QUESTION

I have pelvic mesh! What should I do now?

ANSWER

Now that the FDA has halted use of transvaginal pelvic mesh for repair of pelvic organ prolapse—stating that the risks of serious health problems outweigh the benefits—women who already have these pelvic mesh implants are understandably concerned. If you have a pelvic mesh implant, you need to talk to your surgeon. What you should do about it depends on how the mesh was surgically put into place.

Pelvic organ prolapse (POP) is caused by muscles, ligaments and connective tissue supporting the pelvic organs becoming damaged, such as through childbirth or injury…or weakening as a result of age and menopause…allowing the uterus, rectum or bladder to drop (prolapse) into the vagina. The usual repair for POP has been to restore anatomy by shoring up the torn ligaments. This is done using sutures…or by surgically implanting permanent (pelvic) mesh, a netlike medical device typically made from polypropylene, to permanently support the torn ligaments and muscles and help hold these organs in place.

The Problem with Mesh Implants

The surgical procedure to repair prolapse can be done using mesh placed either through the vagina or through an abdominal incision. Mesh placed through the vagina carries more risk than mesh placed abdominally for prolapse. Reason: The vaginal approach requires a larger piece of mesh and is placed through incisions made inside the vagina. Mesh placed this way is more likely to lead to infection or contraction, or it and can move out of place and/or damage tissues that attach to it—for instance, it can perforate the vaginal tissues or erode into nearby organs.

In 2018, the FDA decided that surgery using polypropylene mesh was unsafe for repair of rectum prolapse (rectocele). In 2019, the FDA said that synthetic mesh repair of bladder prolapse (cystocele), the most common type of pelvic organ prolapse, was also unsafe—saying that they have not “received sufficient evidence to assure that the probable benefits of these devices outweigh their probable risks” and concluding that “these products do not have reasonable assurance of safety and effectiveness.” The companies that sell the mesh were told to stop.

Note: The FDA action does not apply to surgical mesh slings to support the urethra for stress urinary incontinence or synthetic polypropylene mesh implanted abdominally or with laparoscopic/robotic surgery. No direct incisions are made on the vagina for these procedures, and the mesh used is much smaller and lighter weight compared with transvaginal mesh products

If You Have Pelvic Mesh

If your repair is working and you don’t have any problems, the mesh can stay. But do continue regular check-ups annually with your gynecologist or surgeon. Also be alert to signs of trouble, such as…

  • Vaginal bleeding or discharge
  • Pelvic or groin pain, discomfort or pressure
  • Pain during sexual intercourse
  • Pain for a partner during intercourse (could indicate exposed mesh protruding into the vagina)
  • Frequent urinary tract infections
  • Leaking of urine (incontinence)
  • Bulge inside or protruding from your vagina

If you are having health problems caused by your pelvic mesh, you may need to have it removed and a new POP repair done. This is a challenging procedure and should only be done by a specialist in female pelvic medicine and reconstructive surgery called a urogynecologist. Check the American Urogynecologic Society website to find one near you.

Safer POP Options

If you have been diagnosed with POP but have not had surgery, you should work with a pelvic medicine specialist to determine the most appropriate treatment for you. Surgery is usually not the first option. A specialist may advise…

  • Kegel exercises to strengthen your pelvic muscles
  • A pessary, a soft, flexible device that can be inserted (and removed) into the vagina to support prolapsed organs
  • Losing weight if you are overweight

If you do need surgery, there are options other than using the synthetic mesh. These include transvaginal surgery using your own (native) tissue and sutures…laparoscopic and robotic procedures…abdominal surgery with light-weight mesh mostly attaching to your tailbone…or a new technique that uses incisionless suture devices. Clinical trials are currently under way with new innovations for making grafts using your own tissues or other biologic tissues.