In recent years, significant attention has been paid to potential complications surrounding surgical mesh and its role in relieving two conditions: pelvic organ prolapse and stress urinary incontinence. The interest has been fueled by class action lawsuits filed by patients who have suffered from complications of the surgery. There are, however, women for whom this surgery can greatly help; understanding the difference between health conditions and the options to treat them is key.
Jonathan Shepherd, M.D., assistant professor of obstetrics, gynecology and reproductive sciences at the University of Pittsburgh, answers questions about urinary incontinence, pelvic organ prolapse and the treatment options for both conditions.
Q. Can you explain the difference between urinary incontinence and pelvic organ prolapse?
Pelvic organ prolapse is experienced when the support structures which hold up pelvic organs fail and women feel a sensation of something bulging or protruding from the vagina. The primary support to the pelvic organs is provided by the vagina. The vagina supports the bladder, uterus, small bowel and rectum. The vagina, in turn, is supported by a complex network of connective tissues (often referred to as ligaments) and muscles. When these structures are injured, which may occur in childbirth or with chronic straining or heavy lifting, the vagina and the organs supported by it fall into the vaginal lumen and sometimes even through the vaginal opening. Prolapse is frequently seen in conjunction with urinary incontinence, but the conditions can occur separately.
Urinary incontinence is generally divided into two main types. The first is stress incontinence where women leak urine with maneuvers such as coughing, laughing, and sneezing or anything else that increases the pressure in the abdominal cavity. Urgency incontinence is leakage associated with a sudden desire to empty the bladder that is difficult to defer. Women with urge incontinence will frequently leak on the way to the bathroom, when keys rattle in the door arriving at home, or when water is running. Frequently, women will have a mixture of these two.
Q. What are the different treatment options for urinary incontinence? Pelvic organ prolapse?
Urgency urinary incontinence is usually treated first with physical therapy, modifying fluid intake, and/or medications. Stress incontinence can be treated with a pessary, which is similar to a diaphragm, physical therapy, or surgically with a midurethral sling. In the latter, a small piece of mesh is inserted below the urethra like a hammock. Despite the controversy over pelvic mesh, the American Urological Association and the American Urogynecologic Society have published position statements reassuring patients that midurethral slings are very safe, well-studied and effective in the treatment of stress incontinence.
Pelvic organ prolapse has many treatments as well. Physical therapy, pessaries and observation are conservative options in women who are not eligible or choose not to proceed with surgery. Surgical management has multiple approaches as well. The type of operation we recommend is specific to each patient’s specific anatomical defects and the goals she hopes to achieve as a result of the surgery.
Q. Transvaginal surgical mesh has been in the news a lot lately, and there are several class action lawsuits filed against the makers of certain types of mesh. What are some of the risks and complications of mesh procedures?
The FDA released notifications in 2001 and 2008 regarding pelvic meshes. It is important to point out that this notification is centered on prolapse meshes that are delivered transvaginally but also includes incontinence meshes which are delivered through the vagina. The most common mesh complication occurs when the mesh protrudes into the vagina and causes pain because the mesh is tensioned too tightly or it folds or buckles on itself after insertion. Less common complications include mesh erosion into the bladder, urethra, rectum, or other organs and infection. All complications can results in pelvic pain, bleeding, recurrent infections, vaginal discharge, and pain with intercourse. It is important for women to recognize that complications tend to be lower in surgeons who are familiar with mesh and pelvic floor anatomy. Therefore, women with incontinence and prolapse should make sure that if they have surgery it is performed by an experienced specialist.
Q. When would the benefits of a surgical mesh procedure outweigh the potential complications?
Mesh has been shown to improve the strength of the surgical repair so that prolapse is less likely to come back. The benefit depends on where the prolapse is located. Benefits are greatest when the prolapse involves the wall of the vagina that supports the bladder. There may still be a benefit when the prolapse is at the top of the vagina or at the uterus. Prolapse impacting the wall of the vagina that supports the small bowel and rectum is less likely to be improved by using mesh. This is why we do a thorough exam to determine a patient’s exact anatomy before making recommendations. We use this information to help them choose the most appropriate surgery.
Q. What do you believe is most important to keep in mind for women suffering from urinary complications?
Not all cases of urinary incontinence require surgery. However, for stress incontinence, when nonsurgical management has been unsuccessful, there are safe and effective surgical options available. I would hate to think that the recent barrage of commercials against mesh would mean women are avoiding a surgery which has success and satisfaction rates up to 95 percent and very low complication rates.
It’s also important to realize that not all cases of urinary incontinence are managed with surgery. Many women actually have another form of incontinence, urgency urinary incontinence, which will frequently respond to a daily pill. Most of my practice is aimed at improving quality of life for women related to prolapse and incontinence. Women should not continue to suffer due to fears which may not apply to them. In many cases we can help without using any mesh. In others, the mesh is much safer than women think. In any case, it’s probably at least worth coming in to have the conversation.
Jonathan Shepherd, M.D., is a board certified in Gynecology and Female Pelvic Medicine and Reconstructive Surgery. He has a master’s degree in clinical research and has published over 30 manuscripts relating to pelvic organ prolapse and incontinence.