Pelvic Mesh Implants: Issues at a Physical and Psychological Level

In this second article related to pelvic mesh implants, Dr Ivan Ramos-Galvez, discusses the physical and psychological issues that can arise following surgery for pelvic mesh implants. In his first article on the topic Dr Ramos-Galvez explored the medicolegal challenges of pelvic mesh surgery.

Since their development, pelvic mesh implants have become the standard treatment for pelvic organ prolapse and stress urinary incontinence. For the majority of women, surgery is successful, symptoms abate and there is a marked improvement in their quality of life. However, complications following mesh implant surgery occur in around 5% of women, although the proportion varies depending on the condition treated and the method used to insert the mesh. While some issues are apparent immediately after surgery, others may not develop until many years later.

New-onset pain is the most commonly reported complication following pelvic mesh implantation, occurring in up to 30% of women in the year following surgery. Usually, this pain is centred around the pelvis, but some women complain of pain in other areas, including the groin, hip and leg. Risk factors include younger age, poor general health and existing conditions such as fibromyalgia. Often this pain is mistaken for endometriosis, particularly if the patient has previously suffered from this condition, and it can be years before an association is made between the pain and the implant. Muscle spasms in the pelvic floor are a possible cause of this pain, but there is little research into this issue and effective management strategies are lacking. Entrapment of the pudendal nerve, which can also lead to chronic pelvic pain, also frequently follows pelvic mesh implant surgery. Infections, which may become chronic, are another possible cause of pain. There have even been reports of women dying from sepsis caused by unresolved infections arising from pelvic mesh implantation.

Around one-third of the reported complications do not appear to be directly related to the use of pelvic mesh and include symptoms such as runny nose, muscle pain, ‘brain fog’ and lethargy. These side effects are more systemic in nature and may occur as the result of a chronic inflammatory state within the body. Their link to pelvic mesh implantation is suggested by the fact that many women report that these symptoms resolve after removal of their implant.

Although rare, organ perforation is one of the most serious complications associated with the use of pelvic mesh implants, due to the risk of infection and organ damage. As the mesh erodes through body tissues, perforation of the bladder, urethra, bowel or rectum may occur. While subsequent infections can usually be controlled with antibiotics, in order to fully alleviate symptoms, removal of the mesh may be required, but this can be difficult where it is embedded into surrounding tissues. Complete removal may require numerous operations and reconstruction of severely damaged tissues, some of which may be beyond the point of repair. Excessive scarring from chronic inflammation can leave some women with a dysfunctional bladder, urethra or vagina. If the mesh can be successfully removed, the overwhelming majority of women report the resolution of their pain symptoms. However, up to a quarter of women never recover and it can be very difficult for doctors to manage the symptoms reported by these patients. The likelihood of recovery is not linked to characteristics of the individual woman or the type of revision surgery, making it hard to predict the success of this type of surgery.

Many women report some degree of sexual dysfunction due to complications following pelvic mesh implantation. However, as studies have tended to focus on anatomical rather than functional outcomes, it is difficult to gauge the true extent of the problem. Current evidence suggests that among women with complications arising from pelvic mesh implants, only around half are sexually active and around 20% of those report pain during sex. Sexual function is dependent on several factors, including body image and physical function, and even when physical problems have been treated, psychological factors may still impact negatively on various aspects of sexual function. If sex is painful or difficult, the resulting loss of intimacy can place an enormous strain on close relationships.

Perhaps not surprisingly, living day-to-day with the consequences of pelvic mesh implant complications can have a significant effect on the wellbeing of the patient. Women’s experiences tend to follow one of three courses: a downward spiral of health problems, anxiety and depression; acceptance by a previously healthy woman that she is now unhealthy, followed by adjustment to this new status; or, for some, a more or less complete return to health. For those who do not recover, reports of psychological symptoms, ranging from depression to feelings of despair and hopelessness, are common. Some even have suicidal thoughts or engage in self-harm, and many women feel abandoned by the medical profession. Continuing with daily activities, including work, can be impossible and previously active women become more and more sedentary. Clearly, this has the potential to impact every aspect of a woman’s life.

For many women, pelvic mesh implants help to alleviate troublesome symptoms and restore their quality of life. However, for the minority who go on to experience side effects, the consequences can be devastating. The effects are not limited to physical symptoms, but can also have psychological, social and financial consequences. It is important that the medical profession recognises this and develops treatments that cover all aspects of pelvic mesh complications.

About Dr Ramos-Galvez

Dr Ivan Ramos-Galvez, Consultant in Pain Medicine, works at the Royal Berkshire Hospital, with a private practice at Spire Dunedin and Circle Hospitals in Reading.

After extensive training in spinal surgery at the Oxford Deanery, he undertook further specialisation in pain medicine. His understanding of the interactions between these complex areas of medicine means he is often called upon to provide an opinion within his clinical practice or as an expert witness where spinal surgery has led to complications.

His range of expertise with regards pain is widespread and his particular areas of expertise include, but are not limited to:

• Complex Regional Pain Syndrome (CRPS)
• Fibromyalgia
• Spinal Pain
• Chronic and chronic widespread pain
• Chronic Pain Syndromes
• Neuropathic pain
• Pelvic Mesh Pain
• Phantom limb pain and Post Mastectomy Pain Syndrome
• Multi-disciplinary pain management

Further reading:

Dunn, G. E., Hansen, B. L., Egger, M. J., Nygaard, I., Sanchez-Birkhead, A. C., Hsu, Y., & Clark, L. (2014). Changed women: the long-term impact of vaginal mesh complications. Female pelvic medicine & reconstructive surgery, 20(3), 131–136. https://doi.org/10.1097/SPV.0000000000000083

Geller, E. J., Babb, E., Nackley, A. G., & Zolnoun, D. (2017). Incidence and Risk Factors for Pelvic Pain After Mesh Implant Surgery for the Treatment of Pelvic Floor Disorders. Journal of minimally invasive gynecology, 24(1), 67–73. https://doi.org/10.1016/j.jmig.2016.10.001