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Background Perineal lacerations are a very common complication of post-partum. Usually, the repair of 1st and 2nd-grade lacerations is performed after the administration of local anesthesia. Despite the great relevance of the problem, there are only a few studies about the best choice of local anesthetic to use during suturing. We performed a randomised controlled trial to evaluate the efficacy and safety of the use of a local anesthetic spray during the suturing of perineal lacerations in the post-partum. Methods We compared the spray with the standard technique, which involves the infiltration of lacerated tissues, using the NRS scale. 136 eligible women who had given birth at University Hospital of Udine were enrolled and randomly assigned to receive nebulization of Lidocaine hydrochloride 10% spray (experimental group) or subcutaneous/submucosal infiltration of mepivacaine hydrochloride (control group) during suturing of perineal laceration. Results The lacerations included 84 1st-grade perineal traumas (61.7%) and 52 2nd-grade perineal traumas (38.2%). All the procedures were successfully completed without severe complications or serious adverse reactions. There were no statistically significant differences between the two groups in terms of blood losses or total procedure time. Moreover, there were no statistically significant differences in terms of NRS to none of the intervals considered. Regarding the application of the spray in the B group, in 36 cases (52.9%) it was necessary to improve the number of puffs previously supposed to be sufficient (5 puffs). Just in 3 cases, an additional injection was necessary (4.4%). Conclusions Our study demonstrates that lidocaine spray alone can be used as a first line of local anesthetic during the closure of I-II-grade perineal lacerations, as it has comparable efficacy to mepivacaine infiltration. Trial registration The trial was recorded on https://clinicaltrials.gov . Identification number: NCT05201313. First registration date: 21/01/2022. Unique Protocol ID: 0042698/P/GEN/ARCS.

Background Surgical glue has been used in several body tissues, including perineal repair, and can benefit women. Objectives To evaluate the effectiveness of n-butyl-2-cyanoacrylate surgical glue compared to the polyglactin 910 suture in repairing first- and second-degree perineal tears and episiotomy in vaginal births. Design A parallel randomised controlled open trial. Setting Birth centre in Itapecerica da Serra, São Paulo, Brazil. Participants and methods The participants were 140 postpartum women allocated into four groups: two experimental groups repaired with surgical glue ( n  = 35 women with a first-degree tear; n  = 35 women with a second-degree tear or episiotomy); two control groups sutured with thread ( n  = 35 women with a first-degree tear; n  = 35 women with a second-degree tear or episiotomy). The outcomes were perineal pain and the healing process. Data collection was conducted in six stages: (1) up to 2 h after perineal repair; (2) from 12 to 24 h postpartum; (3) from 36 to 48 h; (4) from 10 to 20 days; (5) from 50 to 70 days; and (6) from 6 to 8 months. ANOVA, Student's t, Monte Carlo, x-square and Wald tests were used for the statistical analysis. Results One hundred forty women participated in the first three stages, 110 in stage 4, 122 in stage 5, and 54 in stage 6. The women treated with surgical glue had less perineal pain ( p  ≤ 0.001). There was no difference in the healing process, but the CG obtained a better result in the coaptation item ( p  ≤ 0.001). Conclusions Perineal repair with surgical glue has low pain intensity and results in a healing process similar to suture threads. Trial registration Brazilian Registry of Clinical Trials (UTN code: U1111-1184-2507; RBR-2q5wy8o); date of registration 01/25/2018; www.ensaiosclinicos.gov.br/rg/RBR-2q5wy8/

The type of suture used to repair perineal injury may be associated with this healing process and subsequent sexual function. This study aims to assess whether the suture technique used (continuous or interrupted) has an impact on a woman’s sexual function following childbirth. A single-blind randomised clinical trial was conducted with primiparous women who had experienced a perineal injury during childbirth. A computer-generated random number table was applied to allocate women to each group. Data were collected on sociodemographic variables, variables associated with childbirth, and outcomes during the 3 months after childbirth. Mean difference was used to assess the influence of the suture type on outcomes. Multivariate analyses were carried out to adjust for unbalanced variables after randomisation. Seventy women participated in the intervention group (continuous suture) and 64 women in the control group (interrupted suture). The women in the intervention group scored high for sexual desire, adjusted mean difference (aMD) = 1.8, 95% CI = 1.1–2.6 (p < 0.001); the same happened with arousal (aMD = 1.7, 95% CI = 0.8–2.5, p < 0.001). In the intervention group, orgasm was more easily reached, aMD = 0.8, 95% CI = 0.4–1.1 (p < 0.001). Women who received a continuous suture indicated they felt less discomfort (p < 0.001). Women who had a continuous suture reported better postpartum sexual function. Trial registration: ClinicalTrials.gov NCT03825211 posted 31/01/ 2019.

