OLD COMPLETE PERINEAL TEAR (CPT)

DEFINITION: - Tear of the perineal body involving the sphincter ani externus with or without involvement of the anorectal mucosa is called complete perineal tear. It is called old when passed beyond an arbitrary period of 3 months following the injury.

ETIOLOGY: -

♦ Obstetrical

♦ Gynecological

Obstetrical: Perineal injury (3° and 4°) results from over stretching or sudden stretching of the perineum during child birth. It is more common when the perineum is inelastic.

CLINICAL FEATURES: Patient profile

Patients are usually primiparous with a history suggestive of inadequate care during childbirth.

Symptoms— The chief complaints are:

• Inability to hold the flatus and feces. While incontinence of flatus is invariable, that of feces depends on the extent of damage of the external anal sphincter. If the damage is slight, there is incontinence of only loose stool but if the damage is severe, there is incontinence of hard stool as well.
• Soreness over the perianal region is due to constant irritation by the stool. It is often surprising that, the condition may remain asymptomatic for many years and only discovered accidentally during pelvic examination. Overactivity of the levator ani makes the patient continent with the stool; the incontinence of flatus being ignored.

SIGNS — INSPECTION OF THE PERINEUM REVEALS:

• There is absence of perineum. Vaginal and rectal mucous membranes are found to be continuous, only separated by a bridge of fibrous tissue (rectal mucosa is reddish and the vaginal one is pinkish in color).
• Visible dimple on the skin on either side of the fused mucosa may be present. These represent the retracted torn ends of the sphincter ani externus which have got subcutaneous attachment. Radial wrinkling of the skin is present only on the posterior aspect of the anal opening.

Palpation: There is absence of the sphincteric grip evidenced when a finger is introduced into the rectum. The anal canal is separated from the vagina only by a septum. It is surprising that in spite of deficit of the perineum, there is no prolapse. This is because of over-activity of the levator ani muscle. If prolapse is found along with CPT, it is more likely pre-existing.

DIFFERENTIAL DIAGNOSIS: A rectovaginal fistula situated low down may at times be confused with complete perineal tear. This is especially in cases where overlying skin remains intact. Rectovaginal fistula causes more inconvenience to the patient than CPT.

HOMOEOPATHIC MEDICINES FOR MANAGING PERINEAL TEARS: -

The medicines that can be thought of after considering the totality of symptoms and symptom similarity are:-

• Bellis perennis
• Hypericum
• Aconite nap
• Arnica Montana
• Calcarea phosphorica
• Calendula
• Ipecacuanha
• Ledum palustre
• Millefolium