Sexual problems, including dyspareunia and decreased libido, are reported by up to 53% of women in the immediate postpartum period, and peak at 3 months after delivery [4]. Surprisingly, Signorello et al. [1] found that 12% of first-time mothers who sustained third- or fourth-degree trauma reported improved sexual satisfaction at 6 months. These findings lead one to ask: What is the contribution of perineal trauma to sexual pain? In the past, the effect of episiotomy or laceration on dyspareunia had been open to interpretation, as most studies suffered from methodological issues related to patient selection and design (e.g., mixed degrees of perineal trauma). However, a study comparing vaginal deliveries to cesarean sections without labor reported that although women who had a cesarean birth were less likely to have urinary incontinence and perineal pain than those who delivered vaginally, there was no difference in dyspareunia rate [5].

Signorello and colleagues were among the first to provide a detailed report of the relationship between sexual function and well-defined perineal trauma in a cohort study of primiparous women at distinct postpartum time-points [1]. Patients were grouped at three trauma levels: (i) no trauma or first-degree laceration extending through the vaginal mucosa or perineal skin only; (ii) second-degree tear extending into the perineal muscles as a result of a nonextending episiotomy or laceration, and (iii) third-degree laceration involving the external anal sphincter or fourth-degree tear involving both the sphincter muscle and the anorectal mucosa as a result of either an extending episiotomy or spontaneous laceration. Results indicated that 58% of women with little or no trauma reported pain with first sexual intercourse; the percentage with pain remained relatively high at 3 and 6 months (33% and 18.6%, respectively).

As might be expected, higher degrees of trauma were associated with a greater frequency of dyspareunia. Signorello et al. found that at 3 months, 42% of those sustaining moderate trauma and 61% of those with high-degree trauma reported dyspareunia [1]. At 6 months, though, the rate of dyspareunia decreased to 24% and 27%, respectively, indicating that even dyspareunia associated with severe trauma improves with time. Given that dyspareunia persists in 18.6% of the intact group at 6 months postpartum (which could be considered the baseline rate of dyspareunia), it is reasonable to conclude that the proportion of pain attributable to high-degree perineal trauma is approximately 8%.

Regarding the mode of trauma (i.e., spontaneous tear vs. episiotomy), studies generally indicate that there is little difference in the rate of dyspareunia. Signorello et al. found no significant group differences at 3 and 6 months postpartum [1]. Similarly, Rockner and colleagues found no difference in dyspareunia between women who experienced second- or third-degree spontaneous perineal tears compared with those who underwent mediolateral episiotomy. In contrast, Larson and coworkers [6] found that 11% of women who experienced spontaneous tears reported dyspareunia, while 16% of those who underwent episiotomy reported dyspareunia at 2–3 months postpartum. More recently, Ejegard and colleagues [4] compared 110 primiparas who underwent episiotomy to 153 age-matched women who did not and found that women who underwent episiotomy reported a higher frequency of dyspareunia. In this study, women who sustained a spontaneous laceration also experienced dyspareunia at 12–18 months postpartum.

Few studies have directly compared the effect of different types of episiotomy on dyspareunia. Coats and colleagues conducted a randomized, prospective study comparing the consequences of midline and mediolateral episiotomies and found that patients’ pain estimates were similar [7]. Similarly, Carolli et al. found comparable results for restrictive versus routine mediolateral versus midline episiotomy [5].

Spontaneous and assisted vaginal births have also been investigated. One study indicated that 7% of women who had a normal spontaneous vaginal birth reported apainful perineum, irrespective of episiotomy, compared with 30% of women after assisted vaginal birth [7]. Other studies have also found that after assisted vaginal birth, women have significantly more perineal pain [8]. Christianson et al. found that forceps-assisted deliveries and episiotomy also increased the rate of tears compared to noninstru-mented deliveries and nonuse of episiotomy, respectively [8]. As well, this study found that nulliparous, compared to multiparous, patients were more likely to suffer a tear, suggesting that patients are less likely to suffer tears in subsequent deliveries.

Rarely, coccydynia can result from damage to the coccyx and surrounding soft tissue during childbirth [9, 10]. This pain is characterized by constant pain that is exacerbated by movement or pressure such as that brought on by sitting; it is associated with dyspareunia in 7% of cases [10].