Abstract Background Nonhealing perineal wounds have been reported to be common after proctectomy for Crohn’s disease (CD). We performed a systematic review and meta-analysis of perineal wound healing after proctectomy for CD and assessed the risk factors for nonhealing. Methods A comprehensive literature search was conducted in PubMed, Embase, and Scopus databases from 2010 to 2023, and articles reporting perineal wound healing rates after proctectomy for CD were included. Data on study characteristics and proportion of healed wounds, and risk factors, were extracted. Random-effects meta-analysis was performed to estimate the pooled proportion and 95% CIs using the “meta” package in R. Heterogeneity was assessed using the I2 statistic. Results We identified 501 articles, of which 252 remained after de-duplication. After screening, 4 retrospective cohort studies involving 333 patients were included. Across the 4 studies, the pooled proportion of completely healed perineal wounds at 6 months was 65% (95% CI 52%-80%), and 70% (95% CI 60%-83%) at 12 months. Significant heterogeneity was found between studies (I2 = 86% at 6 months). Three studies examined risk factors for impaired healing after proctectomy. One study identified preoperative perineal sepsis as the only independent factor associated with impaired healing (P = .001) on multivariable analysis. In 1 study, male sex, shorter time from diversion to proctectomy, and higher preoperative C-reactive protein levels were all associated with delayed healing in univariate analysis. Another study found that close rectal dissection was associated with significantly lower healing rates than total mesorectal excision (P = .01). Prior use of tumor necrosis factor inhibitors was not associated with wound healing outcomes. Conclusions This meta-analysis revealed complete perineal healing in only 70% of patients 12 months after proctectomy for CD. This highlights knowledge gaps, including the identification of modifiable risk factors and methods for preventing or as rescue therapy, such as vacuum-assisted closure and flap reconstruction, for nonhealing perineal wounds after proctectomy for CD. Poor perineal wound healing outcomes are likely related to imperfectly understood underlying inflammatory dysregulation and systemically impaired wound healing in patients with CD. Lay Summary Meta-analysis of perineal healing after proctectomy for Crohn’s revealed only 70% of patients at 12 months; the only independent risk factor was preoperative perineal sepsis; biologics did not affect healing. This highlights knowledge gaps, including best practices for prevention and treatment.

Introduction Angioleiomyoma, a vascular leiomyoma is a rare, benign smooth-muscle tumor observed to occur anywhere in the body, most frequently in the lower extremities but very rarely in the digestive system. Angioleiomyoma in the hindgut is infrequent and in particular, rectal/perianal location has been observed very rarely. Case report We describe herein a case of a 50-year-old male patient complaining of perineal discomfort and a swelling at the level of the left ischio-rectal fossa, moderately painful. This solid mass in the left ischio-rectal space was in close relationship with the wall of the ano-rectal junction. After surgical removal and histopathology, the mass resulted an angioleiomyoma, vascular type, desmin positive, a very rare neoplasm. Extensive immune-histochemical studies are fundamental for the correct diagnosis and to rule out other mesenchymal tumors. Discussion/conclusion. Angioleiomyoma is a very rare neoplasm of the gastrointestinal tract, and the fundamental problem of peri-rectal/perianal angioleiomyoma is represented by differential diagnosis from gastrointestinal stromal tumors (GISTs) and other perianal/perirectal swellings. For correct differential diagnosis, the histopathology supported by extensive immune-histochemical study adopting a panel of specific tissue markers is important. The surgical treatment is mandatory with complete excision and subsequent follow-up since local recurrence may occur.

Introduction and hypothesisPerineal preparation techniques for childbirth have been used with the aim of reducing perineal tears during the expulsive phase of labor. However, no studies were found to investigate the effects of instrument-assisted stretching versus perineal massage on pelvic floor muscle (PFM) variables. Therefore, the aim of this study was to evaluate the effect of instrument-assisted stretching versus perineal massage on the extensibility and strength of the PFMs.MethodsPrimiparous women were randomized to the instrument-assisted stretching (IStr) group (n = 13) and perineal massage (PnM) group (n = 14). The groups participated in eight sessions, twice weekly, beginning at the 34th gestational week. The IStr group underwent the intervention for 15 min using EPI-NO®. The PnM group underwent a perineal massage protocol for 10 min. Each woman was evaluated by a blinded physiotherapist before, after four and after eight sessions for primary (PFM extensibility using the EPI-NO® circumference) and secondary (PFM strength using a manometer) outcomes. Covariate analysis (ANCOVA) was used to compare the groups using the baseline values as a covariate.ResultsBoth groups showed an increase in PFM extensibility compared with the evaluations before and after four and eight sessions (PnM group from 17.6 ± 1.8 to 20.2 ± 1.9 cm; IStr group from 19.9 ± 1.6 to 22.9 ± 1.6 cm;p < 0.001). There was no difference between groups. Regarding muscle strength, no statistical differences were observed between evaluations or between groups.ConclusionsInstrument-assisted stretching and perineal massage increase extensibility and do not alter the strength of PFMs in pregnant women.

