What a mesh! A discussion about surgical mesh.

A woman suffering pelvic pain.

This time last year, there was a veritable storm brewing in the gynaecology sphere. Negative publicity was rising regarding surgical mesh used for transvaginal repair of pelvic organ prolapse, and for the treatment of stress urinary incontinence. Concerns were raised as increasing numbers of women came forward reporting adverse side effects following mesh repair surgery, with some of these side effects being extremely debilitating. This culminated in a Senate Committee Inquiry, and their report was released in March 20181. Prior to the Senate Inquiry, the Therapeutic Goods Administration (TGA) in Australia removed all surgical mesh used for transvaginal prolapse repair from the market in late 2017, and some mid-urethral sling meshes or “tapes” were voluntarily removed temporarily as well.

However, many Australian women remain confused about whether mesh continues to be used for gynaecological surgery and why. Those who have had mesh surgery in the past are often concerned they may develop adverse symptoms in the future.

The purpose of this blog is to help women understand more about surgical mesh, including:

  • What is surgical mesh?
  • The types of operations for which surgical mesh was used
  • Some of the adverse side effects reported
  • Why mesh is still used today, and for what kinds of operations?

What is surgical mesh?

Surgical mesh is a synthetic, loosely woven material made from polypropylene2 (a type of plastic).

Mesh was first used surgically for hernia repairs and proved very successful. A similar material was adapted for uro-gynaecology surgery for stress urinary incontinence in the late 1990s, for a procedure called a “mid-urethral sling”. These procedures were first performed in Australia in 1998. It is common for doctors to refer to these types of mesh as “slings” or “tapes”. Surgical mesh for repair of pelvic organ prolapse was first approved by the TGA in 20033.

It is the use of transvaginal mesh for prolapse repair that has caused the most controversy and is associated with the majority of the problems raised at the Senate Inquiry. However, some women have also reported adverse side effects following mid-urethral sling procedures.

What was mesh used for and why?

Prior to the use of mesh tapes for stress urinary incontinence, the best surgery available for this problem was a Burch colposuspension. This was a large operation, with numerous side effects and long hospital stays. With the adoption mesh slings, surgical treatment for stress urinary incontinence became a much simpler and faster procedure, with numerous large studies showing excellent success rates of 80-90%1. Adverse side effects could still occur, as with any surgery, but seemed to be at acceptably low rates. It is estimated approximately 150 000 Australian women have had mid-urethral sling surgery3.

Following the success of mid-urethral slings, gynaecologists in Australia began to use mesh for transvaginal repair of pelvic organ prolapse in 2003. Traditional prolapse repair surgery had a high failure rate – commonly around 30%, and up to 45% in some studies4. Surgeons were hopeful that by inserting mesh sheets through the vagina to support either behind the bladder or in front of the bowel, that they could improve the success of prolapse repair surgery. Indeed, large studies showed higher success rates with transvaginal mesh repair than with traditional “native tissue” repairs5. For some surgeons, transvaginal mesh became the prolapse repair surgery of choice, and it is estimated that up to 40 000 Australian women had transvaginal mesh surgery3.

However, concerning data on adverse events associated with transvaginal mesh was starting to emerge. In conversations I have had with several specialist gynaecologists, they explained that transvaginal mesh was probably used in the wrong type of cases in some women. Although by 2011 many experts were warning transvaginal mesh should not be used as the first treatment option for women with prolapse, but should be reserved for cases of recurrent prolapse, under the guidance of a specialist surgeon, these recommendations were not always being followed3,5.

It is interesting to note that for both mid-urethral slings and transvaginal mesh, approval had been granted by the TGA In Australia before data was available from large studies to support either their benefit or safety3.

What kind of problems were reported from surgical mesh?

The Senate Inquiry report into transvaginal mesh released in March 2018 makes for distressing reading at times. As the report outlines, while the majority of women who had either transvaginal mesh or mid-urethral slings did not report any problems, for those who did have problems “the complications following their surgery have had a devastating impact on their lives.”1 Many affected women not only tell of the enormous impacts on their health and well-being, with ongoing chronic pelvic pain following mesh procedures, but also report significant negative impacts on their sexual relationships, family and social life, their ability to work, and their emotional health1.

So, what are the main problems women report following surgical mesh?

