Transvaginal synthetic mesh: Management of exposure and pain following pelvic surgery

INTRODUCTION — Vaginal synthetic mesh is inserted to augment native tissue; however, these materials have been associated with numerous complications including mesh exposure, perforation, or contraction; pelvic pain; dyspareunia; infection; urinary and bowel dysfunction; and fistula formation [1-5]. This topic will discuss the diagnosis and management of exposure (erosion) and pain resulting from vaginal mesh insertion. Other types of mesh complications are reviewed separately. (See "Transvaginal synthetic mesh: Complications and risk factors", section on 'Complications by procedure'.)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage readers to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

MESH EXPOSURE

Clinical findings and diagnosis — Patients may present with mesh exposure, vaginal bleeding, pelvic pain, nonhealing granulation tissue, dyspareunia, and partner irritation during sex [5,6]. Women with persistent granulation tissue, vaginal bleeding, abnormal vaginal discharge, or recurrent urinary tract infections after mesh placement should be evaluated for possible mesh exposure [7]. Alternatively, some patients feel the mesh themselves. Rare patients with mesh exposure are asymptomatic. The prevalence of symptom type varies by indication for surgery (incontinence versus prolapse), anatomic location of mesh (suburethral, anterior, apical, or posterior), and mode of insertion (transvaginal mesh versus mesh kits). The most common symptoms have a wide prevalence range but are consistently present in at least 10 percent of patients. They include the following [1,6,8-13]:

●Pelvic or vaginal pain

●Mesh exposure

●Dyspareunia

●Bulge sensation

The diagnosis of mesh exposure is made on physical examination; the mesh is visualized or palpated (picture 1). Whenever in doubt, a thorough digital examination commonly identifies exposure that was missed with visual inspection. The spectrum of mesh exposure ranges from simple small exposure following a midurethral sling to complex, large exposure after a transvaginal mesh kit.

Management

General approach — Treatment of mesh exposure is based on expert opinion, clinical experience, and data from observational studies. There are no randomized trials comparing treatments and no standardized treatment algorithms. Our general approach depends on patient symptoms and physical characteristics of the exposure:

●Asymptomatic mesh exposure – Women with asymptomatic exposures of monofilament mesh can be managed expectantly (picture 2) [7]. For example, a sexually inactive woman who is continent following midurethral sling placement but develops an asymptomatic suburethral extrusion (eg, no bleeding or discharge) may not require any intervention. We note the size and location of the exposure in the clinical record, educate the woman regarding concerning signs and symptoms, and offer her expectant management. If the presentation is truly asymptomatic (no bleeding, discharge, dyspareunia, or urinary tract infections), then further evaluation with cystoscopy or imaging is not warranted. If the patient becomes symptomatic, then a reassessment should occur.

We have seen many women who are completely asymptomatic but request to have the mesh removed. For these patients, education is all that is required. In this situation, the mesh should be left in place and the patient reassured that there is no indication to proceed with removal [7]. If symptoms arise in the future, then the patient should be reassessed. Symptomatic patients often require intervention; asymptomatic patients do not.

●Symptomatic mesh exposure — For symptomatic patients with macroporous polypropylene mesh, our approach is based on mesh characteristics:

•Small, flat mesh exposure – A short trial of local estrogen is a reasonable option for the treatment of small, flat (parallel to the vaginal epithelial surface), noninfected mesh exposures (picture 2), defined as less than 0.5 cm by the American College of Obstetricians and Gynecologists [7]. We treat with conjugated estrogen cream 1 g (0.625 mg conjugated estrogen per 1 g cream) vaginally at bedtime two to three times a week until resolution for up to 12 weeks. An alternate treatment option is the estradiol vaginal insert, 10 mcg, inserted into the vagina nightly, until resolution or up to 12 weeks. Patients who do not heal require surgical intervention. (See 'Mesh excision procedure' below.)