Background In order to reduce the complications of perineal damage and the pain caused by it for the mother, this study was conducted to determine the effect of warm perineal compress on perineal trauma (1st-, 2nd-, 3rd-, and 4th-degree perineal tears), postpartum pain, intact perineum (primary outcomes), episiotomy, length of the second stage, and APGAR score at 1 and 5 min after childbirth (secondary outcome). Methods PubMed, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, Web of Science, SID, Magiran, and ClinicalTrials.gov were searched to identify the relevant articles from inception to November 1, 2022, with language restriction (only English and Persian). A manual search was also performed. Risk of bias 2 (RoB2) and ROBIN-I were employed to evaluate the quality of the included papers. Meta-analysis was conducted using RevMan 5.3. Heterogeneity was assessed using I 2 . In cases with high heterogeneity, subgroup analysis was utilized based on the parity and ethnicity, and time of pain measurement after delivery also a random-effects model was used instead of a fixed-effects model. Trial sequential analysis (TSA) was performed for the primary outcomes. The certainty of evidence was assessed using the GRADE approach. Results A total number of 228 articles were found in databases. Of these articles, eighty-six were screened by title, 27 by abstract, and 21 by full text. Finally, 14 articles were included, of which ten were RCT and four were non-RCT. Meta-analysis results revealed that warm perineal compress significantly reduced perineal pain (RR 0.23, 95% CI 0.08–0.66; P = 0.0006), average pain (SMD − 0.73, 95% CI 1.23 to − 0.23; P = 0.004), second-degree perineal tear (RR 0.65, 95% CI 0.54–0.79; P˂0.00001), third-degree perineal tear (RR 0.32, 95% CI 0.15–0.67; P = 0.003), fourth-degree perineal tear (RR 0.11, 95% CI 0.01–0.87; P = 0.04), episiotomy (RR 0.63, 95% CI 0.46–0.86; P = 0.004), and intact perineum significantly increased (RR 3.06, 95% CI 1.79–5.22; P < 0.0001) compared to the control group. However, there was no statistically significant difference in terms of first-degree tear (RR 1.04, 95% CI 0.86–1.25; P = 0.72), length of the second stage of labor (MD − 0.60, 95% CI − 2.43 to 1.22; P = 0.52), the first minute (MD − 0.03, 95% CI − 0.07 to 0.02; P = 0.24) and the fifth minute Apgar score (MD − 0.02, 95% CI − 0.07 to 0.03; P = 0.46) between the two groups. Conclusion Warm perineal compress administered during the second stage of labor reduce postpartum pain, second and third-degree perineal tears, and episiotomy rate while it increases the incidence of intact perineum compared to the control group.

Introduction Although abdominoperineal resection (APR) is required for rectal cancer invading the levator ani muscle, its curative outcomes remain poorer than those of other rectal surgeries. 1 – 3 In particular, the anatomic complexity around the anterior wall of the rectum increases the technical difficulty during APR, resulting in a high frequency of margin involvement that causes local recurrence. In this video, we present the technical details of a robotic perineal-first APR approach. Methods For a 46 year-old man, locally advanced rectal cancer invading the levator ani muscles was diagnosed. Although total neoadjuvant therapy (8 cycles of induction FOLFOXIRI followed by chemoradiotherapy 50.4 Gy) decreased the tumor size, invasion was suspected still to remain. Therefore, robotic APR was performed. Written informed consent was obtained from the patient. For the perineal-first approach, we created a circular incision around the anus, then divided the fat tissues of the ischiorectal fossa until the levator ani muscle was exposed on both sides. Posterior and anterior dissections were performed along the coccyx and external anal sphincter, respectively. After placement of a lap protector to maintain air-tightness, the robotic approach was initiated. Posterior dissection was performed along the coccyx, then was connected to the already-dissected space created earlier by the perineal approach. Next, the levator ani muscle was divided from the dorsal to the lateral side. Finally, anterior dissection was performed along the prostate, followed by division of the rectourethral muscle, the smooth muscle fibers running vertically. The creation of the already-dissected space on the perineal side offers advantages of robotic manipulation from the abdominal side, especially anterior dissection. Results We performed robotic APR using the perineal-first approach for 17 consecutive patients (12 men and 5 women) between 2019 and 2023. All 17 patients achieved complete total mesorectal excision with negative margins. The mean time required for the perineal approach was about 25 min. In anterior dissection using the robotic approach, division of the smooth muscle fibers at the perineal body (i.e., rectourethral muscle in males 4 or muscular intermingling in females 5 ) was reproducibly performed in both males and females. Conclusion Robotic APR with a perineal-first approach can be advantageous in ensuring surgical margin safety (especially for the anterior aspect of the rectum).

