Chronic pain
Diffuse vaginal pain after mesh implantation is unusual; typically, the patient’s report of pain has been preceded by recognition of another, underlying pelvic pain syndrome. Management of such pain is controversial, and many patients will not be satisfied until the entire graft is removed. Whether such drastic intervention actually resolves the pain is unclear; again, work with the patient to create realistic expectations before surgery—including the risk that prolapse will recur and that reoperation will be necessary.
Management note: An existing pelvic pain syndrome should be considered a relative contraindication to implantation of mesh.
Infection of the graft
Rarely, infection has been reported after implantation of Type-1 mesh—the result of either multi-microbial colonization or isolated infection by Bacteriodes melaninogenicus, Actinomyces spp, or Staphylococcus aureus. Untreated preoperative bacterial vaginitis is likely the underlying cause, and should be considered a contraindication to mesh implantation.
Typically, these patients complain of vaginal discharge and bleeding early postoperatively. Vaginal exposure of the mesh results from local inflammation and necrosis of tissue.
Management note: In these cases, it is necessary to 1) prescribe antimicrobial therapy that covers gram-negative and anaerobic bacteria and 2) undertake surgical removal of the exposed mesh, as we outlined above.9
Visceral erosion or fistula
Many experts believe that what is recorded as “erosion” of synthetic mesh into bladder or rectum is, in fact, a result of unrecognized visceral perforation at original implantation. This is a rare complication of mesh implantation.
Patients who experience mesh erosion into the bladder may have lower urinary-tract symptoms (LUTS) of urgency, frequency, dysuria, and hematuria. Any patient who reports de novo LUTS in the early postoperative period after a vaginal mesh procedure should receive office cystourethroscopy to ensure that no foreign body is present in the bladder or urethra.
Management note: Operative cystourethroscopy, with removal of exposed mesh, is the management of choice when mesh is found in the bladder or urethra.
Patients who have constant urinary or fecal incontinence immediately after surgery should be evaluated for vesicovaginal or rectovaginal fistula.
The presence of any of these complications necessitates removal of the involved mesh in its entirety, with concomitant repair of fistula. Typically, the procedures are performed by a specialist.
Our experience with correcting simple mesh exposures
During the past year at our tertiary referral center, 26 patients have undergone mesh revision because of exposure, using the technique we described above (FIGURE 2-6). The problem resolved in all; none had persistent dyspareunia. Many of these patients had already undergone attempts at correction of the exposure elsewhere—mostly, in the office, using techniques appropriate for that setting. Prolapse has not recurred in the 10 patients who required reapproximation of mesh edges because of a defect >2.5 cm.
CASE RESOLVED: Treatment, improvement
Under your care, the patient undergoes simplified outpatient excision of the exposed area of mesh. Mesh edges are reapproximated to support the resulting 3-cm defect.
At a 12-week postop visit, you note complete resolution of the exposure and normal vaginal caliber. The patient continues to apply estrogen cream and reports sustained improvement in sexual function.
- Preoperatively, prepare the vaginal epithelium with local estrogen cream (recommended dosage: 1 g, two nights every week for a trial of at least 6 weeks)
- Use hydrodissection to facilitate placement of the graft deep to the vaginal epithelial fibromuscular fascial layer
- Do not place a synthetic mesh as an overlay to a midline fascial plication
- Be fastidious about hemostasis
- Close the vaginal epithelium without tension
- Leave vaginal packing in place for 24 hours
- Consider using biologic grafts when appropriate (as an overlay to midline plication when used on the anterior vaginal wall).
For simple presentations, success is within reach
Simple mesh exposure can (as in the case we described) be managed by most gynecologists, utilizing the simple stepwise approach that we outlined above (for additional tips based on our experience, see “Pearls for avoiding mesh exposures”). In the case of more significant symptoms, de novo dyspareunia, visceral erosion, or fistula, however, referral to a specialist is warranted.
Transvaginal mesh surgery reduces pelvic organ prolapse
But dyspareunia may develop in premenopausal women
Transvaginal mesh (TVM) surgery is effective in treating pelvic organ prolapse (POP) in both pre- and postmenopausal women but dyspareunia may worsen in premenopausal women, according to a study published online May 23 in the Journal of Sexual Medicine.
Cheng-Yu Long, MD, PhD, from Kaohsiung Medical University in Taiwan, and colleagues compared the changes in sexual function of premenopausal and postmenopausal women after TVM surgery. A total of 68 sexually active women, categorized as premenopausal (36) and postmenopausal (32), with symptomatic POP stages II to IV were referred for TVM surgery. Preoperative and postoperative assessments included pelvic examination using the POP quantification (POP-Q) system, and completing the Female Sexual Function Index (FSFI), Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7).
The investigators found significant improvement in the POP-Q analysis at points Aa, Ba, C, Ap, and Bp in both groups but not in total vaginal length. The UDI-6 and IIQ-7 scores decreased significantly after TVM surgery. The dyspareunia domain score decreased significantly after surgery only in the premenopausal group. Reports of diminished scores of the dyspareunia domain and total scores were more common among women in the premenopausal group, but there were no significant differences in FSFI domains or total scores between the groups.
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