Mesh Complications Patient Story 56
Chronic Vaginal Pain, Discharge, Infection, Mesh Extrusion, and Painful Intercourse following Anterior & Posterior Vaginal Wall Mesh and TOT sling placement
Mesh Complications: Chronic vaginal pain, chronic discharge, low grade temperatures, vaginal bleeding, pain with intercourse, chronic bladder infections, mesh extrusion, pain for spouse with intercourse
Treatment: Vaginal approach to remove the entire anterior and posterior wall mesh and TOT sling
This patient is a 49-year-old female who had a hysterectomy and placement of anterior and posterior wall vaginal mesh (Apogee/Perigee) placed for rectocele, cystocele and vault prolapse. She had this completed in 2009 and has had problems since the surgery. She complained of chronic malodorous vaginal discharge, low grade fevers, recurrent bladder infections, chronic vaginal and pelvic pain, and pain with intercourse. Recently her husband reports painful intercourse, stating he can feel something prickly scratching his penis.
Originally, she was told that the pain after surgery is normal and it will go away, but it did not. She then had a mesh extrusion at her perineum, which they treated in the office and with estrogen cream. She had another mesh extrusion higher in the vagina, which they again treated in the office. She saw a urologist in 2009 that told her there were sutures "Left behind," and they removed these. They did a repeat exam earlier in 2011. She was told nothing was wrong; however, she continued to have the same above symptoms.
Drs. Moore and Miklos evaluated the patient and found large areas of mesh extrusion on the anterior vaginal wall (under the bladder) with malodorous discharge from this erosion. When palpating the mesh arms, which attach the grafts to the levator muscles (arms were under tension and pulling on the muscles), the patient reported intense pain. Most notably, on the right side both anteriorly and posteriorly. She also had pain with palpation of the sling vaginally. She had little pain in the groin and, therefore, we did not feel the mesh would need to be removed from the groin itself. Typically, the mesh in the groin muscle or the arms in the buttock cheeks are not causing the problem usually it is the vaginal portion pulling on the muscles and creating tension that is the problem that needs addressed.
Dr. Moore comment: This is a common problem that can occur with the first generation mesh kits that utilized needle passes through the groin and buttocks and had mesh arms penetrating the levator muscles. If the arms were placed too tight, or tightened over time with healing, this could lead to pain and/or painful intercourse. In this situation, the mesh arm(s) that are causing the issue need to be released or the entire mesh needs to be removed. Newer generation procedures have eliminated these types of needle passes and attachment to the muscles, and there seems to be fewer issues with this type of problem.
Picture 1: The picture shows the posterior wall mesh being dissected free under the vaginal skin.
The patient was taken to surgery, and the entire anterior wall and posterior wall mesh was removed in as well as the vaginal portion of the TOT sling without complication and minimal bleeding. The mesh arms themselves were dissected into their attachments to the levator muscles and removed from the muscle. All tension was removed from the muscles, and the patients own fascia was then utilized to repair any defects that were present. The anterior wall mesh that was chronically exposed was frayed, discolored, and the source of her chronic vaginal discharge and mild infection (see figure 2). The defects in the vaginal walls where the mesh had eroded through were repaired and restored.
Post operatively she recovered well and even immediately post-operatively she could tell a difference in her pain, as the “Pulling” sensation was gone.
Picture 2
Picture 3: Removed Mesh
Picture 4: Removed Mesh
