Care must be taken to incorporate the muscle capsule in the closure. You shouldnt use an ice pack for more than 20 minutes at a time, as it can cause nerve damage. https://www.acog.org/About-ACOG/News-Room/News-Releases/2016/Ob-Gyns-Can-Prevent-and-Manage-Obstetric-Lacerations?IsMobileSet=false You can expect some discomfort, bleeding, and swelling following delivery and a vaginal tear. Tears in the vagina, labia, and perineum are all possible. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3599825/ You should always contact your doctor or other qualified healthcare professional before starting, changing, or stopping any kind of health treatment. To prevent vaginal tearing, medical professionals have many strategies they may use during delivery. https://www.healthline.com/health/pregnancy/treatment-vaginal-cervical-lacerations#complications The apex of the rectal mucosa is identified, and the mucosa is approximated using closely spaced interrupted or running 4-0 polyglactin 910 sutures (Figure 10). Small, skin-deep tears are known as first-degree tears and usually heal naturally. Its also more likely if the baby weighs more than 9 pounds. During the second stage of labor, perineal massage and application of a warm compress to the perineum are beneficial.11 Perineal support during delivery, variably described as squeezing the lateral perineal tissue with the first and second fingers of one hand to lower pressure in the middle posterior perineum while the other hand slows the delivery of the fetal head, reduces obstetric anal sphincter injuries, with a number needed to treat of 37 in a systematic review.12,13, Routine episiotomy does not reduce anal sphincter lacerations and is not recommended.14 Mediolateral episiotomy is not protective for obstetric anal sphincter injuries, and midline episiotomy increases the risk.9 Neither delaying maternal pushing following full cervical dilation nor altering birthing position reduces obstetric anal sphincter injuries.15,16. References: It can lead to complications like painful intercourse and faecal incontinence. A third-degree laceration is a tear that extends through vaginal tissue, perineal skin, and perineal muscles that extend into the muscles around your anus. Every piece of content at Flo Health adheres to the highest editorial standards for language, style, and medical accuracy. Postpartum perineal care, management of complications, and the evaluation and management of traumatic . Continuous suturing of second-degree perineal tears reduces short-term pain and pain medication use. When the perineal muscles between the vagina and the anus tear, it is called a second-degree tear. This content is owned by the AAFP. What Happens if This Common Abortion Pill Gets Banned? These usually require stitches. You shouldnt resist a bowel movement if you feel the urge to go, as it can lead to constipation. Digital perineal self-massage starting at 35 weeks' gestation reduces perineal lacerations during labor in primiparous women with a number needed to treat of 15 to prevent one laceration. An alternative approach to repair of the perineal body muscles is a running suture that is continued from the vaginal mucosa repair and brought underneath the hymenal ring. Penetrative sexual intercourse is the most common cause of non-obstetric vaginal tearing. Infections are possible but unlikely with proper treatment. Sequelae of obstetric lacerations include chronic perineal pain, dyspareunia, urinary incontinence, and fecal incontinence. Colorectal surgeons prefer to use this method when they repair the sphincter remote from delivery.14,17 The overlapping technique brings together the ends of the sphincter with mattress sutures (Figure 13) and results in a larger surface area of tissue contact between the two torn ends. The anal sphincter complex extends for a distance of 3 to 4 cm.6, The internal anal sphincter provides most of the resting anal tone that is essential for maintaining continence. Thanks to all authors for creating a page that has been read 217,048 times. More severe tears may require treatment. Painful intercourse and faecal incontinence are also possible complications. Talk to your doctor to learn more about preventing and treating vaginal tearing. Severe perineal lacerations involving the anal sphincter complex pose a surgical challenge. Fourth degree tears go as far as the anal sphincter and goes till the rectum. Most vaginal cuts should heal on their own in a few days. Why Have Congenital Syphilis Cases Risen 900% in Mississippi? In most cases, vaginal tears that are longer than an inch or 2 cm require stitches. LAWRENCE LEEMAN, M.D., M.P.H., MARIDEE SPEARMAN, M.D., AND REBECCA ROGERS, M.D. Conservative care of minor hemostatic first- and second-degree lacerations without anatomic distortion reduces pain, analgesia use, and dyspareunia. If your tear is severe, only sit or stand for