Can Episiotomy Cause Problems Years Later?

Episiotomy can cause problems that persist for years, though the evidence on exactly which problems and how often varies depending on the complication. Pain during intercourse, changes in bladder control, scar-related issues, and psychological effects have all been documented well beyond the initial recovery window. What makes the picture complicated is that childbirth itself, with or without an episiotomy, carries many of the same risks, and teasing apart the specific contribution of the cut from the contribution of labor and delivery has proved difficult for researchers.

Pain During Sex Is the Most Studied Long-Term Complaint

The most common long-term issue reported after episiotomy is dyspareunia, the medical term for pain during intercourse. A study following women 12 to 18 months after delivery found that those who had an episiotomy reported more frequent pain and insufficient lubrication during sex compared with women who delivered without one. Arousal, orgasm, and satisfaction were not affected, but the pain itself lingered into the second year postpartum. The same study identified episiotomy as an independent risk factor for that pain, alongside perineal tears, fundal pressure during delivery, and a prior history of painful intercourse.¹

Research tracking first-time mothers with episiotomy found sexual dysfunction in about two-thirds of women at three months, dropping to roughly 15% at twelve months.² That downward trajectory is encouraging, but it also means roughly one in seven women was still experiencing sexual dysfunction a full year out. A large systematic review by JAMA found that women with episiotomy had the slowest return to intercourse after delivery. Pain during the first postpartum intercourse was most common and most severe in the episiotomy group. A pooled estimate across two cohorts suggested women with episiotomy were about 50% more likely to report pain at three months, though the finding was not statistically definitive.³

A Cochrane review looking specifically at selective versus routine episiotomy, however, found that by six months or more postpartum, there was probably little to no difference in dyspareunia between women who had the procedure and those who did not.⁴ The takeaway from the combined evidence is that episiotomy reliably makes pain during sex worse in the first several months, but whether that pain persists beyond a year is more uncertain and likely depends on individual healing, scar quality, and other birth-related factors.

Bladder Control and Pelvic Floor Function

One of the original justifications for routine episiotomy was that a clean surgical cut would protect the pelvic floor better than a ragged tear. That reasoning has not held up. A systematic review of 24 studies examining long-term effects concluded that episiotomy might actually be detrimental with respect to urinary incontinence symptoms.⁵ A separate meta-analysis that pooled risk factors across many studies independently identified episiotomy as a risk factor for urinary incontinence later in life, alongside instrumental delivery, tears, and constipation.⁶

On the question of pelvic organ prolapse, the same systematic review of 24 studies found that episiotomy does not seem to worsen prolapse development and might even be slightly protective in terms of severity and prevalence.⁵ The Cochrane review similarly found no clear difference in genital prolapse at three years between women who had the procedure and those who did not.⁴ So the picture splits: episiotomy appears to slightly worsen urinary incontinence risk but does not seem to affect prolapse.

How the Type of Cut Changes the Risk

Not all episiotomies carry the same risks. The two main types are midline (cutting straight down toward the anus) and mediolateral (cutting at an angle away from the anus). The anatomy here matters quite a bit. Cadaver dissections showed that midline incisions did not cut through major neuromuscular structures, but they did increase the risk of injury to the external anal sphincter, simply because the cut heads directly toward it. Mediolateral incisions posed a greater risk of damaging nerve, muscle, erectile, and gland tissues on the side of the cut.⁷

This is why midline episiotomies, which are more common in the United States, carry a higher risk of extending into a severe tear that reaches the anal sphincter. Severe sphincter injuries (third- and fourth-degree tears) significantly increase the risk of anal incontinence years later. A nationwide database analysis found that both severe sphincter injury and unnecessary episiotomy were independently associated with anal incontinence eight years after childbirth.⁸ Mediolateral episiotomy, by contrast, is the standard in much of Europe precisely because it carries a lower sphincter-injury risk, though it trades that for greater soft-tissue disruption on the side of the cut.

What Happens to Pelvic Muscles

The levator ani is the hammock of muscle that supports the pelvic organs. Damage to it during childbirth is linked to later prolapse and incontinence. Whether episiotomy protects or harms this muscle has been studied directly. One study using imaging found that about 11% of women with episiotomy had levator ani avulsion, compared with about 15% without, and the difference was not significant.⁹

A systematic review put the avulsion rate at roughly 23% for women who had an episiotomy, which was similar to the rate for women with spontaneous second-degree tears (22%) and lower than the rate for women with severe sphincter injuries (35%). Women with no perineal tear at all had the lowest rate, around 13%.¹⁰ The conclusion is straightforward: episiotomy does not protect the levator ani. The muscle damage that contributes to later pelvic floor problems happens whether or not an episiotomy is performed.

Scar Tissue and Rare Complications

Most episiotomy scars heal without unusual problems, but a subset of women develop scar tissue that remains tight, painful, or hypersensitive long after the wound has closed. Dense scar tissue in the perineum can make sex uncomfortable by reducing the elasticity of the vaginal opening, and it can cause pain with prolonged sitting or physical activity.