There is some evidence that local estrogen therapy is an effective treatment for mesh exposure. In a multicenter retrospective analysis of 347 women with mesh exposure after midurethral sling and prolapse surgeries, 40.7 percent (72 of 177 women) were successfully treated with a topical estrogen regimen but 59.3 percent (105 out of 177 women) went on to have a surgical intervention [9].

For patients with isolated mesh exposure who do not respond to topical estrogen, it is possible to mobilize the epithelium and reapproximate it without excising the mesh. Prior to attempting epithelial mobilization, factors that increase the risk of mesh exposure are eliminated when possible to reduce the risk of repeat mesh exposure (eg, smoking, immunosuppressive therapy, optimization of vitamin levels in bariatric surgery patients).

•Large or non-flat mesh exposure – In our experience, patients with large (approximately 2 cm or more) exposure, mesh lying at any plane other than parallel to the vaginal epithelium (ie, not flat), or multi-site mesh exposure are unlikely to heal with topical estrogen therapy (picture 3). We treat these patients by surgically removing the exposed portion of mesh. The procedure mobilizes the surrounding epithelium, resulting in a tension-free closure, and the segment of involved mesh is removed. We also advise trimming the vaginal edges to promote healing. In one retrospective case review, 70 percent (63 of 90 women) who underwent surgical excision were found to have mesh that was not flat or tension-free [8].

Infected mesh

Common presentations — Patients with infected mesh exposure typically present with copious malodorous discharge at the exposure site. Alternatively, patients may develop a sinus tract which drains remotely from the site of mesh placement. Sinus tract formation is primarily associated with microporous and multifilament mesh materials and sutures (picture 4 and picture 5 and picture 6 and picture 7 and picture 8 and picture 9). As long as the infection can drain into the vagina, systemic symptoms of infection are rare. Mesh removal, or mesh removal and treatment with a short course of antimicrobial therapy (ciprofloxacin or levofloxacin plus metronidazole for seven days), is often sufficient to treat most presentations.

Mesh type and infection risk

●Macroporous, monofilament meshes (eg, Prolene, Marlex) typically do not become infected (unless the exposure involves the bowel or bladder) even in the setting of large exposure. The large pore sizes allow for not only tissue ingrowth but for macrophage penetration and bacterial clearance, thus preventing mesh infection.

●Microporous, multifilament, or combination micro/microporous materials (eg, Amid Type 2 and 3 meshes such as Gore-Tex, Mersilene and Teflon) have pore sizes less than 10 microns, which prevents immune cell penetration of the mesh. Amid Type 2 and 3 meshes and sutures are prone to infection and are entirely removed if it becomes exposed or an infection or sinus tract develops (picture 10) [14].

●Braided suture (eg, Gore-Tex, Ethibond) may cause abscesses or sinus tracts that necessitate removal. If a microporous mesh was secured with braided sutures, then complete removal of the mesh and suture is performed if infection develops. Incomplete removal results in a recurrence of symptoms.

Unique presentations

●Sacrocolpopexy and diskitis – Sacrocolpopexy involves securing mesh (any type) to the sacral promontory. Inadvertent suture placement in the disc space can lead to diskitis; patients typically present with chronic vaginal discharge and debilitating low back pain [15-18]. These patients require removal of the mesh, combined surgical debridement with orthopedic surgery, and extended IV antimicrobial therapy directed towards culture proven microbes. To avoid this complication, mesh is secured to the anterior longitudinal ligament at the S2 level at the time of the initial surgery.

●Transobturator sling and perirectal sinus tracts – Transoburator slings made of macroporous polypropylene have been associated with sinus tracts that drain through atypical locations, including perineal, perirectal, and lower thigh sites [19-22]. In the authors’ experience, incision and drainage of non-healing abscesses (perineal or perirectal) results in treatment delays if the seeded graft is not removed [23]. Thus, patients with nonhealing perirectal or perineal abscess who have a history of prior slings undergo magnetic resonance imaging (MRI) to evaluate for evidence of infected sling. On imaging there is a hyperintense signal that extends to the involved groin. Definitive treatment requires surgical removal with groin cut-down.