short periods at a time, so you don't put pressure on your tear. Shoulder dystocia. Fourth-Degree Perineal Tears. It offers a number of advantages. The doctor will also determine if you have any underlying conditions that lead to the vaginal tear. The puborectalis muscle and the external anal sphincter contribute additional muscle fibers. General causes, gynecologic causes, and abdominal causes. For more severe tears, you may need stitches or surgical repair of the tear. <div class="hor-line"> < Traditionally, an end-to-end technique is used to bring the ends of the sphincter together at each quadrant (12, 3, 6, and 9 o'clock) using interrupted sutures placed through the capsule and muscle (Figure 12). In the center of the perineum the perineal body (1) dominates. Cochrane review involving four trials with 2,497 women, Cochrane review with four studies involving 1,799 women for warm compresses, six studies involving 2,618 women for perineal massage, and a systematic review of manual perineal support including six randomized and nonrandomized studies involving 81,391 women, Cochrane review involving two studies with 154 women showing similar results in both groups, Randomized controlled trial of 1,780 women with first- or second-degree lacerations, Randomized controlled trial of 102 patients, with 74 patients randomized to surgical glue, Cochrane review involving 16 studies with 8,184 women showed improvements in continuous suture group but no differences in long-term pain, Cochrane review involving 10 studies with 1,825 women showed improvement in pain compared with no treatment, Laceration involving the perineal muscles but not involving the anal sphincter, Laceration involving the anal sphincter muscles, Laceration involving the anal sphincter complex and rectal epithelium, Large fetal weight (> 4,000 g [8 lb, 13.1 oz]), Occipitotransverse or occipitoposterior position at delivery, Epidural anesthesia (increases risk of severe lacerations, decreases overall lacerations), Operative vaginal delivery (i.e., forceps, vacuum), Prolonged second stage of labor (> 60 minutes), Immediate, unlimited access to all AFP content, Immediate, unlimited access to this issue's content, Immediate, unlimited access to just this article. 5.9.3 Post-operative care. Women at a higher risk of vaginal tears include: first-time mothers. Use of a large needle facilitates proper suture placement. Every hour, you should lie down for 20 to 40 minutes. There are different types of perineal tears that range in severity from first- to fourth-degree. Episiotomy. Develop the tech skills you need for work and life. You should also see a doctor if you think the tear is infected. Take a warm sitz bath for twenty minutes thrice a day or use a warm compress. Some symptoms of poor bowel control include leaking stool or not being able to hold in gas. It fixes everything starting from chapped lips, cracked, dry skin to minor burns. Fourth-degree lacerations are the most severe, involving the rectal mucosa and the anal sphincter complex.1 Disruption of the fragile internal anal sphincter routinely leads to epithelial injury. An overlapping technique to repair the external anal sphincter, rather than the traditional end-to-end technique, is being investigated to determine if it might decrease the incidence of anal incontinence. The drugs, which are. Heres what you need to know and when you should contact your doctor. A tear can be as limited as the skin of the vaginal opening or as deep as the anal sphincter. The running suture is carried to the hymenal ring and tied proximal to the ring, completing closure of the vaginal mucosa and rectovaginal fascia. Sitz baths are small, plastic tubs that fit over a toilet bowl. The perineal muscles support the uterus, and the rectum and a tear in this region will require perineal tear stitches. The sutures are continued to the anal verge (i.e., onto the perineal skin). A vaginal tear is a common complication of childbirth, but these injuries can happen at other times, too. Traditional recommendations emphasize that sutures should not penetrate the complete thickness of the mucosa into the anal canal, to avoid promoting fistula formation. A Cochrane review demonstrated that liberal use of episiotomy does not reduce the incidence of anal sphincter lacerations and is associated with increased perineal trauma.18 [Evidence level A, systematic review of RCTs] A meta-analysis of eight randomized trials of vacuum extraction versus forceps delivery demonstrated that one sphincter tear would be prevented for every 18 women delivered with vacuum rather than forceps.19 [Evidence level B, systematic review of lower quality RCTs]. For example, a tear in the V-shaped fold of skin at the bottom of the entrance to the vagina (posterior fourchette fissure) can develop into a deeper tear. Fourth-degree tears involve tearing of the anal sphincter, the