Skip to main content

Perineorrhaphy

Perineorrhaphy is a surgical procedure that reconstructs the perineal body by reapproximating the perineal muscles (bulbocavernosus, superficial and deep transverse perineal muscles) to restore Level III pelvic floor support and reduce the genital hiatus.[1][2][3] Despite being one of the most commonly performed concomitant procedures in pelvic reconstructive surgery, it remains "commonly performed yet poorly understood" — its use is based largely on expert opinion with limited high-quality evidence, and significant heterogeneity exists in both indications and technique.[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.[4][5] It is composed of collagen (29%), adipose cells (27%), smooth muscle (11%), elastin (7%), and skeletal muscle (3%).[6]

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

DeLancey's perineal complex triad hypothesis describes how the perineal body, perineal membrane, and levator ani muscles — united by the vaginal fascia — work together to maintain urogenital hiatus closure. Loss of the connection of the left and right perineal membranes through the perineal body results in diastasis of the levator and a widened hiatus, and downward rotation of the perineal membrane.[7] The perineal body thus represents a critical Level III support structure — its disruption (typically from obstetric trauma) contributes to both posterior compartment prolapse and overall pelvic floor failure.[8][9]

Indications​

The primary indication is an enlarged genital hiatus (GH) with perineal body deficiency, typically performed as a concomitant procedure during pelvic organ prolapse repair.[1][3]

A 2026 multicenter analysis confirmed that surgeons more often perform perineoplasty in patients with:[10]

  • Larger GH (5.2 vs 4.5 cm)
  • Obesity (OR 2.3)
  • Higher parity (30-fold increase for ≥ 4 children vs 1 child)

Surgeons cited lack of evidence and fear of dyspareunia as the primary reasons not to perform it.[10]

Specific indicationThreshold / context
Perineal body deficiency after obstetric traumaVisible perineal scar with confirmed anatomic defect[11]
Genital hiatus ≥ 3.5 cmCommon practical threshold[12][13]
Wide introitus with vaginal-laxity complaints[12]
Concomitant with posterior colporrhaphyStandard adjunct[2][14]
Concomitant with apical suspension[15]

Surgical Technique​

There is significant heterogeneity in how perineorrhaphy is performed — no standardized technique exists.[1] Most surgeons (81%) report incorporating structures both proximal and distal to the hymen in their repairs.[1]

  1. Incision — diamond-shaped or triangular incision on the posterior vaginal wall at the introitus, extending onto the perineal skin. Often continued from the distal end of a posterior colporrhaphy incision
  2. Dissection — vaginal epithelium and perineal skin dissected off perineal muscles bilaterally to expose attenuated / separated musculature
  3. Muscle reapproximation:
    • Bulbocavernosus (bulbospongiosus) identified bilaterally and reapproximated in the midline with interrupted absorbable sutures
    • Superficial and deep transverse perineal muscles similarly reapproximated[2][16]
    • Deep sutures placed into the perineal muscles to build up the perineal body[2][14]
  4. Rectovaginal fascia attachment — ACOG specifies that perineorrhaphy should result in reattachment of the perineal muscles to the rectovaginal septum if a perineal defect is present[3]
  5. Excess tissue excision — redundant vaginal mucosa and perineal skin trimmed
  6. Closure — overlying vaginal and vulval skin closed with absorbable sutures[2]

Technical Considerations​

  • Suture material varies — no consensus on permanent vs absorbable, or braided vs monofilament[1]
  • Avoid excessive narrowing of the introitus (introitus stenosis → dyspareunia)
  • Do not incorporate levator ani plication unless specifically intended — increases dyspareunia risk[3]

Outcomes​

Genital Hiatus Reduction​

StudynResult
Mothes 2023[12]121Mean GH reduced 29.5% (44 → 31 mm, p < 0.001)
Bonglack 2022[17]56Intraop GH reduction sustained at 3 mo (median resting GH 0.5 cm less than end-of-surgery measurement); change in GH baseline → 3 mo significantly greater with perineorrhaphy (−1.5 vs −0.5 cm, p < 0.001)

Symptom Improvement After Perineal Reconstruction​

  • Rotstein 2023 (n = 131): standardized perineal reconstruction for deficient perineum after vaginal delivery — mean total symptom score reduction −9.1 points (from 18.4 / 33, p < 0.001).[11]

Impact on Prolapse Recurrence — The Critical Question​

The evidence on whether perineorrhaphy actually prevents prolapse recurrence is inconclusive:

  • Sutkin 2020 (OPTIMAL secondary analysis, n = 374): concomitant posterior repair (typically including perineorrhaphy) at the time of SSLF or USLS was not associated with improved surgical success (66.7% vs 62.0%; aOR 1.07, 95% CI 0.56–2.07, p = 0.83). Authors concluded posterior repair "may not compensate for the pathophysiology that leads to enlarged preoperative genital hiatus," which remains prognostic of recurrence regardless of repair.[15]
  • 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."[18]
  • Shakhaliev 2024: ongoing RCT (NCT05422209, n = 310) is the first specifically designed to evaluate whether simultaneous perineoplasty improves the efficacy of mesh-augmented sacrospinal fixation. No prior RCT has estimated the influence of simultaneous perineal-body correction on apical-fixation outcomes.[19]

