"Does taking a bath increase your chances
of getting an infection, yeast or UTI?
I am 29 years old, always have menstrual periods
on time, although I am 9 weeks post partum. I seem
to get a lot of yeast infections".
A.N.
If someone told you there would not be any short
or long term vaginal changes after delivery of a baby
through the vagina, I am sure you would not believe
them. Anytime a 4 inch (10 cm) diameter round object
goes through an opening that cannot normally stretch
beyond a 2 inch (5 cm) diameter opening, there is
a strong likelihood of stretching, tearing and pain
afterwards. When that is added to hormonal changes
after delivery with or without breast feeding, a postpartum
woman can have significant vaginal pain, dryness,
burning, fear of intercourse, vaginal opening looseness,
and even difficulty with losing control over urination,
bowel movements or holding bowel gas.
Let us look at some of the changes that can take
place in the lower genital tract after normal, uncomplicated
vaginal deliveries.
Are vaginal infections or vaginal burning common
after delivery?
The hormones of pregnancy, high estrogen and progesterone,
decline rapidly after delivery. The result is an almost
menopausal state with respect to vaginal lubrication.
The condition is called vaginal atrophy with a rise
in the pH of the vagina and a shift away from superficial
vaginal cells that lubricate the vagina and provide
protection from irritation (1). This change also takes
place on the outside of the vulva and is subject to
any irritation from soaps, rubbing, or contact with
chemicals in pads, condoms, lotions or other topically
applied agents.
To answer your questions about whether baths can
cause vaginitis or urinary tract infections (UTIs)
in the postpartum time period, the answer is that
they can produce SYMPTOMS of UTIs or vaginitis, i.e.,
pain with urination, frequency, vulvar burning, but
they are NOT thought to produce actual infections.
They produce symptoms if soaps or bath oils are used
that irritate the already very thin, sensitive skin
in those areas around the vagina and urethra. This
is more of an irritant vulvitis and urethritis rather
than a vaginal yeast infection or a UTI. This does
not mean that you cannot get a yeast infection or
a UTI after delivery -- you certainly can -- but often
it is a case of mistaken etiology.
If one looks at vaginal smears to after delivery
to see how predominant this problem is, we find that
about one third of non lactating women have atrophic
changes for about six weeks before they start improving,
but in 5% the atrophic pattern persists for a long
time (2).
How long will the perineal pain from delivery last
so I can know how long before I can resume intercourse?
One study that looked at how long, on the average,
it took women to recover various functions after normal
vaginal delivery found that the median time (time
for 50% of subjects) "for perineal comfort in
general (including walking and sitting) was 1 month
(range, 0-6 months); 20% of women took more than 2
months to achieve general perineal comfort. For comfort
during sexual intercourse, the median time was 3 months
(range, 1 to more than 12 months); 20% of women took
longer than 6 months to achieve comfort during sexual
intercourse. " (3).
You would think that the pain with intercourse is
only present if you have an episiotomy but that is
not the case. In another study that looked at postpartum
painful intercourse (dyspareunia), they found that
72% of postpartum women had pain especially at entrance
to the vagina (4). While this pain was more likely
if a woman had a vaginal delivery, it was also present
in over 20% of women who had Cesarean sections. Women
who were nursing also had a higher incidence of painful
sexual intercourse.
Therefore, in general, you should expect that it
takes about month before perineal discomfort with
walking or sitting goes away but it may easily take
2 months. Also it will take about 3 months before
the discomfort with vaginal intercourse goes away
but it may be 6 months or more.
What differences are there in vaginal symptoms after
delivery if I have an episiotomy versus having no
episiotomy?
It is very difficult to say for sure what difference
in vaginal symptoms occur on the basis of having or
not having an episiotomy. Even in older studies in
which episiotomies were routinely performed, about
25% of women did not get one either because they delivered
too fast or there was no concern whatsoever that the
baby would cause tearing. The randomized trials that
have been performed in which half the women had routine
episiotomy (only 73% actually had them as intended)
and the other half had episiotomies in restricted
to situations in which the doctors thought they would
significantly tear if it was not performed (27%),
can show us what happens when there is a decrease
of almost 50% in the episiotomy rate (5). These studies
tell us that there is no difference in painful intercourse
or incontinence by whether episiotomy was performed
routinely or not. If episiotomy was causative of painful
intercourse (dyspareunia) then we would have expected
there to be a higher incidence of such problems in
the group that had 50% more episiotomies. This is
also consistent with the study that found that the
postpartum pain with sex was only located at the exact
site of the incision line in 6% of cases when over
45% of women complained of discomfort with intercourse
upon vaginal entry (4).
I have heard of women having problems of uncontrolled
passing of gas or even stool from the anus after delivery.
Is this likely to be a problem for me?
After vaginal delivery, some women do have difficulty
holding their stool or gas. It occurs much more commonly
after injury to the anal sphincter muscle, even if
that injury is surgically repaired at the time of
delivery, than it does if there is no tearing of the
muscle. Ultrasound imaging in one study demonstrated
separated anal sphincter muscles in 40% of the women
with obstetric anal sphincter lacerations, despite
repair at the time of delivery but it also demonstrated
sphincter lacerations 20% of the time that were apparently
unrecognized at the time of delivery (6). At 4 months
after delivery continued anorectal dysfunction was
reported by 43% of subjects in the laceration group
versus only 7% of the control subjects
Recent studies suggest that the incidence of anal
dysfunction as measured by ultrasound and anal pressure
measurements is 8.7% but only 1-2% admit to significant
symptoms (7). While incontinence of stool is not frequent,
passing gas from the rectum involuntarily may happen
as often as 26% of the time in some groups of women
after delivery (8).
What about vaginal opening looseness or pelvic prolapse
after delivery?
This is a common concern that both women and their
partners have about delivery. Unfortunately there
is almost no data concerning to what degree the vaginal
opening is significantly loosened on a permanent basis.
Similarly there is a lack of studies determining how
many women develop pelvic organ prolapse after delivery.
No one even knows if episiotomy and repair results
in less long term vaginal gaping.
Most investigators agree that postpartum perineal
muscle strengthening exercises such as Kegel exercises,
will help restore perineal tone. They have even been
shown to decrease the incidence of urinary incontinence
(9) but they need to be carried on for at least several
months.
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