EpistemisPostpartum dyspareunia due to rigid episiotomy scar
Specialty: Gynecology and breast.
Why it occurs
- Excessive scarring (fibrosis, keloid) of the vaginal introitus and perineum after episiotomy or sutured tear
- Suture performed with excessive tension or poor alignment of the perineal muscle planes
- Atrophy of the vaginal mucosa due to transient hypoestrogenism secondary to exclusive breastfeeding (which accentuates the pain due to rubbing on the rigid scar)
Initial workup
Detailed vaginal and perineal inspection (a tense, whitish or raised fibrous band is evident in the posterior commissure, painful on localized palpation). Evaluation of pelvic floor tone (defensive hypertonia of the perineal muscles against pain).
red flags
Presence of persistent perineal fistula with gas or feces leaking through the episiotomy scar during intercourse or defecation, unbearable pain that prevents minimal superficial penetration, ulceration or easy bleeding of the scar area, signs of active purulent infection in the scar.
Standard management
- Estriol in 0.1% vaginal cream applied directly to the scar and vaginal introitus every 24 hours for 4 weeks to promote mucosal elasticity — especially if the patient breastfeeds
- Daily local massages on the scar with rosehip lubricating oils or moisturizing creams with hyaluronic acid to soften the fibrous tissue. If the scar remains stiff and painful after several months of perineal physiotherapy and topical treatment, surgical correction is indicated (episioplasty or resection of the painful scar under local anesthesia) (note: a joint approach by pelvic floor physiotherapy is important for desensitization through perineal self-massage and stretching).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Gynecology and breast
- Listed causes
- 3
- Treatment options
- 2