≡ Menu

Incontinence & Prolapse – Part 2:
The Strengths and Limitations of Incontinence Surgery

Have you ever sneezed and felt a small amount of urine spurt out (or something worse?!) Do you ever feel the urge to urinate or defecate, and then suddenly can’t wait or control it? Beyond incontinence, you may be suffering from vaginal or pelvic organ prolapse. If you’re exploring medical solutions or have been considering surgery, this article is for you.

Woman upset because of incontinence

Scope of the Problem

Over half of women develop incontinence of urine, gas, or other symptoms of pelvic organ prolapse (POP) during their lifetime.

Pelvic organ prolapse is a general term used to describe the “falling” of the vagina, bladder, rectum, and uterus. Prolapse is when the bladder and rectum bulge into the vagina and fall downward toward the floor (if you’re standing).

You may first experience prolapse symptoms such as leaking gas or urine, as early as your twenties or thirties. Other symptoms include difficulty emptying a bowel movement, needing to press with a finger in the vagina to empty a bowel movement (also called digital defecation), low back pain, and a sensation of something falling out of the vagina.

Most of us start needing treatment for incontinence by our early to mid-fifties. Many women report experiencing symptoms for years or decades before seeking treatment.

Incontinence Surgery Statistics

  • 400,000 = number of incontinence surgeries per year in the United States
  • $26.9 billion (2005 dollars) = annual societal costs of incontinence (includes costs for treating, e.g. surgery, and managing, e.g. pads).
  • 11.1% = your lifetime risk of undergoing incontinence surgery
  • 29% = the re-operation rate for women with prior incontinence surgery (i.e. nearly 1/3 of incontinence surgeries fail to the extent women seek re-operation); some studies report as high as an 80% failure rate at three years of follow-up
  • $751/year = annual cost (in 2006 dollars) for absorbent pads, laundry, related expenses

Prolapse (falling) of the uterus, bladder, vagina, and rectum is often the result of multiple factors:

  • years of trauma (from pregnancy/birth),
  • prior pelvic surgery (e.g. hysterectomy)*
  • aging of the vaginal tissues, loss of estrogen to the tissues, weakening of the vaginal support structures
  • weight gain (overweight/obesity quadruples the risk for incontinence)*
  • smoking*
  • chronic lung disease*
  • failure to adequately exercise the pelvic support muscles*

*These conditions can be treated or modified to reduce prolapse.

Traditional Prolapse Surgery

Traditional prolapse surgery is a little like taking in a large pair of pants. It involves “plicating” or folding over stretched-out vaginal connective tissue and muscle to thicken and reinforce it; and to cinch in extra space.

Unfortunately, traditional prolapse surgeries often fail because the tissue is already damaged, stretched, weakened, thinned, or is no longer supplied with nerves (“de-innervated”) due to a previous pregnancy, advanced age, or weight gain.

Modern Surgery Using Mesh to Correct Incontinence

Because traditional prolapse surgery doesn’t work so well, medical researchers developed mesh in an attempt to apply the principles of hernia repair to female vaginal prolapse. It’s a good concept—except that the vagina is very different from the abdominal wall. The skin and underlying muscles of the vagina are much thinner than stomach muscles and are not made from tissue with the same strength and durability as the abdominal wall.

Most modern incontinence surgery involves placing a supportive mesh tape or “sling” under the urethra to help the urethra close during a cough or sneeze. The short-term success rate for this particular incontinence surgery is high — about 90% of women clear up their incontinence with this procedure. However, nearly one third of women who undergo incontinence surgery require re-operation for the problem within 10 years.

Some of this failure can be attributed to patient weight gain after the incontinence surgery. Weight gain contributes significantly to the problem of incontinence, and to the failure of incontinence surgeries. It makes sense: extra weight makes already weak muscles weaker – just the opposite of what we need to reduce incontinence!

Mesh does not solve the problem of weak tissue.

The hitch with mesh is that your vagina is a completely different environment than your abdominal wall, as we already saw. The vaginal skin is thin, is not buffered by fat tissue, is more fragile than external skin, and has to contend with more trauma and different bacteria than external skin (e.g. with intercourse, tampons, etc.). The vagina does not have the same type of skeletal muscle just beneath the skin, as does the abdominal wall. Over time, mesh can work its way through the vaginal skin, causing discharge, pain, and sexual dysfunction.

