There are multiple surgical and nonsurgical approaches for treating pelvic organ prolapse (POP), and deciding which one best fits a given patient is often based on care provider preference and experience with certain techniques. With POP stages >2, marked by the vaginal wall protruding to varying degrees through the vaginal opening, many urogynecologists intervene surgically.
“In addition to conventional colporrhaphy, transvaginal mesh-based repairs had gained acceptance as a treatment option for POP over the last ten years, only to see the pendulum swing the other way secondary to fanfare surrounding postoperative complications,” explains Matthew Davies, M.D., of Penn State Hershey Obstetrics and Gynecology.
The Food and Drug Administration (FDA) issued a safety warning for mesh repair of POP, noting that mesh erosion is the most common complication, potentially requiring hospitalization and secondary re-operation.
“In addition to the risk for erosion, another complication seen with mesh-based repair is dyspareunia; unlike erosion or infection, dyspareunia may not resolve when the mesh is explanted and may be permanent. Because of these reported risks, many patients with POP are fearful and refuse to undergo a mesh-based repair,” says Davies.
To identify pre-operative factors linked to erosion, Davies and his colleagues at Penn State Hershey conducted a large retrospective review of 200 POP cases repaired with macroporous synthetic mesh over a period of five years.1
“Overall, 7.8 percent of the patients experienced erosion. To our surprise, hypertension significantly decreased the risk of erosion. Other factors we examined showed a statistically significant increase in the risk of erosion including smoking and undergoing hysterectomy at the same time as the mesh-based repair.” With such evidence, Davies has been performing robotically-assisted laparoscopic mesh-based repairs since 2009. Data published in 2013, however, showed success and complications by this method are not much different than with transvaginal placement.
These findings highlight the difficulty in identifying patients at high risk prior to surgery. Davies observes, “I base the decision of how to treat POP on considerations such as the patient’s age, if she is sexually active, if she is a smoker, which impacts post-operative healing, and whether there is a history of prior repairs. If one or a combination of these factors is present, I consider using an absorbable mesh, or more likely a conventional, non-mesh repair.
While looking at the published evidence is helpful, each surgeon needs to be keenly aware of his or her own track record with a given technique or device; how well does that technique perform in his or her hands? Ultimately, while we can present options, opinions, and information, the patient determines what course is chosen.”
A range of other treatment options are available for patients with less severe POP that does not yet warrant surgery, such as Kegel exercises, physical therapy, a pessary, and biofeedback treatment. These treatments aim to strengthen the pelvic floor, normalize pelvic floor muscle activity (both relaxation and contraction), and help slow POP progression
|Matthew F. Davies, M.D., FACOG
Chief, Female Pelvic Medicine and Reconstructive Surgery
Penn State Hershey Obstetrics and GynecologyPHONE: 717-531-3503
RESIDENCY & INTERNSHIP: OB/GYN, Penn State Milton S. Hershey Medical Center
MEDICAL SCHOOL: Penn State College of Medicine
BOARD CERTIFICATION: Female Pelvic Medicine and Reconstructive Surgery
1 Deimling T, Davies M, Harkins GJ. Pre-Operative Risk Factors for Mesh Erosion in Patients Undergoing Anterior/Apical Vaginal Prolapse Repair–A Retrospective Analysis. Poster Presentation at American Urogynecologic Society Annual Meeting: Chicago, IL, October 3–6, 2012.