Perineal tears are a common event after a vaginal birth with incidences ranging between 53 and 85%, widely depending on patients’ characteristics, delivery dynamics and obstetric assistance given during labor [14].
Most of vaginal tears are minor (I and II grade) and heal without consequences [17]. However, in literature it is not mentioned the incidence for tear severity in our Country. In our case history, the rate of perineal tears of births registered between 2015 and 2021 resulted of 2.4% for III and IV degree and of 53% for I and II degree.
The damage at the complex of the anal sphincter can be the cause for pelvic floor dysfunction with a grade of severity that is scarcely commented in the different studies.
Urinary and fecal incontinence are the cause of important embarrassment and social discomfort in a woman’s life and are difficult to investigate during post-partum control visits. Hence the need of relying on validated questionnaires that permit to categorize and subsequently follow over time the course of pathology specific symptoms.
The survey PFDI-20 was introduced in 2001 to measure the quality of life in women with pelvic floor disorders to evaluate the efficacy of a specific therapy or to compare symptoms among different groups of patients. The questionnaire followed further surveys, firstly described by Shumaker et al [23], made for women with lower urinary tract dysfunction (UDI-Urinary Stress Inventory and IIQ-Incontinence Impact Questionnaire) [22].
Although these tools have been generally applied on symptomatic populations, our study is the first that offers PFDI-20 to a group of women regardless of their symptomatology. In fact, perineal examination alone hasn’t demonstrated to be a good predictor for the whole spectrum of symptoms related to pelvic floor dysfunction [24]. For these reasons, we believe PFDI-20 provides additional information to identify and stratify possible disorders according to a certain degree of vaginal tear.
Despite the direct relationship between perineal damage severity and grade of reported discomfort has been subject of debate [25, 26, 27], our study has shown that most of pelvic floor disturbances tend to be worsening or persisting during time in the group of severe perineal tears rather than in the control group.
According to K.L. Shek [27], one of the hypotheses in support of genital prolapse onset is that III- and IV- grade vaginal tears are more frequently associated to occult avulsion of elevator ani muscle. In fact, our study confirms that women with major perineal damages experience more frequently symptoms of organ prolapse such as pressure, heaviness, and dullness in the lower abdomen.
On the other hand, intestinal symptoms related to pelvic prolapse have shown to have an import impact on daily life of women with previous major lacerations. These patients have demonstrated to suffer from lack of defecatory stimulus, incomplete intestinal voiding, gas and fecal incontinence, pain and defecatory urgency, meteorism and genital bulging burden.
These results agree with a systematic review [28] showing that III- and IV-degree sphincter rupture is the only etiological factor strongly (complete anal incontinence) or moderately (flatus incontinence) associated to postpartum fecal incontinence. Therefore, from our point of view the CRADI subsection is a fundamental tool in evaluating and following during time patients with vaginal-sphincter tears.
A cross-sectional study conducted three months after delivery on 537 women, showed that the prevalence of urinary symptoms in primiparas was of 8.2% and of 5.5% for respectively stress and urge incontinence, finding a significant correlation with frequency and dysuria which increased with subsequent vaginal births [29].
In our study, among urinary symptoms severe perineal tears were associated more frequently to pollakiuria, urge and stress incontinence, and incomplete vesical emptying. Effectively, it is estimated that during the first 3 months postpartum, the prevalence of any postpartum incontinence is as high as 33% and longitudinal studies within the first year postpartum have reported only small changes of prevalence over time [28]. Maternal age and nulliparity are the factors with major impact on this aspect [30].
Therefore, our study confirms what already known about the tight relationship between vaginal delivery, severe perineal tear, and pelvic floor dysfunction. The statistical significance of most of the items analyzed for each survey seems to support the importance of PDFI-20 as a tool in the diagnosis and the follow-up of pelvic floor disorders in women with previous III- and IV-degree perineal tear.