In October 2008 the FDA issued a “Public Health Notification” on “Serious Complications Associated with Transvaginal Placement of Surgical Mesh in Repair of Pelvic Organ Prolapse and Stress Urinary Incontinence.” This report placed a “black box” warning on mesh.

Mesh tape still has a place in correcting stress urinary incontinence: it is very effective with a lower risk of complications than the mesh sheets used for vaginal prolapse. You may be wondering what other solutions are available. Is surgery a sustainable solution or is there ? [link to Incontinence III post]?

What is your experience?

Have you had surgery for incontinence or prolapse?
If so what convinced you to have the surgery (i.e. doctor’s recommendation, research on the Internet, scientific studies, etc.)
Were you satisfied with the surgery? Why or why not?

Be Sociable, Share!

{ 11 comments… add one }

  • Amy February 16, 2011, 10:34 am

    Open any peer reviewed journal written for gynecologists and urologists and it won’t take long to uncover one of the largest controversies concerning women’s health. Synthetic mesh kits for the treatment of urinary incontinence and pelvic organ prolapse has rapidly become a routine procedure in surgical centers and hospitals throughout the United States. The mesh kits are associated with serious complications such as erosion and chronic pain syndromes, reported by some at rates of 53% and 30% respectively1. It is these and other major complications that have fueled a heated debate among pelvic floor specialists, gynecologists and urologists.
    The US department of Health and Human Services released a report on Urologic Diseases in 2004. According to the report nearly three-fourths of adult women report the symptom of urinary incontinence. Additionally 1 in 10 women will undergo surgical intervention for urinary incontinence or pelvic organ prolapse2. Device manufacturers have recognized this as a tremendous opportunity for profits, bombarding the market with synthetic mesh products.
    Many of these products have been approved through the US Food and Drug Administration’s 510(k) process. In 1996, the ProtGen sling was approved after a 90 day study in rats. After high rates of erosion and complications the sling was withdrawn from the market in 1999. The ObTape by Mentor corporation was approved as “equivalent” to the Tension-Free Vaginal Tape made by Ulmsten. Despite these recalls many comprable devices approved by the FDA as “equivalent” remain on the market without undergoing rigorous studies3.
    Although the rates of major complications continue to rise, the media and women devastated by synthetic mesh remain relatively silent. The reticence of women experiencing complications must be understood in context. The experiences of these complications are frequently marginalized by gynecologists and urologists practicing in tertiary care centers and smaller hospitals. Many women are told that such complications are very rare and that they are just incredibly unlucky. Women experiencing chronic pain from synthetic mesh are often told that mesh isn’t causing their pain. These women are frequently referred to general surgeons, physical therapists, orthopedists, psychiatrists and pain clinics. It is unclear if these gynecologists and urologists are oblivious or deliberate in their lack of transparency.
    Another reason for the silence of women experiencing chronic pain is the very personal nature of the complications. Women are conditioned by society to not speak of intractable rectal spasms, mesh eroding through the vagina, urethral pain, excruciating intercourse, groin and buttock pain or of urinary retention and incontinence.
    A significant amount of women will undergo multiple procedures to remove the mesh. Women of privilege may find surgeons experienced in mesh removal by flying across the country and paying the out-of-network fees. Women of fixed incomes or deteriorating health who are unable to travel for surgery end up in a continuing experiment in the hands of inexperienced surgeons lacking the technical capabilities to remove the mesh effectively.
    As many gynecologists and urologists refuse or fail to recognize some mesh complications and patients are referred out, it is unlikely that complications are accurately reported. It is a reasonable assumption that the totality of complications, are grossly underrepresented in the literature. A study in Neurourology and Urodynamics, reports major complications are estimated to occur 20-fold higher than reported12. Others have reported that chronic pain, dyspareunia and erosion commonly occur more than three years postoperatively1. The delay in onset of major complications compromises the accuracy of many studies reporting lower complications as they commonly follow patients for 1 year or less.
    Several experts report rising rates of disabling complications necessitating complete removal of synthetic mesh4,5,6. The delay in onset of complications and failure to report is very likely contributing to the high variability of complications among studies. Reports of chronic pain following sling placement range from 0-30%7.
    In a blistering editorial published in the International Urogynecology Journal, Lewis Wall, M.D. and Douglas Brown, PhD. assert the American College of Obstetrics and Gynecologists unethically altered the practice bulletins, eliminating the word “experimental” in describing the use of these kits without evidence to support that these kits are safe or effective8. Dr. Lawerence, the presiding Vice President of ACOG attempted to defend the revision to the bulletin citing complaints by fellows of ACOG9. Anne M. Weber, M.D, author of the ACOG practice bulletin vehemently opposed the removal of the term “experimental” to describe synthetic mesh kits for the treatment of urinary incontinence and pelvic organ prolapse. She also acknowledged the lack of evidence to support the indiscriminate use of these kits. In what could be a professionally alienating statement she disclosed the real reason for the change in wording. This reason was also published in the International Urogynecology Journal. She disclosed the explanation she received from an ACOG staff member of the Committee on Practice Bulletins. It was explained to her that the committee recognized the wording would possibly deny payments for some physicians10.
    Following the revision to the practice bulletin the US Food and Drug administration released a public health notification in October 2008 about the serious complications. Despite the warning, few women are adequately informed of the unknown long-term safety of these devices or the severe and disabling complications. A systematic review of mesh kits for pelvic organ prolapsed and incontinence between 1950 and 2007 cautions “surgeons should counsel patients that device-related complications that may occur when using these procedures are not rare; most are related to the use of mesh and their management may necessitate surgical intervention under anaesthetic.11”
    As synthetic mesh kits continue to ascend, potentially affecting 1 in 10 women, perhaps history will concur with the opinion of women already devastated by complications. The systemic and indiscriminate use of synthetic mesh kits for the treatment of urinary incontinence and pelvic organ prolapse, is among the most egregious social injustices ever perpetrated by a professional medical organization.

