Jessica M. DeLong, MD
Kurt A. McCammon, MD, FACS
BASICS
DESCRIPTION
• Mesh erosion is 1 of the major complications of prolapse surgery conducted by transvaginal approach.
• Currently, most common mesh used for pubovaginal sling (PVS) and pelvic organ prolapse (POP) repair is polypropylene mesh
• Most sling erosions diagnosed 1–18 mo postoperatively (mean 9 mo)
• Most common and consistently reported mesh-related complication for POP (1)
• May occur in isolation or in combination with urethral or bladder erosion
• Note: More specific term may be “vaginal extrusion”
EPIDEMIOLOGY
Incidence
• 0.012–23% for midurethral slings; varies widely in literature (2)
• Wide variation with POP repair as well
– Attributed to type of synthetic material used
– Older synthetic materials had higher risk of extrusion due to intrinsic properties
Prevalence
• Unknown; increasing over time with increasing use of mesh
• Likely underreported
RISK FACTORS
• Patient factors
– Estrogen deficiency
– History of local radiation
– Early resumption of intercourse
• Operative factors
– Use of tightly woven, large-diameter mesh
– Excessive sling tension or mesh too loose
– Perforation of urethra or bladder
– Inadequate vaginal closure
– Superficial mesh placement
Genetics
N/A
PATHOPHYSIOLOGY
• Not completely understood. Theories:
– Subclinical infection
– Poor wound healing
– Iatrogenic injury/technical error (3)
ASSOCIATED CONDITIONS
• Stress incontinence
• POP
• Cystocele
GENERAL PREVENTION
• Perform intraoperative cystoscopy to minimize risk of urinary tract erosion
• Appropriate patient selection
• Rigorous surgical technique
ALERT
Be familiar with FDA warnings regarding risks of intravaginal mesh & counsel patients appropriately.
DIAGNOSIS
HISTORY
• Determine timing, details of initial surgical procedure and type of mesh used
• Patients often present with storage symptoms, vaginal discharge, pelvic pain/dyspareunia, UTI
• May complain of de novo lower urinary tract symptoms (LUTS)
• Delay in presentation is common
• Sexual activity/sexual function
PHYSICAL EXAM
• Pelvic exam
– Localize sites of pain
– Palpate for exposed mesh
– Note discharge, if present
• Abdominal exam
– Assess for tenderness, suprapubic pain if retropubic sling placed
DIAGNOSTIC TESTS & INTERPRETATION
Lab
Urine analysis
Imaging
Usually not indicated
Diagnostic Procedures/Surgery
• Cystoscopy
– Perform if concern for urethral or bladder involvement
• Urodynamics may be of value to assess lower urinary tract function
• Check PVR if concern for retention
Pathologic Findings
Inflammation, fibrosis
DIFFERENTIAL DIAGNOSIS
• Urethral mesh erosion
• Bladder mesh erosion
• UTI
TREATMENT
GENERAL MEASURES
• In general treatment is divided into:
– Conservative
– Surgical
• Some patients may be observed with reasonable success
MEDICATION
First Line
• Culture specific antibiotic course if UTI present
• Vaginal estrogen cream
– May be effective for small erosions
– Apply small amount to tip of index finger, apply vaginally 2–3 times/wk
Contraindicated if history of deep venous thrombosis (DVT), estrogen-responsive cancer
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Transvaginal excision
– Only exposed mesh vs. entire mesh
• Primary reapproximation of tissue over exposed mesh (4)
• Martius flap interposition at the discretion of the surgeon
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Unclear in literature
– Recurrent SUI is common and may be alleviated by repeat PVS placement
Generally autologous material preferred
– Pain may not be corrected with mesh removal
• Expectant management may be successful in up to 42% of patients
• However, a recent multicenter review of the topic indicated that the majority of women who present for management of synthetic mesh complication after POP or SUI surgery have severe complications that require surgical intervention, with a significant proportion requiring >1 surgical procedure (5).
COMPLICATIONS
• Voiding dysfunction after surgical management of synthetic sling erosion is common (3)
• Sexual dysfunction, male and female dyspareunia
• Persistent pain
• Vesicovaginal fistula formation
• Recurrent stress urinary incontinence (SUI)
– Can place 2nd pubo vaginal sling (PVS)
FOLLOW-UP
Patient Monitoring
• Depends upon treatment
– If patient observed, will need follow-up exams
– If mesh excised, patient should return if bothersome symptoms
Patient Resources
www.fda.gov—health notification regarding use of surgical mesh for POP and SUI
REFERENCES
1. U.S. Food and Drug Administration. FDA safety communication:UPDATE on serious complications associated with transvaginal placement of surgical mesh for pelvic organ prolapse. Available at: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm262435.htm (Accessed July 12, 2014)
2. AUA guidelines: Guideline for the surgical management of female stress urinary incontinence: Update(2009). Available at: http://www.auanet.org/education/guidelines/incontinence.cfm (Accessed July 12, 2014)
3. Starkman JS, Wolter C, Gomelsky A, et al. Voiding dysfunction following removal of eroded synthetic mid urethral slings. J Urol. 2006;176:1040–1044.
4. Giri SK, Narasimhulu G, Flood HD, et al. Management of vaginal extrusion after tension-free vaginal tape procedure for urodynamic stress incontinence. Urology. 2007;69:1077–1080.
5. Abbott S, Unger CA, Evans JM, etal. Evaluation and management of complications from synthetic mesh after pelvic reconstructive surgery: A multi-center study. Am J Obstet Gynecol. 2013 Oct 11. pii: S0002-9378(13)01065-X. doi: 10.1016/j.ajog.2013.10.012. [Epub ahead of print]
ADDITIONAL READING
• Dmochowski RR, Blaivas JM, Gormley EA, et al. Update of AUA guideline on the surgical management of female stress urinary incontinence. J Urol. 2010;183(5):1906–1914.
• Dmochowski RR, Padmanabhan P, Scarpero HM. Slings: Autologous, biologic, synthetic and midurethral. In: Wein AJ, Kavoussi LR, Novick AC, et al., eds.Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Saunders; 2011.
• Mohr S, Kuhn P, Mueller MD, et al. Painful love-”hispareunia” after sling erosion of the female partner. J Sex Med. 2011;8(6):1740–1746.
See Also (Topic, Algorithm, Media)
• Hispareunia
• Pelvic Organ Prolapse (Cystocele and Enterocele)
• Stress Urinary Incontinence, Female
• Urethral Discharge
• Urethral Sling, Indications and Anatomic Positions
• Urethral Sling, Materials
• Vaginal Mesh Erosion Image 
CODES
ICD9
• 599.84 Other specified disorders of urethra
• 629.31 Erosion of implanted vaginal mesh and other prosthetic materials to surrounding organ or tissue
• 996.39 Other mechanical complication of genitourinary device, implant, and graft
ICD10
• N36.8 Other specified disorders of urethra
• T83.711A Erosion of implnt vag prstht mtrl to surrnd org/tiss, init
• T85.628A Displacement of other specified internal prosthetic devices, implants and grafts, initial encounter
CLINICAL/SURGICAL PEARLS
• Erosion commonly presents with vaginal discharge, discomfort; urgency, urge urinary incontinence, and irritative voiding symptoms.
• Preoperative counseling is key; inform patients about risks and benefits of mesh use.
• Good physical exam is key to early detection.