Problem with a crack on the perineum
I have a problem with a crack on the perineum.
The area of the perineum at the opening to the vagina (called the posterior commissure) is a thin tissue which is usually elasticated and hence stretchable. In some cases, however, this stretchability is less, which leads to tearing, cracking, or sometimes fissures. These cause recurring pain in the place of occurence. The pain of these cracks is often described as being like a paper cut.
Most women with these problems are sexually active and the problems often arise after sexual intercourse. The symtoms can be of varying intensity and most disappear within a few days.
Common symtoms are:
Pain during sexual intercourse during entry into the vagina, dyspareunia
Pain felt while fitting a tampon
Pain during a gynecological examination
A feeling of cutting
Bleeding
Itching
A burning sensation during contact with water, sperm, or urine
A crack can occur during the first attempt at vaginal intercourse or much later in women who have given birth multiple times or, on the other hand, those who have never given birth. Other symptoms can be, for example, cracks in other skin folds than in the area of the genitals.
How the problem is diagnosed
The crack is visible from a carefully performed inspection or clinical examination. You may be able to find it yourself by touch (unevenness of the skin, often painful or burning to the touch) and afterwards, with the use of a mirror, you can see it (redness, a boil, swelling, scarring). Mostly this occurs in the middle area. Sometimes, however, the crack is so thin that it can only be seen using a colposcope (a microscope with a clear light).
After healing the external genitalia (vulva) can appear to be perfectly normal. Often, however, the crack can reappear, even as a result of mild pulling or tension at the skin.
What is the cause?
A crack occurs at a time when the skin of the exterior genitals is strained and cracks. This often occurs during sexual intercourse. This is because the skin is thin, fragile or inflamed. The reasons, however, are not always apparent.
In some cases the crack occurs as a secondary problem resulting from a range of skin diseases which can include:
mycosis
genital herpes
atrophic vulvovaginitis (inflammation resulting from atrophy)
contact dermatitis (an inflammatory response to irritating the skin)
allergy
seborrheic dermatitis (a combination of increased production of the sebaceous glands and the presence of the yeast pityrosporum ovale)
atopic dermatitis (eczema)
lichen simplex nebo sclerosus (autoimmune disease acting against the structures of the external genitalia)
slower healing of the perineum after birth
vaginismus
How the problem is treated
It is not usually neccessary to perform a specific examination because the appearance related to anamnesis is typical. In some cases a sample is taken for a cultivation to evaluate the presence of infection (possibly even a sexually transmitted disease). In some cases it is appropriate to perform a biopsy – the removal of a small sample of tissue for diagnosis. The description in the histology often merely describes some non-specific, chronic inflammation or scar tissue, which does not help us much clinically. If, however, a skin infection or autoimmune inflammation is described, it is certainly appropriate to employ a specific treatment (antimycotic, antivirotic, localized hormone treatment in the form of oestrogen or corticoids).
It is currently recommended to take a general overall approach:
avoiding soap, spermicide creams, certain lubricants that can cause irritation
application of vaginal moisturizing agents, gels, creams or ointments (emollients)
a warm seated bath with bath oil
the use of non-soap cleaning agents
oil-based lubrication during sexual activity
local analgetics (gels or ointment)
certain sexual positions (such as with the woman on top)
vaginal dilators
perineal plastic surgery
Surgery can
Perineal plastic surgery
Surgery can be useful for women with more difficult problems. Perineal plastic surgery is carried out under local or short-term general anaesthesia (according to individual agreement with the patient). The crack must be completely removed. In some cases the loosened vaginal endometrium must cover the resultant defect so that the tissue remains free of any excess strain. Perineal plastic surgery can lead to normal pain-free sexual intercourse. It is not, however, always successful.
Laser therapy
Laser therapy is a safe, well-tolerated method with a potential effect. The studies so far are promising, but the results are too short-lived to form a clear conclusion.