An episiotomy can cause problems that persist well beyond the initial recovery period. Research over the past two decades has dismantled the once-standard belief that cutting the perineum during delivery protects against worse injuries, and the accumulated evidence shows that episiotomy carries its own set of long-term risks to bowel control, sexual comfort, pelvic floor strength, and psychological well-being. The picture is not uniformly grim, and the type of cut matters, but the days of treating episiotomy as a harmless shortcut are firmly over.
How Episiotomy Became Routine and Why That Changed
For much of the twentieth century, episiotomy was performed on the majority of women giving birth vaginally, especially first-time mothers. The reasoning sounded logical: a clean surgical cut would heal better than a ragged natural tear and would protect the pelvic floor from lasting damage. That reasoning turned out to be wrong. A landmark Cochrane-style analysis found that a restrictive policy on episiotomy, meaning performing it only when clinically needed, resulted in significantly less perineal trauma, less suturing, and fewer healing complications at seven days compared with routine use.1PubMed Central. Routine episiotomy should be abandoned Meta-analyses and reviews have since confirmed that episiotomy does not reduce rates of urinary incontinence, perineal pain, or sexual problems, and does not prevent pelvic floor damage.2PubMed Central. Long- and short-term complications of episiotomy Most major obstetric organizations now recommend selective rather than routine use, though practice varies widely across countries and individual hospitals.
Bowel Control and Anal Sphincter Injury
One of the most serious long-term consequences of episiotomy is damage to the anal sphincter, the ring of muscle that controls bowel movements and gas. A retrospective cohort study found that women who had a midline episiotomy were roughly five times more likely to experience fecal incontinence at three months postpartum compared with women whose perineum stayed intact. Even when compared with women who had a spontaneous second-degree tear of the same severity, episiotomy tripled the risk of fecal incontinence and nearly doubled the risk of gas incontinence.3PubMed Central. Midline episiotomy and anal incontinence: retrospective cohort study That finding is striking because it means the surgical cut was worse than a natural tear of comparable depth. The effect held even after accounting for the baby’s weight, how long pushing lasted, and whether instruments were used.
Not every study reaches the same conclusion on bowel symptoms. One study of first-time mothers found that episiotomy did not appear to lead to anal incontinence, though it did find a connection to painful intercourse.4PubMed Central. Episiotomy and the development of postpartum dyspareunia and anal incontinence in nulliparous females The discrepancy likely comes down to the type of episiotomy performed. Midline cuts, which go straight down toward the anus, carry a much higher risk of extending into the sphincter than mediolateral cuts, which angle off to the side. This distinction is central to understanding why episiotomy research sometimes seems to contradict itself.
The Midline Versus Mediolateral Question
There are two main types of episiotomy, and they behave quite differently. A midline (or median) episiotomy cuts straight down from the vaginal opening toward the anus. A mediolateral episiotomy angles about 45 to 60 degrees off to one side. In many parts of the world, the mediolateral technique is standard; in the United States, midline has historically been more common, largely because it is easier to repair and tends to cause less immediate pain.
The trade-off, however, is significant. In a comparative study, deep perineal tears occurred in about 15% of women who received a midline episiotomy, compared with 7% of those who had a mediolateral cut. Risk factors for those deep tears included the midline technique itself, being a first-time mother, shorter maternal height, larger babies, and forceps delivery.5PubMed Central. The outcomes of midline versus medio-lateral episiotomy Despite this difference in tearing risk, the two techniques showed no significant difference in blood loss, infection, pain, or painful intercourse afterward. So the main advantage of mediolateral is that it is less likely to rip further into the sphincter, which is the complication most strongly linked to lasting bowel problems.
If you have had a midline episiotomy and are experiencing bowel control issues months or years later, the connection is well-established in the literature. For mediolateral episiotomy, the risk of sphincter damage is lower but not zero, especially in deliveries involving forceps or vacuum extraction.
Pelvic Floor Strength and Urinary Incontinence
Your pelvic floor is a group of muscles that supports the bladder, uterus, and rectum. Any vaginal delivery puts stress on these muscles, but the question is whether episiotomy makes that stress worse or, as was once believed, reduces it by controlling where the tissue gives way.