Mesh excision procedure — Mesh excision can be a challenging procedure. Paradoxically, good anatomic support created by the material can limit the surgeon's ability to gain adequate exposure to perform the excision. In addition, removal of mesh from multiple sites can increase the risk of surgical bleeding and need for transfusion severalfold [24].

Office or operating suite — There are no data comparing office with operating suite excision of mesh. If the area is small and readily accessible, it is reasonable to attempt excision in the office under local anesthesia. If mesh exposure is large (approximately greater than 2 cm), if exposure is limited, or if a previous office procedure failed, then removal in the operating room is warranted.

Basic components — We excise the exposed mesh, mobilize the surrounding epithelium (to allow a tension-free closure), trim the epithelial edge (to promote healing) and close the wound with interrupted delayed absorbable closures. If the mesh exposure is large (>4 cm) or associated with pain, we recommend segmental removal of the mesh body and portion of the arms. Some surgeons inject a solution of 1% lidocaine and 1:100,000 epinephrine into the vaginal epithelium for hydrodistention and hemostasis [25].

Because macroporous, monofilament meshes rarely become infected, only the exposed portion requires excision (eg, removal of the entire mesh is not required). If the mesh is microporous or multifilament, then the whole mesh is removed.

Anterior compartment — In cases of large mesh exposure or pain involving the anterior compartment, we take the following approach:

●A midline incision is made from the vaginal apex to the bladder neck.

●The epithelium is dissected off the inferior surface of the mesh to the level of the descending pubic ramus on either side.

●The mesh is incised in the midline and the superior surface of the mesh is dissected from the overlying bladder. Adhesion formation increases the risk of urinary tract injury, so cautious dissection is warranted [26].

●The dissection is continued laterally to the inferior border of the descending pubic ramus or to the lateral edge of the mesh, and the mesh arms are cut as laterally as possible.

●If residual pubocervical connective tissue remains, a concomitant suture plication anterior colporrhaphy is performed.

●If there is no residual connective tissue, hemostasis is secured and the vaginal epithelium closed with interrupted delayed absorbable suture.

●In cases with significant bleeding, we use hemostatic agents prior to closing the epithelium and pack the vagina for one to several days.

Posterior compartment — For large, posterior mesh exposure or refractory pain, we take the following approach:

●A midline vaginal incision is made from the introitus to the level of the vaginal apex.

●The epithelium is dissected off the superior surface of the mesh and the mesh is split in the midline.

●With a finger in the rectum, the inferior surface of the mesh is dissected from the anterior rectal wall.

●The mesh arms are dissected towards the ischial spine and excised as far lateral and inferiorly as possible to relieve tension. Care should be taken when dissecting the arms towards the ischial spine, as aggressive dissection may result in hemorrhage.

●If rectovaginal connective tissue remains after the mesh excision, a posterior colporrhaphy may be performed.

Management of epithelial gap — Resection of large mesh exposure may leave a gap in the remaining vaginal epithelium. Primary reapproximation of the vaginal epithelium with sutures often results in narrowing of the vagina, which may further impair sexual function. In this setting, we use porcine small intestinal submucosa to bridge the gap between the epithelial edges so that the vagina can be closed without compromising caliber (picture 11). We prescribe vaginal estrogen (see 'Management' above) and dilators to maintain the vaginal depth and diameter postoperatively.

Reoperation — Patients with mesh exposure may require multiple surgeries to close the exposure. In a retrospective multicenter study of 347 women with mesh complications, 60 percent of patients required two or more interventions [9]. The original indication for mesh insertion impacted the outcome after mesh excision. For women who had a midurethral sling only, 56 percent (54 of 96 women) required further surgery. By contrast, 69 percent (18 of 26 women) who had both midurethral sling and transvaginal mesh required further surgical mesh excision.