Symptoms after second-degree tears and in particular episiotomies are common. Our aim was to investigate the prevalence and degree of dyspareunia and level of satisfaction with the outcome of the perineal repair after a spontaneous second-degree tear compared to an episiotomy. Further, we aimed to identify risk factors for dyspareunia and dissatisfaction with the outcome. This register-based cohort study included 5 328 primiparous women who sustained a spontaneous second-degree tear (n = 4 323) or an episiotomy (n = 1005) between 2014 and 2019 in Sweden. The primary outcomes were self-reported degree of dyspareunia and level of satisfaction with the outcome of the perineal repair at one year. Data were collected from national health and quality registers and online questionnaires at eight weeks and one year. Logistic regression was used and results are presented by Odds Ratios (OR) with 95% confidence intervals (CI) after adjustment for age, body mass index and mode of delivery. 30.0% of women with a spontaneous tear and 29.1% of women with an episiotomy reported mild or moderate dyspareunia, while 2.4% of women with a spontaneous tear compared to 3.8% of women with an episiotomy reported strong or unbearable dyspareunia (aOR 1.5; CI 0.9-2.4). 73.4% of women with a spontaneous tear and 67.1% with episiotomy were satisfied or very satisfied with their outcome, while 6.7% with an episiotomy compared to 3.7% with a spontaneous tear were dissatisfied (aOR 1.8; CI 1.2-2.6). Postpartum infection, scar dehiscence, re-suturing and perineal pain at eight weeks were risk factors for dyspareunia and dissatisfaction at one year. Approximately one-third of women with either a spontaneous tear or an episiotomy reported mild or moderate dyspareunia at one year, while strong or unbearable pain was uncommon in both groups. The majority of women were satisfied or very satisfied with the outcome although episiotomy more often predicted dissatisfaction.

Limited data on the correlation between the perineal body (PB) and stress urinary incontinence (SUI) are available. The objectives of this study were to quantify the PB using shear wave elastography (SWE) technology with a high-frequency linear array probe to evaluate the relationship between the properties of PB and stress urinary incontinence (SUI). This study included 64 women with SUI and 70 female control participants. The length, height, perimeter, and area of PB in all participants were calculated using transperineal ultrasound, and the elasticity of PB was assessed by SWE at rest and during the maximal Valsalva maneuver, respectively. In addition, the comparison of PB parameters between the patients with SUI and the healthy participants was conducted. The transperineal ultrasound and SWE examination was performed in 134 participants, and the elastic modulus values were significantly increased from participants at rest to those during the maximal Valsalva maneuver in all participants ( E max : 35.59 versus 53.13 kPa, P  < 0.001; and E mean : 26.97 versus 40.25 kPa, P  < 0.001). E max and E mean of PB exhibited significant differences during the maximal Valsalva maneuver between the SUI group and the control group (47.73 versus 58.06 kPa, P  < 0.001; and 35.78 versus 44.33 kPa, P  < 0.001) and had a negative correlation with SUI. The BMI and PB height during the maximal Valsalva maneuver in the SUI group were found to be significantly higher than that in healthy volunteers. E max and E mean of PB negatively correlated with BMI during the maximal Valsalva maneuver ( r  = -0.277, P  = 0.001 and r  = -0.211, P  = 0.014). ROC curve analysis demonstrated that PB perimeter of less than 12.68mm was strongly associated with SUI during the maximal Valsalva maneuver, and an E max of less than 55.76 kPa had a 100% specificity in predicting SUI. SWE can quantify the elasticity of PB, identifying a significant difference between participants at rest and during Valsalva maneuver. In addition, the stiffness of the PB was significantly lower in women with SUI than in healthy women, which may provide a noninvasive clinical practice in SUI prediction.