It is believed pelvic organ
prolapse affects millions of women, however many women do not seek medical
intervention due to the nature of the problem. Pelvic organ prolapse occurs
when an organ within the pelvic region drops from its normal spot, pushing
against the vaginal walls. Approximately 200,000 women will undergo a surgical
procedure for pelvic organ prolapse annually. Of the women who undergo the
procedure, at least 30 percent will require an additional prolapse repair
procedure. Most women with pelvic organ prolapse experience discomfort and pain
on a daily basis. Many will also be unable to exercise or engage in sexual
relations.
Pelvic organ prolapse
primarily occurs when the muscles holding the pelvic organs in place are
weakened from childbirth or surgery. Women going through menopause and elderly
women are also more likely to suffer from pelvic organ prolapse. When the
pelvic muscles and connective tissues—which are largely comprised of collagen
and elastin— are subject to repeated or severe strain, they will no longer hold
the pelvic organs in place. Candidates for surgical repair of pelvic organ
prolapse are generally women for whom conservative management has not offered
significant relief. The type of surgical procedure will depend on the site of
the prolapse, whether urinary incontinence is present, the overall health of
the patient and the specific patient preferences.
An article published last June
in the Current Urology Reports Journal
reviews the use of synthetic mesh in the treatment of pelvic organ prolapse.
Significant data supports mesh use for POP surgeries although the authors of
the Journal article also note the risks involved in the use of transvaginalmesh. Fibroblasts—cells which are involved in the synthesis of the connective
tissues—are responsible for a decrease in elastin and an increase in the enzyme
which breaks down elastin. It is likely that the increased levels of this
enzyme, elastase, probably plays a role in the high failure rates of pelvic
organ prolapse surgeries which is estimated to be as high as 29%.
While native tissue was widely
used prior to the introduction of synthetic mesh—and continues to be used in
many cases—the use of native tissue can further break down connective tissues.
Biological grafts also have the tendency to break down when placed in an
environment known to break down those proteins. Because of this, the use of
mesh seems to have a definite advantage over native tissue or biological grafts
as they are—in theory at least—resistant to these protein breakdowns.
The authors consider the ideal
graft, whether biological or synthetic, to be “sterile, inert,
non-carcinogenic, durable, non-inflammatory, inexpensive, readily available and
easy to use.” Mesh implants with larger pore sizes are believed to encourage
tissue growth and prevent infections when compared with smaller pore mesh. The
most common type of mesh used is made from polypropylene and classified as Type
1, macroporous. Type II mesh, Gore-Tex, is microporous which allows limited
tissue growth. In turn, that limited tissue growth may lead to higher erosion
and infection rates.
The FDA issued a warning
regarding synthetic mesh in 2011; the authors of this study present data from
four trials as well as summaries from an additional three trials which compare
the repair of the anterior vaginal wall through colporrhaphy vs. the use of
mesh. Colporrhaphy is a surgical procedure in which narrowing of the vagina is
accomplished through the use of sutures. While the mesh procedures resulted in
lower rates of anatomic failures, from 3.2-19% of those patients required
treatment for vaginal extrusion. Mesh extrusion can result in painful intercourse,
vaginal discharge, odor, pelvic pain and bleeding.
Although most extrusions can
be treated in a doctor’s office, others require surgical intervention. The
article concludes that while there is insufficient data to support the FDAwarning regarding pelvic pain and mesh contraction, the following improvements
suggested by the FDA should be implemented: improved regulations, the careful
selection of mesh patients, improvement in patient education, open discussions
with patients regarding the risks and benefits of mesh treatment, deeper
incisions to allow adequate vaginal tissue coverage and the appropriate
training of physicians.
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