    References
    1) Knight, D., Scott, P., How to treat pelvic organ prolapsed. Australian Doctor. 2010; 23-30 on-line (www.australiandoctor.com) retrieved October, 2010.
    2) Nygaard, I., Thom, D., Calhoun, E., Urinary incontinence in women. Urological Diseases in America. The US Department of Health and Human Services, Public Health Service.
    3) Wall, L., Brown, D. The perils of commercially driven surgical intervention. American Journal of Obstetrics and Gynecology DOI 10.1016/j.ajog.2009.05.031
    4) Baessler, K., Hewson, A., Tunn, R., Schuessler, B., Maher, C. Severe mesh complications following intravaginal slingplasty. Obstetrics and Gynecology. 2005; 106:4:713-716
    5) Ordorico, R., Rodriguez, A., Coste-Delvecchio, F., Hoffman, M., & Lockhart, J.
    Disabling complications with slings for managing female stress urinary incontinence. British Journal of Urology International. 2008; 102, 333-336

    6) Pikaart, D., Miklos, J., Moore, R. Laparoscopic removal of pubovaginal polypropylene
    tension-free tape slings. Journal of the Society of Laparoendoscopic Surgeons. 2006; 10:
    220-225

    7) Rigaud, J., Pothin, P., Labat, J., Riant, T., Guerineau, M., Normand, L., Gleman, P., Robert, R.,Bouchot, O. Functional results after tape removal for chronic pelvic pain following tension-free tape or transobturator tape. Journal of Urology. 2010;184:2:610-615

    8) Lewis, L., Brown, D., Commercial pressures and professional ethics: Troubling revisions to the recent ACOG practice bulletins on surgery for pelvic organ prolapsed. International Urogynecology Journal. 2009;20:765-767

    9) Lawrence, H. Comments on Wall and Brown: Commercial pressures and professional ethics: Troubling revisions to the recent ACOG practice bulletins. International Urogynecology Journal; 2009

    10) Weber, A., Response to Wall and Brown:”Commercial pressures and professional ethics: Troubling revisions to the recent ACOG practice bulletins on surgery for pelvic organ prolapsed. International Urogynecology Journal. 2009;20;1523

    11) Feiner, B., Jelovesek, J., Maher, C., Efficacy and safety of transvaginal mesh kits in the
    treatment of prolapse of the vaginal apex: A systematic review. British Journal of Obstetrics
    and Gynecology ;116:15-24

    12) Deng, D., Rutman, M., Raz, S., Rodriguez, L. Presentation and management of major complications of midurethral slings: Are Complications Under-reported? Neurourology and Urodynamics 26:46-52 (2007)

    13)

    • Shelley Binkley April 4, 2011, 1:39 pm

      It is unfortunate that a lot of this is true.

