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Sometimes the cure for pelvic organ prolapse is worse than the condition

Doctors look at other options for treatment of pelvic organ prolapse
Kim Kyle Morga, Houston Chronicle
Updated 1:52 pm, Sunday, March 24, 2013

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  • Dr. Benjamin Dillon of Kelsey-Seybold Clinic corrects vaginal mesh problems after prolapse/pelvic surgeries. Photo: Eric Kayne / © 2013 Eric Kayne
    Dr. Benjamin Dillon of Kelsey-Seybold Clinic corrects vaginal mesh problems after prolapse/pelvic surgeries. Photo: Eric Kayne

 

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Prolapse repair

Graft: Typically made from human or animal tissue, promotes scar tissue formation, dissolves over time

Mesh: Nonabsorbent material, bolsters scar tissue formation to enhance longevity

The American College of Obstetricians and Gynecologists and the American Urogynecologic Society's recommendations on vaginally placed mesh implants:

A Development of a surveillance registry for current and future patients

A Comparative effectiveness trials of synthetic mesh versus native tissue repair

A Limiting use to high-risk women for whom the benefit may justify the risk

Information:

www.voicesforpfd.org

www.acog.org/For_Patients/Patient_Education_Videos/Pelvic_Organ_Prolapse

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It's a fact of life for some 3.3 million women in the United States, and each year about 350,000 of them will undergo surgery to rid themselves of the pelvic pressure, lower back pain and urinary incontinence associated with pelvic organ prolapse.

But for some, the cure seems worse than the condition, particularly if the surgery involved vaginal placement of mesh. Used to bolster scar tissue formation, mesh is made of a nonabsorbent material and is said to provide better support for prolapse than stitching or tissue grafts.

In some cases, migrating mesh results in chronic pelvic pain and painful intercourse, meaning a second trip to the operating room.

"The biggest problem with mesh is erosion or extrusion," said Dr. Benjamin Dillon, a urologist trained in female pelvic medicine and pelvic reconstructive surgery at Kelsey-Seybold Clinic. "Extrusion is when the mesh comes through the walls of the vagina; erosion is when the mesh erodes into surrounding tissue."

Surgical approaches to remove the mesh depend on the location of the erosion but can be quite invasive, requiring an abdominal incision similar to a C-section incision and reconstruction of surrounding structures.

If the mesh has eroded into the bladder or urethra, there's an easier fix via laser. Dillon said the surgery takes only an hour or two, and women are able to go home shortly after.

"The thermal energy of the laser melts the mesh fibers, and then we just irrigate or wash it out of the bladder, avoiding the need for reconstructive surgery of the urethra," Dillon said.

Dillon has been performing this laser repair for more than a year now, after honing the procedure in Dallas at the University of Texas Southwestern Medical Center with urologists Dr. Gary Lemack and Dr. Philippe Zimmern.

While the procedure is indeed less invasive, it's similar to traditional surgeries in that there's no guarantee the remaining mesh won't migrate. "You never take out the entire mesh," Dillon said. "You just take out the offending portion."

In 2008, the FDA issued its first notice against vaginal mesh kits for prolapse repair, stating that although it was rare, there were reports of complications. In 2011, a new notice came out stating that complications were more common than initially thought - although only if the mesh is placed vaginally instead of laparoscopically or abdominally.

Dr. Peter Lotze, a clinical assistant professor in the department of obstetrics and gynecology in the division of uro-gynecology at the University of Texas-Houston, wants women to know that surgery for prolapse isn't always the only or best option.

"Prolapse is not life threatening - it's a quality-of-life issue, which means there's time to investigate all options," Lotze said. "Women tend to believe that if they don't rush out and fix it right now, it's going to get worse, but that's not entirely true."

For mild prolapse that is not bothersome or emotionally distressing, Lotze recommends simply observing the situation to see if it progresses. Kegel exercises performed properly also can be beneficial in mild cases. "If you look down and see a bulge out of the vagina, kegels will not help," he said.

For moderate cases, a vaginal pessary may help. Pessaries are removable, diaphragmlike devices that come in a variety of types and sizes to support the vagina and uterus. If properly fitted by a gynecologist, women shouldn't even feel the pessary, Lotze said. Pessaries can be worn continuously or only when a woman feels it's warranted, such as while exercising. Many women who use pessaries don't wear one while sleeping, since, thanks to gravity, prolapse tends to be worse while standing.

Sometimes surgery is required. "Literature supports the thought that if women choose to do nothing, there's a chance things will progress - but there's a greater chance things will not progress," Lotze said. "The flip side of this is that if the bulge does progress, it becomes harder to fix with one surgery. In other words, success rates drop."

According to the National Association For Continence, one in five women will go through prolapse surgery in her lifetime. NACF, a national, nonprofit organization, estimates that the number of women undergoing surgery to treat pelvic organ prolapse will increase by 48 percent between 2010 and 2050. Furthermore, 27 percent will have repeat surgery.

Women considering surgery for prolapse should ask their surgeon if mesh or a tissue graft will be required. "It's been shown in numerous well-designed trials that mesh is often superior to simply using just stitches to fix prolapse or stress incontinence," Lotze said.

Kim Kyle Morgan is a freelance writer in Tomball. Contact her at kim@kimkylemorgan.com