By now you would have noticed the controversy and social media noise regarding the notorious mesh procedures being used for pelvic organ prolapse. Hundreds of women have joined a class action lawsuit against the healthcare giant “Johnson & Johnson” who manufactured the mesh for surgeons to use in women who suffered from pelvic floor dysfunction. In some cases… the results have been horrific, with tape eroding the soft tissues of the vagina resulting in irreparable pain, damage, further bladder and bowel dysfunction and destruction of women’s sex lives.
In our clinic we continue to see women who have had mesh, been recommended mesh or thought about having the mesh procedure to treat their pelvic organ prolapse. But how can one person possible manage the barrage of information from gynecologists, surgeons, physiotherapists, Facebook, social media, the news and old Aunt Beryl? Well, for all the questions that you have been itching to ask, we have… ‘The Mesh Interview’ (*cue dramatic music) with our resident expert Jane Strachan (APA Continence & Women’s Health Physiotherapist) who treats prolapse and see’s the effects of mesh procedures on a daily basis.
The Mesh Interview.
Q. Jane, can you tell us what ‘mesh’ is and why it might be used or recommended?
A. In basic terms, the mesh that they use to support a pelvic prolapse is a type of polypropylene surgical material, essentially a type of plastic with very small holes throughout it. The mesh is designed to be placed within the walls of vagina where it is supposed to prevent the pelvic organs from dropping down and reduce the symptoms of prolapse that the patient is experiencing.
Q. What sort of conditions might surgical mesh be used for?
A. The mesh we are discussing is used to treat pelvic organ prolapse. If a patient is struggling or bothered with their prolapse symptoms (such as bulging, heaviness or dragging) then the surgical option will potentially assist their bladder bowel control.
Q. What if the prolapse is not bothersome? Is mesh still recommended?
A. Pelvic floor physiotherapy can offer a lot of other options before surgery if the prolapse is not symptomatic. Around 50% of all women who have delivered a baby vaginally will have a prolapse by the time they reach menopause. So it is actually a very common thing for a health professional to have noticed when performing a vaginal exam. If you are not having symptoms yet, having surgical intervention (such as mesh) would be an extreme option for management.
Q. Is mesh a permanent fix for prolapse?
A. Not necessarily. In some research, mesh has shown some good short term success rates of up to 95%. This reduces as time goes on, and has been known to have about an 85% success rate at 12 months. This means that 8 out of 10 people will have success maintained for 12 months. So 2 out of 10 will not be happy with how the surgery has gone and at 5 years those figures drop further.
Q. Is surgical mesh permanent once it is inserted?
A. For most women, once the mesh is inserted it is a permanent fixture. A few surgeons can remove mesh if it hasn’t worked. However, it is like tiny chicken wire, and your tissues grow into the mesh, making it very hard to removed once it is in. So in terms of an option for prolapse management, we would recommend surgery as a last resort when conservative management has failed.
Q. Why has the Therapeutic Goods Administration banned the use of mesh in the treatment of pelvic organ prolapse in Australia?
A. Mesh has been banned because there has been a high rate of patients encountering complications following the mesh surgery . For example, ongoing chronic pain in the vagina and pelvis, including pain that prevents them from having intercourse. Some women have reported erosion, which is where the mesh has moved, pushing out into the vagina or even the bladder. There has also been increased rates of infection to the point that the TGA felt there needed to be more investigation into the product used for prolapse support before any more patients could receive it to treat pelvic organ prolapse.
Q. Can they tell which patients will suffer from those complications?
A. No. That is one reason why it is banned as it is not always clear who will have issues. We have a few indicators as to who might have issues but it is in not way clear enough to give good advice.
Q. Apart from surgery, what other options exist to treat pelvic organ prolapse?
A. Prolapse can be managed in a number of ways. A prolapse can occur when there is an imbalance between the fascia supports of the pelvic organs and the support that exists from underneath the pelvic floor. So as a conservative management we often start with a pelvic floor examination to make sure the pelvic floor muscles are working as effectively as they can to support the pelvic organs from underneath. Pelvic floor muscle training is a highly effective way to help train these muscles and is often enough for some women to control their symptoms. If it’s not, the next conservative option is to use a support pessary for pelvic prolapse. A pessary is a small silicone device which is worn up inside the vagina and supports the walls of the vagina and the pelvic organs.
Copyright 2001 ?/font> Bioteque America Inc. All rights reserved.Available. http://pessaries.com/pessaries/Cube_Pessary.html
Q. What are the pros and cons of conservative management versus surgical management?
A. Both surgery and conservative therapy have similar success rates of 85%, however the pros and cons are very different. The negative outcomes of surgery could be death, intractable pain and ongoing infection, versus conservative managements (support pessary for pelvic prolapse) cons which may include discomfort or a mild infection. In the case of conservative management, we are able to try another shape of pessary or remove the pessary to treat the infection. The reversal of surgery is much more difficult and in some cases impossible.
The pros and cons of surgical versus conservative management are very different, so making sure you exhaust your conservation management options before of trialling a surgical option is best. In fact the Royal College of Obstetricians and Gynaecologists and the British Society of Urogynaecology have released their position statements on the matter.
“The joint guideline of the Royal College of Obstetricians and Gynaecologists and the British Society of Urogynaecology (2015) does not support the first-line use of transvaginal mesh in women with post-hysterectomy vaginal prolapse and says that women should be fully informed of the potential complications.”
Q. Is the mesh used to urine leakage problems under the same scrutiny?
A. You can have a tape support for bladder control, also called a mid urethral sling or a mini sling. This is the same mesh product, but it is a different shape. It is a long thin piece of tape versus a wider square shape that is used to support the prolapse. It has slightly different complication rates, but it still has complications. Discussing this topic with your gynecologist is a good course of action.
If you or someone you care about is considering mesh or suffering from the effects of mesh, please get in touch. Physiotherapy can help. Remember, with all medical and health consultations use the B.R.A.I.N analogy to ensure you are informed of your choices. You are always entitled to a second (and third or fourth) opinion.
Are you ready for the silly season? Our physiotherapists will highlight what you need to know these holidays to keep your bladder and bowels healthy and protected. Hint. Not all of them are as obvious as you may think!
Be kind to yourself,
Royal College of Obstetricians and Gynaecologists, British Society of Urogynaecology. Post-hysterectomy vaginal vault prolapse. Green-top Guideline No. 46. www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg46