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The Lowdown on Vaginal Mesh for Prolapse
What choices do women have when their pelvic floor fails?
By Emily Willingham
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It happened to a queen of England, and it will happen to as many as 50 percent of women over the age of 40 today: pelvic or vaginal prolapse, a condition in which the muscles of the pelvic floor weaken so much that they no longer support the organs resting on them. After Queen Victoria’s death, her physician found that she had a prolapsed uterus, which isn’t too surprising considering that the famously fertile queen was the mother of nine children.
“The primary risk factor is childbirth,” says Steve Abramowitch, PhD, assistant professor of bioengineering and obstetrics, gynecology, and reproductive sciences at the University of Pittsburgh. “While most women will not prolapse, the ones who will usually have had one, two, or more children.” He says that vaginal birth bumps up a woman’s risk by four times with the first child. That risk goes up 11 fold by the third vaginal birth.
Other risk factors for pelvic prolapse are obesity and a history of constipation, says Dr. Abramowitch. While lifestyle interventions might help with those, we can’t do much about one of the risks: our genetics.
“You can’t choose your parents, and part of it is genetic,” says Lauren Streicher, MD, associate clinical professor of obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine and Everyday Health columnist. She says that some women even go so far as to try to ask for a cesarean section with their first pregnancies because of a family history of pelvic prolapse. But for women considering a cesarean after they’ve already given birth vaginally? “Don’t bother," she says. "The damage is already done with the first baby.”
One thing any woman can change about her risk for prolapse, says Dr. Streicher, is smoking. “You can’t control baby size and genetics,” she says, “but you can control smoking, and that’s going to be a huge factor.” Although the reasons are not clear, large studies have shown smoking is one of the risk factors, and one we can modify, notes the University of Texas Southwestern Medical Center in Dallas.
For many women, a vaginal delivery is already part of their history. For those who go on to develop prolapse, what can they do?
Support for Women’s Organs After a Prolapse
A temporary, nonsurgical measure is a pessary, a plug that can be inserted into the vagina to keep the prolapsed organs supported. “Some women have success with that, but many patients become a little frustrated with it, because it requires constant insertion and cleaning and it can start to wear against the vaginal wall,” says Abramowitch. But for many patients, this measure is a bridge to having a surgical intervention.
And that’s where the choices become a little tough. One method to keep the organs where they belong is to implant a support that will hold up the organs against the pull of gravity. The two options women have are a synthetic mesh or a repair using their own tissues. Each option carries its own risks, as the legal and medical dramas unfolding around the meshes illustrate.
Pros and Cons of Synthetic Mesh
“The main reason the meshes started to become popular was because many of the native tissue repairs were failing,” says Abramowitch. Tissue repairs of prolapse failed as often as 40 percent of the time, he adds, so that women often had to return for a second surgery. Sometimes, that second surgery isn’t a possibility because the tissue is just too fragile to use for support.
But the meshes, while sturdier, carry the possibility of complications, as with any medical intervention. Abramowitch says reports of mesh complication rates vary. While certain studies suggest a complication rate as high as 30 percent, studies that he characterizes as “better” set the complication rates at 10 to 15 percent. “It’s been a success for a large number of patients,” Abramowitch says. “Unfortunately, with the litigations, it’s scaring patients into believing that mesh is not a viable option now.”
Prolapsed Bladder: A Patient’s Experience With Mesh
One patient who did decide to go ahead with the mesh is 73-year-old Kathryn S. of Stanhope, New Jersey. Kathryn discovered her condition one day while she was in the bathroom. “I remember going, ‘where did this come from?’” she recalls about finding her prolapsed bladder. “I don’t know how to describe it — it was like a little head, it was really soft, and you could push it back up.”
Kathryn started treatment for her prolapse with a pessary while she investigated her other options. She read medical reports online about the procedure and determined that many of the drawbacks were linked to how the device was inserted by the surgeon.
After doing her research, Kathryn decided to go with the transvaginal mesh implant. At a few weeks after her procedure, except for a little expected fatigue, she says, “my experience is all positive.”
She thinks that many women may have her condition but don’t want to talk about it, much less seek help for it. “A woman I work with, she called me the other day,” she relates, “and she said, ‘I get that, too, and I just push it back up.’”
Kathryn turned to Michael Ingber, MD, a urologist at Morristown Medical Center in New Jersey, for her procedure. Ingber specializes in pelvic surgeries, and Kathryn chose him because of his extensive experience.
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Streicher says that when a woman does decide to go the surgery route, seeking clinicians with the right experience is critical. “People really don’t understand that there are plenty of doctors out there who are truly not experienced in the things they say they are,” she says.
What a patient needs to know isn’t a specific number of procedures performed but how routinely a surgeon does the work. “You want to hear ‘I do them every week,’” Streicher says. “Don’t be afraid of offending a doctor by asking about or questioning their experience,” she adds.
Pelvic Mesh Procedures
Two procedures are possible when using mesh to address prolapse, says Dr. Ingber. One involves going through the abdomen, and the other involves implanting the mesh vaginally. The choice of which route to go depends on individual patient factors.
“Every patient is different,” he says. “In a young, sexually active woman who’s maybe 40 years old who’s had a bladder or uterine prolapse, the better procedure is to go in through the abdomen.” For women over age 70, who have a different anatomy and might not be as sexually active, the vaginal route might be preferable because it’s a faster surgery with a quicker recovery.
Kathryn’s surgeon, Ingber, is one of the investigators in a post-marketing surveillance study for a mesh that is currently on the market. These studies are designed to track patients using these marketed products as a way to keep tabs on emergent problems. Kathryn finds her recovery manageable so far. “I think the mesh is a great thing,” she says.
Video: WishTV - Pelvic Organ Prolapse - Indy Style
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