Pelvic floor problems such as prolapse and incontinence usually happen when the muscles and connective tissues of the pelvic floor become damaged or weakened. Operations to fix these problems have traditionally involved reinforcing the body’s own tissues with dissolving stitches.
Around 20 years ago, as it was thought that using a plastic mesh material to reinforce weakened vaginal tissues during operations for prolapse and incontinence would lead to better long-term success.
We now know that operations involving the use of vaginal mesh carry risks of chronic pain and mesh exposure / erosion into the vagina or other pelvic organs. Research has shown these complications are highest in women having vaginal mesh implanted for prolapse – these operations are no longer recommended. Mesh operations are still offered for stress incontinence (TVT) and prolapse repairs where mesh is implanted within the abdominal cavity rather than the vagina.
As with all operations, women undergoing these procedures should be informed of the risks of surgery and should be offered the option of a ‘non-mesh alternative’ procedure.
Vaginal mesh operations for incontinence and prolapse involve implanting mesh just below the vaginal skin. Sometimes the vaginal wounds don’t heal properly or the mesh can expose through the vaginal skin over time resulting in a vaginal mesh exposure. Some women may have vaginal mesh exposure and be completely unaware. This does not necessarily require treatment. Exposed mesh may cause pain, vaginal discharge, bleeding or painful sex for the woman (dyspareunia) or her partner (hispareunia). Small exposures can be treated either non-surgically with topical vaginal oestrogen therapy, or surgically by over-sewing the exposed mesh, or removing the mesh (partial or total mesh removal surgery).
Mesh tapes for incontinence (TVT or TVT-O) can ‘cheese-wire’ through the water pipe (urethra) or bladder. This may result in pain, recurrent urinary tract infection, recurrent incontinence, or fistula formation (abnormal communication between the urethra / bladder and the vagina leading to constant leakage). This complication requires complex mesh removal surgery involving a multidisciplinary team of specialists.
Pain in the inner thigh area is more common in women who have undergone a TVT-O procedure compared with retropubic TVT. Both operations involve insertion of a plastic mesh tape through a 1cm vaginal incision although the TVT-O exits through the inner thigh whereas the retropubic TVT exits through the lower abdomen. The retropubic TVT avoids the nerves and muscles of the inner thigh, theoretically reducing risk of groin pain. Groin pain is managed by a team of professionals (multidisciplinary team) including gynaecologists, urologists, pain specialists and physiotherapists.
Sometimes vaginal mesh for incontinence (TVT or TVT-O) can be felt just below the vaginal skin as a tight band of tissue (para-urethral band). This scar tissue is often firm and lacks the flexibility and suppleness of normal vaginal tissue. This may result in painful sex for the woman or her partner. Surgery to remove vaginal mesh can improve symptoms, although there are no guarantees. For some women pain will not improve after mesh removal surgery and there is also a risk that urinary incontinence will return.