A rarer but well-documented complication is endometriosis developing within the episiotomy scar. Endometrial cells can implant in the surgical wound during delivery and later grow into a painful mass that flares with the menstrual cycle. Case reports describe women presenting with a painful perineal lump months to years after delivery. One case involved a woman who developed a painful mass on her episiotomy scar two years after a mediolateral cut, with no prior history of endometriosis.¹¹ Scar endometriosis is considered rare, but clinicians recommend that any woman with a history of vaginal delivery who develops a painful perineal mass that worsens during menstruation should be evaluated for it. Wide excision of the affected tissue remains the standard treatment.¹²

Nerve injury is another uncommon but meaningful complication. The perineal branch of the pudendal nerve runs through the area where episiotomy cuts are made. One case series examining women with chronic perineal nerve pain found that episiotomy was the mechanism of injury in nearly a third of patients. Nerve damage in this area can cause burning pain, numbness, or hypersensitivity around the perineum that persists indefinitely if untreated.

Effects on Future Pregnancies

If you’ve had an episiotomy and are planning another vaginal birth, the research has some sobering findings. A study of subsequent deliveries found that women who had an episiotomy the first time around had significantly higher rates of perineal tears the second time. First- and second-degree tears were nearly twice as common (roughly 34% vs. 18%), and even severe third- and fourth-degree tears were more frequent.¹³

A separate analysis found that after adjusting for other factors, the risk of having a second-degree or higher spontaneous tear in the next delivery was about fivefold higher for women who had perineal trauma the first time. The risk of undergoing another episiotomy in the second delivery was roughly threefold.¹⁴ The scar tissue from the first episiotomy appears to make the perineum less flexible, increasing the chance it will tear again or that a provider will judge another episiotomy necessary. This creates a cycle that some researchers have summarized with the phrase “once episiotomy, always episiotomy.”

This finding also feeds into the psychological effects of the procedure. A qualitative study of women’s experiences found that episiotomy created what researchers called a “psychological shadow” over future pregnancies. Women expressed doubt about whether their scar would split open during the next delivery, whether they would be subjected to another cut, and whether vaginal birth was worth attempting again. At least one participant stated she would request a cesarean section specifically to avoid another episiotomy.¹⁵

Psychological and Body Image Effects

The physical complications of episiotomy get most of the attention, but the psychological toll is increasingly recognized. A survey of genital body image and sexual self-esteem after vaginal birth found that women who had episiotomies reported significantly more negative sexual and body esteem than women who did not.¹⁶

A longitudinal study comparing women with episiotomy to those with severe sphincter tears found an interesting pattern. At 6 to 12 weeks postpartum, women with episiotomy reported a more negative perception of their body image than even those with the most severe tears. Both groups were more likely to have experienced the birth as traumatic. At 6 to 10 months, women with episiotomy continued to report more anxiety-related symptoms than women with severe tears. The researchers concluded that psychological impacts for women with episiotomy may merit more support than is currently provided.¹⁷

That finding may seem surprising: how could a controlled surgical cut cause more distress than a severe tear? Part of the explanation may be that episiotomy is something done to you, often without clear consent or explanation in the moment, while a tear is experienced as something that happened during birth. The sense of bodily violation, combined with visible scarring in an intimate area, can shape how a woman feels about her body and her sexual identity for years.

What Can Be Done When Problems Persist

If you’re dealing with lasting effects from an episiotomy, treatment options exist across a range of approaches. Pelvic floor physiotherapy is considered a first-line option for many issues, including myofascial pain, scar tightness, and pelvic floor weakness. A specialist can work with scar tissue mobilization techniques and targeted exercises. For episiotomy wounds that haven’t healed properly, a case series reported that radiofrequency and magnetotherapy treatments achieved 50% pain relief with total recovery within a week, though this was a small early-stage study.¹⁸ Myofascial pain and wound complications may require physical therapy and, in some cases, local injections such as corticosteroids or anesthetic agents.¹⁹

For women with more significant anatomical changes, surgical repair through perineoplasty is an option. A study evaluating perineoplasty for perineal damage from vaginal delivery found significant improvement in desire, arousal, lubrication, orgasm, and sexual satisfaction after the procedure. However, pain during intercourse did not significantly improve.²⁰ That’s an important distinction: surgery can restore anatomy and improve many aspects of sexual function, but if the pain is driven by nerve damage or deeply embedded scar tissue rather than structural looseness, it may not resolve the most bothersome symptom.

Why These Problems Are Often Dismissed

A recurring frustration for women dealing with long-term episiotomy complications is that their problems are minimized or normalized. A systematic analysis published in The Lancet Global Health argued that the historical focus on reducing maternal death during childbirth has come at the expense of complications that emerge or persist months and years later. The authors contended that the absence of these conditions from the global health agenda has led to the widespread misconception that they are uncommon or unimportant.²¹

A review of long- and short-term episiotomy complications captured the state of the evidence bluntly: most episiotomy research has focused on short- or medium-term outcomes, and the number of studies investigating truly long-term effects is insufficient. The review noted that while episiotomy is often associated with incontinence and sexual dysfunction, there is no concrete evidence settling the question for the long term. What is clear is that routine episiotomy does not prevent pelvic floor damage, and the recommended approach has shifted from routine to restrictive use.²²

The gap in research matters practically. If you’re experiencing perineal pain, incontinence, or sexual dysfunction years after an episiotomy and your provider attributes it solely to aging or “normal” postpartum changes, the evidence suggests pushing for a more thorough evaluation is reasonable. The connection between the episiotomy and your symptoms may be difficult to prove, but it is also far from implausible, and treatments exist that can help regardless of whether the exact cause is pinned down.