Aesthetic proctology: repairing changes after childbirth

Aesthetic proctology combines proctology with reconstructive surgery. Proctology deals with diseases of the rectum and the anal area. In this field, the goal is to restore both the function and the appearance of the perineum (the area between the vaginal opening and the anus) and the pelvic floor, which change after childbirth and with age. The pelvic floor is the group of muscles and ligaments that closes off the bottom of the pelvis like a hammock: it holds the bladder, uterus and rectum in place.

This is sometimes called intimate surgery, but the goal is not only appearance. It is about everyday comfort: having bowel movements easily, not leaking urine when you cough, not feeling discomfort during sex. Concern about appearance is a valid reason too, because it affects how comfortable a woman feels in her own body. At the consultation, we treat it with the same care.

Throughout pregnancy, the growing uterus presses on the pelvic floor for months, and hormones soften the ligaments. During a vaginal delivery, the pelvic floor muscles and connective tissue are stretched to their limit and sometimes tear. This is a natural process, and the tissues often recover without a trace. Sometimes, however, weakness remains.

Factors that increase the risk:

• a large baby, a long pushing stage, a delivery with vacuum or forceps;
• a perineal tear or cut (episiotomy);
• several births;
• chronic constipation, heavy lifting, a long-lasting cough, excess weight;
• menopause: as estrogen levels fall, tissues become thinner and weaker.

A cesarean section (C-section) partly protects the pelvic floor from birth injury, but pregnancy itself also puts a load on it. That is why these problems also occur in women who gave birth by C-section and, more rarely, in women who have never given birth.

Changes after childbirth differ from woman to woman. Often several appear together, but each has its own cause and its own treatment.

Rectocele: difficulty with bowel movements

The front wall of the rectum bulges into the vagina, and stool gets stuck in this “pocket.” The main signs: heavy straining, a feeling that the bowel has not emptied completely, and needing to press on the vagina or perineum with a finger to have a bowel movement. More: rectocele and its treatment, with a plain-language explanation in our article What is a rectocele?

Cystocele and urinary incontinence

The bladder can sag into the front wall of the vagina (cystocele). When the support of the urethra weakens, urine leaks when you cough, laugh, sneeze or lift something heavy: this is called stress urinary incontinence. Leakage that comes with a sudden, strong urge has a different cause and is treated differently. More: cystocele and urinary incontinence treatment.

Vaginal laxity

After childbirth, the vagina can become wider and its muscle tone weaker. Women describe reduced sensation during sex, air escaping from the vagina and a feeling of “looseness.” This can be corrected with vaginoplasty, that is, vaginal tightening.

Changes in the labia minora

After childbirth or a sharp change in weight, and sometimes simply over the years, the labia minora can become larger, sag or become asymmetric. In some women this is present from birth. If the change causes rubbing in underwear, irritation and discomfort, it can be corrected with labiaplasty.

Perineal tears and scars

During childbirth, the perineum can tear or be cut. In most cases the wound heals without a trace, but sometimes a tight, painful scar, a deformity or a widened vaginal opening remains. During perineal repair (perineoplasty), the scar tissue is removed, the perineal muscles are brought back together and the shape of the vaginal opening is restored. This operation is done on its own or together with other vaginal repair procedures.

Hemorrhoids and anal fissure after childbirth

Pregnancy and pushing during labor are among the main causes of hemorrhoids. Hard stools during the first bowel movements after childbirth can lead to an anal fissure. Most of these are treated without surgery, and we choose medications with breastfeeding in mind. More: hemorrhoid treatment and anal fissure treatment.

Colporrhaphy, vaginoplasty and TOT: what is the difference?

These operations are often done in the same session, but one does not replace another. For example, vaginoplasty does not treat urinary incontinence, and TOT does not put a sagging bladder or uterus back in place.

The first months are a recovery period. During this time, many kinds of discomfort are normal and gradually pass:

• pain, stinging and pulling at the stitches in the perineum usually ease within the first 2–3 weeks, and most stitches dissolve on their own;
• leaking a few drops of urine when you cough or laugh, and a feeling of looseness and heaviness in the vagina, often lessen during the first months as the pelvic floor gets stronger;
• hemorrhoids that appeared during pregnancy often shrink in the weeks after delivery;
• vaginal dryness and discomfort during sex while breastfeeding are linked to low estrogen and usually go away after breastfeeding ends.

It is completely natural to be afraid of the first bowel movement after childbirth. But do not put it off: the longer you wait, the harder the stool gets, and it can cause an anal fissure. If needed, use a stool softener on your doctor's advice.

