TITLE:
Patient-Reported Functional Recovery Following Primary Repair of a Fourth-Degree Perineal Tear: A Case Report and Surgical Insights
AUTHORS:
Ebenezer Benson Hawanga, Lusajo Mwagobele, Edward Kijazi, Clarence Sumbizi, Shweta Jaiswal, Ally Mwanga
KEYWORDS:
Fourth-Degree Perineal Tear, Obstetric Anal Sphincter Injury, Perineal Reconstruction, Anal Continence, Postpartum Recovery
JOURNAL NAME:
Open Journal of Obstetrics and Gynecology,
Vol.16 No.10,
October
19,
2026
ABSTRACT: Background: Fourth-degree perineal tears are severe obstetric anal sphincter injuries involving the external anal sphincter, internal anal sphincter, and anorectal mucosa. They may result in anal incontinence, chronic perineal pain, dyspareunia, wound complications, and impaired quality of life. Early recognition, anatomical repair, and structured postoperative follow-up are central to management. Case Presentation: A 30-year-old primigravida at 39 weeks’ gestation presented in spontaneous labour. Her pregnancy had been uncomplicated. During a prolonged second stage of approximately 3 hours, a median (midline) episiotomy was performed. She delivered a live female infant weighing 2,890 g with Apgar scores of 8 and 9 at 1 and 5 minutes. Post-delivery examination demonstrated a fourth-degree perineal tear extending through the episiotomy, with disruption of the external and internal anal sphincters, anorectal mucosa, and approximately 4 cm of the mid-vaginal wall. Multidisciplinary primary repair was performed within 1 hour of delivery. Discussion: This patient had recognised risk factors for obstetric anal sphincter injury, including primiparity, a prolonged second stage, and a midline episiotomy, despite the absence of fetal macrosomia, operative vaginal delivery, or shoulder dystocia. Recovery was gradual: anal incontinence was still reported at 4 weeks, improved by 8 weeks, and by 6 months the patient reported continence. At approximately 1 year, she reported no faecal or flatus incontinence, urgency, soiling, pain, or sexual dysfunction and had returned to usual daily activities. These outcomes were based on clinical review and patient-reported symptoms; no validated continence score, endoanal ultrasonography, or anorectal manometry was performed. Conclusion: Prompt recognition, multilayer anatomical repair, postoperative care, pelvic-floor rehabilitation, and longitudinal follow-up were associated with a favourable patient-reported functional outcome in this case. Objective sphincter imaging and physiological assessment were unavailable, so the long-term outcome should be interpreted as patient-reported rather than proof of complete anatomical or physiological recovery.