Perineal pain is common after any degree of perineal trauma and has been reported to affect 92 % of women, resolving by 2 months’ postnatally in the majority of cases [41]. Whilst most perineal pain is self-limiting and manageable with simple analgesia, a small proportion of women will develop longer term symptoms. In the short term, women should be reassured and treated with analgesia as necessary. Perineal trauma is known to be associated with a decrease in sexual function at 6 months postpartum, with second degree tears leading to an 80 % increased risk of dyspareunia and third/fourth degree tears leading to a 270 % increased risk of dyspareunia [42]. Pain, refractory to conservative measures may be addressed with a variety of interventions, but there is no extensive evidence base to support these measures. Local perineal injections with hydrocortisone, marcaine and hyaluronidase are well tolerated and have been reported to lead to a significant fall in pain visual analogue scale scores (from 6.1 to 4.1) and resolution of dyspareunia in 89 % of sexually active women [43], but there is currently no randomised control trial evidence to support these data. There are very little other data in the literature on strategies for long term perineal pain in the obstetric population. Dyspareunia secondary to scarring or tightness at the fourchette following suturing is generally initially treated with dilators and topical oestrogens, but there are no data on outcomes of this intervention. In the presence of obvious scarring and anatomical constriction of the fourchette, women with refractory symptoms may be considered for a surgical revision of the perineum. This will generally involve a longitudinal incision of the scarred area with mobilisation of the underlying tissues and suturing transversely to ensure that a persistent skin bridge does not form. As with other interventions in this patient group, there is little in the literature on outcomes. A prospective study of 9 women who underwent a perineal revision for dyspareunia following perineal trauma reported a significant decrease in pain scores from 6.1 to 0.5 and an increase in coital frequency and satisfaction in 89 % of the cohort [44]. In the presence of associated spasm of the levator muscles, botulinum toxin injections to the levator muscles may also be an effective treatment [45].

It is estimated that 11 % of women having had a perineal tear will have a wound infection [46], with prolonged rupture of membranes and instrumental delivery being significant risk factors. Administration of prophylactic antibiotics at the time of third/fourth-degree tear repair has been found to lead to a significantly lower risk of wound infection [47], which is important after a sphincter repair; however, women with second-degree tears are not routinely given antibiotics since there is no proven benefit. Wound infections should be treated with broad spectrum antibiotics including anaerobic cover, unless sensitivities based on wound swabs suggest otherwise. The majority of perineal infections will resolve with a course of antibiotics and good perineal hygiene. Perineal wound breakdown is less common, but can lead to considerable distress and impact on quality of life for affected women. As with other postnatal perineal complications, there is a poor evidence base to guide management. By convention, most practitioners manage the wound expectantly, treating any infection, and awaiting healing by secondary intention. Women should be seen at intervals by an experienced professional to keep the wound under review and provide reassurance. A recent systematic review of suturing versus expectant management for perineal wound breakdown identified only two small randomised trials of poor quality [48]. Only one of these trials evaluated wound healing as a primary outcome measure, and although there was a trend towards better healing in the resuturing group, this did not reach statistical significance and the authors also did not specify how this outcome was quantified. The authors concluded that there is currently insufficient evidence to favour either treatment. An adequately powered randomised trial of these two interventions is underway to evaluate for the primary outcome measure of wound healing, in order to effectively evaluate these management strategies [49].