  1. Mesh erosion or exposure. This means the mesh device has worn through adjacent tissues and in some cases may be felt by the woman in her vagina or elsewhere. Erosion/exposure typically occurs in the vaginal walls, but there have been cases of mesh eroding into the bladder or bowel. Mesh erosion/exposure occurred in about 10% of women who had transvaginal mesh and 1-2% of women who had mid-urethral slings1.
  2. Chronic pelvic pain. This is related to mesh erosion in many cases, but some women without obvious mesh erosion have also reported severe ongoing pelvic pain following mesh surgery, which sometimes continues even after the mesh is removed1.
  3. Pain with intercourse. Almost 10% of women reported pain with intercourse following transvaginal mesh. However, it is interesting to note that almost 9% of women who have “native tissue” repair without mesh also report pain with intercourse1.
  4. Recurrent urinary tract infections. This can occur after any gynaecological surgery, however, it seemed to be more common following transvaginal mesh surgery1.
  5. New onset of incontinence. This also occurred at higher rates following transvaginal mesh surgery compared with traditional prolapse repair. There is also a known 8-10% risk of new urinary urgency (a sudden, desperate need to empty the bladder) following mid-urethral sling surgery1.

What is it still used for today and why?

As outlined earlier, the TGA withdrew all transvaginal mesh from the market in Australia in late 2017, so mesh is no longer used for this purpose in Australia. However, mesh is still being used for some other types of surgery. This is because the relative risks of those procedures are judged to be far lower than those seen with transvaginal mesh, and the benefits far outweigh the risks.

Some of the surgeries for which mesh is still used include:

  • Mid-urethral slings. These surgeries have an 80-90% success rate and the risk of mesh exposure is only 1-2%.
  • Mesh sacrocolpopexy – done either through a larger abdominal incision or by laparoscopic surgery. Mesh is inserted around the outside of the vagina, then hitched up to the sacrum. This surgery is performed by highly specialized surgeons for treatment of recurrent prolapse of the top of the vagina. The risk of mesh exposure is only 2-3%.

In all cases where mesh continues to be used, it should not be the first choice of treatment. Experts recommend women should always try conservative measures first to manage prolapse or stress incontinence3,5. This can include:

  • Pelvic floor muscle exercises done under the guidance of a Women’s Health Physiotherapist
  • Lifestyle management, including bowel care, limiting strain etc
  • Support pessaries for prolapse

If women do need surgery for prolapse, it is recommended that “native tissue” repair should be tried first. That is the woman’s own tissues are stitched up to try to create more support. If the prolapse recurs, further surgery may include mesh, but your doctor should thoroughly explain the risks and benefits and explain that mesh is being used.

Women who have mesh surgery in the pelvis should be prescribed vaginal oestrogen for life if they are post-menopausal. This will help maintain more plump and healthy vaginal tissue and lower the chances of mesh erosion. They should also receive ongoing monitoring of their condition.

For those unlucky enough to have had complications following pelvic mesh, there is help available. A special Pelvic Mesh Clinic has been set up at the Royal Adelaide Hospital to help women in the public health system. Women are also encouraged to report any adverse events from mesh with this clinic. Women in the private health sector can also get help. A specialist Gynaecologist can often help to establish if mesh is the cause of the problem, and discuss surgical and non-surgical treatment options. A team approach to treatment is recommended, with women often seeing a Gynaecologist, a pain specialist, a Women’s Health Physio and a sexual counsellor.

For more information, the references below are freely available. Alternatively, you can contact the Pelvic Mesh Consumer Support Line on 1800 66 MESH, or speak with your GP, Gynaecologist or Women’s Health Physio.

References

  1. Commonwealth of Australia Report. Number of women in Australia who have had transvaginal mesh implants and related matters. 28 March 2018.
  2. SA Health factsheet. Pelvic Mesh: Frequently asked questions.
  3. Maher. Vaginal mesh controversy shows collective failure of the TGA and Australia’s specialists. The Conversation; June 7, 2017.
  4. Maher et al. Surgical management of pelvic organ prolapse in women (Review). The Cochrane Collaboration; 30 November 2016.
  5. Maher et al. Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse. The Cochrane Collaboration; February 2016.

About Us

Jenny Phillips is a Titled Continence and Women’s Health Physiotherapist. She offers skilled advice and management for all types of pelvic floor and pre- and post-natal problems.

Life Cycle Physiotherapy also offers exercise classes and 1:1 exercise sessions for women at all stages of life, including pregnancy and postnatal classes.

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