Int Urogynecol J
DOI 10.1007/s00192-016-3210-6
ORIGINAL ARTICLE
Female sexual function following different degrees
of perineal tears
Waleed Ali Sayed Ahmed 1 & Eman Ahmed Kishk 1 & Rasha Imam Farhan 1 &
Rasha Elsayed Khamees 1
Received: 22 July 2016 / Accepted: 7 November 2016
# The International Urogynecological Association 2016
Abstract
Introduction and hypothesis Perineal tears may have a nega-
tive impact on female sexual function (FSF). The aim of the
study was to assess the effect of different degrees of perineal
tears sustained during delivery on subsequent FSF.
Methods This prospective cohort study assessed women with
third- or fourth-degree perineal tears following vaginal deliv-
ery (study group) and compared them with women who
underwent episiotomy or had minor lacerations (control
group). Sexual function of postpartum women meeting inclu-
sion criteria was assessed using the validated Arabic version
of the Female Sexual Function Index (FSFI) questionnaire at 6
and 12 months postpartum.
Results One hundred and fifty-six women completed the
study: 56 and 100 in the study and control groups, respective-
ly. Mean total FSFI scores were significantly different be-
tween groups at 6 months postpartum [28.1 ± 4.1 vs. 18 ± 2.4
(p < 0.002)]. After 12 months, and despite slight improvement,
sexual function was significantly lower in the repaired com-
pared with the control group (21.8 ± 2.9 vs. 29.2 ± 4.1).
Women in the study group showed significant decreases in
the scores of desire, arousal, lubrication, orgasm, satisfaction,
and pain domains 12 months postdelivery.
Conclusion Higher-degree perineal tears negatively affect
FSF up to 1 year after delivery. Evaluation of FSF and appro-
priate counseling are necessary for women with perineal tears,
especially the higher degree tears.
* Waleed Ali Sayed Ahmed
waleed.asa@gmail.com
1
Department of Obstetrics and Gynecology, Faculty of Medicine,
Suez Canal University, Round Road, Ismailia 41111, Egypt
Keywords Perineal tears . Episiotomy . Female sexual
dysfunction . FSFI
Introduction
More than 85 % of women having a vaginal birth sustain some
form of perineal trauma, and 60–70 % receives stitches [1]. A
third- or fourth-degree perineal tear occurs in ∼3 % of primipa-
rous women and 0.8 % of multiparous women [2]. However,
data from a systematic review reported that the true incidence
may be as high as 11 % [3]. Obstetric Anal Sphincter Injuries
(OASIS) may impair women’s quality of life (QoL) both on the
short and long term. In the long term, perineal pain may lead to
dyspareunia, which may alter sexual function [2]. Increased
rates of third- and fourth-degree perineal tears may result from
raising awareness, training, and early diagnosis of perineal inju-
ries during labor [4]. However, Andrews et al. [5] found that
OASIS is associated with more perineal pain compared with
other perineal trauma, even if properly repaired, and this
pain/dyspareunia may subsequently result in sexual problems.
Female sexual dysfunction is a term that covers several
aspects of sexual health and has been classified by the
American Psychiatric Association into distinct disorders of
desire, arousal, orgasm, and pain. According to the World
Health Organization (WHO), Ball women should be asked
about resumption of sexual intercourse and possible
dyspareunia, as a part of an assessment of overall well-being,
2 to 6 weeks after delivery^ [6]. Postpartum sexual morbidity
is common, as shown in different studies: 83 % 3 months and
64 % 6 months after delivery, as shown by Barret et al. [7], and
64.3 % in the first year, as shown by Khajehei et al. [8].
However, this problem receives little attention despite its prev-
alence and is not often discussed during antenatal or postnatal
care, especially in conservative communities. So, the aim of