A prospective cohort study that followed women for two years after their first vaginal delivery found that women who had episiotomies showed measurably weaker pelvic floor muscle contractions on electromyography compared with women who did not have the procedure. The difference in muscle strength persisted at both 12 and 24 months after birth. While the two groups did not differ significantly in actual urinary incontinence rates, weaker pelvic floor muscles correlated with worse urinary symptoms across all participants.6PubMed Central. Two year follow-up and comparison of pelvic floor muscle electromyography after first vaginal delivery with and without episiotomy and its correlation with urinary incontinence In other words, episiotomy appeared to weaken the muscles that keep you continent, even if the clinical symptoms had not yet fully manifested at the two-year mark.
A systematic review looking at longer-term outcomes reached a more cautious but still concerning conclusion: episiotomy might be detrimental with respect to urinary incontinence symptoms, though the relationship between episiotomy and eventually needing incontinence surgery remained unclear.7PubMed. Long-term effects of episiotomy on urinary incontinence and pelvic organ prolapse: a systematic review This is a case where the evidence leans in one direction without being definitive. The original promise that episiotomy would protect pelvic floor function has not held up, and there are signs it may do the opposite, but the long-term data needed to say so with full confidence is still incomplete.
Pelvic Organ Prolapse, Where Evidence Clashes
Pelvic organ prolapse, where the bladder, uterus, or rectum drops from its normal position because the supporting muscles and tissues have weakened, is a common concern after childbirth. Whether episiotomy contributes to prolapse is genuinely contested in the research.
One large study found that episiotomy was not associated with any pelvic floor disorder, including prolapse. The odds of prolapse were similar whether a woman had no episiotomies, one, or multiple.8PubMed Central. Pelvic Floor Disorders After Childbirth: Effect of Episiotomy, Perineal Laceration, and Operative Birth Another study using the standard clinical measurement system for prolapse found no statistically significant association between episiotomy and prolapse stage, with roughly similar rates of prolapse in women with and without episiotomy history.9European Journal of Obstetrics & Gynecology and Reproductive Biology. The effect of episiotomy on pelvic organ prolapse assessed by pelvic organ prolapse quantification system
On the other hand, a study that specifically investigated risk factors for prolapse found a strikingly different picture. After adjusting for age, weight, and number of pregnancies, episiotomy was independently and strongly associated with increased odds of prolapse. Other major risk factors in that study included higher body weight, more pregnancies, and delivery of large babies.10Clinical and Experimental Obstetrics & Gynecology. Does Episiotomy Play a Role in the Development of Pelvic Organ Prolapse? The disagreement between studies is real and not easily explained away by differences in method. It is possible that episiotomy interacts with other risk factors like number of deliveries and body composition in ways that only show up in certain populations or study designs. The honest answer is that the science has not settled this question.
Painful Intercourse After Episiotomy
Dyspareunia, pain during intercourse, is one of the more commonly reported long-term effects of episiotomy, and it is the complaint that tends to get the least clinical attention. One study of first-time mothers found that while episiotomy did not appear linked to anal incontinence in that particular sample, it did appear to cause dyspareunia.4PubMed Central. Episiotomy and the development of postpartum dyspareunia and anal incontinence in nulliparous females Scar tissue from the repair can make the perineal area tighter or less flexible, and nerve damage during the cut can alter sensation in ways that range from numbness to sharp pain during penetration.
Interestingly, the type of suture material used to close the wound does not appear to make much difference to long-term comfort. A Cochrane review of suture materials for episiotomy and second-degree tear repair found no significant differences between groups for pain at three months or for painful intercourse at three to twelve months.11PubMed Central. Absorbable suture materials for primary repair of episiotomy and second degree tears A more recent systematic review and meta-analysis confirmed that suture material did not significantly influence pain outcomes.12European Journal of Obstetrics & Gynecology and Reproductive Biology. Outcomes of suture material, suture technique and tissue adhesives for repair of childbirth-related perineal trauma: A systematic review and meta-analysis This suggests that if you are experiencing persistent pain at the episiotomy site, changing the suture type at a future delivery would not have prevented it. The pain likely stems from the tissue disruption itself rather than how it was stitched.
For women dealing with ongoing dyspareunia after episiotomy, pelvic floor physiotherapy and, in some cases, scar massage or desensitization techniques can help. If pain persists beyond six months, it is worth raising with a provider rather than assuming it will resolve on its own.
