Pelvic mesh

Mesh is woven synthetic netting, usually made from Polypropylene. Pelvic mesh is mesh that is implanted into the pelvis for a variety of conditions, usually pelvic organ prolapse and stress urinary incontinence.

Conditions pelvic mesh may be used for:

• Stress incontinence - a condition where the supporting tissues of the bladder neck and urethra lose their natural support which causes an accidental loss of urine with physical activity such as coughing, sneezing or exercise. 
• Prolapse - a condition where a woman’s vaginal walls and pelvic organs (uterus, bladder & bowel) lose their natural support which causes them to bulge down within, and sometimes outside of, the vagina. 

These two conditions are different but both may occur in the same woman, and the surgeries for the two conditions may be performed together.  The mesh used in each condition is made from the same material, but the nature of the operation for each condition is quite different.

In most cases:

• Women can safely choose to not have treatment if they prefer to manage with pads or other aids.
• Treatment is usually only recommended if prolapse or incontinence symptoms are bothersome, or there is an extremely large prolapse creating bladder blockage, kidney blockage, vaginal ulceration or pelvic pain. 
• Recommended first line treatment for either condition is with a physiotherapist trained in pelvic floor problems, except in severe prolapse as outlined above.
• Women should consider conservative (non-surgical) treatment before considering surgical treatment.
• Surgery for both prolapse and stress incontinence generally involve procedures that reinforce the weakened support tissues.
• Many women choose to go on to surgery because they have not gained sufficient improvement with non-surgical treatments, and the condition is affecting their quality of life.

For further information on these conditions please see the patient information sheets that more fully describe the conditions, treatments, success and risk factors on the UroGynaecological Society of Australasia (external site) and patient information on the International Urogynecological Association (external site).

Stress Incontinence – An operation that uses only the woman’s natural pelvic tissues for reinforcement has a very poor chance of success for stress incontinence. Mid urethral slings (MUS) are small thin strips of mesh that sit underneath and around the urethra to provide support. For stress incontinence the mid urethral sling is considered the first line surgical treatment for most women, because it provides the best balance of success versus overall complications (both non-mesh complications and mesh complications).

The most commonly known mid urethral sling is the Tension free Vaginal Tape (TVT), otherwise known as Transvaginal Tape. This sling is placed through the retropubic space behind the pubic bone, to exit just above the pubic bone. The next most common sling is the TVT-O. This sling is placed through the obturator area underneath the pubic bone to exit at the groin.

Mid urethral slings have been more extensively researched than any other surgical procedure for stress incontinence, including Colposuspension (Bladder Neck Elevation), Fascial sling and Peri-urethral bulking. There is evidence for up to five years on the effectiveness and safety of mid urethral slings. However, there are only a small number of randomised controlled trials (these produce the most reliable findings of all studies) with results beyond five years after surgery. Hence there is less information about long-term effectiveness and safety, but the existing evidence points to a lasting positive result. More information on long-term results is essential.

Prolapse – Native tissue vaginal repair (repair via the vagina that uses a woman’s natural pelvic tissues for reinforcement) has a reasonable chance of success for prolapse.  It is the first line surgical treatment for prolapse in most women because it provides the best balance of success versus complications. For prolapse, mesh is NOT first line surgical treatment because on balance, the risk of severe complications outweigh chances of success.

When the prolapse mesh is inserted through a vaginal incision it is called Transvaginal Mesh (TVM). When the mesh is inserted via the abdomen (either by open cut incision or keyhole surgery) it is usually called Abdominal Mesh Sacrocolpopexy.

Transvaginal mesh (TVM) repair is a much higher risk procedure than native tissue repair so should be reserved for women who have a much higher than usual risk of prolapse recurring and where no other option is feasible or appropriate. There is good information on the long-term effectiveness and safety for abdominal mesh Sacrocolpopexy but little long-term information for the currently available TVM mesh kits. More information on long-term results is essential.

The majority of women have a good outcome from transvaginal prolapse mesh, abdominal prolapse mesh and mid urethral slings. However, there are women who have suffered complications. Some of these are very serious and life changing, particularly for women who experience severe chronic pain, have had mesh exposure or erosion into the bladder, urethra or bowel, or recurrent vaginal exposure and infection.

In August 2016, the Australian Therapeutics Goods Administration (TGA) issued an alert to the possible complications associated with pelvic mesh implants. Similar issues have also been reported and actions taken by other international regulatory bodies. The Australian Pelvic Mesh Support Group listed possible complications following pelvic mesh surgery (external site).

Please note that some of these problems (other than mesh exposure/perforation) may also occur (but less likely), due to either non-mesh surgery, the original condition, another related or non-related condition, or any combination of these.

Symptoms that may be associated with pelvic mesh implant complications include:

• Pain that is not improving - low abdominal, pelvic, groin, thigh or buttock pain 
• Poking/prickling sensation or spasms in the pelvic area
• You or your sexual partner feeling the mesh through the vaginal wall
• Pain (either you or your partner) during sexual intercourse
• Abnormal vaginal bleeding or discharge 
• Difficulty with bladder emptying
• Pain associated with urination
• Recurrent bladder infections
• Abscess or swelling at the mesh insertion or exit sites.