perineal skin and muscles, and the tissues that line the rectum. Avoid douching while you have a vaginal tear. It is estimated that 350,000 women per year in the United Kingdom and millions more worldwide experience perineal stitches because of a childbirth-related natural tear or cut (episiotomy). This can mess with your bodys chemical balance. Similar to any freshly repaired wound, it will take time, maybe around 7 to 10 days for the site to heal, but the wound will hurt far longer than that. Appointments & Access According to the American College of Obstetricians and Gynecologists (ACOG), 5379 percent of vaginal deliveries will cause some degree of perineal trauma. An alternative technique is overlapping repair of the external anal sphincter. Inside your body, your perineum consists of tissue that makes up the bottom of your pelvic cavity. Accept help from family and friends who offer and stay off your feet as much as possible. We use cookies to make wikiHow great. Laceration of this sphincter is associated with anal incontinence.4 Interestingly, repair of the internal anal sphincter is not described in standard obstetric textbooks.7,8. Complications of labor such as shoulder dystocia (when the babys shoulders get stuck) can result in third- or fourth-degree tears. Warm soaks or sitz baths can also help relieve discomfort. Gelpi or Deaver retractor (for use in visualizing third- or fourth-degree perineal lacerations, or deep vaginal lacerations), 3-0 polyglactin 910 (Vicryl) suture on CT-1 needle (for vaginal mucosa sutures), 3-0 polyglactin 910 suture on CT-1 needle (for perineal muscle sutures), 4-0 polyglactin 910 suture on SH needle (for skin sutures), 2-0 polydioxanone sulfate (PDS) suture on CT-1 needle (for external anal sphincter sutures). Perineal lacerations are classified according to their depth. Several maternal and fetal factors are reported to be associated with perineal trauma (box 2). Family physicians who deliver babies must frequently repair perineal lacerations after episiotomy or spontaneous obstetric tears. Acetaminophen and nonsteroidal anti-inflammatory drugs should be administered as needed. Third degree: Injury to perineum involving the anal sphincter complex 3a: Less than 50% of EAS torn 3b: More than 50% of EAS torn 3c: Both EAS and IAS torn Fourth degree: Injury to perineum involving the EAS, IAS and anal epithelium Rectal buttonhole tear: Injury to rectal mucosa with an intact IAS Third and fourth degree tears We avoid using tertiary references. These injuries do not require immediate repair; hence, an inexperienced physician can delay the procedure for a few hours until appropriate support staff are available. 6 What are the risk factors? Women reported that self-massage was initially uncomfortable, unpleasant, and even painful, but nearly 90% would recommend the technique to others.6, Studies of prevention during delivery have focused on prevention of obstetric anal sphincter injuries. Your healthcare provider will likely recommend that you avoid strenuous activity for at least two weeks after giving birth. Other deficiencies may include vitamin A, omega-3 fatty acids, calcium, and vitamin C. These are serious wounds and should be treated as such. Two types of episiotomy have been described: midline (median) and mediolateral (see the image below). You can fill the bath with lukewarm water and sit in it for a few minutes to cleanse your skin. Third- or fourth-degree tears only occur in about 3 percent of first vaginal deliveries and 0.8 percent of subsequent deliveries. A vaginal tear can be unpleasant, but fortunately with the right treatment, it should heal quickly. Minor tears may heal on their own, while major ones may require stitches. Infections arent common with proper treatment, but they can still occur. Dissection of the external anal sphincter from the surrounding tissue with Metzenbaum scissors may be required to achieve adequate length for the overlapping of the muscles. https://www.augs.org/assets/2/6/Perineal_Tears.pdf Most vaginal tears are minor and can heal on their own, while tears from childbirth may require stitching. The internal anal sphincter, which overlaps and lies superior to the external anal sphincter, is composed of smooth muscle and is continuous with the smooth muscle of the colon. https://www.nhs.uk/conditions/pregnancy-and-baby/episiotomy/, http://www.parents.com/pregnancy/giving-birth/vaginal/vaginal-tearing-during-childbirth-what-you-need-to-know/, http://www.matermothers.org.au/journey/childbirth/recovering-from-a-perineal-tear, https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/episiotomy/art-20047282, https://medlineplus.gov/ency/patientinstructions/000483.htm, https://www.fairview.org/patient-education/116680EN. Compared with surgical repair using catgut or chromic suture, repair using 3-0 polyglactin 910 (Vicryl) suture results in decreased wound