Most women who give birth vaginally for the first time sustain some perineal trauma, whether a tear or an episiotomy. The majority heal well. A significant minority do not — and are left with scar pain, tightness, pain with intercourse, or bowel symptoms that nobody warned them about and that they are often too embarrassed to raise.
Obstetric anal sphincter injuries — third and fourth degree tears, collectively OASI — occur in a small percentage of vaginal births but carry a much higher risk of long-term bowel symptoms. These need specialist pelvic floor physiotherapy, and the earlier it starts the better the outcome tends to be.
Jency Sudha works within the colorectal and pelvic floor team at the Royal London Hospital, where OASI management is core clinical work.
Degrees of perineal tear
Knowing what you had matters, because management differs considerably.
First degree
Skin of the perineum or vaginal lining only. Often heals without stitches and usually without lasting problems.
Second degree
Involves the perineal muscle as well as the skin. Usually stitched. Heals well in most cases, though scar tightness and pain with intercourse can persist.
Episiotomy
A surgical cut, usually mediolateral, made to enlarge the opening. Comparable to a second degree tear in depth, and prone to the same scar-related problems.
Third degree (OASI)
Extends into the anal sphincter muscle. Repaired surgically, usually in theatre. Carries a meaningful risk of later bowel control problems and warrants specialist physiotherapy.
Fourth degree (OASI)
Extends through the anal sphincter into the lining of the bowel. Repaired surgically. The highest risk of long-term bowel symptoms, and the strongest case for specialist follow-up.
Not sure what you had?
Many women are told at the time and do not retain it. Your maternity notes will record it, and your GP or the maternity unit can confirm — it is worth knowing.
Symptoms worth getting assessed
These are all treatable, and none of them is something you simply have to accept as the price of childbirth.
- Pain with intercourse — at the entrance, or a specific tender spot at the scar
- Ongoing perineal pain or a pulling sensation, particularly on sitting or walking
- Scar tightness, or a sense that the opening is narrower than before
- Urgency to open your bowels — needing to rush, or being unable to defer
- Difficulty controlling wind — very commonly under-reported
- Leakage of stool, including staining or soiling
- Incomplete emptying, or needing to press on the perineum to empty
- Numbness or altered sensation around the perineum or scar
Bowel symptoms after a third or fourth degree tear are common, treatable, and almost never volunteered by patients unless they are asked directly. If any of these apply to you, please raise them — they are exactly what this service exists to treat.
How treatment works
Assessment
A detailed history including what degree of tear you had and how it was repaired, plus — with your consent — examination of the scar, pelvic floor and, where bowel symptoms are present, the anal sphincter. This determines whether the problem is scar tissue, muscle function, nerve involvement, or a combination.
Perineal scar mobilisation
Hands-on work to restore tissue glide and reduce tethering, plus instruction so you can continue at home. Effective for scar pain, tightness and pain with intercourse, including on scars that are years old.
Desensitisation
Graded exposure for scars that are painful or hypersensitive to touch, retraining the nervous system's protective response.
Pelvic floor and sphincter rehabilitation
Targeted strengthening of the pelvic floor and, for OASI, specifically of the anal sphincter complex. Supervised training is considerably more effective than unsupervised, and biofeedback is often used where the muscle is hard to isolate.
Biofeedback
Particularly valuable after sphincter injury, where sensation is altered and patients often cannot tell whether they are contracting the right muscle. See biofeedback therapy.
Bowel management
Stool consistency is the single biggest determinant of continence after sphincter injury. Fibre, fluid, medication where appropriate, defaecation mechanics and urgency deferral strategies all form part of treatment.
Return to intimacy
Addressed directly rather than left unspoken — including scar treatment, pelvic floor downtraining where muscles have become protectively overactive, and graded reintroduction. See painful sex physiotherapy.
Future pregnancies after OASI
If you have had a third or fourth degree tear, mode of delivery for a subsequent birth is a genuine decision rather than a foregone conclusion, and it should be discussed with an obstetrician.
Pelvic floor and sphincter function are part of that discussion. An assessment documenting current sphincter strength and any ongoing symptoms gives you and your obstetric team objective information to work with, rather than relying on recollection of how the first birth went.
Physiotherapy before a subsequent pregnancy is worthwhile in its own right: sphincter function that is optimised beforehand copes better with a further birth, whichever route is chosen.
Frequently Asked Questions
How long does a perineal tear take to heal?
The surface tissue usually heals within two to six weeks depending on the degree of tear, but scar tissue continues to remodel for many months. Persistent pain, tightness or pain with intercourse beyond about three months is not something to keep waiting out — it is a common reason for referral and it responds well to treatment.
I had a third degree tear and I cannot always control wind. Is that permanent?
No, and it is one of the most treatable symptoms after obstetric anal sphincter injury. Difficulty controlling wind reflects sphincter function and is frequently improved by supervised pelvic floor and sphincter rehabilitation, usually combined with biofeedback and stool-consistency management. It is also under-reported, so please raise it — it will not surprise your physiotherapist.
Is sex supposed to hurt after a tear?
Not permanently. Some discomfort when resuming intercourse after perineal trauma is common, but ongoing pain months later usually indicates scar tethering, a specific tender point at the scar, or protective overactivity of the pelvic floor muscles. All three respond well to treatment, and the combination of scar mobilisation and pelvic floor downtraining resolves it for most women.
When can I start perineal scar massage?
Once the tissue has fully healed, typically around six weeks after birth and after your postnatal check has confirmed healing. Starting earlier risks disrupting the repair. If the area is still open, bleeding, discharging or acutely painful, seek medical review first.
Is it too late if my tear was years ago?
No. Scar tissue responds to mobilisation long after the original injury, and pelvic floor and sphincter muscles respond to training at any age. Women treated several years after an OASI regularly gain significant improvement in bowel control, scar pain and pain with intercourse.
Will I need a caesarean next time?
Not necessarily — it is a discussion to have with an obstetrician rather than an automatic decision. Current sphincter function and any ongoing symptoms are relevant to that decision, and a physiotherapy assessment documenting them gives your obstetric team objective information rather than relying on recall of the previous birth.
Clinically reviewed by Jency Sudha, Consultant Pelvic Health Physiotherapist & Biofeedback Specialist — last updated 26 July 2026
The information on this page is for general guidance and does not replace individual clinical assessment. If your symptoms are new, worsening, or accompanied by bleeding, fever or severe pain, contact your GP or NHS 111.
These Symptoms Are Treatable
Bowel symptoms and scar pain after birth are common, rarely mentioned, and respond well to specialist treatment.
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