this study was to assess postpartum sexual function in women
with third- and fourth-degree perineal lacerations.
Patients and methods
This prospective cohort study was conducted at the Department
of Obstetrics and Gynecology, Suez Canal University Hospital,
from January 2011 to March 2016. After study approval by the
hospital’s ethical committee, informed written consent was ob-
tained from all 156 participants, all of whom were Egyptian and
completed the study. Follow-up was to 12 months postdelivery,
and participants completed the FSFI questionnaire at 6 and
12 months. Participants were divided into study group (56) with
a diagnosis of third- or fourth-degree tears and the control group
(100) with episiotomy or minor lacerations sustained after de-
livery. Sample size was calculated based on a study power of
80 %, an α-error of 0.05 [9], an expected 25 % worsening of
sexual function at 6 months postpartum [10], and an expected
female sexual dysfunction incidence of 52.8 % based on the
study by Ibrahim et al. [11]. The minimum number required in
each group was 43.
Women were approached if they sustained perineal
lacerations/tears or underwent episiotomy during delivery.
They were approached either in the labor ward or in the inpa-
tient room before they were discharged; none was contacted
during the antenatal period or before delivery. Charts were
reviewed to confirm obtained data only, such as past medical
or obstetric history. All cases of third- or fourth-degree peri-
neal tears were diagnosed and managed in the presence of a
senior obstetrician, as per department protocol, and usually
one of the authors was in the labor ward helping with patient
diagnosis and recruitment. Those with a history of inflamma-
tory bowel disease (ulcerative colitis or Crohn’s disease),
prepregnancy anorectal surgery, prepregnancy fecal inconti-
nence, and presence of a neurological condition that would
predispose to urinary or fecal incontinence, were excluded.
Enrollment data comprised age, education, presence of asso-
ciated morbidities, and the accustomed frequency of sexual
activity. Full obstetric history was obtained: mode of delivery;
perineal tear and its management. Women were instructed to
record the date they resumed complete sexual activity, and
their contact details were obtained.
Third-degree tears involve the perineal skin, superficial,
deeper perineal muscles, and anal sphincter affecting <50 %
of the external anal sphincter fibers (3a), >50 % of the external
anal sphincter fibers (3b), and external and internal anal
sphincter rupture (3c); fourth-degree tears involve complete
anal sphincter rupture that extends into the anal epithelium
[12]. First-degree tears involving the perineal skin and/or vag-
inal mucosa and second-degree tears involving injury to the
perineal muscles but not the anal sphincter [13] are considered
minor. Episiotomy could be medial or mediolateral.
Int Urogynecol J
Repair of third- and fourth-degree tears followed the Royal
College of Obstetricians and Gynecologists (RCOG) guide-
lines [13]. In brief, the repair was conducted by a senior ob-
stetrician, in the operating theater, under regional or general
anesthesia, with good lighting, and with appropriate instru-
ments. The anorectal mucosa is repaired using interrupted
sutures. An end-to-end suturing technique using 3/0
polydioxanone (PDS) suture material was usually performed
to repair the torn anal sphincter. Broad-spectrum antibiotics
and laxatives were routinely prescribed postoperatively, and a
3-month appointment was given for follow-up [13] at which
visit patients were asked about bowel control. Perineal repair
was considered adequate if the patient had no complaints , and
if the perineum was intact and of adequate length.
The Arabic FSFI version of the FSFI, validated by Anis et al.
[14], is a 19-item, self-administered, screening questionnaire
that measures aspects of sexual function in women. Questions
are grouped in six domains: desire (1 and 2), arousal (3–6),
lubrication (7–10), orgasm (11–13), satisfaction (14–16), and
pain (17–19) [15]. Responses were scored from 0 (no sexual
activity) or 1 (suggestive of dysfunction) to 5 (suggestive of
normal sexual activity). Individual domain scores are obtained
by adding scores of individual questions in each domain and
multiplying the sum by the domain factor provided in the FSFI
for each domain. The full score was obtained by combining the
total scores of the six domains (minimum score possible 2;
maximum score 36) [16]. A total FSFI score ≤ 26.55 was con-
sidered as diagnosing sexual dysfunction [16].
Data were processed using SPSS version 15 (SPSS Inc.,
Chicago, IL, USA). Quantitative data were expressed as mean
± standard deviation (SD) and qualitative data as numbers
(%). Student’s t test was used to test significance of difference
for quantitative variables and chi-square and Fisher’s exact
tests for qualitative variables. A probability value (p) < 0.05
was considered statistically significant.
Results
A total of 156 women were evaluated. Study (n = 56) and
control (n = 100) groups were matched regarding age (mean
29.4 ± 7.7 and 31.1 ± 5.6 years, respectively). Higher educa-
tion was significant in the control group. Primiparous women
constituted 67.9 % and 55 % of study and control groups,
respectively (p < 0.05). Both groups were matched regarding
female circumcision [71.4 % and 68 %, respectively
(p = 0.34)] and breast feeding at the 6- (p = 0.5) and 12-
(p = 0.12) month visits. Resumption of sexual activity was
significantly delayed in the study group (16.5 vs. 8.2 weeks)
(Table 1). All women were married and had partners during
the study period.
The number of women in the subgroups with third- and
fourth-degree tears were 39 and 17 respectively, of whom 26
Int Urogynecol J