Some changes, however, do not go away on their own. Urinary leakage that continues about 3 months after childbirth, a bulge in the vagina that you can see or feel, needing to help yourself with a finger to empty your bowels, or a tight or painful scar all need an examination. There is no need to put up with them as “an inevitable mark of childbirth.” We also explain this topic in our article 5 intimate problems after childbirth.

Do not wait — seek urgent care if you have:

• fever together with increasing pain in the perineum, swelling, pus draining from the stitches, or stitches coming apart;
• gas or stool coming from the vagina;
• inability to pass urine;
• a sudden, very painful, hard, bluish lump at the anus, or bleeding that does not stop.

Being unable to hold in gas or stool is not an emergency, but do not delay an examination: this problem is easier to treat when it is assessed early. If you have problems with your stitches or bleeding in the first weeks after childbirth, be sure to also let the obstetrician-gynecologist who delivered your baby know.

The first visit starts with a conversation. We ask how many births you have had and how they went, how long you have had your symptoms, about your bowel and bladder habits, and whether you have any discomfort during sex. Please answer these questions openly: there are no strange or embarrassing questions here.

Then comes the examination. We usually examine you lying down, and sometimes ask you to cough or strain so that any prolapse becomes visible. If needed, we order anoscopy (a look into the anal canal with a small instrument), an ultrasound, a urine test or defecography.

The examination is done by a female doctor, and you can ask for a pause at any moment. Your medical information is not shared with anyone, and no photos are taken without your consent.

Pelvic floor exercises are the foundation of recovery after childbirth. They reduce urinary leakage, slow the progression of mild prolapse and help protect the result after surgery. After an uncomplicated delivery, you can start gentle exercises as soon as pain allows. If you had stitches or a severe tear, talk to your doctor first.

1. Find the muscle. While urinating, try to stop the flow for a moment: the muscle that tightens is your pelvic floor. Do this only once or twice to recognize the muscle, not as a regular exercise. Or insert a clean finger into your vagina and squeeze: if you feel tightening around your finger, you have found the right muscle.
2. Empty your bladder. Do the exercises with an empty bladder.
3. Start lying down. At first, lie on your back; you can put a small pillow under your hips.
4. Squeeze and relax. Squeeze the muscle for 5 seconds, relax for 5 seconds, and gradually build up to 10 seconds. Ten repetitions make one set; 3 sets a day are enough.
5. Use only the pelvic floor. Do not tighten your abdominal, thigh or buttock muscles, and do not hold your breath.
6. Make it a daily habit. Once you have learned it, you can also do the exercise sitting or standing. Briefly squeezing the muscle before you cough, sneeze or lift something heavy helps prevent leaks.

Be patient: improvement is usually felt after several months of regular exercise, often after 3–5 months. If you cannot find the muscle, we check at the appointment whether you are squeezing correctly. If needed, biofeedback is recommended, which means exercising while watching the muscle's activity on a screen.

Not every change requires surgery. A surgical solution is considered if your symptoms persist despite exercises and other measures and make your life difficult: every trip to the toilet becomes an ordeal, urinary leakage gets in the way of work and sports, or sex brings discomfort.

Timing matters too. Pelvic floor recovery takes months, so planned repair surgery is usually done at least 6 months after childbirth and after breastfeeding has ended. Ideally, surgery is done when a woman is no longer planning to give birth again, because another vaginal delivery can weaken the repaired tissues again.

These rules are not absolute. The timing is chosen individually for each woman: if the symptoms are very severe, a long wait may not be necessary. If you are planning a future pregnancy, we decide on the timing of surgery and the method of your next delivery together with an obstetrician-gynecologist. Treatment of hemorrhoids and anal fissures, on the other hand, can start without waiting.

Problems after childbirth often do not come alone: the same woman may have a rectocele and hemorrhoids, a cystocele and a rectocele, or urinary incontinence and vaginal laxity. When there is a medical indication and your general health allows, we treat them in the same session, under one anesthetic. This is called combined, or “bouquet,” surgery.

The advantage is clear: one anesthetic, one hospital stay, one recovery period. But this approach is not right for everyone. The number and extent of the operations, the length of anesthesia, your age and any other conditions are taken into account, and the decision is made after an examination and tests. More: surgical and conservative treatment, combined surgery.

A patient in her late thirties who had given birth three times came to us with several complaints: constipation, having to help herself by hand to empty her bowels, and air escaping and discomfort during sex. The examination revealed a cystocele and a rectocele, and her vagina had also become wider. In the same session, she had anterior and posterior colporrhaphy, anterior levatorplasty and vaginoplasty. The operation took about 1 hour 15 minutes, and the patient stayed in the clinic for 1 day. Every patient's situation is individual.