For patients who have failed the epithelial mobilization or who want definitive therapy and whose only symptom is mesh exposure, we would recommend waiting several months after removal before considering a reoperation. Commonly continence is either preserved or only modestly compromised (assuming that only a 1 to 2 cm area of the infra urethral mesh is removed) after limited mesh excision.

Concomitant surgery — For patients who present with mesh exposure and stress incontinence, there is insufficient evidence to advise the patient regarding a concomitant incontinence procedure at the time of mesh excision. Based on preoperative counseling, the surgeon and patient may select a repeat incontinence procedure after a thorough discussion covering the following risks and benefits:

●Repeat mesh insertion versus alternate materials (eg, autologous fascia)

●Retropubic midurethral sling versus transobturator midurethral sling

●Retropubic slings versus alternative procedures such as an autologous bladder neck sling

If another midurethral sling is selected the patient should eliminate risk factors for recurrence (eg, smoking, immunosuppressive therapy, vitamin deficiency). We generally perform a retropubic sling to optimize continence outcomes. If a patient is reluctant about the use of mesh she is offered an autologous sling.

Outcome — The outcome after mesh excision varies based on the symptom measured. In a review of 90 patients treated for mesh complications at a referral center, 51 percent (43 of 90 women) had resolution of all presenting symptoms after mesh excision [8]. Of the women who presented with isolated mesh exposure, 95 percent (53 of 56 women) were treated successfully and did not require further treatment. However, of the women who presented with pain, 51 percent (30 of 58 women) had persistent symptoms after the mesh excision. Similarly, in another study that surveyed 41 women after mesh excision, 54 percent reported a successful outcome (22 of 41 women), yet 87 percent reported persistence of their preoperative dyspareunia (20 of 23 women) [27].

For patients whose pain improves with surgical excision, the pain does not appear to recur. A study of 125 women whose mesh-related pain resolved after mesh excision surgery reported that 97 percent remained pain-free after a median of 3.5 years of follow-up (range 0.5 to 10.0 years) [28].

Concomitant prolapse repair — Controversy exists around the timing of recurrent prolapse repair when mesh excision is performed. We recommend waiting until the mesh excision has healed before doing an additional surgical repair for recurrent prolapse or incontinence.

PELVIC PAIN FOLLOWING MESH INSERTION

General approach — Management of chronic pain following mesh insertion depends the timing of symptoms and the etiology. Once anatomic causes have been excluded by physical examination, causes include pelvic floor muscle spasm, pudendal neuralgia, infection, and mesh-related pain (eg, contraction) [25,29]. A detailed pelvic examination includes an assessment for pelvic floor tone, location of tenderness, intraluminal mesh, and prominent vaginal bands along the course of the respective arms [25]. A rectal examination is performed to assess for posterior compartment exposure. Cystoscopy is performed in patients with urinary symptoms.

We agree with the 2017 American College of Obstetricians and Gynecologists (ACOG) Committee Opinion that states, "Pelvic pain (including dyspareunia), possibly related to nonexposed mesh, is complex, may not respond to mesh removal, and should prompt referral to a clinician with appropriate training and experience, such as female pelvic medicine and reconstructive pelvic surgery specialist. Mesh removal surgery should not be performed unless there is a specific therapeutic indication" [7]. We have found that nuances regarding timing of pain onset and clinical scenario impact the treatment options. In our practice, we take the following approaches:

●Timing of pain onset

•Acute onset – Patients who develop acute and severe pain immediately following vaginal mesh procedures in the absence of clear etiology (eg, hematoma, abscess, or visceral injury) undergo excision to prevent development of a mature scar and chronic pain. If the procedure is performed early during the postoperative recovery (within the first two to four weeks after surgery), the scarring process is not complete and even polypropylene mesh can be removed completely.

