Transvaginal Mesh - The Need to Assess Risks, Benefits… and Options

Albany, NYDealing with weak abdominal muscles and the debilitating conditions that can come with it is fast becoming one of the biggest issues in women’s health. Urologist and surgeon Dr. Brian Murray sees women in his practice every day struggling with “pelvic organ prolapse” (POP) and “sudden urinary incontinence” (SUI).

“Pelvic organ prolapse is a big problem we have to tackle. There are more and more women in the baby boomer generation that will face this, and we have to figure out how to deal with it,” says Dr. Murray.

Aging, childbirth and surgery can all take their toll. The pelvic floor tissues weaken, stretch and become exhausted. Organs such as the bladder, the bowel, the uterus and the rectum begin to shift, sometimes bulging (or prolapsing) past the vaginal opening.

It can cause extreme pain in the pelvic area, difficulty with intercourse, and difficulty controlling bladder and bowel functions.

Pelvic prolapse is far from a rare condition. According to a 2011 report by the FDA, a woman’s “estimated lifetime risk of POP is 30 to 50 percent, with 2 percent of women becoming symptomatic.”

Surgeons have been using metallic or synthetic mesh to shore up the pelvic area and help deal with incontinence. In 2010, for example, the FDA reported that approximately 560,000 women had surgical procedures to deal with either POP or SUI. According to the report, one out of three POP surgeries used mesh to repair the problem and eight out of 10 SUI surgeries involved mesh.

Dr. Murray does about 200 pelvic prolapse surgeries a year. About 10 to 20 of those surgeries are remedial - that is to repair or remove mesh that is causing the patient problems. “When we do see problems, they are memorable. But there are two sides to the issue,” says Dr. Murray. “There certainly have been problems with mesh. Often it is too tight or it has been put in the wrong place,” adds Dr. Murray, “there was not enough regulation when the mesh first came to market (in the 1990s).”

Before going forward with any surgery to repair or ameliorate POP or SUI, Dr. Murray talks to his patients about risks and benefits to this type of surgery.

“If you don’t have symptoms, why would you consider this?” says Dr. Murray. “Still, I see people coming in for a prolapse fix just for a bulge. To me this is not a good plan because you have a bit of bulge that is not causing any symptoms and you are going to an operation that might cause significant symptoms.

“However, if a patient comes in and they are having terrible prolapse, having pain and incontinence - particularly incontinence - that is something you are reminded of every day and fixing it makes sense,” says Dr. Murray.

If surgery is an option, he usually prepares his patients with estrogen therapy to restore as much muscle function as possible, and he often sends patients to physiotherapy to further prepare the muscles before surgery.

“This generation of women is not likely to accept pelvic prolapse and the conditions that go along with it,” says Murray. “I have had a couple of patients where we had to take whole pieces of mesh out and used acellular collagen, which is pig bladder to patch the area. Plastic surgeons have used it for burns and it takes care of the wound and you can grow a surface on the vaginal wall with it.

“We are looking at it as substitute for some of the meshes that are being used. There are a couple of other products on the market - such as pig intestine, but it tends to be stiff and we don’t want to stiffen the vaginal wall,” says Dr. Murray.