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Perineorrhaphy

Perineorrhaphy reconstructs the perineal body, commonly by reapproximating bulbospongiosus and transverse perineal muscle or connective-tissue components to support the distal vagina and reduce the genital hiatus. The structures and suture sequence vary by surgeon and defect.[1][14] Despite frequent use alongside pelvic reconstructive surgery, it remains "commonly performed yet poorly understood"; indications and technique are heterogeneous, and its independent effect on prolapse recurrence is uncertain.[1]

Anatomy of the Perineal Body​

The perineal body is a pyramidal fibromuscular structure between the vagina and rectum, serving as a central tendon for the pelvic floor.[2][3] In a histologic study of postmenopausal specimens, median tissue fractions were collagen 29%, adipose cells 27%, smooth muscle 11%, elastin 7%, and skeletal muscle 3%.[4]

LevelContacts
SuperficialExternal anal sphincter, bulbospongiosus, superficial transverse perineal
DeepPuboperinealis, puboanalis

DeLancey's perineal complex triad hypothesis proposes that the perineal body, perineal membrane, and levator ani muscles, linked by vaginal support tissues, work together in urogenital hiatus closure. Disruption of the midline perineal connection may permit a wider hiatus and downward rotation of the perineal membrane.[5] The perineal body is a Level III support structure; obstetric injury and other defects can coexist with posterior compartment prolapse.[6][7]

Indications​

A common reason to consider it is an enlarged genital hiatus (GH) with perineal-body deficiency, often alongside pelvic organ prolapse repair.[1][8] Perineal symptoms and the defect inform selection.[1][8]

A 2026 multicenter observational analysis found that surgeons more often selected perineoplasty for patients with:[8]

  • Larger GH (5.2 versus 4.5 cm)
  • Obesity (OR 2.3)[8]
  • Higher parity (30-fold higher odds of receiving perineoplasty for ≥ 4 children versus 1 child)

Surgeons cited lack of evidence and fear of dyspareunia as the primary reasons not to perform it.[8]

Specific indicationThreshold / context
Perineal body deficiency after obstetric traumaVisible perineal scar with confirmed anatomic defect[9]
Enlarged genital hiatusOne retrospective combined-repair series used ≥ 3.5 cm or wide-introitus symptoms[10]
Wide introitus with vaginal-laxity complaints[10]
Concomitant with posterior colporrhaphyOften considered when a distal perineal defect also needs repair; posterior colporrhaphy and perineorrhaphy are distinct components[1][12]
Perineal-body defect during apical suspensionPerineal symptoms and the defect guide selection; OPTIMAL evaluated surgeon-selected posterior repair during apical suspension, without isolating perineorrhaphy.[1][8][12]

Surgical Technique​

There is significant heterogeneity in how perineorrhaphy is performed; no standardized technique exists.[1] In a survey of 183 responding surgeons at a 2014 Society of Gynecologic Surgeons meeting, 106 of the 169 surgeons (63%) who answered the repair-location question said they incorporated structures both proximal and distal to the hymen.[1]

  1. Incision. A described approach uses a diamond-shaped or triangular incision on the posterior vaginal wall at the introitus, extending onto the perineal skin; it may continue from the distal end of a posterior colporrhaphy incision[14]
  2. Dissection. Dissect the vaginal epithelium and perineal skin off the perineal muscles bilaterally to expose attenuated or separated musculature.
  3. Muscle reapproximation:
    • Bulbocavernosus (bulbospongiosus) identified bilaterally and reapproximated in the midline with interrupted absorbable sutures
    • Transverse perineal muscle or connective-tissue components reapproximated according to the identified defect; the depth and order vary[1][14]
    • Sutures through the separated perineal tissues rebuild the perineal body without relying on epithelial narrowing alone[1][14]
  4. Rectovaginal support. When a distal rectovaginal-septal defect is present, its attachment to the reconstructed perineal body may be restored; surgeons vary in whether and how they include this step[1][13]
  5. Excess tissue excision. Trim redundant vaginal mucosa and perineal skin. 6.[1][14] Closure. Vaginal epithelium is closed; management of perineal skin varies by technique and tissue condition[1][14]