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

The association between GH size and prolapse is robust:

StudyFinding
Handa 2019[20]Relative to GH ≤ 2.5 cm: GH 3 cm → HR 3.0 for POP; GH ≥ 3.5 cm → HR 9.0 (95% CI 5.5–14.8)
Siff 2020 OPTIMAL ancillary[13]Immediate postop GH ≥ 3.5 cm associated with anatomic failure (aOR 1.6) and surgical failure (aOR 1.5) at 2 yr
DeLancey 2025[8]3D MRI: resting urogenital hiatus area 68% larger in women with prolapse vs controls; failure frequency increased with prolapse size
Casas-Puig 2023[21]After MIS sacrocolpopexy, only patients with 6-mo GH > 3 cm underwent retreatment (composite recurrence NS by GH size)

Complications​

Postoperative Urinary Retention — most notable​

Cervantes 2026 (n = 715): patients who had perineoplasty were significantly more likely to have urinary retention (30.2% vs 19.1%, p < 0.001).[22]

Dyspareunia​

  • De novo dyspareunia after prolapse surgery ranges 0–9% for most procedures; rates are higher with posterior repair (which often includes perineorrhaphy)[23]
  • Excessive narrowing of the introitus is the primary mechanism
  • Surgeons frequently cite fear of dyspareunia as a reason to omit perineoplasty[10]
  • Mothes 2023 found no difference in QOL improvement between sexually active and inactive patients, suggesting perineorrhaphy does not disproportionately impair sexual function when performed appropriately[12]

Other​

  • Wound infection / dehiscence — uncommon
  • Hematoma — uncommon
  • Perineal pain — typically self-limited
  • Vaginal stenosis — if excessive tissue excised

Perineorrhaphy in Obstetric Perineal Repair​

Perineorrhaphy is also performed as part of obstetric laceration repair (second-degree and higher). The technique reapproximates the bulbospongiosus and transverse perineal muscles in the midline after vaginal-mucosal closure. Continuous suturing causes less short-term pain than interrupted suturing. The skin does not require separate closure — a skin suture layer increases perineal pain at 3 mo postpartum.[16][24]

Summary of Current Evidence and Practice Patterns​

AspectCurrent evidence
Primary indicationEnlarged genital hiatus (≥ 3.5 cm) with perineal body deficiency[1][2][3]
GH reductionSustained ~ 30% reduction at follow-up[12][17]
QOL improvementSignificant in all domains; 87–90% report cure[11][12]
Prolapse recurrence preventionNot demonstrated — insufficient evidence[15][18]
Standardized techniqueNone — significant practice heterogeneity[1]
RCT evidenceNo completed RCTs; one ongoing (NCT05422209)[19]
Key complicationPostoperative urinary retention 30% vs 19%[22]
Guideline recommendationACOG: "can be performed as needed if a perineal defect is present"[3]

Key Takeaways​

Perineorrhaphy is a widely performed but evidence-poor procedure. The anatomic rationale is strong — the perineal body is a critical Level III support structure, and an enlarged genital hiatus is one of the strongest predictors of prolapse development and recurrence.[8][20] Perineorrhaphy effectively reduces GH size and improves patient-reported symptoms.[11][12][17] However, the central question — whether GH reduction through perineorrhaphy actually prevents prolapse recurrence — remains unanswered. The OPTIMAL secondary analysis found no benefit of adjuvant posterior repair on surgical success, and no completed RCT has evaluated perineorrhaphy as an independent variable.[15][19] Until such evidence is available, the decision to perform perineorrhaphy should be individualized based on perineal-body deficiency, GH size, patient symptoms, and shared decision-making regarding the risks (urinary retention and potential dyspareunia).[1][10][22]

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. Baessler K, Christmann-Schmid C, Haya N, et al. "Surgery for Women With Pelvic Organ Prolapse With or Without Stress Urinary Incontinence." Cochrane Database Syst Rev. 2026;2:CD013108. doi:10.1002/14651858.CD013108.pub2

3. Committee on Practice Bulletins—Gynecology and American Urogynecologic Society. "Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214." Obstet Gynecol. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. Mowat A, Maher D, Baessler K, et al. "Surgery for Women With Posterior Compartment Prolapse." Cochrane Database Syst Rev. 2018;3:CD012975. doi:10.1002/14651858.CD012975

15. 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

16. Arnold MJ, Sadler K, Leli K. "Obstetric Lacerations: Prevention and Repair." Am Fam Physician. 2021;103(12):745-752. PMID 34128611

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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