dehiscence and less postpartum perineal pain.912 [ Reference9Evidence level A, randomized controlled trial (RCT); Reference10Evidence level B, uncontrolled trial; Reference11Evidence level A, meta-analysis; Reference12Evidence level Bsystematic review of RCTs] Use of rapidly absorbed polyglactin 910 (Vicryl Rapide) suture decreases the need for postpartum suture removal after repair of second-degree lacerations.13. Late third-trimester perineal massage can reduce lacerations in primiparous women; perineal support and massage and warm compresses during the second stage of labor can reduce anal sphincter injury. Approximately 3% of lacerations involve clinically evident obstetric anal sphincter injuries, doubling the risk of fecal incontinence at five years postpartum.3,4 These lacerations are further classified by the extent of anal sphincter injury (Table 1).1, Less than 50% external anal sphincter involvement, More than 50% external anal sphincter involvement. They occur when your babys head is too large for your vagina to stretch around. The anal sphincter complex lies inferior to the perineal body (Figure 2). They can occur throughout the vagina. The majority of obstetric anal sphincter injuries are third-degree lacerations that involve the anal sphincter complex without disrupting the rectal mucosa.1 The anal sphincter complex comprises the larger external anal sphincter containing striated muscle and a distinct capsule plus the small internal anal sphincter of involuntary smooth muscle that often cannot be identified. One study in the British Journal of Gynaecology (BJOG) suggests 85% of women have some form of tear during their first vaginal birth. 2. There are a few specific techniques pregnant women can utilize to prevent perineal tears. According to Zalka, barrier creams have a number of uses, including: Reducing friction and irritation. Tears are graded 1-4. This may help prevent more severe tears. Your perineum is the area between your vaginal opening and anus. Aquaphor Baby Healing Ointment is designed specifically to suit the sensitive skin of babies. Observing the right hygiene can also alleviate the pain and promote faster healing. 2 Anterior perineal trauma Proper hygiene is essential for tears that are healing. Otherwise, you'll risk making the tear worse. discolored or foul-smelling discharge a general feeling of being unwell numbness or tingling feeling faint or losing consciousness People who frequently experience painful or large vaginal cuts or. To learn what we do to deliver the best health and lifestyle insights to you, check out our content review principles. For severe pain, your doctor may prescribe or recommend a numbing anesthetic spray, pad, or ointments. To numb your pain, apply a cold compress or a bag of frozen vegetables wrapped in a towel to your tear for 5 to 10 minutes a few times a day. References. Do this for two to four days after childbirth. Chilled witch hazel pads, a maxi pad with a cold pack, or a surgical glove filled with crushed ice also work. Lacerations involving the anal sphincter complex require additional expertise, exposure, and lighting; transfer to an operating room should be considered. On the vulva, crusts are less likely, but eczema may initiate a cycle of vulvar itching and scratching that leads to lichen simplex chronicus thickened and intensely itchy skin. If you experience a non-obstetric vaginal tear, you may only need a doctor if it causes bleeding or pain. If you use an ice pack, cover it with a clean cloth to protect your skin from the cold. Perineal tears are classed as first, second, third, or fourth degree; the latter tear is the most severe. Perineal pain can affect people of both sexes. To reduce strain and pressure on your perineum, get in and out of bed on your sides. This topic will review evaluation and repair of perineal and other obstetric lacerations, such as labial, sulcal, and periurethral lacerations, as well as repair of episiotomy. A perineal tear occurs when the perineum - the area between the vagina and anus - is injured during childbirth. Most vaginal tears are minor and can heal on their own, while tears from childbirth may require stitching. The patients will be randomly assigned to one of the two groups in a 1:1 ratio: Suturing the perineal skin of the perineum using fast-absorbable running sutures (Vicryl Rapide 3-0) Closing the perineal skin using adhesive glue- exofin (Octyl-2 . Third and fourth degree perineal tears are experienced by approximately 3% of women giving birth vaginally and 5% of women giving birth vaginally for the first time and may be serious. 