Technical Considerations​

  • Suture material and caliber vary. The Kanter survey reported use of monofilament and polyfilament materials.[1]
  • Avoid excessive narrowing of the introitus, which can cause introital stenosis and dyspareunia.
  • Perineal-body repair is distinct from levator ani plication. Levator plication is a separate choice with potential effects on introital caliber and sexual pain; discuss it explicitly if considered[1][20]
  • As one chapter author's approach to a scarred posterior introitus, Baggish tests vaginal mobility with Allis clamps before excising the scarred tissue, to estimate whether the advanced vagina will reach the perineal edge without tension, and performs a rectal examination before deep dissection and again at completion to confirm the rectum's position and bowel-wall integrity. He checks the final closure with two loosely approximated fingers.[22]
  • Twiss and colleagues describe a site-specific technique performed at the end of transvaginal rectocele repair: the perineal musculature anterior to the anal sphincter is reapproximated to the transverse perineal muscles with a series of interrupted horizontal-mattress sutures. No long-term durability data are reported for this variant.[23]

Outcomes​

Genital Hiatus Reduction​

StudynResult
Mothes 2023[10]121In a retrospective cohort receiving combined native-tissue POP repair and perineorrhaphy, mean GH was 29.5% smaller postoperatively (44 → 31 mm, p < 0.001)
Bonglack 2022[14]56 who completed 3-month follow-up (29 with perineorrhaphy, 27 without)In a surgeon-selected prospective cohort, median resting GH at 3 mo was 0.5 cm smaller than at the end of surgery in the perineorrhaphy group (p < 0.01); baseline-to-3-mo GH change was −1.5 vs −0.5 cm with vs without perineorrhaphy (p < 0.01), a difference not seen in the sacrocolpopexy subgroup (n = 24). Baseline Valsalva GH was larger in the perineorrhaphy group (4.5 vs 3.5 cm), and apical procedures differed between groups

Symptom Improvement After Perineal Reconstruction​

  • Bergman 2020 randomized 70 women at least 6 months postpartum with a symptomatic, poorly healed second-degree tear to perineorrhaphy plus distal posterior colporrhaphy or pelvic-floor muscle therapy. At 6 months, 25/35 (71%) versus 4/35 (11%) met the patient global improvement outcome in a worst-case-imputed intention-to-treat analysis.[27]

  • Rotstein 2023 (131 operated; 119 returned the follow-up inventory, with 107 complete follow-up total scores): standardized reconstruction for symptomatic deficient perineum after vaginal delivery, without concomitant POP or incontinence surgery; mean total symptom-score reduction −9.1 points (from 18.4 / 33, p < 0.001).[9]

Impact on Prolapse Recurrence — The Critical Question​

Whether perineorrhaphy prevents prolapse recurrence remains uncertain.[25] In a 2023 prospective multicenter registry analysis of 641 apical repairs, concomitant perineorrhaphy was associated with lower 12-month composite recurrence (adjusted OR 0.43, 95% CI 0.25–0.74).[25] Other evidence includes:

  • Sutkin 2020 (OPTIMAL secondary analysis, 190 with and 184 without surgeon-selected posterior repair at SSLF or USLS): 24-month composite surgical success was 100/150 (67%) with posterior repair versus 86/138 (62%) without (aOR 1.07, 95% CI 0.56–2.07, p = 0.83).[12] Posterior repair was not standardized and may or may not have included perineorrhaphy.[12]
  • Kikuchi 2021 narrative review: while enlarged GH is strongly associated with prolapse, there is "insufficient evidence to support surgical reduction of the GH as prophylaxis against future prolapse."[15]
  • Shakhaliev 2024: published protocol for a planned 310-patient RCT comparing mesh-augmented sacrospinal fixation with versus without perineoplasty alongside posterior repair.[16] The trial registry lists status unknown after its July 2024 update and posts no results.[16]

Genital Hiatus Size and Prolapse Risk — The Rationale for Perineorrhaphy​

The association between GH size and prolapse is reported in the following studies:

