study population, women with 2C-tears reported the highest percentages of dyspareunia three and twelve months postpartum. However, after adjusting for confounding factors the differences between the percentages of reported dyspareunia in women with the most severe second-degree tear and lesser forms did not remain statistically significant. The small numbers of women in some of the perineal tear categories is a limitation of our study and should be considered when interpreting the results.
The percentage of women reporting dyspareunia increased from pregnancy to one year after delivery for all perineal tear categories. Thereby, the results indicate that experiencing dyspareunia is complex and may be related to other factors during birth and the postpartum period, and not independently associated with the severity of perineal tears.