Managing Perineal Pain Following Tearing or Episiotomy
If you’re experiencing lasting pain in your perineum after an episiotomy or perineal tear, you’re not alone. A 2014 study found that 12.8% of those who received an episiotomy experienced perineal pain at 5 months postpartum. A 2020 review by the British Journal of Anesthesia reported that of those experiencing perineal trauma during childbirth, up to 55% continued to experience pain at 3 months postpartum.
A number of factors influence the likelihood of lasting pain following an episiotomy or perineal tear with the most common link being severity of tearing or laceration. Fortunately, there are a number of options available to help manage perineal scar pain after childbirth!
But before we dive in to managing perineal pain at home, remember that while perineal tearing is the most common form of tearing during childbirth, other forms of tearing may occur. Click here to learn more about periurethral tearing, periclitorial tearing, sulcus and vaginal tears, labial tears and more.
Now, onto the good stuff. Below are 8 things you can do to help manage and treat perineal pain following an episiotomy or perineal tear.
1. Pelvic floor physical therapy
Number one on our list is pelvic floor physical therapy. While the majority of the techniques recommended in this post will be ones you can try at home, physical therapy needs a home at the top of this list. Pelvic floor physical therapy is one of the most effective and efficient ways to treat perineal or vaginal pain following childbirth. A personalized assessment, information about what’s going on with your body and some hands-on, manual therapy can go a long way in managing pain.
What’s the hands on work for? Both episiotomies and perineal tearing leave scar tissue behind. Scar tissue is less stretchy and that stiffness in your tissue can lead to pain. While most people in pain opt to avoid touching a painful area altogether, the opposite is quite helpful.
When patients come to see us in the Austin clinic for perineal pain, we typically see a reduction in symptoms after just a few visits. Pelvic floor physical therapy is an extremely effective way to treat perineal pain following childbirth.
2. Perineal massage
Perineal massage can be an effective way to manage perineal pain following childbirth and if you performed perineal massage during pregnancy to prepare for birth, this won’t be all that different. To perform perineal massage to address your perineal pain, follow these steps:
Find a comfortable, supported, laid back position - ideally propped up on pillows.
Get lube and use it liberally. I recommend coconut oil for perineal massage because it doesn’t absorb quickly. If you use coconut oil, please use a separate jar from the one you use to cook with! Read below for more specifics on choosing a lube.
Insert one finger, or you can use a pelvic wand.
With moderate pressure, causing no more than 3-4/10 pain, massage from 3 to 9 o’clock along the bottom of the vaginal opening.
If you find yourself clenching your jaw or anus against the pain, use less pressure. You can always add pressure overtime as your body adjusts.
Give your body an opportunity to relax into the discomfort and breathe.
If your pain increases, please contact your provider! And if you’re a visual person, download our free perineal massage handout, here!
3. Diaphragmatic breathing
Don’t overlook this simple technique when it comes to managing perineal pain! Tight pelvic floor muscles are a common contributor to pain following an episiotomy or perineal tear and diaphragmatic breathing is one of the simplest tools you can use to relax a tight pelvic floor. Plus, you can do it anywhere, anytime, in any position.
Here’s a link to one of my favorite gifs demonstrating diaphragmatic breathing. I show this to my patients who are having a hard time visualizing a diaphragmatic breath. A diaphragmatic breath, also known as a belly breath or deep breath, is all about breathing into your rib cage, allowing your abdomen to expand, and feeling your pelvic floor relax as you inhale. As you inhale slowly and deeply, here are some sensations you can look for:
Feel your vaginal and anal openings relax as you inhale
Feel gentle pressure build between your sit bones as you inhale
Imagine your tailbone uncurling as you inhale
Visualize your sit bones spreading as you inhale
If you’re having trouble feeling any of the cues I listed above, consider seeing a pelvic floor PT who can help you work on that mind-body connection!
4. Foam rolling your glutes
Perineal pain may start as a result of a tight scar, but when we experience pain, the muscles surrounding the pain site tend to clench. That clenching can cause pain to stick around, even once our tissue has healed.
Foam rolling your glutes is an excellent way of reminding your body and your pelvis that you are safe to relax. Plus, it feels like that kind of amazing-awful sensation you get during a deep tissue massage, in the comfort of your own home! If you don’t have a foam roller, you can use a circular water bottle (preferably a hefty, metal one) or a lacrosse ball. Learn more about foam rolling to relax your pelvic floor, here.
5. Go on walks
Move. Your. Body. It’s not uncommon for people in pain to move less. This can be because of fear of pain, fear of hurting themselves, fear because they don’t know if movement will help or hurt. But movement is medicine! Motion is lotion! Here’s a rule of thumb for determining if movement is helpful or harmful:
If you try a movement and the pain gets worse as you continue or feels worse following, you may have overdone it. If you try a movement and the pain gets better as you continue and doesn’t hurt afterwards, you’re probably in the clear.
Moving will help bring blood flow to the area to your healing tissue, release endorphins that help bring down pain, and offer a helpful distraction for your brain. If you’re postpartum and wondering where to start, check out our ebook Baby Steps Fitness to help guide your return to exercise!
7. Use lube
For those experiencing perineal scar pain specifically with penetration, lube is so important. When inserting anything, including a pelvic wand, toy or penis, use lube. This is especially important during the early postpartum period and for as long as you lactate because the body has less estrogen at the vaginal opening during this time frame, leading to dryness.
Few things feel worse for a painful scar than friction from dryness. Using lube generously can make a huge difference! Here’s a simple breakdown of benefits and drawbacks of the most common type of lube:
Water based: This is a great choice for someone with sensitive skin. Water based lubes do, however, absorb quickly and can require frequent reapplication. My favorite water based lube is Slippery Stuff.
Silicone based: Silicone based lubes last much longer than water based without need for reapplication. They cannot, however, be used with silicone toys as they can cause breakdown. I recommend Uberlube for silicone lubes.
Oil based: Similar to silicone lube, they last longer and are more affordable. Oil lubes should not be used with latex condoms as they can cause breakdown.
8. Last but not least… talk to your provider about topical estrogen
Our last suggestion for managing scar pain following an episiotomy or perineal tear is to discuss topical estrogen with your healthcare provider. As mentioned above, estrogen levels plummet after childbirth, leaving vulvar tissue estrogen deficient. This estrogen deprivation can cause dryness and sensitivity at the vaginal opening, contributing to discomfort in vulva. Using a topical estrogen can assist in scar tissue healing, reduce pain at the vaginal opening and improve self lubrication. It’s typically well tolerated but does need to be prescribed by a medical doctor.
For more tips on managing pain through pregnancy, preparing for birth or recovering postpartum, sign up for our newsletter! For more on postpartum recovery, check out our 6 week postpartum program, Baby Steps Fitness. And as always, if you’re interested in working with us 1:1 either in our Austin clinic or virtually from anywhere in the world, give us a shout!
This post was written by Dr. Rebecca Maidansky, PT, DPT, owner and founder of Lady Bird Physical Therapy. Rebecca is a pelvic floor physical therapist in Austin, TX and founded Lady Bird Physical Therapy in 2019. She is the creator of Birth Preparation and Postpartum Planning, Baby Steps Fitness and the head writer and editor of The Pelvic Press.
Rebecca is a passionate writer and vocal advocate for pelvic health and the importance of improving access to perinatal care. She believes strongly that many common pregnancy pains and postpartum symptoms can be eased or even prevented with basic education and care.
She created this blog to help all birthing people manage common pregnancy pains, prepare for birth and recover postpartum.