StudyFinding
Blomquist 2018[17]In a postpartum longitudinal cohort, relative to GH ≤ 2.5 cm and stratified by delivery mode: GH 3 cm → HR 3.0 (95% CI 1.7–5.3) for incident POP; GH ≥ 3.5 cm → HR 9.0 (95% CI 5.5–14.8).
Siff 2020 OPTIMAL ancillary[11]Larger immediate postoperative resting GH was associated with anatomic failure (aOR 1.6, 95% CI 1.1–2.3) and surgical failure (aOR 1.5, 95% CI 1.0–2.1) at 2 yr in adjusted models; ≥ 3.5 cm was an exploratory cutoff with weak discrimination
DeLancey 2025[6]3D MRI case-control study: resting urogenital hiatus area was 68% larger in women with anterior-predominant prolapse versus controls. MRI area is not the POP-Q GH length
Casas-Puig 2023[18]After MIS sacrocolpopexy, 3/108 women underwent surgical retreatment by 24 months, all with 6-month GH > 3 cm; composite recurrence did not differ between GH groups, and the 3-cm cutoff had ROC AUC 0.52 for vaginal bulge and/or retreatment
Vaughan 2018[24]Retrospective cohort, 260 women after native-tissue vaginal vault suspension, grouped by 6-week postoperative GH: composite anatomic failure (recurrence beyond the hymen or retreatment) was 51.3% when a preoperative GH ≥ 4 cm remained ≥ 4 cm at 6 weeks, versus 16.6% when it had been reduced below 4 cm and 6.3% when GH was normal throughout (adjusted OR 4.41, 95% CI 1.99–9.76, versus the improved group).

Complications​

Postoperative Urinary Retention​

Cervantes 2026 (retrospective n = 715): patients selected for perineoplasty during native-tissue vaginal POP surgery more often failed the postoperative voiding trial and required a discharge catheter (30.2% versus 19.1%, p < 0.01).[19]

Dyspareunia​

  • Reported de novo dyspareunia after prolapse surgery varies by operation and concomitant repair; posterior repair may carry greater risk[20]
  • Excessive narrowing or scarring can contribute to pain with intercourse
  • Surgeons frequently cite fear of dyspareunia as a reason to omit perineoplasty[8]
  • Mothes 2023 found similar overall QOL improvement in sexually active and inactive subgroups after combined POP repair.[10]

Other​

  • Wound infection or dehiscence: frequency depends on definition, setting and concomitant procedures
  • Hematoma is a recognized operative risk.
  • Perineal pain often improves; persistent pain warrants assessment.
  • Vaginal stenosis can follow excessive tissue excision.

Perineorrhaphy in Obstetric Perineal Repair​

Reconstruction of the perineal body is also part of obstetric laceration repair when a second-degree or deeper tear disrupts it. That immediate postpartum repair is a different population and operation from elective POP perineorrhaphy. Obstetric guidance describes reapproximation of the bulbospongiosus and transverse perineal muscles after vaginal-mucosal closure. For episiotomy or second-degree tear repair, continuous suturing reduces short-term pain compared with interrupted suturing; when a suitable wound permits it, leaving the skin unsutured can reduce pain at 3 months.[13][21]

Summary of Current Evidence and Practice Patterns​

AspectCurrent evidence
Common selection factorsEnlarged GH, perineal-body defect and symptoms; one combined-repair series used ≥ 3.5 cm[1][8][10]
GH reductionObserved after combined repair; one retrospective cohort reported 29.5% mean reduction and a small prospective cohort found a greater 3-month change with perineorrhaphy, without isolating long-term recurrence benefit[10][14]
Patient-reported symptomsImproved in selected uncontrolled cohorts; in Mothes' combined-repair cohort, 87% felt partially or fully cured and 90% reported partial or full goal achievement[9][10]
Prolapse recurrence preventionNot demonstrated; the evidence is insufficient[12][15]
Standardized techniqueNone; practice is heterogeneous[1]
RCT evidenceIn a randomized apical-suspension trial (46 enrolled; 38 assessed at 3 months), investigators detected no between-group differences in body-image scores or secondary outcomes including pain, pelvic-floor symptoms, sexual function and prolapse stage; follow-up was too short to establish long-term recurrence benefit.[26] A separate published protocol describes a planned 310-patient trial.[16]
Safety signalDischarge with catheter after failed voiding trial: 30.2% vs 19.1% in one retrospective concomitant-surgery cohort[19]
Treatment decisionNo single GH cutoff or observational risk estimate establishes that perineorrhaphy prevents recurrent POP; match repair to the actual defect and symptoms[1][12][15]

