Surgical Technique for Reverse Perineorrhaphy

Objectives: The aim of this surgical video is to provide a step-by-step guide on how to perform a reverse perineorrhaphy.

Methods: This surgical video presents two cases of women who presented with vaginal stricture and significant dyspareunia. The first case is a 38-year-old with a history of vacuum assisted vaginal delivery and episiotomy who then subsequently underwent reconstruction of the posterior vaginal introitus with advance of bilateral labial flaps for her vaginal stricture now presenting with persistent symptoms. On exam, she had a small introitus measuring 1 cm with valsalva as well as a circumferential scar 2 cm proximal to the introitus creating a tight band. She was unable to tolerate conservative therapy with vaginal dilators and desired surgical management. The second case is a 49-year-old with a remote history of a fourth degree perineal laceration following a vaginal delivery as well as a previous posterior repair for prolapse. She had a narrow genital hiatus of 1.5cm with a small band at the introitus. She also desired surgical management given her significant symptoms. This video was edited to create a cohesive and informative educational video, including English narration, to demonstrate the steps of a reverse perineorrhaphy. Measures were taken to protect the patients’ privacy and confidentiality throughout the video creation process. The target audience for this education video are Urogynecologists, fellows, and residents.

Clinical Relevance: Patients who undergo pelvic surgery can potentially have side effects of dyspareunia, decreased libido, and decreased lubrication,1 highlighting the importance of proper preoperative counseling. Secondary repair of the perineum following childbirth can lead to symptoms of superficial dyspareunia, which can be easily treated by surgery. Reverse perineorrhaphy can be an option for patients who have had dyspareunia following a perineoplasty or perineal scarring from obstetric perineal laceration repair and have failed conservative management with physical therapy and vaginal dilators. Revision perineorrhaphy has been shown to be effective in improving dyspareunia and perineal pain, as well as increasing coital frequency and satisfaction. To our knowledge, there is sparse data in the literature describing techniques for this procedure. In this video, we highlighted two patients who have required a revision of their perineorrhaphy secondary to dyspareunia and vaginal stenosis. We discuss the surgical approach of creating a 3-4 cm vertical incision in the posterior vaginal wall at the perineum. Then we perform a horizontal closure with interrupted sutures to widen the genital hiatus and decrease stricture or banding. Additionally, the video emphasizes the importance of pelvic floor physical therapy and vaginal dilators post-operatively to aid in the proper healing and preventing the reformation of scar tissue.