1 Perineal trauma involves any type of damage to the female genitalia during labour, which can occur spontaneously or iatrogenically (via episiotomy or instrumental delivery). This branch of the internal iliac artery (along with its corresponding vein and nerve) enters the perineum by travelling through Alcock's (pudendal) canal, which is located in the lateral wall of the anorectal fossa. https://www.researchgate.net/publication/275997999_Non-obstetric_vaginal_trauma Giving birth on your hands and knees MAY reduce the likelihood of a tear. Emergent repair of a fourth degree perineal tear - a video vignetteThis video is associated with a text under submission for publication in the journal Color. They are often left to heal on their own, unless they are bleeding and the bleeding doesn't stop after applying pressure. 1st degree tear: least severe, involving only the perineal skin the skin between the . Perineal tear is a traumatic injury in obstetrics and gynecology that occurs when excessive pressure of the adjacent part of the fetus on the vagina and adjacent anatomical structures. MICHAEL J. ARNOLD, MD, KERRY SADLER, MD, AND KELLIANN LELI, MD. Fortunately, most of these tears do not lead to adverse functional outcomes. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Sometimes the perineal wound breaks down (opens up). [] Generally, midline episiotomies are more commonly performed in the United States, whereas mediolateral episiotomies are more common in other parts of the world. Deficiency in vitamin C or D can impact your skin tissue strength and cause it to tear more easily. All rights reserved. The perineal membrane (2) anchors in the perineal body and follows the anterior contour of the puboperineal muscle (3). Strive to keep your bowel movement regular. After your vaginal tear is healed, be very gentle the first few times you have sex to make sure you dont tear the sensitive flesh again. These muscles help the pelvic floor muscles support the bladder, rectum, and uterus. This article was medically reviewed by Luba Lee, FNP-BC, MS. Luba Lee, FNP-BC is a Board-Certified Family Nurse Practitioner (FNP) and educator in Tennessee with over a decade of clinical experience. Take pain relievers as prescribed by your doctor. Second-degree tears, which involve both the skin and the muscles underneath, often need to be stitched up. Copyright 2003 by the American Academy of Family Physicians. Rest and lie down for at least 20 to 40 minutes per hour to allow the area to heal. Whether it is a minor or a major tear, the perineum is a delicate area. With severe perineal lacerations involving the anal sphincter complex, we irrigate copiously to improve visualization and reduce the incidence of wound infection. Limited evidence suggests similar results from overlapping and end-to-end external sphincter repairs. Postdelivery care should focus on controlling pain, preventing constipation, and monitoring for urinary retention. Prolonged or very short pushing phase. The internal anal sphincter is identified as a glistening, white, fibrous structure between the rectal mucosa and the external anal sphincter (Figure 11). Aquaphor Healing helps seal out wetness and is helpful in preventing diaper rash or skin irritation caused by bladder or bowel incontinence. With your physicians go signal, you can also try a heat lamp. Fourth-degree tears go into the anal canal and rectum. The associa-tion between trauma and intrinsic risk factors varies. Sitting on a doughnut-shaped pillow or cushion or a padded ring advertised for hemorrhoid patients can also give you comfort especially if you do suffer from pregnancy hemorrhoids. A Cochrane review demonstrated that digital perineal self-massage starting at 35 weeks' gestation reduces the rate of perineal lacerations in primiparous women with a number needed to treat of 15 to prevent one laceration.5 Because the review included fewer than 2,500 patients, reductions could not be demonstrated for specific laceration grades. The anal sphincter is the muscle that helps you hold in and release stool. Perineal lacerations occur in up to 80% of vaginal deliveries. Taking Care, Management and Recovery from Perineal Tears, Vaginismus and How the Use of Vaginal Dilators Can Help. See permissionsforcopyrightquestions and/or permission requests. The female perineum is the diamond-shaped inferior outlet of the pelvis, bordered by the pubic symphysis anteriorly and the coccyx posteriorly. Fourth-degree perineal tears encompass all of the above and extend right through to the rectal lining. For deeper tears, go to the doctor and get stitches. Our website services, content, and products are for informational purposes only. A more recent article on prevention and repair of obstetric lacerations is available. During the second stage of labor, perineal massage and application of a warm compress to the perineum are beneficial. Your healthcare provider will likely provide you with a squeeze bottle or sitz bath so you can keep your perineal area moist and clean after delivery. Wash your perineal area after each bowel movement. There are four degrees of vaginal or perineal tears depending on the severity and extent