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Vaginal Mesh Complications: Treatment for Vaginal, Pelvic, Leg, Buttock, and/or Abdominal Pain
Mesh used vaginally for incontinence or prolapse can occasionally cause pain vaginally, throughout the pelvis, in the legs/groins, buttocks and/or abdominally. Typically when this occurs it is secondary to the mesh being placed too tight, or healing in a position that is pulling on the muscles and nerves and causing irritation to these structures. Rarely, as with any pelvic floor surgery, a nerve injury can occur and this can cause pain as well. Again, one has to remember that pain as a complication can occur with any pelvic surgery, whether mesh is used or not. Some of the newer technology to attach the mesh in place vaginally actually has less risk of causing pain or a nerve injury compared to some of the older, more “traditional” surgery where mesh is not used. However, even with the best technology, risks such as pain exist and the most important thing is to recognize the complication and get adequate treatment early in the process. In most cases, pain is a complication that can be treated and eradicated if properly recognized and treated.
When a woman has pain following a mesh procedure for incontinence or prolapse a conservative approach can be utilized at first, however if the pain does not improve or is very severe (which may be a sign of nerve injury), a surgical approach may be indicated. Conservative therapy may involve pelvic floor physical therapy (ie manual therapy on the muscles and the nerves in the vagina and pelvis to help them relax or relieve spasm that may be causing pain) and/or trigger point injections into the muscles and/or nerves in the vagina that may be causing the pain. If the pain does not respond to this therapy, then surgery is indicated.
Typically, when mesh is causing pain, it is secondary to healing too tight, being placed to tight, “bunching up” in the vagina, or one of the attachment points pulling on a muscle or nerve causing pain. Typically, the pain can be reproduced on vaginal exam and the an area of ‘banding” of the mesh can be palpated, which indicates the mesh is too tight in this region.
Vaginal Mesh for Prolapse (Cystocele/Rectocele/Vault)
With the first generation mesh kits (such as Avaulta, Apogee/Perigee, Prolift) , as well as the TOT slings, the mesh arms penetrate through and through the pelvic sidewall muscles and then go through the groins and if these arms are too tight, it can cause pain vaginally or in the groins. In many instances, these arms or “bands” of tension can be palpated vaginally and the arms surgically released or cut, which takes the pressure off the muscles and nerves and relieves the pain. In other instances, the entire mesh (ie for prolapse repair) will need to be stripped out and removed. On occasion, if the mesh arm has been placed through and through the sacrospinous ligament (ie with Prolift) the mesh arm will need to be dissected out of the ligament and the pudendal nerve released away from this area. Rarely, an abdominal approach will be necessary to take care of pain from mesh placed vaginally or abdominally with sacralcolpopexy. If this is the case, most surgeons will recommend major surgery with a large abdominal incision. Drs. Moore and Miklos actually achieve the same procedure through mini-incisions in the abdomen and a laparoscopic approach, which allows for early return to home and rapid recovery.
Pain after sling surgery (TVT/TOT/Mini)
This is also the same for mesh tape slings such as the TOT sling or the TVT sling. The TOT sling and Mini sling are attached to the obturator muscles, with the TOT sling coming out of groin incisions. In most cases, the tension can just be released vaginally through a small vaginal incision and/or the vaginal portion of the sling removed and this will solve the pain issue. Many surgeons are hesitant to do this type of simple release as they have very little experience in treating sling complications. Drs. Miklos and Moore helped develop many of these procedures and have taught surgeons all over the world (Dr. Miklos was one of the first three surgeons in the US to complete the TVT sling and Dr. Moore did the first MiniArc sling ever in the US, Russia, Finland, Columbia, Chile and India) and with this experience, they also have extensive experience in treating complications and are not hesitant to do so. If a nerve has been irritated in the groin, then this may require the entire sling being removed from the groin as well. Unfortunately, if there is a nerve injury in the groin, the pain may be a chronic problem, even with sling removal. This is especially true if there is a delay in treatment.
If abdominal pain ensues following a TVT type sling (ie TVT, SPARC etc), then again this can be caused by the sling being too tight, or irritating a nerve or muscle abdominally. If conservative therapy is unsuccessful, the TVT sling will need to be removed in its entirety. Again, this is a very advanced and complex procedure and one that most surgeons would recommend be done through a large abdominal incision. Drs. Miklos and Moore will remove the sling with a laparoscopic approach abdominally which is an outpatient procedure with rapid recovery. They actually wrote the first published paper in the world on this technique and their center is one of the only one’s in the US that will do this procedure through a laparoscopic approach.