  • Shelli Christensen April 4, 2011, 10:25 am

    I am one of the many women who have had the MiniArc and am experiencing terrible pelvic pain. My GYN/surgeon has never had a patient with problems and is treating for scar tissue. Can you recommend a surgeon who has successfully removed the mesh? I am hesitant for another surgery but cannot live with pain while sitting, driving, etc. I live in the Portland, OR area. Thank you for your input.

    • Shelley Binkley April 4, 2011, 1:33 pm

      I don’t know any specific gyn surgeonsin your area. However, usually the mesh can be removed, especially if it’s a mini-arc. Enough of the mesh should be able to be removed to alleviate the pain. Good luck!

  • Shelli Christensen April 5, 2011, 9:28 pm

    Thank you for your input. I will be searching for a skilled surgeon who has experience with removal. Please forward on any names you may find. Shelli

  • Cindy July 16, 2011, 8:38 pm

    I had surgery for prolapse in 2001 with mesh and it has worked great. My bladder was hanging out of my vagina and I could not empty my bladder so had to go all the time. I am having incontence now but my bladder suspension is still holding.

  • D Huggins September 22, 2011, 3:02 pm

    I’m 52 and I had the mesh surgery in 2005 (6 years ago) and now am having a problem with blood in my urine for the last month and a half, pain with intercourse, burning and discomfort. Just visited a new Gynourologist and she has scheduled tests to see if the mesh is eroding into the urethra. She examined me and said I have great support, so the sling is holding good and I do not have incontinence but it does not feel right. I have a hard time believing that the mesh would still be able to erode after 6 years? I would think there would be scar tissue built up around it? I also had a rectocele repaired at the same time and have had some problem with a kink in the colon that the doctor suspects is from scar tissue. Unfortunately, I had the first surgery for this problem back in 2000 with a hysterectomy. My Gynocologist and a Urologist tied everything up (not using mesh) and that proved to be a temporary fix. That’s why I considered using the mesh.

  • Cathy July 20, 2012, 11:53 am

    Hi there! I’ve suffered with incontinence for at least six years. The past 6 months has been the worst. Paid big bucks for a urologist to do testing and was told the same thing that my gyn told me…your options are physical therapy or surgery. I have stress incontinence. I decided to try a natural remedy. Magnesium was the remedy I decided to try mostly because it was the easiest to do/take. In three days my incontinence was gone! I’ve been able to walk my hour long steep hill walks without a pad/pads and I went on my first hike in 4 years without leakage (actually, had just a little bit but it didn’t even fill up a panty shield. I look forward to skiing with my husband and children this winter too! Blessings and check out magnesium! It’s the most important mineral for our body! By the way the urologist nurse practitioner was interested in my remedy but the gyn nurse was very rude. My husband suggested that I don’t bother telling them because they wouldn’t care…he was right.

    • Shelley Binkley December 3, 2013, 5:01 pm

      Hi Cathy,

      If the incontinence recurs, you may also want to try Kegel exercises. They are very effective when done regularly for at least 6 wks.

      Thank you for reading the blog and sharing your experience.

      -Dr. B

  • Diane May 24, 2013, 11:27 am

    I am having problems after rectopexy and sacrocolpopexy performed in Sept 2012.My consultant organised MRI scan and proctogram because of pain in the sacrum.Can anyone advise on mesh removal as this was mentioned at my last consultation?

    • Shelley Binkley October 21, 2013, 6:35 am

      Hi Diane,

      Thank you for reading the blog and sharing your experience. I apologize for taking so long to respond. Mesh removal can be very complicated, but sometimes it is the best solution.
      Please feel free to share any updates in your experience.

      -Dr. B

Leave a Comment