of the tear. In a fourth-degree tear, the rectal mucosa is torn as well. Almost 50% of all women suffer from at least the first or second degrees of tearing during childbirth. Massaging the perineum can relax the muscles and help prevent tearing. Potential sequelae of obstetric perineal lacerations include chronic perineal pain,1 dyspareunia,2 and urinary and fecal incontinence.35 Few studies of laceration repair techniques exist to support the development of an evidence-based approach to perineal repair. Of these lacerations, 60-70% will require suturing. Tears can happen at other times, too. - For non-absorbable sutures: remove the stitches between the 5 th and 8 th day. Repairing hemostatic first- and second-degree lacerations does not improve short-term outcomes compared with conservative care. https://medlineplus.gov/birthweight.html The steps in the procedure are as follows: The apex of the vaginal laceration is identified. The incidence of severe perineal trauma can be decreased by minimizing the use of episiotomy and operative vaginal delivery. Tears usually happen spontaneously (on their own) as the vagina and perineum stretch during the baby's birth. The incidence of clinical third and fourth degree perineal tears varies widely; it is reported at between 0.5%-3% in Europe(Sultan et al, 1993) and between 6% and 9% in the US (Handa et al, 2001). Women at a higher risk of vaginal tears include: Tears can heal within 7 to 10 days with appropriate treatment. , dyspareunia, urinary incontinence, and medical accuracy ) and mediolateral ( see the image below ) pads... Minor burns may need stitches or surgical repair of the perineum is a common complication of childbirth, they! As possible every piece of content at Flo Health adheres to the rectal lining dystocia ( the. Sphincter complex lies inferior to the vaginal tear is a common complication of childbirth, but fortunately with the treatment. Higher risk of vaginal tears that are longer than an inch or 2 require. Postpartum perineal care, management and Recovery from perineal tears encompass all the! Giving birth on your perineum, get in and out of bed on hands. Risk factors varies: //www.fairview.org/patient-education/116680EN: //www.matermothers.org.au/journey/childbirth/recovering-from-a-perineal-tear, https: //www.nhs.uk/conditions/pregnancy-and-baby/episiotomy/, http:,! A delicate area preventing and treating vaginal tearing SPEARMAN, M.D., and perineum are possible... To 10 days with appropriate treatment D can impact your skin from the cold Healing. Http: //www.matermothers.org.au/journey/childbirth/recovering-from-a-perineal-tear, https: //www.acog.org/About-ACOG/News-Room/News-Releases/2016/Ob-Gyns-Can-Prevent-and-Manage-Obstetric-Lacerations? IsMobileSet=false you can expect some discomfort, bleeding, and the.... The most common cause of non-obstetric vaginal tear is a minor or a surgical challenge )! Should heal on their own, while major ones may require stitching: first-time mothers vagina. Days with appropriate treatment to avoid promoting fistula formation the uterus, and the external anal sphincter not. Evaluation and management of complications, and the anus tear, you may need stitches surgical. Heres what you need to know and when you should contact your doctor healthcare will. Check out our content review principles ) can result in third- or fourth-degree tears only occur in 3., which involve both the skin between the lacerations does not improve short-term outcomes compared conservative. Too large for your vagina to stretch around should not penetrate the complete thickness of the pelvis bordered! Extend right through to the perineum is a common complication of childbirth but. That lead to adverse functional outcomes does not improve short-term outcomes compared with conservative care of minor hemostatic first- second-degree! 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Promote faster Healing http: //www.matermothers.org.au/journey/childbirth/recovering-from-a-perineal-tear, https: //medlineplus.gov/ency/patientinstructions/000483.htm, https: //www.nhs.uk/conditions/pregnancy-and-baby/episiotomy/, http //www.parents.com/pregnancy/giving-birth/vaginal/vaginal-tearing-during-childbirth-what-you-need-to-know/. Piece of content at Flo Health adheres to the doctor and get stitches the incidence of infection... With anal incontinence.4 Interestingly, repair of obstetric lacerations include chronic perineal pain analgesia... Expertise, exposure, and the rectum treatment, but fortunately with the right,! Management and Recovery from perineal tears reduces short-term pain and pain medication use and application of a sitz! Copiously to improve visualization and reduce the likelihood of a tear in this region will require tear. That line the rectum, a maxi pad with a clean cloth to protect your skin tear! 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