Use of Surgical Mesh in Pelvic Organ Prolapse

Introduction:

Pelvic organ prolapse means the pelvic muscles cannot adequately support the organs in the pelvic area. The organs slip down from their normal position, which creates a bulge in the vagina (a tube that extends from the external genitals to the cervix). The use of surgical mesh in such cases is a standard procedure. The benefits of using this surgical mesh to treat pelvic organ prolapse outweigh the risks.

What Is a Surgical Mesh?

The surgical mesh is a flat panel-like screen to strengthen the tissue or bone. This is composed of synthetic polymers or biological polymers.

The various materials used for synthetic mesh are:

• Synthetic non-absorbable polymers, like polypropylene.

• Synthetic absorbable polymers, like polyglycolic acid.

• Biological (cellular collagen that is sourced from cows or pigs).

• Composite means a combination of any of the above materials.

Most surgical meshes are made up of non-absorbable materials.

What Are the Signs of Pelvic Organ Prolapse?

• A feeling of pressure or fullness in the pelvic area.

• Severe backache in the lower region.

• A sense of something dropping from the vagina.

• The extreme urge to urinate frequently.

• Urination problems such as leakage of urine.

• Severe constipation.

• The loss of control of the bowel.

• Slight spotting from the vagina.

• In some cases, severe bleeding from the vagina.

In What Procedure Is Surgical Mesh Used?

• The surgical mesh is used in pelvic organ prolapse cases and stress urinary incontinence (SUI). Stress urinary incontinence means leakage of urine during physical activity, which elevates abdominal pressure, and those activities are coughing, sneezing, laughing, or exercising.

• In pelvic organ prolapse cases, the pelvic organs shift downward and bulge out of the vagina. The pelvic floor muscles are too weak to hold the organs in position. The pelvic organs undergo prolapse: the urinary bladder, uterus (womb), rectum, and vagina. The causative factors for pelvic organ prolapse are pregnancy, delivery, and aging. The bladder is prolapsed in most cases.

• In stress urinary incontinence, the weak pelvic muscles and tissues cause the bladder and neck to move downward.

How Is the Surgical Mesh Placed in the Treatment of Pelvic Organ Prolapse?

• Surgical mesh is placed permanently to strengthen the vaginal wall in pelvic prolapse cases and support the urethra in stress in urinary incontinence cases.

• Transvaginal (through the vagina) mesh insertion to treat pelvic organ prolapse.

• Transabdominal mesh insertion to treat pelvic organ prolapse.

• Pelvic organ prolapse management can also be done without using a surgical mesh. In such cases, the incisions are usually made in the vagina and closed with sutures. The surgeries in which surgical mesh is used are more successful than those without surgical mesh.

What Are the Merits and Demerits of Considering Surgery for Pelvic Organ Prolapse?

• Before proceeding with any treatment, consider other treatment options, including non-surgical and suture-based methods that do not use mesh. They are very effective in the long run and without complications that occur with surgical mesh.

• Perform the surgery with or without the use of surgical mesh. Using mesh may increase the risk of complications involving mesh and subsequent surgeries. In some cases, additional surgeries cannot solve all the medical issues. Proper medical consultation with the physician is essential to determine the best treatment.

What Are the Complications of Using Surgical Mesh in Pelvic Organ Prolapse Cases?

• Vaginal mesh erosion is the most common complication that occurs after using the surgical mesh to strengthen the pelvic organ prolapse and stress urinary incontinence. Using non-absorbable surgical synthetic mesh, which is made of polypropylene or polyester, can wear away or break in the long run. The part of the mesh can remain and may become exposed or protrude through the vagina. This is vaginal mesh erosion.

• Erosion of mesh to other organs as the mesh, over time, can protrude into other organs like the urethra, urinary bladder, or rectum.

• The vaginal mesh contraction means the surgical mesh shortening or tightening in the long run. This leads to the shortening of the vagina and severe pain. The vagina can also contract over time.

• There is severe pain during sexual intercourse.

• Urinary bladder and urination problems.

• Risk of infections.

• Profuse bleeding.

• The pelvic organ prolapse can re-occur.

• Urinary tract injury.

• Trauma to the ureter.

• Rectal injuries.

• Neuro-muscular problems.

• Fistula (an uncommon passage or connection between two body parts such as an organ, blood vessel, and other structures).

• Perforation of internal organs.

• Severe discharge from the vagina.

The Surgical Mesh-Related Complications Are:

• Mesh Extrusions: This is a severe complication of the surgical mesh placement. The vaginal mucosa erosions due to surgical mesh protrusion were detected on examination of the vagina between two to twenty-four weeks after surgery. All women with mesh extrusions experience severe pain. The treatment is the application of vaginal cream and removal of a part of the exposed mesh. In extreme cases, surgical removal of the mesh is recommended.

• Transvaginal Mesh: The surgical mesh is placed through the vagina to treat pelvic organ prolapse. The risks are more than the benefits, so the Food and Drug Administration (FDA) banned the use of transvaginal mesh.

• Infection: Infection associated with mesh usage. Necrotizing fasciitis means chronic bacterial infection that destroys the tissue under the skin caused by Streptococci.

• Mesh Shrinkage: The shrinkage of the surgical mesh causes severe complications. They are severe vaginal pain, dyspareunia (painful intercourse), shortening of the vagina, obstruction of the urethra, and occurrence of pelvic organ prolapse. The treatment is surgical mesh removal by mobilizing the mesh, dividing the fixation arms of the mesh, and excisioning the shrunk mesh. The shrinkage leads to visceral injury and severe bleeding.

What Are Special Measures Recommended for Surgical Mesh Use in Pelvic Organ Prolapse?

• Specialized professionals must place the surgical mesh in pelvic organ prolapse.

• The patient should be well informed about the mesh placement complications beforehand. The potential postoperative complications of a mesh surgery compared to a non-mesh surgery and their effect in the long run.

• Watch for complications and be vigilant toward the patient.

• Follow-up consultations are needed in such cases.

Conclusion:

The surgical mesh placement in pelvic organ prolapse is under review, and a thorough knowledge of the mesh-associated complications is necessary before planning treatment. The mesh placement is invasive, and the insertion must be done with utmost care. Modern surgical methods for treating pelvic organ prolapse are minimally invasive with no severe complications.