What is the Perineum?
The perineum is a small area of the body on both males and females. It is located between the anus, or bowel movement opening and the overt genitals. In men, the perineum extends from anus to right below the testicles, and in women it extends from the anus to the vaginal opening. This area is highly sensitive and contains numerous nerve endings, which makes many consider it an erogenous zone.
Massage may have absolutely nothing to do with sexual interest, however. When women have children this area can stretch or “tear,” which can cause scarring and discomfort. During a vaginal birth, many doctors opt to perform a small cut at the perineum on the vaginal opening end, called an episiotomy. This is then stitched after the baby is born. It is widely believed that episiotomies may shorten birthing times. By opening the perineum, the baby has more room to exit the vagina. In the absence of these, slight tearing of the perineum can occur, and most doctors feel it’s better to produce a clean cut than allow the area to tear, which it may do unevenly.
Yet there are many interested in avoiding an episiotomy and/or perineal tearing, and there is some evidence that massaging the perineum daily, about six weeks prior to labor, may help reduce need for one. The instructions for perineal massage are complex, and involve using the thumbs inside the vagina to push the floor of the vagina down toward the perineum until a slight stinging sensation is achieved. This may be best done with a water-based lubricant, and is more easily performed in a lying down position with the legs spread apart.
There are a number of websites and books that cover perineal massage extensively. One good book that treats of this subjects is The Baby Book, by Dr. William Sears and Martha Sears. If the procedure still remains unclear, an obstetrician or the doctor who will deliver the baby is an excellent resource. Doctors can usually instruct patients on how to perform massage and stretching of the perineum in order to reduce risk of tearing or episiotomy. This is not necessarily failsafe, and certain types of birth, especially with forceps, may require a large episiotomy.
It's important to know that ACOG (American College of Obstetrics and Gynecology) does *not* recommend routine episiotomy. Some doctors do prefer it, yes, but tears can actually heal better because they may not be as deep or long. A doctor who still performs routine episiotomies is one who is behind the times and ignoring scientific evidence! Some women will experience perineum pain for months after an episiotomy (others heal more quickly), so I encourage pregnant women to discuss this practice with their provider.
what cpt code would i use for removal of a fistula perineum. thank you. --Paula
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