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Vulva : Overview, Anatomy, structure and function - Sentelhealth

 Overview : The vulva is a part of the female reproductive system and is also part of the external genitalia. The vulva consists of labia minora, labia majora, mons pubis, clitoris, vestibular bulb, vulval vestibule, urinary meatus the vaginal opening, hymen, and Bartholin's glands. other parts of the vulva include sebaceous glands, urogenital triangle, and pudendal cleft. Pelvic floor muscles support the structures of the vulva and vulva including the entrance to the vagina. Vulva goes through changes during childhood, puberty, menopause, and post-menopause. Structure: A) Mons pubis: it is present in both sexes and act as a cushion during sexual intercourse and is more pronounced in female. the mons pubis is a soft fatty tissue at the front of the vulva in the pubic region covering the pubic bone. the lower part of the mons pubis is divided by a fissure called pudendal cleft. it separates mons pubis and labia majora, the mons pubis, and labia majora get covered by pubic hair at pu...
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Perineal tear - Overview,classification,causes,complications and treatment

A perineal tear is the laceration of skin and other soft tissue of the perineum which is the area separating the vaginal opening and the anus. The perineal tear is the most common form of obstetric injury and occurs as a result of childbirth in women. While minor tears are quite common and require no treatment, gross injury is a result of the mismanaged second stage of the labour and can cause significant bleeding and dysfunction.

What is the difference between perineal tear and episiotomy?

A perineal tear is different from episiotomy in which the perineum is intentionally incised for ease of delivery. An episiotomy is generally done in the second stage of the labour under local anaesthesia and is done to prevent perineal tear and facilitate easy delivery of the baby whereas, a perineal tear is a result of the overstretched perineum. Your doctor(an obstetrician) should take your consent prior to doing the episiotomy.

How are perineal tears classified?

Perineal tears can be classified as follows:
A) First-degree tear - injury to the perineal skin only
B) Second-degree tear -  injury to the perineal skin, perineal muscles and fascia but not to the anal sphincter.
C) Third-degree tear - injury to the perineal skin, muscles, fascia and anal sphincters (both internal and external sphincter). Third-degree tears can be further classified into 3 subcategories :
3a: tear of the external anal sphincter involving less than 50% thickness of the sphincter.

3b: tear involves more than 50% of the thickness of the sphincter.

3c: tear of the internal anal sphincter.
D) Fourth-degree tear - this degree of the perineal tear involves perineal skin, perineal muscles and fascia, tear of the anal sphincter and rectal mucosa tear.
Buttonhole tear: buttonhole tear is a special type of perineal tear characterised by a tear of the rectal mucosa with an intact anal sphincter.

What are the causes of the perineal tear?

While minor perineal injuries are very common and are inevitable they usually require little to no treatment. However, the major injuries especially third and fourth-degree tears are serious injuries and can be caused by:
A) Overstretching of the perineum: in humans, the birth canal is much smaller compared to the foetal head and as the foetal head passes through it, it gets stretched and compressed and can result in some degree of trauma. This can especially occur if the foetal head is large. Sometimes, abnormalities in the female pelvis can also cause perineal tears like in the android pelvis, gynaecoid pelvis. The risk of the tear can increase significantly if the baby's head is in the face forward position (occiput posterior).

Rapid stretching of the perineum: rapid stretching of the perineum when the perineum is inelastic like in elderly primigravida ( first pregnancy) or in presence of the perineal scar, can lead to a severe perineal tear.

What are the complications of a perineal tear?

Minor perineal tears (1st and 2nd degree) rarely cause any problems in the long term. However, patients with 3rd and 4th-degree perineal tears can have chronic perineal pain, faecal urgency, faecal incontinence, pain during sex and fistula formation ( rectovaginal fistula) which is usually a result of the faulty technique.
"Retention of the urine" is the most common complication of the perineal tear post repair.
These complications occur in a very small percentage of the patients and are usually asymptomatic after 8-12 months of repair.
Sometimes, overcorrection of the perineal tear with a so-called "husband stitch" can cause increased vaginal tightness and result in pain during sex.

What is the treatment of the perineal tear?

Normally first and second-degree tears require little to no treatment and can heal naturally and a basic course of oral antibiotics is sufficient in most cases. However, the more severe perineal tears require surgical repair. Ideally, a recent tear should be repaired immediately following the delivery of the placenta as it reduces the chance of infection and minimizes blood loss.

In case, if the tear is delayed beyond 24 hours antibiotics should be started and the tear should be repaired after 3 months.
A step by step process for the repair of the perineal tear is as follows:
A) Step 1: The patient is put in the lithotomy position and the area is cleaned with an antiseptic solution. Local anaesthesia with 1% lignocaine is given to desensitize the area.

B) Step 2: The area is inspected to find out the extent of the tear
1) anal rectal mucosa and anal mucosa are sutured first from above downwards then the rectal muscles including rectal fascia is sutured
2) followed by the reconstruction of the external anal sphincter.
3) internal anal sphincter is reconstructed.
4) Lastly, perineal muscles with the vaginal wall and the perineal skin are sutured.

Aftercare :

Proper care of the repaired tear is necessary and plays a crucial role in the healing of the tear. Apart from proper perineal care from trained health professionals following things should also be kept in mind:

1) Keep the wound dry

2) The perineum should be swabbed after micturition and defaecation with an antiseptic solution ( Betadine is a prefered antiseptic for it).

3) A proper perineal wash should be given on a daily basis.

4) The bowels should be confined until at least the fifth day of the operation.

Retention of the urine is the most common complication of perineal tear and the patient should be reviewed after 6-12 weeks after repair.


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