Dyspareunia is a special form of pelvic pain. It belongs to the pelvic floor disorders and still is rather unnoticed hence undertreated. Dyspareunia negatively affects women’s relationship, physical health and quality of life (1). Vaginal delivery with its sequelae like episiotomies and perineal injuries which include I° and II° and especially III°/ IV° perineal tears, summarized as obstetric anal sphincter injuries (OASIS) are known to have an influence on postpartum dyspareunia. There are still few data which analyze if postpartum dyspareunia still is a burden one year after.
The aim of this study was to look for the frequency of dyspareunia one year postpartum in relation to possible influencing factors like mode of delivery, e.g. spontaneous vaginal delivery versus vacuum assisted delivery, birthing methods, e.g. bed versus water delivery, perineal lesions as episiotomies and perineal injuries in a cohort of primiparae after vaginal deliveries of singletons in cephalic presentation.
Our hypothesis: Vacuum assisted deliveries (VAD), episiotomies and obstetric anal sphincter injuries are related to a higher frequency of dyspareunia one year postpartum.

In a cohort of 3298 primiparae we retrospectively compared the frequency of dyspareunia one year postpartum in the following birthing methods and mode of deliveries:
1. spontaneous bed delivery (SBD), 2. spontaneous water delivery (SWD), 3. spontaneous vaginal delivery other than bed or water, 4. vacuum assisted deliveries (VAD). And we compared the frequency of the following perineal lesions: 1. intact perineum / no perineal lesion, 2. episiotomies, 3. I° perineal tears, 4. II° perineal tears and 5. OASIS.
Objective and subjective data were immediately collected in a specially designed questionnaire. One year after delivery the specially designed questionnaire was sent out; and checked for dyspareunia. 
Inclusion criteria: primiparae, ≥ 37 0/7 weeks of gestation, singleton, cephalic presentation, waterbirth with complete delivery of the baby under water, bedbirth, other spontaneous vaginal deliveries (e.g birthing chair) in different positions and vacuum assisted delivery.
Exclusion criteria: preterm birth < 37 0/7 weeks of gestation, cesarian section, multiparae, breech presentation.
The delivery management by the medical staff was identical in all mode of deliveries, e.g., fetal heart rate monitoring, indication for use of oxytocin, restrictively used episiotomies.
For pain relief epidural anesthesia was offered for all deliveries, except for spontaneous water birth.
Episiotomies and perineal tears I° and II° were treated by residents mostly. The diagnosis of OASIS was made by a consultant of obstetrics and gynecology and then treated by them. For all perineal injuries pain management was offered with antiinflammatory analgetics. After OASIS stool regulation was recommended. 
Maternal age, fetal birth weight, duration of the delivery were recorded in the questionnaire.
Subgroup analysis to look for the influence between the birthing method/mode of delivery and the perineal injury was performed.
Data were captured and analysed using the IBM SPSS Statistics software 24. Overall p-values were calculated by Pearson's chi-square or Fisher’s exact test for categorical data. A p-value < 0.05 was considered as significant. The confidence interval was 95%.

In the cohort of 3298 primiparae 1210 women had a spontaneous bed delivery, 1148 had a spontaneous water delivery, 421 women had a spontaneous delivery other than bed or water and 519 had a vacuum assisted delivery. In 765 women an intact perineum was reported, 797 women had episiotomies, 530 I° perineal tears, 780 II° perineal tears and 191 OASIS. In 235 women the information about the perineal lesion was not available out of the questionnaire so they weren’t included in the perineal lesion groups.
Birthing method and dyspareunia: A year after delivery dyspareunia was reported by 189 (15.6%) women after spontaneous bed delivery, 139 (12.1%) women after spontaneous water delivery, by 55 (13.1%) women after vaginal deliveries in different positions and by 94 (18.1%) women after vacuum assisted delivery. The spontaneous water delivery group had a statistically significant lower frequency of dyspareunia compared to spontaneous bed deliveries and vacuum assisted deliveries, p = 0.008, p < 0.001 respectively. The difference between spontaneous bed delivery and vacuum assisted delivery as well as between spontaneous other delivery didn’t reach significance, p = 0.113, p = 0.234, respectively. 
Perineal lesions and dyspareunia: 765 women had an intact perineum, 797 women had an episiotomy (mostly mediolateral), 530 women suffered from I°, 780 from II° perineal tears and 191 women suffered from OASIS (III° and IV° perineal tear). 
Primiparae with intact perineum showed a significantly lower frequency of dyspareunia one year postpartum compared to primiparae with episiotomies, I° perineal tears, II° perineal tears and OASIS: p = 0.027, p = 0.008, p < 0.001, p < 0.001 respectively. The difference between I° perineal tears and episiotomies did not reach significance, p = 0.559, whereas the the primiparae with II° perineal tears had a significant higher frequency of dyspareunia compared to primiparae with episiotomies, p < 0.001.

Bed deliveries, others than bed/water deliveries and vacuum assisted deliveries didn’t show a significant different frequency of dyspareunia a year postpartum. Water delivery seemed to have a positive effect because it showed a significantly lower frequency of dyspareunia. 
With 20.4% the group of OASIS had a high frequency of dyspareunia one year postpartum. Interestingly the II° perineal tear group had the highest frequency of dyspareunia even significantly higher than the episiotomy group. In earlier years episiotomies were found to have more side effects than benefits like increased blood loss, greater postpartum pain and dyspareunia so opinion shifted to a restrictive episiotomy policy. Still there are data which show better psycho-physical health status 12 month postpartum in women who underwent an episiotomy (3).

Dyspareunia is an underdiagnosed and -treated pelvic floor disorder. Vacuum assisted deliveries, OASIS and II° perineal tears increase the frequency of postpartum dyspareunia which lasts over a year. 
As up to 20 % of primiparae suffer from postpartum dyspareunia we should focus on two things:
1.	the anatomically correct repair of perineal lesions; with a careful use of suture material and a meticulous technique. Residents should be taught and supervised. 
2.	A systematically and reliable long term follow-up by a gynecologist as the urgency for treatment seem obvious. 
Further studies are needed to prove if the pelvic floor exercises/physiotherapy, perineal massage and low dose local estrogen might be beneficial.

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Frohlich J, Kettle C. Perineal care. BMJ Clin Evid. 2015 Mar 10;2015: 1401. PMID: 25752310; PMCID: PMC4356152.
Bertozzi S, Londero AP, Fruscalzo A, Driul L, Delneri C, Calcagno A, Di Benedetto P, Marchesoni D. Impact of episiotomy on pelvic floor disorders and their influence on women’s wellness after the sixth month postpartum: a retrospective study. BMC Womens Health. 2011 Apr 18;11:12. Doi: 10.1186/1472-6874-11-12. PMID: 21501462; PMCID: PMC3098166.

Continence 2S2 (2022) 100445
DOI: 10.1016/j.cont.2022.100445