Postpartum sexual health and dyspareunia

World Health Organisation (WHO) defined sexual health as a complex biological and sociological concept that requires an active and responsible approach to sexuality and sexual relationships and is directly affected by a range of physical, psychological, cognitive, sociocultural, religious, legal, political and economic factors [1]. Pregnancy, labour, childbirth and parenting are all complex events which bring in many sexual health changes in a couple’s relationship. Postpartum sexual health is an underdeveloped concept which is not well understood. In 2013, the UK Department of Health had published a document on the framework for improvement in sexual health in England. Ironically postpartum sexual health was never mentioned in this report [2].

Olsson et al. [3] conducted a study to explore women’s perception of their sexual health after childbirth. The interesting fact identified was their midwives never advised or reassured about resuming sexual activity. Potentially postpartum sexual problems are not recognized leaving the couples anxious and uncertain. Pre-pregnancy sexual health concerns could attribute to postpartum sexual health problems [4,5]. The emotional, physical and social changes after the childbirth may alter the sexual needs of women and impact on their relationship with their partner. The psychological aspects in resuming sexual activity include fear of dyspareunia and worry about baby’s well-being. Dyspareunia after childbirth is an under-reported symptom in the literature. It has an impact on the emotional well-being of women and affects body image and sexual function. It was estimated that around 62-88% women resume intercourse 2-3 months after delivery and around 17-33% women complain of superficial dyspareunia. According to another study, 60% of women had coital difficulties after birth at three months, and 30% had persistent dyspareunia even at six months [6].

Olsson et al. conducted a focus group discussion with women within three months of childbirth, to elucidate about sexual life after delivery. It was illustrated in their article that 75% of all primiparous women had vaginal lacerations during childbirth. Women, who had major perineal tears and episiotomies, experienced considerably painful intercourse which affected the resumption of a satisfactory sexual life after childbirth. Similarly, Rathfisch et al. [7] reported that episiotomy and perineal tears were considered as potential risk factors for poor postpartum sexual health. Perineal tears cause superficial dyspareunia due to scar tissue formation or poor alignment of tissues during reconstruction after perineal trauma, or due to vaginal atrophy or dryness. It is important to deal with the condition earlier to avoid long-term consequences of sexual dysfunction.

Treatment of superficial dyspareunia

There are conservative methods to treat superficial dyspareunia such as vaginal dilators and perineal massage which provides relief in a minority of the patients. Fenton’s procedure is performed to widen the tight vaginal introitus. The original method involves a transverse incision at the mucocutaneous junction at the posterior fourchette to raise a vaginal mucosal flap. Then a longitudinal incision was made towards external anal sphincter cutting through perineal skin, perineal body, and the perineal muscles. Both incisions are closed together in layers in the transverse plane to widen the introitus. The modified version of Fenton’s procedure is not so invasive and involves longitudinal incision over lower vagina and perineum, dissecting the underlying tissues to release the scarring and closing it transversely in one or two layers with 3/0 Vicryl Rapide suture material. There is very limited evidence in the literature regarding the efficacy of Fenton’s procedure or the modified method for treating superficial dyspareunia [8].

Chandru et al. [9] evaluated the modified Fenton’s procedure for superficial dyspareunia due to scar tissue or narrowing due to the webbing of introitus, that did not respond to conservative approaches. The study included 24 women who had dyspareunia after childbirth. Out of 24 women, seven sustained a third-degree tear, 14 had a right mediolateral episiotomy or second-degree tear and three had labial or first-degree tear. They were advised to follow conservative treatment such as perineal massage with vitamin-E cream or sweet almond oil for 6-8 weeks. At the end of 8 weeks, if there was no symptomatic relief, they were offered modified Fenton’s procedure. The procedure was done under local anaesthesia, and in selected cases, general Z was used. All these women were reviewed three monthly for 12 months. The study concluded that 60.8% women had complete relief, and 39% had moderate relief. The drawback of this study was that it was a case series, and the treatment was not randomized among the participants.

Fenton’s procedure for other conditions

Fenton’s procedure is performed for superficial dyspareunia secondary to other clinical conditions such vulval lichen sclerosus and vulval vestibulitis. Gurumurthy et al. [10] conducted a retrospective case review to evaluate the surgical management of complications of vulval lichen sclerosus. They concluded that the Fenton’s procedure was the most common surgery performed to alleviate dyspareunia secondary to adhesions and scarring. It was simple to perform and yielded high symptomatic relief to the women followed by laser division of the adhesions.

Frappell et al. [11] suggested double opposing Z-plasty with V-Y advancement as a new alternative to Fenton’s procedure in women with previous failed Fenton’s, scarring secondary to episiotomy or lichen sclerosus. This new technique had excellent cosmetic and functional results with no need for repeat surgery. However, this surgical procedure requires an extensive study to evaluate its actual efficacy. A case report was presented by Singh et al. [12] about a woman who was known to have bladder exstrophy and had a single stage repair. She presented with coital difficulty and incomplete penetration and underwent Fenton’s procedure for widening of the introitus. She conceived spontaneously five years later and underwent a caesarean section at 36 weeks for preterm labour and breech presentation.

Postpartum sexual health should be dealt very sensitively especially in women who had an episiotomy or more than first-degree perineal tears after the childbirth. Modified Fenton’s procedure should be discussed and offered to all women who have superficial dyspareunia after delivery. The procedure can be performed under local anaesthesia to avoid anaesthetic complications. Larger prospective data is required to evaluate the success of this procedure.