If you are having symptoms you should visit your GP to determine if your symptoms may be associated with the mesh implant. If your GP does not have details of your operation you may ask for a copy from the hospital via Freedom of Information, or ask your GP to do this. If you are not experiencing any symptoms then you do not need to do anything.

Further assessment and any additional treatment should be undertaken by experienced Urogynaecologists or Urologists who specialise in pelvic surgery. In the WA public sector, only King Edward Memorial Hospital (KEMH) has doctors with the expertise to manage the most serious complications.

As part of the process, assessment and treatment options specific to each woman’s circumstance should be discussed and tailored to their concerns and problems.

ASSESSMENT

The most common assessments are bladder function tests, (urodynamics), telescope look inside the bladder (cystoscopy) and examination under anaesthetic. In some women a specialised ultrasound may be helpful. The 3D ultrasound is a computer generated picture of what can be seen on 2D and gives a picture that is easier to visualise.  A decision whether or not ultrasound could be helpful needs to be made in consultation with each woman as an individual, taking into account all the circumstances.

TREATMENT

What can be done to help a woman in these circumstances very much depends on each individual woman’s circumstances, in particular what is found on assessment, other medical factors, and her expectations.

Treatment may include bladder and/or pain medications, expert physiotherapy (particularly for bladder/bowel dysfunction and down regulation of pelvic muscles; standard pelvic floor exercises are not appropriate and may lead to increased pain), pain management strategies and psychological support, targeted partial removal (particularly for localised problems such as a small painless vaginal exposure) or full removal (particularly for chronic pain). Combinations of these management strategies are often recommended. A decision regarding whether or not each of these could be helpful needs to be made in consultation with each woman as an individual, taking into account all the circumstances.

When considering mesh removal there needs to be an individualised balance struck between the risk of further complications from any remaining mesh compared to the risk of complications from any removal procedure and/or removal not resolving the problem; particularly chronic pain. As yet, there are no robust studies for guidance on who would benefit from removal, or would benefit from full compared to partial removal

King Edward Memorial Hospital (KEMH) has commenced a mesh complication service (Pelvic Mesh Complications Clinic) run by urogynaecologists with a dedicated multidisciplinary team. KEMH sought health consumer input, particularly from the Australian Pelvic Mesh Support Group, as to what was required of this service by consumers.

This service is run in addition to the usual urogynaecology/urology clinics with access to a multidisciplinary team including a pain specialist, clinical psychologist, physiotherapist, urodynamics and urogynaecology specialist nurse, social worker, occupational therapist, dietitian and ultrasound specialist. As treatment will be individualised not every woman will need to see all members of the multidisciplinary team.

What can I do now?

If you are worried or have symptoms that may be related to your surgery you are encouraged to call the King Edward Memorial Hospital Pelvic Mesh contact line to register your details.

You will be asked by the contact person whether you wish to register your details and have your concerns further assessed by the King Edward Memorial Hospital urogynaecology team, or just register your details. You will then be contacted as soon as possible to arrange an appointment if assessment was requested.

Pelvic Mesh contact phone line: 1800 962 202

In addition, your GP may be able to refer you to a private urogynaecologist or urologist who specialises in this area, or refer you to the dedicated public King Edward Memorial Hospital Pelvic Mesh Complications Clinic.

Alternatively, you may refer yourself to the King Edward Memorial Hospital Pelvic Mesh Complications Clinic. If you self-refer, it is still advisable to obtain a letter from your GP with all your past medical history, medications, allergies and information pertaining to your mesh surgery if that is known.

If you present to an Emergency Department for any of your symptoms please ensure you tell the health professional staff if you have a pelvic mesh so that your care can be managed accordingly.

If you are worried or have symptoms that may be related to your surgery you are encouraged to call the King Edward Memorial Hospital Pelvic Mesh contact line to register your details.

You will be asked by the contact person whether you wish to register your details and have your concerns further assessed by the King Edward Memorial Hospital Urogynaecology team, or just register your details. You will then be contacted as soon as possible to arrange an appointment if assessment was requested.

Pelvic Mesh contact phone line: 1800 962 202

In addition, your GP may be able to refer you to a private Urogynaecologist or Urologist who specialises in this area, or refer you to the dedicated public King Edward Memorial Hospital Mesh Clinic. 

Alternatively, you may refer yourself to the King Edward Memorial Hospital Mesh Clinic. If you self-refer, it is still advisable to obtain a letter from your GP with all your past medical history, medications, allergies and information pertaining to your mesh surgery if that is known.

If you present to an Emergency Department for any of your symptoms please ensure you tell the health professional staff if you have a pelvic mesh so that your care can be managed accordingly.

• Australian Pelvic Mesh Support Group – Facebook group (external site)
• WA Pelvic Mesh Support Group – Facebook group (external site)
• Health Consumers’ Council (WA) Inc. (external site)