Table 2 Description of included studies with perineum injury morbidity as exposure

1. Women´s sexual health after childbirth.

Barret G et al., 2000 [37]

Cross sectional

Sexual problems (vaginal dryness, painful penetration, dyspareunia, vaginal tightness, vaginal looseness, bleeding/irritation after sex and loss of sexual desire)

Mailed questionnaires.

1^st July to 31 December 1997

London, UK

484 postpartum primiparous women.

Evaluation at 3 and 6 months after delivery.

Dyspareunia at 3 months after birth:

Minor perineal laceration: 55 % (115/209)

3^rd degree laceration: 64 % (7/11)

Dyspareunia at 6 months after birth:

Minor perineal laceration: 26 % (62/235)

3^rd degree laceration: 33 % (4/12)

2. Postpartum sexual functioning and its relationship to perineal trauma: A retrospective cohort study of primiparous women.

Signorello LB et al., 2001 [38]

Retrospective cohort

1. Time to resumption of sexual intercourse

2. Dyspareunia

Sexual satisfaction

Sexual sensation

Likelihood of achieving orgasm.

Mailed questionnaires.

From August 1, 1996, and February 8, 1997.

Boston, Massachusetts, USA.

626 postpartum women (6 months)

Group 1, n = 211 (intact perineum or first-degree perineal tear)

Group 3, n = 68 (third- or fourth-degree perineal trauma)

1. Resumption of sexual activity:

In 7–8 weeks

Group 1: 30.8 % (61/211)

Group 3: 35.0 % (21/68)

In 6 months:

Group 1: 94.8 % (199/210)

Group 3: 92.5 % (62/67)

Time to resume in weeks (mean and SD):

Group 1: 7.1 (3.3)

Group 3: 9.3 (3.5)p < 0.001

2.Pain (dyspareunia) at first intercourse:

Group 1: 57.8 % (115/211)

Group 3: 77.4 % (48/68)

(p < 0 .001).

3 months postpartum:

Group 1: 32.8 % (60/211)

Group 3: 51.4 % (35/68)

(p trend < 0 .001)

6 months postpartum:

Group 1: 18.6 % (37/211)

Group 3: 26.7 % (16/68)

3. Sexual satisfaction, sexual sensation and achievement of orgasm.

3. Which factors determine the sexual function 1 year after childbirth?

van Brummen et al., 2006 [42]

Prospective cohort

MMQ-S scale

Self-applied questionnaires at pregnancy (12 and 36w), and at 3 and 6 months postpartum.

From January 2002 to July 2003.

Netherlands

377 women evaluated at 3 periods (pregnancy, 3 and 5 months postpartum)

Sexual activity 1 year after childbirth (resumption):

YES:

Intact/1^st/2^nd degree laceration: 46,3 %

3^rd/4^th degree laceration: 56,5 %

NO:

Intact/1^st/2^nd degree laceration: 53,7 %

3^rd/4^th degree laceration: 43,5 %

MMQ-S questionnaire:

No differences among groups (NS)

4. Women’s health 18 years after rupture of the anal sphincter during childbirth: II. Urinary incontinence, sexual function, and physical and mental health.

Otero et al., 2006 [44]

Retrospective cohort.

FSFI

Mailed questionnaire

18 years after childbirth that occurred between January 1st, 1982, and December 31th, 1983.

Geneva, Switzerland

453 women.

Exposed: 230 (women who had had anal sphincter injury during childbirth)

Not exposed: 223 (randomised postpartum women not exposed to the injury and with the same parity)

FSFI <25: NS

Anal Injury: 39/230

No injury: 38/223

RR 1,0 (CI 95 % 0,8-1,2 p = 0.75)

5. Long Term effects of anal sphincter rupture during vaginal delivery: faecal incontinence and sexual complaints.

Mous et al., 2007

Retrospective cohort study

Sexual complaints (including dyspareunia)

2005 assessment of postpartum women who gave birth between 1995 and 1996.

Rotterdam, Netherlands

Total included in 2005:

119 cases (sphincter injury)

90 controls (no injury)

Dyspareunia:

Sphincter injury: 29 % (35/119)

Controls: 13 % (12/90)

6. Women's dyspareunia after childbirth: a case study in a hospital in Acapulco, Mexico.

Solana-Arellano, et al., 2008 [40]

Case control study.

Dyspareunia.

From October 2005 to January 2006

Acapulco, Mexico.

Cases: 152 postpartum women who resumed sexual activity and referred pain or bleeding during intercourse.

Controls: 152 postpartum women who resumed sexual activity and not referred the same symptoms.

2–6 months after childbirth.

27 women had perineal laceration.

Perineal laceration:

(27/152) 17.8 % in cases with dyspareunia

(23/152) 15.1 % in controls without dyspareunia

7. Sexual Function 6 Months After First Delivery.

Brubaker et al., 2008 [43]

Prospective cohort

Resumption of sexual activity at 6 months

Sexual Function Short Form Questionnaire (PISQ-12)

September 2002 and September 2004

USA

536 postpartum primiparous women at term, 459 sexually active.

Sphincter tear: 198

Vaginal controls: 200

Cesarean controls: 61

Interviewed at 6 weeks and 6 months after childbirth.