Psychological Effects and Birth Trauma
The physical consequences of episiotomy tend to dominate the conversation, but the psychological effects are real and underappreciated. Women who experienced an episiotomy or a severe perineal tear were more likely to have experienced the birth as traumatic.13European Journal of Obstetrics & Gynecology and Reproductive Biology. The postnatal effects of perineal trauma on maternal psychological and emotional wellbeing: A longitudinal study A population-based survey found that women who experienced perineal trauma reported more postnatal physical symptoms and were more likely to report post-traumatic stress symptoms. Each increase in physical symptom burden was associated with substantially increased odds of adverse psychological outcomes.14PubMed Central. The relationship between perineal trauma and postpartum psychological outcomes: a secondary analysis of a population-based survey
The psychological dimension gets complicated by the consent issue. A study on the ethics of consent during labor found that a surprisingly high proportion of episiotomies are performed without the woman’s informed consent. In the Netherlands, about 42% of women reported unconsented episiotomies. In Australia, the figure was 34%, and in Italy, 39%. Women in both the Netherlands and the United Kingdom reported receiving minimal information and having little choice about the procedure, which contributed significantly to negative and traumatic birth experiences.15PubMed Central. The ethics of consent during labour and birth: episiotomies When a procedure is done to your body without your knowledge or agreement, the resulting scar carries a different emotional weight. If you feel distressed about an episiotomy you did not consent to, that response is not unusual, and it is a recognized dimension of what researchers now call obstetric violence.
Effects on Future Deliveries
A question that comes up frequently is whether having an episiotomy in one delivery increases your risk of problems in the next. The short answer is yes. A study examining subsequent deliveries found that women who had previously undergone episiotomy had significantly higher rates of both minor and severe perineal tears during their next vaginal birth. Rates of first- and second-degree tears were roughly double in the prior-episiotomy group, and rates of the most severe third- and fourth-degree tears were also higher.16PubMed Central. Once episiotomy, always episiotomy? The scar tissue from the first episiotomy likely makes the perineum less elastic, so it is more prone to tearing during subsequent deliveries. This finding is particularly relevant because one historical justification for episiotomy was that it would make future births easier, and the opposite appears to be true.
If you have had an episiotomy and are planning another vaginal delivery, discussing perineal massage in the final weeks of pregnancy and positioning options during labor with your provider may help reduce the likelihood of re-tearing. Some providers may suggest another episiotomy to control where the tissue gives way, but the evidence does not support that approach as a blanket strategy.
Rare but Serious Delayed Complications
Beyond the more common issues of pain, incontinence, and pelvic floor weakness, there are uncommon complications that can appear months or even years after an episiotomy.
Scar endometriosis is one such condition. Endometrial tissue, the tissue that normally lines the uterus, can implant in the episiotomy scar during delivery and later grow in response to hormonal cycles. The result is a painful nodule at the scar site that swells and aches in sync with menstruation. This is very rare, occurring after roughly 0.01% of vaginal deliveries, and it is typically treated with surgical excision.17European Gynecology & Obstetrics. Perineal scar endometriosis: Case report If you notice a lump at your episiotomy scar that becomes more painful around your period, scar endometriosis is worth investigating.18PubMed Central. Perineal endometriosis on an episiotomy scar: diagnosis based on clinical, radiological, and hormonal criteria (case report)
A rectovaginal fistula, an abnormal connection between the rectum and vagina, is another rare but serious complication that can follow an episiotomy, particularly one that extends or is complicated by infection. One reported case involved a woman who developed gas incontinence and abnormal vaginal discharge six months after delivery. The fistula required surgical repair, and the repair itself failed and had to be repeated. Delayed management of these fistulas tends to increase the risk of recurrence.19PubMed Central. Delayed surgical management of rectovaginal fistula: a case report highlighting challenges and lessons learned Rectovaginal fistula after episiotomy is uncommon, but symptoms like persistent abnormal discharge or the passage of gas through the vagina warrant prompt evaluation.
When Episiotomy Is Still Considered Appropriate
None of this means episiotomy should never be performed. There are clinical situations where it is considered reasonable: when the baby is in distress and delivery needs to happen quickly, during certain instrumental deliveries with forceps or vacuum, when the baby is in an unusual position, or when the perineum is so rigid that it is clearly going to tear severely. The shift in obstetric practice is from routine to selective. The procedure exists as a tool for specific situations, not as a default for every vaginal birth.
If you are approaching a vaginal delivery and want to reduce the chance of needing an episiotomy, the evidence supports perineal massage in the final weeks of pregnancy, warm compresses during the pushing stage, and controlled rather than directed pushing. Providers who adopt a “hands-on” approach to guarding the perineum during crowning can also reduce tearing. None of these eliminate the risk entirely, but they lower it meaningfully. And if an episiotomy does become necessary during your birth, understanding the potential long-term effects puts you in a better position to monitor your recovery and seek help early if problems develop rather than assuming that lingering symptoms are just something you have to live with.