Synthetic mesh (type I macroporous monofilament polypropylene) augments native-tissue prolapse repair — the current standard for POP is sacrocolpopexy with mesh suspension to the sacral promontory. Complications, though usually minor, can be difficult to reverse.
Complications
Mesh complications occur in ~10% of patients and may arise from the material, host response, surgical factors, or unknown processes — sometimes months to years later. The Committee on Gynecologic Practice advises counseling on: mesh exposure (1–19%), buttock/groin/pelvic pain (0–18%), de novo dyspareunia (2–28%), and reoperation (1–22%).
Diagnosis and Evaluation
- History/exam — review the prior operative record. Mesh penetration into urethra/bladder presents with hematuria, UTIs, and pain. Retropubic sling arms can injure the ilioinguinal (L1) and genital branch of the genitofemoral nerve (sharp localized pain); obturator arms can injure femorocutaneous, pudendal, perineal, inferior anal, or obturator nerves. Vaginal exposure presents with bleeding, infection, fistula, pain, dyspareunia, organ perforation, obstruction, or dysfunction.
- Imaging: VCUG (obstruction), CT (abscess), MRI (osteitis/osteomyelitis), translabial ultrasound (mesh location/size).
Management
- Expectant — mild voiding dysfunction/discomfort often resolves; asymptomatic exposure without pain or organ dysfunction can be observed. Persistent problems (prolonged voiding dysfunction, obstruction, pain/dyspareunia, erosion into an organ or vaginal exposure, defecatory dysfunction) warrant intervention.
- Medical — antibiotics if infection is suspected; vaginal estrogen for atrophy.
- Surgical — mesh removal improves symptoms in most with severe refractory pain. Counsel that removal carries a ~20% risk of anterior prolapse recurrence and a 30–50% risk of incontinence after sling removal; persistent retention may need urethrolysis.
Self-Test
1. What is the most widely used mesh material and type? Polypropylene — a type I macroporous monofilament mesh.
2. How often do mesh complications occur, and what should patients be counseled about? ~10% — counsel on mesh exposure (1–19%), pain (0–18%), de novo dyspareunia (2–28%), and reoperation (1–22%).
3. What are the risks of mesh removal? ~20% anterior prolapse recurrence and 30–50% incontinence after sling removal.