•Remote onset – Patients who have mesh-related pain that develops remote from surgery (eg, more than four weeks) typically demonstrate mesh contractures, tight vaginal bands along the trajectory of the arms, or, at the very least, pain with palpation of the arms. If pain can be reproduced, then procedures to excise the tight arms or remove mesh from the affected compartment can be helpful. In the authors' experience, response to surgery appears related to timing between insertion and presentation for removal. It is unclear exactly how long, but patients who delay treatment for >4 years appear more likely to have pain persist despite removal. Regardless, the authors typically follow surgery with aggressive pelvic floor physical therapy.

•Pain unrelated to mesh insertion – There is now a group of women who happen to have had a mesh procedure and subsequently develop diffuse pelvic pain. As an example, we have seen women who develop pelvic pain years after an incontinence sling that is not anatomically related to the sling surgery. Similarly, there are women who had pelvic pain prior to mesh insertion that has persisted unchanged. In the absence of any vaginal bands or suburethral discomfort, these women typically do not need mesh excision but rather therapy directed at the pain source (eg, myofascial abdominal wall pain or pelvic floor muscle spasticity). Additionally, anecdotal evidence suggests that the more remote the patient is from mesh surgery, the less likely that mesh excision surgery will result in significant improvement.

●Type of prior mesh surgery

•For incontinence patients who require mesh removal to treat pain, we discuss the risk and benefits of reoperation versus aggressive physical therapy (with a pelvic floor expert) and nonsurgical options for stress incontinence. A nuanced discussion of risks and benefits of specific surgery is required in these patients. As an example, for women who desire removal of the synthetic sling and insertion of an autologous fascial sling because the lower risk of exposure with autologous fascial sling, the rate of urinary retention requiring revision is 13-fold higher compared with a synthetic sling and 39-fold higher compared with a Burch colposuspension [30,31].

•Prolapse patients who require mesh excision because of pain have a number of potential surgical options including transection of the involved arm, partial removal of the arm(s), and segmental (eg, from the anterior or posterior compartment) removal of the mesh body and arms. (See 'Basic components' above.)

Nonsurgical treatment options of pain include vaginal dilators, medication, and trigger point injections (see "Myofascial pelvic pain syndrome in females: Treatment"). In patients with severe pelvic floor muscle spasm, trigger point injection with onabotulinumtoxinA can be used to aid muscle relaxation and increase tolerance of physical therapy [32,33].

Pain outcome — Pain improvement rates after mesh excision range from 51 to 88 percent [8,29,34]. A review of 233 patients who underwent mesh excision for the indication of pain reported [34]:

●Pain improvement in 73 percent

●No change in pain in 19 percent

●Worsening of pain in 8 percent

However, duration of pain symptoms may impact pain resolution. The pain literature suggests chronic peripheral pain may lead to neuropathic pain syndrome (pain that remains after resolution of the inciting event).

Refractory pelvic pain — For those patients who fail all of the above options, anecdotal evidence suggests sacral nerve modulation may improve pain in patients who also have bladder dysfunction. However, this treatment modality has not been approved by the US Food and Drug Administration (FDA) for the treatment of pelvic pain resulting from vaginal mesh surgery.

INCONTINENCE OR PROLAPSE FOLLOWING MESH EXCISION — Women with mesh complications can have incontinence or prolapse prior to mesh excision surgery. It is important to document symptoms and preoperative abnormalities. Women who do not have incontinence or prolapse prior to mesh excision may develop incontinence or prolapse, either return of prior symptoms or new symptoms. Studies of outcomes following mesh excision are limited by relatively small sample sizes and short durations of follow-up.

●Urinary incontinence – The risk of return of urinary incontinence (UI) appears to vary with the amount of mesh that is removed [35,36]. Sling release performed with either sling incision or loosening appears to be associated with higher patient satisfaction (ie, less subsequent incontinence) [36].

