Resource for patients with pelvic mesh

Dear Doctor,

This letter explains the possible symptoms and signs of women presenting with pelvic meshrelated conditions and if required, where to signpost them for further help.

What is pelvic mesh?

Pelvic surgical mesh implants are made of materials such as polypropylene plastic and used to strengthen weak tissue to fix pelvic organ prolapse or rectal prolapse and urinary incontinence in women. The mesh is inserted via the vaginal or abdominal routes.

Why was mesh used?

Pelvic mesh slings were common surgical practice for stress urinary incontinence, common procedures were TVT and TVTO. Pelvic mesh for incontinence procedures was suspended from use in 2018. Abdominal mesh procedures for prolapse remain under high vigilance since 2018 and include:

• Sacrocolpopexy to repair vaginal vault prolapse
• Sacrohysteropexy to repair uterine prolapse
• Ventral mesh rectopexy to repair internal or external rectal prolapse

Immediate or late-stage complications?

Complications from these devices can happen early, or even many years, after mesh placement and can be catastrophic. Pain, erosion, voiding dysfunction, infection, recurrent UTIs, fistulae, organ perforation, bleeding, vaginal scarring, neuromuscular alterations, lower urinary tract symptoms and bowel complications. The evidence of direct link between pelvic mesh and systemic inflammatory response and or autoimmune disease remains unclear but patients do report many of these symptoms to the Patient Safety Commissioner. Women may be asymptomatic for several years following mesh surgery before presenting with some of the problems described below. The occurrence of any of the symptoms below does not necessarily indicate a mesh complication, however given the seriousness of mesh complications they warrant careful consideration alongside other investigations for potential other causes.

Common symptoms which patients describe to the Patient Safety Commissioner are:

• Pain in lower abdomen, vagina, groin, legs, hips, back, anus
• Pain is worse on sitting and on movement
• Loss of sex life and or painful sex in the woman, her partner or both
• Erosion where mesh is cutting through vaginal
  walls or into bladder, bowel or urethra
• Recurrent UTIs Becoming antibiotic resistant
• Unexplained vaginal bleeding
• Chronic fatigue
• Recurrent or new bladder and bowel symptoms
• Chronic vaginal discharge resistant to treatment
• Prickling, sore or burning feeling in vagina
• Symptoms of nerve damage eg loss of sensation or increased sensation/pain in legs
• Fever
• Nausea

What are common examination findings?

Examination findings may be normal, or there may be visible pelvic mesh if it has eroded into the vagina.

Investigations

Investigations are best arranged by the specialist centre and include translabial and/or
transanal ultrasound. CT and MRI may also be arranged by the specialist centre but these
may not always show evidence of mesh complications. MRI scans as well as diagnostic
laparoscopy can be helpful in the diagnosis of complications following rectopexy,
sacrocolpopexy and sacrohysteropexy.

Some patients also describe systemic inflammatory response symptoms:

• Fibromyalgia
• Autoimmune diseases
• Dry eyes
• IBS
• Allergies
• Skin rashes
• Psoriasis
• Arthritis
• Lichen sclerosis
• Sjorgen Syndrome
• Thinning hair

Next steps

Patients with pelvic mesh can be referred directly by their GP to any of the 9 specialist mesh centres in England [Link]. Patients with rectopexy mesh can be referred to specialist gynaecology centres for further investigation. While it may be possible for those with rectopexy mesh to be seen at a specialist mesh centre in the future this is not currently commissioned in this way. If it’s not certain whether pelvic mesh was implanted as part of the incontinence or prolapse treatment, GPs can contact to the local gynaecology service for clarification.

Thank you for the care and attention you are providing to your patients. There is more information in the annex below.

Best wishes, yours sincerely

Dr Henrietta Hughes OBE FRCGP
Patient Safety Commissioner

Annex

Vaginally inserted prolapse mesh was banned in December 2017, mesh slings for incontinence were discontinued in 2018. Abdominal prolapse mesh is still used, under high vigilance restriction, including fully informed consent and direct approval by the NHS Trust Medical Director with full fulfilment of strict clinical governance requirements.

Further reading

• E-learning : Pelvic Mesh Complications – elearning for healthcare (e-lfh.org.uk)
• Pelvic mesh was one of three women’s healthcare treatments in a review of how the health system responds when patients and their families raise concerns about safety. The Government announced this review in 2018 which led to the publication of the Baroness Cumberlege First Do No Harm report in July 2020. This report looks at pelvic mesh, sodium valproate and the hormone pregnancy test Primodos.
• Vaginal mesh was suspended across the UK in 2018 on the recommendation of Baroness Cumberlege as part of the Independent Medicines and Medical Devices Safety Review.
• In January 2023, the Government’s Health Select Committee updated on the harrowing effects of pelvic mesh and the response to improving patient safety.
• Among recommendations of the First Do No Harm report was the appointment of a Patient Safety Commissioner for England, a first for the UK. Taking the role is GP Dr Henrietta Hughes.
• How to report pelvic mesh complications to the MHRA via the Yellow Card system.
• MHRA summary of the evidence on the benefits and risk of vaginal mesh implants.