Surgical Mesh: Use and Complications in Women

What is surgical mesh?

Surgical mesh is a screen-like material that is used as a reinforcement for tissue or bone. It can be made of synthetic polymers or biopolymers.

Materials used for surgical mesh include:

• Non-absorbable synthetic polymers (polypropylene).
• Absorbable synthetic polymers (polyglycolic acid or polycaprolactone).
• Biologic (acellular collagen sourced from cows or pigs).
• Composite (a combination of any of the three previous materials).

Most surgical mesh devices used for female pelvic reconstructive surgery are made of non-absorbable synthetic polypropylene.

For what procedures in women are surgical mesh typically used?

Surgical mesh may be used to help repair pelvic organ prolapse (POP) and stress urinary incontinence (SUI) in women.

In pelvic organ prolapse, the pelvic organs may shift downward and bulge out of the vagina. This occurs in women whose pelvic floor muscles and tissue are too weak to hold the organs in place.

Pelvic organs that may be subject to a prolapse include the bladder, uterus, rectum, vagina and urethra. Factors that can increase the chance of POP in women include pregnancy, childbirth and aging. The bladder is most often involved in pelvic organ prolapse. Prolapse of the bladder is called cystocele.

In stress urinary incontinence certain activities that increase pressure on the abdomen can cause urine to leak. These activities can include coughing, laughing, sneezing or exercising. The weakening of the pelvic muscles and tissues causes the bladder neck to move downward. As with pelvic organ prolapse, factors such as pregnancy, childbirth and aging may cause the pelvic muscles to stretch or weaken.

How is surgical mesh used to repair pelvic organ prolapse and stress urinary incontinence?

Surgical mesh can be permanently implanted to reinforce the vaginal wall for POP repair, or support the urethra or bladder neck for the repair of SUI.

There are three main surgical procedures performed using surgical mesh:

• Transvaginal insertion of mesh to treat POP.
• Transabdominal insertion of mesh to treat POP.
• Mesh sling to treat SUI: A multi-incision sling procedure may be performed in which three incisions (cuts) are made. In the retropubic procedure, two very small incisions are made above the pubic bone and a third incision is made in the vagina. In the transobturator procedure, two very small incisions are made in the groin and thigh and one is made in the vagina. A mini-sling procedure, in which a shorter piece of surgical mesh is inserted, requires only one incision.

POP can also be repaired without surgical mesh. In that case, the incisions are usually made in the vagina, and they are closed with sutures only. Surgeries in which mesh slings are used have been successful in most cases and in about 70% to 80% of cases within one year following surgery.

SUI may also be surgically treated without surgical mesh. The surgeon can harvest a piece of your own muscle fascia to use in the shape of a sling to reestablish support of the bladder and urethra. In that case, fascia may be taken from your abdominal muscles through a C-section “bikini” incision, or from your leg muscles with an incision on the inner thigh.

How common is the use of surgical mesh to repair pelvic organ prolapse and stress urinary incontinence?

About 300,000 women in the United States underwent surgery to repair POP in 2010. Surgical mesh was used in about one out of three procedures. About 250,000 women in the U.S. underwent surgery to repair SUI in 2010, with mesh placement being used in over 80% of the procedures. The mesh sling has been the most widely studied procedure for stress incontinence in the history of stress incontinence surgery. All of the major urologic and gynecologic societies in the U.S. have supported its continued use as of 2019.

What are complications associated with surgical mesh devices for pelvic organ prolapse and stress urinary incontinence repair?

• Vaginal mesh erosion: This is the most common complication following the use of surgical mesh devices to repair pelvic organ prolapse and stress urinary incontinence. Non-absorbable synthetic surgical mesh, such as that made of polypropylene or polyester, can break down or wear away over time. Part of the mesh may become exposed or protrude through the vagina.
• Erosion of mesh into other organs: Less commonly, the mesh may erode into the urethra, bladder or rectum.
• Vaginal mesh contraction: Shortening or tightening of the mesh over time can cause vaginal shortening, tightening or pain.
• Pain during sexual intercourse.
• Urinary problems.
• Infections.
• Bleeding.
• Pelvic organ prolapse that returns.
• Emotional problems.

Surgery may be needed to remove the mesh or correct other complications as they can occur at times after mesh placement, although the overall incidence is rare. Over 50% of women who experienced erosion with non-absorbable synthetic mesh needed to have the mesh surgically removed. Some patients required two or more operations after the mesh was removed.

It’s important to know that the risks related to surgical mesh are different with various mesh-based repairs:

1. Mesh sling for SUI: The average rate of mesh erosion following SUI sling surgery is about 2% after one year. The U.S. Food and Drug Administration (FDA) has stated that polypropylene slings are safe and effective in the treatment of SUI as of 2019. However, erosion may sometimes be treated with vaginal cream or by removing part of the exposed mesh in a doctor’s office. In other cases, the mesh must be surgically removed.
2. Sacrocolpopexy: This is suspension of the top of the vagina to the inside of the tailbone using a strip of mesh. The average rate of mesh erosion following mesh sacrocolpopexy ranges from 1.9% - 5%. As with slings, the FDA has stated that mesh use for sacrocolpopexy is safe and effective as of 2019. However, erosion may sometimes be treated with vaginal cream or by removing part of the exposed mesh in a doctor’s office. In other cases, the mesh must be surgically removed.
3. Transvaginal mesh: As of April 2019, the FDA has banned the use of transvaginal mesh (placement of mesh through the vagina) for treatment of POP. This action was taken due to a significant increase in reported negative effects associated with use of this type of mesh.

Negative effects following surgery can be life-changing for some women. Pain may persist even after the mesh is removed.

What are recommendations for women considering surgery for pelvic organ prolapse?

Consider various options regarding POP treatment, including non-surgical methods and suture-based methods that don’t use mesh, as they have been shown to be very effective in the long term without some of the complications associated with mesh use.

Surgery may be performed with or without the use of surgical mesh. Use of mesh may increase the risk of subsequent surgeries due to complications involving the mesh. In a small percentage of patients, additional surgeries might not solve all medical problems. However, surgical treatment with mesh may offer a more durable repair of the prolapse than non-mesh surgeries. Consult a specialist in this area as experience does help in determining the best course of management.

What are the recommendations for me if I have undergone pelvic reconstructive surgery?

You should follow up with routine check-ups and pelvic examinations each year. Let your healthcare provider know if you have symptoms such as vaginal bleeding or discharge, pelvic or groin pain, or pain during sexual intercourse. Tell your doctor about any surgical mesh implants if you plan to have surgery to treat a related condition or another type of operation. Talk to your provider if you have any questions or concerns.