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Use of mesh for the surgical treatment of vaginal prolapse and urinary incontinence

29 October 2017

RANZCOG Communiqué – Updated 29 October 2017


There has been a great deal of interest and comment in both the mainstream and social media about the Senate Inquiry into the use of mesh as part of the surgical treatment of vaginal prolapse  and urinary incontinence.

It is important to understand that different mesh procedures have been used to treat different conditions. Each of these procedures has unique risks and benefits and it is important to understand  the difference.
 

  • Pelvic organ prolapse (POP). When the ligaments and muscles that support a woman's pelvic organs weaken, prolapse can occur.  As part of the treatment of POP, surgical mesh can be implanted to reinforce the weakened vaginal wall supports. Surgery can be done through the abdomen (trans-abdominal) or through the vagina (trans-vaginal).

 

  • Stress urinary incontinence (SUI). This is unintentional loss of urine occurring with physical movement or activity, such as coughing, sneezing, running, or heavy lifting, and is due to a weakness of the normal ligaments supporting the bladder neck.  To correct this and restore urinary continence, a narrow tape made of surgical mesh can be placed to support the urethra or bladder neck. This is known as a mid-urethral sling procedure.


The majority of women who have had surgical treatment with the use of mesh for POP or SUI have a good long-term result.

Unfortunately, some women have suffered complications with the use of mesh in these procedures.  In most cases, the complications are relatively minor.  However, in a small number of cases the complications have been very serious.  These cases are those where women experience severe and difficult-to-treat pain, or where there has been mesh exposure or erosion into the bladder or urethra requiring further surgical correction.

Erosion occurs as a complication of between 1–2% of operations where a midurethral sling is placed, and up to 10–12% of operations where transvaginal mesh is used for prolapse.1  In some cases the erosion occurs with no symptoms, but it may cause bleeding, discomfort or awareness by either or both partners during sexual activity. A tender or exposed area in the majority of cases usually can be managed with the use of oestrogen creams, or may require a minor procedure to relieve the symptoms.

Complete mesh removal can be technically very complex but this can generally be performed by experienced pelvic floor surgeons.2-5 There is certainly adequate expertise in Australia available to women seeking mesh removal. There is evidence that partial mesh removal can be adequate to relieve symptoms; however, any mesh removal surgery needs to be very thoroughly discussed on an individual basis with an experienced specialist. Long-term pelvic pain associated with mesh may be a complex condition requiring multidisciplinary care.

Treatment options for POP and SUI
For women experiencing symptoms of SUI, non-operative treatment options include pelvic floor muscle rehabilitation with a pelvic floor physiotherapist is often successful. However, for those women who continue to have symptoms, the use of mid-urethral slings to treat SUI is established as a safe and effective treatment, and regarded as the “gold standard” for SUI surgery. Success rates for MUS are high, with rates of complete cure or significant improvement of 80–90%.

For women experiencing symptoms of POP, the use of vaginal support pessaries and/or pelvic floor physiotherapy may be suitable.  In some women, due to clinical reasons or their personal preference, surgery is a more appropriate treatment.  Surgical options with and without mesh should be discussed with the treating specialist.  For some women, a transvaginal mesh procedure may be the most effective and durable treatment.

Further information
If you have undergone a mesh procedure in the past and are well, it is not likely that any adverse effects or complications will develop in the future, however, some women might experience a late vaginal mesh exposure/erosion.

Please see your doctor if you have any concerns or experience any abnormal vaginal bleeding or pain, regardless of whether you have had mesh surgery.  

You may wish to return to your original surgeon or obtain a referral from your GP to a public hospital urogynaecology / pelvic floor clinic.  Alternatively a list of urogynaecologists is available on the College website at https://www.ranzcog.edu.au/Womens-Health/Locate-an-O-G-doctor

For more information on surgery for pelvic organ prolapse and stress incontinence, please also refer to the following statements and patient information.

Polypropylene Vaginal Mesh Implants for Vaginal Prolapse (C-Gyn 20)
Midurethral Slings, Position Statement (C-Gyn 32)
RANZCOG Pamphlet Stress Urinary Incontinence
RANZCOG Pamphlet Pelvic Organ Prolapse


 References

  1. Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Marjoribanks J. Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse. Cochrane Database Systematic Reviews 2016, Issue 2. Art. No.: CD012079. DOI: 10.1002/14651858.CD012079 
  2. Danford JM, Osborn DJ, Reynolds WS, Biller DH, Dmochowski RR.  Postoperative pain outcomes after transvaginal mesh revision.  Int Urogynecol J 2015;26(1):65-9.
  3. Crosby EC, Abernethy M, Berger MB, DeLancey JO, Fenner DF, Morgan DM.  Symptom resolution after operative management of complications from transvaginal mesh.  Obstet Gynecol 2014;123(1):134-9.
  4. Marcus-Braun N, von Theobald P.  Mesh removal following transvaginal mesh placement: a case series of 104 operations. Int Urogynecol J 2010;21(4):423-30.
  5. Gyang AN, Feranec JB, Patel RC, Lamvu GM. Managing chronic pelvic pain following reconstructive pelvic surgery with transvaginal mesh. Int Urogynecol J 2014;25(3):313-8.



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