Table 1 Demographic data of all

participants Study group Control group P value
N = 56 N = 100

Age (years) (mean ± SD) 29.4 ± 7.7 31.1 ± 5.6 0.15 (NS)
Education Illiterate and primary 42 (75 %) 36 (36 %) <0.05*
Secondary and higher 14 (25 %) 64 (64 %)
Parity Primiparous 38 (67.9 %) 55 (55 %) <0.05*
Multiparous 18 (32.1 %) 45 (45 %)
Breast feeding At 6 months 46 (82.6 %) 84 (84 %) 0.5 (NS)
At 12 months 29 (51.9 %) 59 (59 %) 0.12 (NS)
BMI kg/m2 (before delivery) 29.7 31.2 0.13 (NS)
Circumcised 40 (71.4 %) 68 (68 %) 0.34 (NS)
Resumption of sexual activity (weeks) 16.5 ± 5.4 8.2 ± 1.5 <0.05*

BMI body mass index, NS no statistically significant difference

*Statistically significant difference (p < 0.05)

(66.7 %) and 12 (70.6 %) were primiparous. All women re-
ported adequate repair and satisfactory bowel control in
follow-up visits. The incidence of a higher-degree perineal
tear in the 4 years of recruitment (5th year for follow-up)
was 0.9 %. Episiotomy was performed in 63 women in the
control group and 13 in the study group. All episiotomies were
mediolateral. Thirty-seven women in the control group had
either first- or second-degree lacerations; 32 in the study group
and 12/56 (21.4 %) in the control group had instrumental
vaginal delivery (outlet forceps/ventose).
The study group had a significant decrease in FSFI scores
at 6 and 12 months compared with the control group [18 ± 2.4
vs. 28.1 ± 4.1 (p <0.002) at 6 months and 21.8 ± 2.9 vs. 29.2 ±
4.1 (p <0.05) at 12 months]. In addition, total FSFI scores
among primiparous and multiparous women decreased signif-
icantly compared with the control group at 6 and 12 months.
However, no significant difference was noted in the FSFI
scores between women in the third- and fourth-degree-tear
subgroups (Table 2).
Table 3 shows that 12 months postdelivery, all FSFI do-
mains (desire, arousal, lubrication, orgasm, satisfaction, and
pain) were significantly decreased in the study group
compared with the control group. However, when dividing
the study group into subgroups of third- and fourth-degree
tears, no significant difference was noted.
Discussion
This study shows that women with third- and fourth-degree
perineal lacerations reported lower scores on the FSFI ques-
tionnaire at 6 and 12 months compared with the control group.
The study confirms the negative impact of perineal tears—
especially high-grade tears—on female sexual function.
Postpartum sexual problems may manifest in delayed resump-
tion of sexual intercourse, loss of desire, dyspareunia, lack of
lubrication, pain, and decreased ability to achieve orgasm [7,
8, 17, 18]. Resumption of sexual activity was significantly
delayed in the study group, which reflects the long-term ef-
fects of OASIS injuries on female sexual function. This delay
is probably due to either pain encountered while attempting
intercourse or the fear of pain or wound disruption. There
were no clear instructions by the managing physicians as to

Table 2 Total Female Sexual

Function Index (FSFI) among FSFI score Control group Third-degree Fourth-degree P value
primiparous and multiparous perineal tear perineal tear
women at 6 and 12 months
postpartum After 6 months (mean ± SD) Total 28.1 ± 4.1 18 ± 2.4** <0.002*
Primiparous 27.2 ± 4.7 17.7 ± 5.6 17.1 ± 5 <0.001*
Multiparous 29.3 ± 2.7 18.9 ± 5.1 18.1 ± 6.3 <0.001*
After 12 months (mean ± SD) Total 29.2 ± 4.1 21.8 ± 2.9** <0.05*
Primiparous 29 ± 3.2 21.3 ± 5.7 18.3 ± 4.3 <0.01*
Multiparous 29.7 ± 1.7 23.7 ± 3.3 19.8 ± 4.9 <0.05*

FSFI Female Sexual Function Index, PP postpartum, SD standard deviation

*Statistically significant difference
**Total FSFI score of the study group (3rd + 4th degree tears)
 Int Urogynecol J

