Postpartum perineal lacerations

29 y/o G2P2 presents for 6 week postpartum visit s/p forceps assisted vaginal delivery resulting in a 4th degree perineal laceration. Review of systems remarkable for persistent perineal pain relieved with Motrin, flatus incontinence, occasional constipation, and difficulty cleaning stool from rectum after defecating. Denies urinary incontinence or urgency. Pelvic exam remarkable for healing perineal wound right of midline with sutures coming out without signs of infection. Anal sphincter had good tone, vaginal sphincter tone diminished. She also had a small posterior rectocele and anterior cystocele. Rest of the exam was nl. These were obvious signs of pelvic floor disruption with possible anal sphincter problems. As far as management, the provider was not too concerned, but I did recommend kegel exercises. I also thought we could have done more for her. The literature is unclear about how aggressive early management should be or when it should be initiated, when there are signs of pelvic floor disruption. Surgery is certainly not an option unless symptoms are severe and she is done childbearing, but perhaps this patient may have been a candidate for pelvic floor physical therapy. 3rd and 4th degree perineal lacerations or episiotomies can have significant long-term consequences and the sequela (constipation, anal sphincter dysfunction, pelvic organ prolapse, urinary incontinence, perineal pain, rectovaginal fistulas) is what we are most likely to see in our practices as FNPs.