Key Takeaways​

Perineorrhaphy is widely performed, with variable indications and technique. Perineal-body anatomy provides a rationale, and enlarged GH predicts incident POP in observational cohorts; neither finding proves that surgically reducing GH prevents recurrence.[1][5][17] Selected cohorts report a smaller postoperative GH and improved symptoms after repairs that include perineorrhaphy, but the operation's independent, long-term benefit remains uncertain.[9][10][14] Decisions should consider the actual perineal defect, symptoms, GH, planned concomitant surgery and patient preferences, while discussing potential urinary retention and dyspareunia without treating observational associations as causal estimates.[1][8][19]

See Also​

References​

1. Kanter G, Jeppson PC, McGuire BL, Rogers RG. "Perineorrhaphy: Commonly Performed Yet Poorly Understood. A Survey of Surgeons." Int Urogynecol J. 2015;26(12):1797-801. doi:10.1007/s00192-015-2762-1

2. Vukasović I, Kalafatić D, Banović M, Banović V. "Ultrasound Assessment of the Perineal Body: A Scoping Review." Eur J Obstet Gynecol Reprod Biol. 2025;318:114904. doi:10.1016/j.ejogrb.2025.114904

3. Santoro GA, Shobeiri SA, Petros PP, Zapater P, Wieczorek AP. "Perineal Body Anatomy Seen by Three-Dimensional Endovaginal Ultrasound of Asymptomatic Nulliparae." Colorectal Dis. 2016;18(4):400-9. doi:10.1111/codi.13119

4. Kochová P, Cimrman R, Jansová M, et al. "The Histological Microstructure and in Vitro Mechanical Properties of the Human Female Postmenopausal Perineal Body." Menopause. 2019;26(1):66-77. doi:10.1097/GME.0000000000001166

5. DeLancey JO, Pipitone F, Masteling M, et al. "Functional Anatomy of Urogenital Hiatus Closure: The Perineal Complex Triad Hypothesis." Int Urogynecol J. 2024;35(2):441-449. doi:10.1007/s00192-023-05708-w

6. DeLancey JOL, Mastrovito S, Masteling M, et al. "Hiatus and Pelvic Floor Failure Patterns in Pelvic Organ Prolapse: A 3D MRI Study of Structural Interactions Using a Level III Conceptual Model." Am J Obstet Gynecol. 2025;233(1):47.e1-47.e12. doi:10.1016/j.ajog.2025.01.011

7. DeLancey JO. "Structural Anatomy of the Posterior Pelvic Compartment as It Relates to Rectocele." Am J Obstet Gynecol. 1999;180(4):815-23. doi:10.1016/s0002-9378(99)70652-6

8. Swieten ECAMV, Chaghouaoui Y, Stralen KJV, Roovers JWR. "Patient Factors Affecting Physicians' Decision to Add Perineoplasty to Pelvic Organ Prolapse Surgery: A Quantitative Analysis." J Clin Med. 2026;15(3):916. doi:10.3390/jcm15030916

9. Rotstein E, Ullemar V, Engberg H, et al. "One-Year Follow-Up After Standardized Perineal Reconstruction in Women With Deficient Perineum After Vaginal Delivery." Acta Obstet Gynecol Scand. 2023;102(10):1338-1346. doi:10.1111/aogs.14666

10. Mothes AR, Raguse I, Kather A, Runnebaum IB. "Native-Tissue Pelvic Organ Prolapse Repair With Perineorrhaphy for Level III Support Results in Reduced Genital Hiatus Size and Improved Quality of Life in Sexually Active and Inactive Patients." Eur J Obstet Gynecol Reprod Biol. 2023;280:144-149. doi:10.1016/j.ejogrb.2022.11.023

11. Siff LN, Barber MD, Zyczynski HM, et al. "Immediate Postoperative Pelvic Organ Prolapse Quantification Measures and 2-Year Risk of Prolapse Recurrence." Obstet Gynecol. 2020;136(4):792-801. doi:10.1097/AOG.0000000000004043

12. Sutkin G, Zyczynski HM, Sridhar A, et al. "Association Between Adjuvant Posterior Repair and Success of Native Tissue Apical Suspension." Am J Obstet Gynecol. 2020;222(2):161.e1-161.e8. doi:10.1016/j.ajog.2019.08.024