Table 3 Distribution of Female

Sexual Function Index (FSFI) FSFI domains Control group Study group P value
scores between groups and
subgroups 12 months’ Total 3rd-degree tear 4th-degree tear
postdelivery
Desire 4.8 ± 0.9 3.7 ± 0.9 3.9 ± 1 3.2 ± 0.7 <0.05*
Arousal 4.7 ± 0.8 3.5 ± 0.8 3.7 ± 0.8 3.3 ± 0.9 <0.03*
Lubrication 5.2 ± 1.1 4 ± 0.9 4.2 ± 0.9 3.6 ± 0.9 <0.05*
Orgasm 5±1 3.3 ± 1.1 3.5 ± 1 2.8 ± 0.9 <0.01*
Satisfaction 5.1 ± 0.8 3.6 ± 0.9 3.7 ± 0.9 3.2 ± 0.8 <0.03*
Pain 4.4 ± 1 3.5 ± 1 3.5 ± 1 3.3 ± 1 <0.05*
Total score 29.2 ± 4.1 21.8 ± 2.9 22.5 ± 4.8 19.4 ± 3.9 <0.01*

Statistical significance between control group and total score in study group
FSFI Female Sexual Function Index
*Statistically significant

when sexual function should be resumed. Of note, even wom-
en who had an episiotomy or minor laceration had delayed
sexual activity. The WHO recommended that resumption of
sexual intercourses occurs within 6 weeks after delivery [6].
Despite a slight improvement in sexual function
throughout the first year after delivery, those in our
study with repaired third- and fourth-degree tears
expressed more sexual dysfunction than those who had
repaired episiotomy or perineal lacerations. It is con-
ceivable that dyspareunia would improve as time goes
on. In a cross-sectional study of 796 primiparous wom-
en over a 6-month period after delivery, Barret et al.
found that 62 % experienced dyspareunia in the first
3 months, decreasing to 31 % at 6 months [7]. In a
retrospective cohort study of 626 primiparous women
over a 6-month period after delivery, Signorello et al.
found that compared with women with an intact perine-
um, those with second-degree trauma were 80 % more
likely [confidence interval (CI) 1.2–2.8] and those with
third- or fourth-degree perineal trauma were 270 %
more likely (CI 1.7–7.7) to report dyspareunia at
3 months postpartum [10].
Several factors may contribute to the occurrence of sexual
dysfunction after perineal lacerations. Vaginal delivery itself
may cause injury to the pudendal nerve, which is responsible
for transmitting sensory and motor impulses to/from female
external genitalia through dorsal nerve of the clitoris and per-
ineal nerve [19]. Also, vaginal delivery may cause anal
sphincter injury and dyspareunia. Further, vaginal laxity due
to stretching during labor can lead to decreased ability to
achieve orgasm [20]. In addition, scarring of repaired tears
may add to the occurrence of pain. Psychologically, women
may fear wound disruption if intercourse is attempted shortly
after delivery and in the event of repaired third- and fourth-
degrees tears.
Glazener et al. found that a high percentage of postpartum
women reported problems with intercourse, but only 7–13 %
asked for help [8]. Buhling et al. confirmed that up to 83 % of
women reported sexual problems at 3 months postpartum; 18–
30 % of them still experience sexual problems, including
dyspareunia 6 months after childbirth [21]. This finding
reemphasizes the importance of diagnosis of higher-degree
perineal tears, the appropriate repair of which has a profound
effect on sexual function. Hence, accurate diagnosis is of par-
amount importance.
One limitation of the study is that baseline sexual
function was not assessed before pregnancy or even prior
to delivery. It is therefore difficult to precisely gauge the
contribution of perineal tears to sexual dysfunction. Also,
a longer follow-up would give a better idea about long-
term effects of perineal laceration on sexual function. In
addition, and despite adopting a similar technique of re-
pair, repairs were performed by different physicians,
which could potentially affect outcomes. However, this
issue can be addressed in a future study evaluating phy-
sician training levels on patient subsequent sexual func-
tion. Women were not screened for depression , which
can negatively impact sexual function, in either the im-
mediate postpartum period or during follow-up.
In conclusion, this study indicates that despite early post-
partum repair of perineal tears of a higher degree, such tears