●Pelvic organ prolapse – Regarding recurrent prolapse, a study of 19 women who underwent complete excision of sacrocolpopexy mesh and concomitant autologous fascia sacrocolpopexy, no patient required secondary surgery or pessary treatment for apical vaginal support at a median follow-up of 9.9 months (range 2.4 to 39 months) [37]. Median time from initial mesh placement to excision was 4.5 years (range 0 to 13). The indications for mesh removal were refractory pelvic pain (18 of 19, 95 percent), symptomatic mesh exposure (8 of 19, 42 percent), and ureteral obstruction with ureterovaginal fistula (1 of 19, 5 percent). However, as synthetic mesh repair is associated with lower rates of recurrent prolapse and repeat prolapse surgery compared with native tissue repair, it is possible that studies with longer duration of follow-up will demonstrate higher rates of recurrent prolapse following mesh excision [38].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic surgery".)

SUMMARY AND RECOMMENDATIONS

Mesh exposure

●After vaginal mesh insertion, patients may present with nonhealing granulation tissue, mesh exposure, vaginal bleeding, pelvic pain, dyspareunia, and partner irritation. The diagnosis of mesh exposure is made on physical examination. (See 'Clinical findings and diagnosis' above.)

●For treatment of small (less than 0.5 cm), flat (parallel to the vaginal epithelial surface), noninfected mesh exposure, we use a short trial of local estrogen as first-line therapy rather than excision. (See 'Management' above.)

●For treatment of large (approximately 2 cm or more) exposures or mesh lying at any plane other than parallel to the vaginal epithelium (ie, not flat), we surgically remove the exposed portion of mesh as these exposures are unlikely to heal with topical estrogen therapy alone. (See 'General approach' above.)

●Patients with infected mesh are diagnosed by clinical presentation with or without imaging depending on location of infection or symptoms. Infected microporous, multifilament mesh should be entirely removed. Antibiotic therapy may be indicated, especially if bony or soft tissue involvement is documented. (See 'Infected mesh' above.)

●The basic components of mesh excision include removing the exposed mesh, mobilizing the surrounding epithelium (to allow a tension-free closure), trimming the epithelium edge (to promote healing), and closing the wound with interrupted delayed absorbable closures. (See 'Basic components' above.)

●If resection of the mesh exposure leaves a gap in the remaining vaginal epithelium, four-ply porcine small intestinal submucosa can be inserted as a bridge. (See 'Management of epithelial gap' above.)

●Patients with mesh exposure may require multiple surgeries to close the exposure. (See 'Reoperation' above.)

●There is insufficient evidence to advise the patient regarding a concomitant procedure for incontinence or prolapse at the time of mesh excision. We wait until the mesh excision site has healed before doing an additional surgery to address recurrent prolapse or incontinence. (See 'Concomitant prolapse repair' above.)

Pelvic pain following mesh insertion

●The etiology of chronic pelvic pain after vaginal mesh placement is variable; causes include pelvic floor muscle spasm, pudendal neuralgia, levator myalgia, infection, and mesh contraction. (See 'General approach' above.)

●Examination of patients with pain after mesh insertion includes an assessment for pelvic floor tone, location of tenderness, intraluminal mesh, and prominent vaginal bands along the course of the respective arms. A rectal examination is done to look for posterior compartment exposure. Cystoscopy is performed in patients with urinary symptoms. (See 'General approach' above.)

●Patients who present with severe pain in the absence of clear etiology (eg, hematoma, abscess, or visceral injury) are managed with mesh excision and aggressive pelvic floor physical therapy. (See 'General approach' above.)

●Patients who present with severe pain in the absence of clear etiology (eg, hematoma, abscess, or visceral injury) are managed with mesh excision followed by aggressive pelvic floor physical therapy. Other nonsurgical treatment options include vaginal dilators, medication, and trigger-point injections. (See 'General approach' above.)

●Patients who fail conservative treatment have a number of potential surgical options including transection of the involved arm, partial removal of the arm(s), and segmental (eg, from the anterior or posterior compartment) removal of the mesh body and arms. (See 'General approach' above.)