13. Arnold MJ, Sadler K, Leli K. "Obstetric Lacerations: Prevention and Repair." Am Fam Physician. 2021;103(12):745-752. PMID 34128615

14. Bonglack M, Maetzold E, Kenne KA, Bradley CS, Kowalski JT. "Prospective Evaluation of Genital Hiatus in Patients Undergoing Surgical Prolapse Repair." Int Urogynecol J. 2022;33(11):3247-3254. doi:10.1007/s00192-022-05157-x

15. Kikuchi JY, Muñiz KS, Handa VL. "Surgical Repair of the Genital Hiatus: A Narrative Review." Int Urogynecol J. 2021;32(8):2111-2117. doi:10.1007/s00192-021-04680-7

16. Shakhaliev RA, Shulgin AS, Kubin ND, et al. "The Influence of Simultaneous Posterior Colporrhaphy and Perineoplasty on the Efficiency and Safety of Mesh-Augmented Sacrospinal Fixation (Apical Sling) in Advanced POP Repair." Trials. 2024;25(1):647. doi:10.1186/s13063-024-08448-4

17. Blomquist JL, Muñoz A, Carroll M, Handa VL. "Association of Delivery Mode With Pelvic Floor Disorders After Childbirth." JAMA. 2018;320(23):2438-2447. doi:10.1001/jama.2018.18315

18. Casas-Puig V, Yao M, Propst KA, Ferrando CA. "Is There an Association Between 6-Month Genital Hiatus Size and 24-Month Composite Prolapse Recurrence Following Minimally Invasive Sacrocolpopexy?" Int Urogynecol J. 2023;34(10):2593-2601. doi:10.1007/s00192-023-05578-2

19. Cervantes I, Kracaw RA, Moran G, et al. "Perineoplasty, Pain, and Urinary Retention Following Native Tissue Vaginal Prolapse Surgery." Int Urogynecol J. 2026;37(2):437-443. doi:10.1007/s00192-025-06318-4

20. Antosh DD, Megahed NN. "Sexual Function After Pelvic Reconstructive Surgery." Obstet Gynecol Clin North Am. 2021;48(3):639-651. doi:10.1016/j.ogc.2021.05.015

21. Kettle C, Dowswell T, Ismail KM. "Continuous and Interrupted Suturing Techniques for Repair of Episiotomy or Second-Degree Tears." Cochrane Database Syst Rev. 2012;11:CD000947. doi:10.1002/14651858.CD000947.pub3

22. Baggish MS. Plastic repair of the perineum (perineorrhaphy). In: Baggish MS, Karram MM, eds. Atlas of Pelvic Anatomy and Gynecologic Surgery. 5th ed. Elsevier; 2021:973–978.

23. Twiss CO, Triaca V, Konijeti R, Raz S. Reconstructive surgery for pelvic floor relaxation. In: Montague DK, Gill IS, Angermeier KW, Ross JH, eds. Textbook of Reconstructive Urologic Surgery. Informa Healthcare; 2008:548.

24. Vaughan MH, Siddiqui NY, Newcomb LK, Weidner AC, Kawasaki A, Visco AG, Bradley MS. Surgical alteration of genital hiatus size and anatomic failure after vaginal vault suspension. Obstet Gynecol. 2018;131(6):1137-1144. doi:10.1097/AOG.0000000000002593

25. Ferrando CA, Bradley CS, Meyn LA, et al. "Twelve Month Outcomes of Pelvic Organ Prolapse Surgery in Patients With Uterovaginal or Posthysterectomy Vaginal Prolapse Enrolled in the Multicenter Pelvic Floor Disorders Registry." Urogynecology (Phila). 2023;29(10):787-799. doi:10.1097/SPV.0000000000001410

26. Ninivaggio CS, Komesu YM, Jeppson PC, et al. "Perineorrhaphy Outcomes Related to Body Imagery: A Randomized Trial of Body Image Perception." Female Pelvic Med Reconstr Surg. 2021;27(5):281-288. doi:10.1097/SPV.0000000000000841

27. Bergman I, Westergren Söderberg M, Ek M. "Perineorrhaphy Compared With Pelvic Floor Muscle Therapy in Women With Late Consequences of a Poorly Healed Second-Degree Perineal Tear: A Randomized Controlled Trial." Obstet Gynecol. 2020;135(2):341-351. doi:10.1097/AOG.0000000000003653