are associated with a long-term negative impact on female
sexual function and can cause sexual dysfunction up to 1 year
of follow-up, at least. This finding reinforces the importance
of accurate diagnosis of such tears and that the attendance of
well-trained physicians and midwives is mandatory during
birth to appropriately deal with this maternal morbidity.
Finally, sexual function should be routinely assessed follow-
ing vaginal delivery, especially when complicated by third-
and fourth-degree perineal tears.
Compliance with ethical standards
Conflicts of interest None.
Int Urogynecol J
References
1. Kettle C, Tohill S. Perineal care. BMJ Clin Evid. 2011; 2011.
Review.
2. Harkin R, Fitzpatrick M, O’Connell PR, O’Herlihy C. Anal sphinc-
ter disruption at vaginal delivery: is recurrence predictable? Eur J
Obstet Gynecol Reprod Biol. 2003;109:149–52.
3. Dudding TC, Vaizey CJ, Kamm MA. Obstetric anal sphincter inju-
ry: incidence, risk factors, and management. Ann Surg. 2008;247:
224–37.
4. Gurol-Urganci I, Cromwell DA, Edozien LC, Mahmood TA,
Adams EJ, Richmond DH, et al. Third- and fourth-degree perineal
tears among primiparous women in England between 2000 and
2012: time trends and risk factors. BJOG. 2013;120(12):1516–25.
5. Andrews V, Thakar R, Sultan AH, Jones PW. Evaluation of post-
partum perineal pain and dyspareunia-a prospective study. Eur J
Obstet Gynecol Reprod Biol. 2008;137:152–6.
6. World Health Organization. Postpartum care of the mother and
newborn: a practical guide. Available at: http://www.who.
int/maternal_child_adolescent/documents/who_rht_msm_983/en/.
Published 2013.
7. Barrett G, Pendry E, Peacock J, Victor C, Thakar R, Manyonda I.
Women’s sexual health after childbirth. BJOG. 2000;107(2):186–95.
8. Khajehei M, Doherty M, Tilley PJ, Sauer K. Prevalence and risk
factors of sexual dysfunction in postpartum Australian women. J
Sex Med. 2015;12(6):1415–26.
9. Fleiss JL. Statistical methods for rates and proportions. New York:
Wiley; 1981.
10. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum
sexual functioning and its relationship to perineal trauma: a retro-
spective cohort study of primiparous women. Am J Obstet
Gynecol. 2001;184(5):881–8.
11. Ibrahim ZM, Ahmed MR, Sayed Ahmed WA. Prevalence and risk
factors for female sexual dysfunction among Egyptian women.
Arch Gynecol Obstet. 2013;287(6):1173–80.
12. Sultan AH, Thakar R. Lower genital tract and anal sphincter trau-
ma. Best Pract Res Clin Obstet Gynaecol. 2002;16(1):99–115.
13. Royal College of Obstetricians and Gynecologists. The manage-
ment of third- and fourth-degree perineal tears. London: RCOG;
2015.
14. Anis TH, Gheit SA, Saied HS, Al Kherbash SA. Arabic translation
of female sexual function index and validation in an Egyptian pop-
ulation. J Sex Med. 2011;8(12):3370–8.
15. Rosen R, Brown C, Heiman J, Leiblum S, et al. The Female Sexual
Function Index (FSFI): a multidimensional self-report instrument
for the assessment of female sexual function. J Sex Marital Ther.
2000;26(2):191–208.
16. Wiegel M, Meston C, Rosen R. The Female Sexual Function Index
(FSFI): cross-validation and development of clinical cutoff scores. J
Sex Marital Ther. 2005;31(1):1–20.
17. Thompson JF, Roberts CL, Currie M, et al. Prevalence and persis-
tence of health problems after childbirth: associations with parity
and method of birth. Birth. 2002;29(2):83–94.
18. McDonald EA, Gartland D, Small R, et al. Dyspareunia and child-
birth: a prospective cohort study. BJOG. 2015;122(5):672–9.
19. Pollack J, Nordenstam J, Brismar S, Lopez A, Altman D,
Zetterstrom J. Anal incontinence after vaginal delivery: a five-
year prospective cohort study. Obstet Gynecol. 2004;104(6):
1397–402.
20. Nichols CM, Gill EJ, Nguyen T, Barber MD, Hurt WG. Anal
sphincter injury in women with pelvic floor disorders. Obstet
Gynecol. 2004;104(4):690–6.
21. Buhling KJ, Schmidt S, Robinson JN, Klapp C, Siebert G,
Dudenhausen JW. Rate of dyspareunia after delivery in primiparae
according to mode of delivery. Eur J Obstet Gynecol Reprod Biol.
2006;124(1):42–6.