CLARIFYING THE USE OF TRANSVAGINAL MESH

The difference between prolapse and incontinence is the key to understanding the recent controversy around transvaginal mesh.

Recent media coverage of the use of transvaginal mesh may have been confusing, and perhaps caused unnecessary concern amongst women.

A report produced as a result of the Senate Inquiry into the use of transvaginal mesh noted the use of mesh as a ‘last resort’.

While this finding is in line with current treatment guidelines for pelvic organ prolapse (POP), the report – and subsequent media coverage – did not adequately emphasise the key distinction between the use of mesh for POP and its use for stress incontinence.

“It’s crucial that female patients and their doctors understand the difference between the use of mesh for prolapse and its use for stress incontinence,” said Associate Professor Vincent Tse, urologist with an interest in female pelvic floor medicine and surgery at Macquarie University Hospital.

“Transvaginal mesh in the form of slings is safe for incontinence. However, it should not be used as a first-line treatment for POP. The use of mesh for treating this type of prolapse needs further research with clinical innovation and refinement of the mesh and implanting techniques before it can be safely used.”

The recent government inquiry highlights the need to see the appropriate specialist for POP and incontinence issues, such as a urologist with sub-specialty interest in female prolapse and incontinence.

“The current problem is not with the mesh itself, but with the specialist’s recommendations on when it is appropriate to use, and whether the particular specialist has the necessary training and experience in performing the mesh surgery,” said Dr Tse.

Dr Tse, who often works alongside Dr Audrey Wang, performs pelvic floor reconstructive surgery for prolapse that includes cystocele, rectocele, uterine or post-hysterectomy vault prolapse.

Dr Vivian Yang, a gynaecologist with an interest in prolapse and incontinence, also performs this surgery. When bowel issues are present, Dr Anil Keshava, colorectal surgeon, may also be required to participate in the care.

This multidisciplinary and collaboration approach is paramount to female pelvic floor problems because many women have both urinary, bowel and prolapse problems.

The mid-urethral sling with mesh requires surgeons to make one small incision down below and two small incisions above the pubic bone.

Associate Professor Tse and others at Macquarie University Hospital can also offer the long-established pubovaginal fascial sling treatment for stress incontinence, which does not involve mesh use.

Dr Amanda Chung, another urological surgeon working on the team explained “For women looking for a more natural way of having their stress urinary incontinence or prolapse treated, a sling or reinforcement can be made using the woman’s own natural tissues called ‘fascia’. I would encourage women to ask their doctors whether this may be a suitable option for their kind of condition.”

In addition to performing traditional approaches to prolapse surgery, Dr Tse is an accredited robotic surgeon for female pelvic prolapse surgery, and was the first urologist in Australia to perform robotic sacrohysteropexy.

“Robotic prolapse surgery can be suitable in selected patients and offers many advantages,” said Associate Professor Tse. “It enables suturing to be more precise, which is important for any type of reconstructive surgery, and results in less blood loss, less pain and shorter stay in hospital. Generally, recovery time is superior to traditional surgery.”

Like Associate Professor Tse, Dr Wang, Dr Yang and Associate Professor Keshava are also accredited robotic surgeons who treat prolapse.

TREATING PROLAPSE

First line treatment for pelvic organ prolapse (POP) is pelvic floor muscle strengthening through exercise with a qualified physiotherapist, as well as behavioural modification.

Only if there is no improvement, should surgical options be discussed.

Women should see their GP first, and then a urologist or gynaecologist with a special interest in POP or incontinence. Multiple treatment options should always be presented to women for either condition.

INCONTINENCE IN WOMEN

There are two main types of incontinence that affect women:

• Stress incontinence results from abdominal pressure on the bladder through sneezing or coughing, for example, and is caused by either childbirth or ageing when menopause results in lower hormone levels.
• Urgency incontinence is the sudden strong urge to urinate and is usually caused by an overactive bladder.

Less common types of incontinence include:

• Continuous incontinence is due to anatomical sphincter damage associated with treatment or an operation.
• Overflow incontinence happens when there is urine leakage due to obstruction of the urine outlet.

Women should also be aware that certain types of fluids – in particular, caffeine –stimulate the bladder.

REFERRING PATIENTS TO MACQUARIE UNIVERSITY HOSPITAL’S INCONTINENCE SERVICE

The Hospital offers a continence service as a first-line treatment for women experiencing stress urinary incontinence. The clinic has an experienced continence nurse practitioner who works with women to promote healthy bladder and function.

Patients can make a direct appointment with the continence service at Macquarie University Hospital.

T: 0431 812 889