Mesh Misadventures, Misinformation, and Delayed Treatment- A Case Presentation

Posted: August 15, 2015

Written by Meghana Gowda, MD, FPMRS

Case presentation:

A 59 year old patient presents with vaginal pain, difficulty sitting for prolonged time intervals, and new onset vaginal bleeding. She denies any significant medical co-morbidities with the exception of pelvic organ prolapse and associated incontinence. Surgical history is significant for hysterectomy remotely and unspecified “bladder tacking” 3 years ago. She has already seen the previous surgeon who has not specified any further treatment course.

The operative notes were reviewed and indicated that a vaginal mesh kit for prolapse had been used. On physical exam, the patient did have a mesh exposure that measured approximately 3cm in the midline posterior vaginal wall. Palpation of this exposure did reproduce tenderness and scant vaginal bleeding. The patient also had pain with palpation of the mesh fixation arms. Although these areas did not demonstrate any exposure, the fixation arms appeared to be under chronic tension and elicited tenderness to palpation.

She underwent excision of the exposed mesh and lysis of the tensioned mesh arms with excellent resolution of pain. Her post-operative course did include consultation with physical therapy and she is now able to engage in sexual activity with her partner with no recurrence of prolapse.

Discussion:

The use of mesh in the primary repair of prolapse is controversial at this time. In fact, emerging data including the most recent Cochrane review enforces the higher complication and re-operation rates for repair utilizing vaginal mesh. The American College of Obstetrics and Gynecology has issued a Committee Opinion that acknowledges that “success rates of native tissue repair may be higher than previously thought”. Virginia Urology’s fellowship-trained providers agree that an active dialogue regarding the risk and benefits of vaginal mesh is necessary in all patients, and autologous options should also be reviewed. Lastly, some patients may not realize that vaginal bleeding, pain, and dyspareunia may be related to mesh placement, and these symptoms should prompt a thorough expert urologic evaluation. VU has served as a  high volume referral source for mesh corrective surgery. We have performed over 500 mesh corrections.

Pearls of Wisdom:

Patients may not be aware that pelvic pain, vaginal bleeding, hematuria, and recurrent urinary tract infections may be related to vaginal mesh. These concerns should prompt a thorough evaluation including pelvic exam and cystoscopy.

The FDA Safety Communication alerts patients that it may be impossible to remove all implanted mesh. However, these patients still warrant evaluation and treatment options and should be referred to subspecialists with a specific interest and experience with mesh complications.

Resources:

http://www.augs.org/p/cm/ld/fid=598