Vaginal Mesh Exposure Presentation, Evaluation, and Management

According to FDA, in 2010, approximately 300,000 women underwent surgical procedures in the USA to repair pelvic organ prolapse and approximately 260,000 underwent surgical procedures to repair stress urinary incontinence. From 560,000 surgeries, synthetic mesh was used in one out of three, and three out of four were performed transvaginally. The incorporation of mesh into pelvic organ prolapse repair has improved the long-term surgical anatomical outcomes and lower recurrence rates. However, vaginal mesh placement is associated with risks such as vaginal mesh erosion, exposure, and infection.

The main objectives of this study were to review the literature regarding vaginal mesh exposure and, based on the literature evidences, develop an algorithm to help urologists and gynecologists to promptly recognize the problem and treat it effectively with minimal additional morbidity.

Diabetes mellitus, advanced age, smoking, concomitant hysterectomy, surgeon's experience, surgical technique, and proper training in pelvic organ reconstructive procedures have all been shown to be risk factors for vaginal mesh exposure. The clinical presentation of mesh exposure varies and the management depends upon the extent and location of exposure, associated patient bother, voiding complaints, and involvement of adjacent viscera if any. Once vaginal mesh exposure is diagnosed, it would be pragmatic to rule out simultaneous perforation/erosion into the bladder/urethra or bowel and associated collection if any.

The exponential increase in the number of mesh-related complications is related mainly to a lack of surgeon's experience and proper training in reconstructive pelvic surgeries as well as availability of easy-to-handle kits. Despite improvements in short- and long-term outcomes since the introduction of mesh in pelvic surgeries, the incidence of post-operative complications remains elevated. We developed an algorithm to facilitate prompt recognition and treatment of vaginal mesh exposure aiming to help urologists and gynecologists to achieve better outcomes and success rates.