The Vaginal Mesh Mess
By Marja Sprock, M.D.

The vaginal mesh mess, sounds cute, however there is a lot of misunderstanding about mesh, the reason it is sometimes used in repair of the vagina, and the possible complications of it. Actually there is a lot of misunderstanding about vaginas, since mesh is not used in well supported vaginas with strong healthy tissue, but in prolapsed vaginas with weak tissue and broken support systems. A vagina that supports bladder, uterus or small bowel and rectum well, will not require the insertion of a mesh. It is the vagina that is coming down, looking like when you pull a sock inside out, which possibly requires the insertion of a mesh.

If you turn on the radio or TV, you can find ads looking for people who had certain kinds of meshes placed in the vagina. The FDA came out with a “vaginal mesh warning’ in 2008. This warning summarizes some of the potential problems, but at the same time advises to look for an experienced surgeon. It has been proven by several studies on numerous different surgical interventions and procedures: surgeons who perform a certain surgery more often, “high volume” surgeons, tend to have better outcomes and fewer complications.

I often tell people, “You should not choose to have an urogynecologist insert your knee replacement”, however that does not mean the knee implant is defective, it means choose your surgeon carefully. If your own knee has worn down to a degree that there is so much damage that it can not be repaired and it bothers you tremendously in daily life, replacement may be a good thing. Will that mean that everything will be 100% guaranteed fine and your knee will be as good as new? Obviously not. Naturally with any surgical intervention there are potential problems, some can be prevented, others not.

It is not much different when a vagina requires a repair. For some severely prolapsed vaginas, studies have proven that the use of a mesh, will lead to less recurrence of the problem. The chance of a repair of the front of the vagina, cystocele (bladder coming down), recurring has been estimated to be close to 30%. That is a high percentage and with the use of a mesh it has been brought down. The mesh will be placed to provide extra support to the weakened tissue, which has a lot of body weight pushing on it. Also the mesh makes it possible to put less tension on tissue, and recreate support. Your own tissue will grow into the mesh and incorporate it. The softer more open weave meshes which are used more often nowadays can often only be palpated at the connection points and only by an experienced surgeon, not by the patient.

Vaginal prolapse is like a hernia. Surgeons often repair abdominal hernias with a mesh, since the repair has been proven to be sturdier. There can be complications, like non-healing, infection and failure, no surgery is 100% guaranteed.

When I showed one of my patients an example of the mesh and told her which parts of the mesh I probably would trim, she said: “why would you trim it, I like this, it feels nice and soft, like the lace I use for sewing”.

Over the last couple of years, the mesh material used in vaginal repairs has made significant advances. The risk of complications depends on the patient, the mesh used, the procedure and the surgeon. If a patient is older, has a poor blood supply, has thinning of the vaginal tissue and systemic diseases like diabetes or obesity, the chance of complications is higher. The meshes nowadays have larger pores, are flexible and have smaller diameters of the fibers used to make the mesh.

Risk of the use of meshes is erosion or extrusion of the mesh, meaning a piece of it will be visible in the vagina. Sometimes not a problem, but a potential sexual partner will be less enthusiastic. It is however often easy to fix in the office, and currently almost a problem of the past. There are people who ended up with significant pain in the vagina after mesh was used, which often can be relieved by an experienced vaginal surgeon. There are also numerous people who end up with vaginal pain after a repair without mesh. This is often more difficult to correct since surgeries without a mesh, often involve removal of a significant amount of vaginal tissue. Once it is gone, it can not be recreated. In mesh repairs, the support is recreated and there is minimal to no removal of tissue. Remember repairs are done for vaginas that are not well supported, like the “sock which is turning inside out”, not a healthy vagina.

The risk of infection varies dependent on the type of mesh used and numerous other factors. If the patient is obese, has hypertension, a thin non-estrogenized vagina and diabetes chances of potential problems like infections and non-healing are significantly increased. There are other risks to vaginal surgery like possible injury to organs like bladder and rectum. Not common and if recognized early often quite easy to repair.

Vaginal meshes often lead to sturdier repairs and in the right surgeons hands, complications can be kept to a minimum.  A mesh should only be used for significant prolapse, not for a mild descend of the vagina. Currently there is a witch hunt going on and it will not help women if vaginal meshes were abandoned, nor do they deserve the bad press. I have seen numerous poorly repaired vaginas with women unable to have intercourse in vaginal repairs done without mesh, where too much tissue was removed and it all was pulled too tightly.

Since meshes have been proven to increase the success rate and longevity of several vaginal repairs, it is unlikely they will disappear; neither would it benefit women if placement was abandoned. It pays to be well informed. Make sure your surgeon has experience in vaginal mesh repair and understand your options. Realize that everything you do in life has a potential risk. If you get into a car, you can get into an accident and you accept that risk and try to minimize it. If your vagina is severely prolapsed and interfering with your quality of life, you can choose to let it be, have a pessary inserted or have a surgical intervention. Weighing the pros and cons this may mean the insertion of a mesh. If a mesh is placed in your vagina for support it will be because your natural support is defective and it is being used as an aid.

To make a long story short: the success of a vaginal repair depends on the patient, the surgeon, the procedure and the possible mesh product used. Meshes used for repair of severely prolapsed vaginas have often more advantages than disadvantages, which should all be discussed and evaluated carefully. No 100% guarantee can be given, not for vaginal meshes and not for life. The vaginal mesh mess may not be as messy after all.

Marja Sprock, MD is a fellowship trained urogynecologist who will be able to assist you in the best choice of treatment for your bladder, bowel or vaginal prolapse problems. Also your specialist for cosmetic vaginal surgery.

Call our Rockledge office at 321-806-3929, send us a note or visit us online at www.CFUroGyn.com.