Palpable or visible mesh fibrils can be trimmed in the office; they might even respond to local estrogen alone. Consider these options if the patient displays vaginal atrophy.
Typically, vaginal estrogen is prescribed as 1 g nightly for 2 weeks and then 1 g two or three nights a week. Re-examine the patient in 3 months; if symptoms of mesh exposure persist, it’s unlikely that continued conservative therapy will be successful, and outpatient surgery is recommended.
When exposure is asymptomatic, you can simply monitor the condition for 3 to 6 months; if complaints or findings arise, consider intervention.
Small (<0.5 cm in diameter) exposures can also be managed in the office, including excision of exposed mesh and local estrogen. If the exposure is easily reachable, we recommend grasping the exposed area with pick-ups or a hemostat and with gentle traction, using Metzenbaum scissors to trim exposed mesh as close to the vaginal epithelium as possible. Local topical or injected anesthesia may be needed. Bleeding should be minimal because no dissection is necessary. Silver nitrate can be applied for any minor bleeding. Larger (0.5–4.0 cm) exposures are unlikely to heal on their own. They require outpatient excision in the operating room.
Preoperative tissue preparation with local estrogen is key to successful repair of these exposures. Vaginal estrogen increases blood flow to the epithelium; as tissue becomes well-estrogenized, risk of recurrence diminishes.
The technique we employ includes:
- circumferential infiltration of vaginal epithelium surrounding the exposed mesh with 1% lidocaine with epinephrine
- sharp circumscription of the area of exposure, using a scalpel, with a 0.5-cm margin of vaginal epithelium (FIGURE 2)
- wide dissection, with undermining and mobilization of surrounding healthy vaginal epithelium around the exposure (FIGURE 3)
- excision of the exposed mesh and attached vaginal mucosa, with careful dissection of the mesh off underlying tissues with Metzenbaum scissors—being careful to avoid injury to underlying bladder or rectum (FIGURE 4)
- reapproximation of mesh edges, using 2-0 polypropylene suture to close the resulting defect so that prolapse does not recur (FIGURE 5)
- closing of the previously mobilized vaginal epithelium with 2-0 Vicryl suture, without tension, to cover the reapproximated mesh edges—after irrigation and assurance of adequate hemostasis (FIGURE 6).
FIGURE 2 Incision of vaginal epithelium
Allow for a 0.5-cm margin.
FIGURE 3 Undermining and mobilization of epithelium
Perform wide dissection.
FIGURE 4 Dissection of mesh from underlying tissue
Keep clear of underlying bladder and rectum!
FIGURE 5 Reapproximation of edges to re-establish support
Our choice of suture is 2-0 polypropylene.
FIGURE 6 Irrigation of vaginal epithelium, followed by closure
Before you close, ensure that hemostasis is adequate.The choice of closure—vertical or horizontal—depends on the nature of the original defect.
You can watch a video of this technique that we’ve provided.
Several cautions should be taken with this technique, including:
- avoiding narrowing the vaginal canal
- minimizing trauma to healthy vaginal epithelium that will be used for closure
- maintaining hemostasis to avoid formation of hematomas.
Largest (>4 cm) exposures are likely the result of devascularized sloughing of vaginal epithelium. They are, fortunately, uncommon.
It’s unlikely that, after excision of exposed mesh, the vaginal epithelial edges can be approximated without significantly narrowing or shortening the vaginal canal. Proposed techniques for managing these large exposures include covering the defect with a biologic graft, such as small intestinal submucosa, to allow epithelium to re-grow. Regrettably, prolapse is likely to recur in the unprotected area that results.
Contraction and localized pain
Hardening and contraction typically occur along the fixation arms of the mesh. These complications might result from mesh shrinkage or from mesh being placed too tight, so to speak, at implantation. Rarely does the entire implanted mesh contract.
Severe mesh contraction can result in localized pain and de novo dyspareunia. Symptoms usually resolve after identification of the painful area and removal of the involved mesh segment.8
Diagnostic maneuver. In-office trigger-point injection of bupivacaine with triamcinolone is useful to accurately identify the location of pain that is causing dyspareunia. After injection, the patient is asked to return home and resume sexual intercourse; if dyspareunia diminishes significantly, surgical removal of the involved mesh segment is likely to ameliorate symptoms.
If dyspareunia persists after injection, however, the problem either 1) originates in a different location along the graft or 2) may not be related to the mesh—that is, it may be introital pain or preexisting vaginal pain.
The findings of trigger-point injection and a subsequent trial of sexual intercourse are useful for counseling the patient and developing realistic expectations that surgery will be successful.
Management note: Mesh contraction should be managed by a surgeon who is experienced in extensive deep pelvic dissection, which is necessary to remove the mesh arms.