Resumption of sexual activity at 6 months:

Sphincter tear: 88 % (171/198)

Vaginal controls: 93.9 % (13/200)

Cesarean controls: 85.9 % (51/61)

p = 0.028

Mean PISQ-12 scores at 6 months: 39 ± 4

p = 0.92 NS

8. Tears in the Vagina, Perineum, Sphincter Ani, and Rectum and First Sexual Intercourse after Childbirth: A Nationwide Follow-up.

Rådestad I et al., 2008 [48]

Prospective cohort

Resumption of sexual activity

Mailed questionnaire

Between 1999 and 2000

Sweden

2,134 postpartum women at 2 months and 1 year after childbirth (vaginal delivery).

Tears in sphincter ani/rectum: 59

Resumption of sexual activity:

Tears in sphincter:

≥3 Months: 49.2 %

≤3 Months: 23,3 %

RR = 2.1 (CI 1.6–2.8)

p < 0.001

No tears in sphincter:

≥3 Months: 23.3 %

≤3 Months: 76.7 %

RR = 1

Difference between groups: 25.8 % (49.2 %–23.3 %)

NNH: 3.9 (CI 95 % 2.6-7.7)

Tears in sphincter:

≥6 Months: 13.6 %

≤6 Months: 86.4 %

RR = 1.8 (CI 0.9–3.5)

p = 0.130

No tears in sphincter:

≥6 Months: 7.6 %

≤6 Months: 92.4 %

RR = 1

Difference between groups: 6.0 % (13.6 %–7.6 %)

NNH: 16.8 (CI 95 % 6.8-35.2)

At 12 Months: 4 % NO sexual activity (NS)

9. Sexual Function in Women 3 Days and 6 Weeks After Childbirth: A Prospective Longitudinal Study Using the Taiwan Version of the Female Sexual Function.

Chang, et al., 2010 [45]

Prospective longitudinal

FSFI

From November 2007 to April 2009

Taipei, Taiwan

356 postpartum women

199 vaginal delivery (no intact perineum)

FSFI Day3:

1^st/2^nd degree laceration (182/199) LSM = 7.0

3^rd or 4^th degree: (17/199) LSM = 7.1

p = 0.984 (NS)

FSFI Week 6:

1^st/2^nd degree (158/172) LSM = 13.6

3^rd or 4^th degree (14/172 ) LSM = 15.1

p = 0.7 (NS)

Sexual activity score Day 3:

1^st/2^nd degree laceration (182/199) LSM = 15.0

3^rd or 4^th degree: (17/199) LSM = 14.1

p = 0.8548 (NS)

Sexual activity score Week 6:

1^st/2^nd degree laceration (182/199) LSM = 18.8

3^rd or 4^th degree: (17/199) LSM = 20.9

p = 0.7193 (NS)

Satisfaction score Day 3:

1^st/2^nd degree laceration (182/199) LSM = 51.7

3^rd or 4^th degree: (17/199) LSM = 56.0

p = 0.6691 (NS)

Satisfaction score Week 6:

1^st/2^nd degree laceration (182/199) LSM = 151.1

3^rd or 4^th degree: (17/199) LSM = 166.5

p = 0.4723 (NS)

Desire score Day 3:

1^st/2^nd degree laceration (182/199) LSM = 6.2

3^rd or 4^th degree: (17/199) LSM = 31.4

p = 0.1703 (NS)

Desire score Week 6:

1^st/2^nd degree laceration (182/199) LSM = 271,0

3^rd or 4^th degree: (17/199) LSM = 233.8

p = 0.3056 (NS)

10. Obstetric anal sphincter injury in the UK and its effect on bowel, bladder and sexual function.

Marsh F et al., 2010

Prospective cohort

Resumption of sexual activity

Dyspareunia

From 2004 to 2009

Leeds, UK

435 postpartum women with obstetric anal injury (up to 3 Months after delivery)

Resumption of sexual activity:

57 % (134/235)

Dyspareunia: 32 % (75/235)

11. Pelvic floor dysfunction 6 years post-anal sphincter tear at the time of vaginal delivery.

Baud et al., 2011 [46]

Case–control study

FSFI

From 1996 to 2006

Lausanne, Switzerland

Cases: 66 postpartum women with anal injury (1,5 % from 13,213)

Controls: 192 without anal injury.

Up to 6 years postpartum.

FSFI ≤ 25 (severe dysfunction): NS

Data not available: contact authors.

FSFI total scores:

Cases: 26.1 + 6.8

Controls: 27.3 + 5.9

p = 0.185

12. The effects of mode delivery on postpartum sexual function: a prospective study.

De Souza et al., 2015 [47]

Prospective cohort

FSFI

Self-applied questionnaire

From January 2010 to July 2011

Melbourne, Australia

391 women interviewed during pregnancy and after 6 and 12 months after childbirth

Completed 3 interviews:

9/264 (4.8 %) women with 3^rd degree laceration

82/264 (44.1 %) with minor perineal injury

FSFI score (means):

Pregnancy: 24.22

6 months: 22.79

12 months: 25.06

No differences associated to type of laceration

Arousal domain, means (maximum 6):

Pregnancy: 3.46

6 months: 3.44

12 months: 3.97

p = 0.007

12 months highest score related to perineal injury

p = 0.019

Orgasm domain, means (maximum 6):

Pregnancy: 4.23

6 months: 4.20

12 months: 4.66

p = 0.026

6 months/12 months = 0.015

No interaction over time due to perineum status

(p = 0.108)

FSFI scores < 25 not showed