Recurrent Fissures at the Posterior Fourchettes

The posterior fourchette is the delicate, fold of skin at the bottom of the vaginal entrance. A fissure is a small tear or split in this skin. For some women, this tearing happens repeatedly, which is known as a recurrent fissure. The pain is often described as a sharp, “paper-cut” or “knife-like” sensation.

What Causes These Recurrent Fissures?

The immediate cause is stretching of the vulva, most commonly during sexual intercourse. However, the skin tears because it is fragile, inflamed, or unable to stretch properly due to an underlying reason. Causes are generally grouped into two categories:

1. Secondary Fissuring (with an identifiable cause):
This is when the fissuring is a symptom of another condition, such as:

• Infections: Recurrent thrush (Candida), bacterial vaginosis, or genital herpes.

• Skin Conditions: Eczema (atopic dermatitis), contact dermatitis (a reaction to soaps, lubricants, or laundry products), lichen sclerosus, or seborrheic dermatitis.

• Hormonal Changes: Low estrogen levels, particularly after menopause or during breastfeeding, can lead to thin, dry, and fragile skin (atrophic vaginitis).

• Pelvic Floor Dysfunction: High tension in the pelvic floor muscles (which can contribute to vaginismus) can put excessive pressure on the skin, making it more likely to tear.

2. Primary Fissuring (no other cause found):
In some cases, no specific underlying skin disease or infection is identified. The skin in this area may simply be naturally more fragile or prone to poor healing.

What are the Common Symptoms?

Symptoms are typically triggered by activities that stretch the vulva and can include:

• A sharp, cutting, or burning pain during or after sexual intercourse (dyspareunia).

• Pain when inserting a tampon or during a pelvic examination.

• A visible small cut or split in the skin.

• Light spotting or bleeding after sex.

• Stinging or burning when the area comes into contact with urine, water, or semen.

• Itching or general discomfort.

The fissure may heal between episodes, only to reappear the next time the skin is stretched.

How is it Diagnosed?

Diagnosis begins with a detailed discussion of your symptoms and a gentle, respectful physical examination. To provide the best care, we may recommend:

• Swabs: To check for infections like thrush or bacterial vaginosis.

• A Skin Biopsy: A small sample of skin may be taken (under local anaesthetic) if a condition like lichen sclerosus is suspected. This helps us tailor your treatment precisely.

What are the Treatment Options?

Treatment is highly personalised and depends on the underlying cause. Dr Li’s goal is to help the skin heal, become stronger, and prevent future tearing.

1. Treating the Underlying Cause:
If an infection or skin condition is found, treating this is the first and most important step. This may involve:

• Antifungal or antibacterial creams.

• Topical corticosteroid creams to reduce inflammation.

• Oestrogen cream to help thicken and moisturise the skin if hormonal changes are a factor.

2. Conservative Management & Self-Care:
These strategies are helpful for all women with this condition:

• Gentle Hygiene: Wash gently with warm water, avoid soap or any irritants.

• Lubrication: Use generous amounts of a gentle, water-based lubricant during intercourse.

• Emollients: Apply bland emollients (like petroleum jelly) or specialised vaginal moisturisers regularly to protect the skin.

• Pelvic Floor Physiotherapy: Can be extremely beneficial to relax tight muscles if they are contributing to the problem.

3. Medical & Surgical Management:
If conservative measures are not enough, we can discuss:

• Topical Anaesthetics: Lidocaine gel can be applied before intercourse to reduce pain.

• Perineoplasty: This is a surgical procedure considered for severe, persistent cases that have not responded to other treatments. It involves carefully removing the damaged, fragile skin and reconstructing the area with healthier tissue to reduce tension and allow for pain-free stretching. It has a high success rate.

Dr Li will discuss all potential treatments with you at your initial consultation. If all traditional treatments are not effective for you, Dr Li will discuss alternative treatment options with you.

What to Expect During Your Consultation

Dr Li provides a supportive and understanding environment. She will:

• Listen carefully to your history and concerns.

• Perform only the examinations you are comfortable with.

• Work with you to create a clear, individualised management plan.

• Ensure you understand all your options and have realistic expectations.

At your initial consultation, Dr Sharon Li will discuss your specific concerns and aesthetic goals, and make every effort to ensure your concerns are fully understood. If you would like to book your initial consultation, please call us at 07 3219 6868.

Please bring a GP referral, prior to attending your initial consultation, as this allows Dr Li to access information regarding your general health, past medical history, psychiatric history and suitability for treatment.

 

 

Dr Sharon Li

Obstetrician and Gynaecologist

MBBS FRANZCOG

AHPRA MED0001402739