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Sample WCM OnDemand Second Opinion
Expert Opinion Provided by:
Dr. Tirsit Asfaw
Assistant Professor, Obstetrics and Gynecology, Weill Cornell University
About Dr. Asfaw
Dr. Tirsit S. Asfaw is a urogynecologist who specializes in the care of women with pelvic floor weakness resulting in conditions such as pelvic organ prolapse and bladder dysfunction. She offers personalized treatment options that combine effective long term results with safe and quick recovery. Dr. Asfaw has an avid interest in clinical as well as basic science research and has presented her work at numerous national meetings and published in peer-reviewed journals.
Medical School: Temple University School of Medicine in Philadelphia, PA
Residency: Obstetrics and Gynecology residency at New York University, New York, NY
Fellowship: Urogynecology and Reconstructive Pelvic Surgery at the University of Pennsylvania, Philadelphia, PA
Certifications and Awards
Chughtai B, Hauser N, Anger J, Asfaw T, Laor L, Mao J, Lee R, Te A, Kaplan S, Sedrakyan A. Trends in surgical management and pre-operative urodynamics in female medicare beneficiaries with mixed incontinence. Neurourol Urodyn. 2015 Dec 17.
Segal S, Saks EK, Asfaw TS, Arya LA. Increased fluid intake is associated with bothersome bowel symptoms among women with urinary incontinence. Female Pelvic Med Reconstr Surg. 2013 May-Jun;19(3):152-6.
Asfaw TS, Greer JA, Ramchandani P, Schimpf MO Utility of preoperative examination and magnetic resonance imaging for diagnosis of anterior vaginal wall masses. Int Urogynecol J. 2012 Aug;23(8):1055-61.
Summary to the Patient
PATIENT NAME, thank you for allowing me to review your case and provide my opinion. Before I answer your questions and offer my recommendations, let me summarize your medical history and concerns based on what I have learned from your medical records and the questionnaire you completed.
You are 48 years old, and in 2009, you underwent a hysterectomy and pelvic floor repair that involved the use of mesh. Following the procedure you did well for several years, but you recently began to experience vaginal bleeding. You describe it as "spotting" and have been having it daily. You were evaluated by a gynecologist in early May; when she examined you, she saw mesh poking through the apex (top) of your vagina and referred you to a urogynecologist for further evaluation. The urogynecologist has recommended surgery to remove the mesh and repair the top of your vagina (called the vaginal cuff); she proposes doing the procedure through the vagina and not the abdomen.
You are understandably concerned about the bleeding you are experiencing and would like to understand if it is being caused by the mesh or some other problem. You do not want to have unnecessary surgery, and if you do pursue surgery, you want to be sure that you have the most appropriate procedure.
Before I respond to your specific questions, I'd like to provide you with a bit of background information about pelvic organ prolapse, as this is what led to your surgery in 2009 and ultimately to the bleeding you are now experiencing. Although you may be familiar with some of what I'm going to tell you, I feel that the information will be helpful in better understanding the recommendations that I make.
Pelvic organ prolapse is a condition that happens when tissues that support the organs in the lower belly relax. These tissues are sometimes referred to as the "pelvic floor." When they relax too much, organs can drop down and bulge — or prolapse — into the vagina. Some women with prolapse do not have any symptoms and do not require treatment. Others, however, may experience a fullness or pressure in the pelvis or vagina, a bulge in the vagina, leakage of urine (particularly when laughing, coughing, or sneezing), a sudden need to urinate, or difficulty emptying the bowels. These symptoms can be bothersome and a sign that treatment is necessary.
Treatment for prolapse typically includes pelvic floor muscle exercises or a vaginal pessary, but in women with more severe prolapse, surgery may be indicated. (From reading your records, it's my understanding that you tried a pessary, but because it didn't work, you elected to have surgery.) The procedure that you had, called a sacral colpopexy, is done to correct prolapse at the top of the vagina using a supportive synthetic mesh. Although this type of surgery tends to be highly effective in alleviating prolapse symptoms, over time, the mesh can erode into surrounding tissues such as the vagina and cause other problems.
Questions from the Patient
I'd like to acknowledge the concern that this problem has caused you over the last year. You have asked some very thoughtful questions, and I encourage you to share my responses and recommendations with your physicians as you work on developing a treatment plan.
What types of testing or procedures should I undergo to identify the cause of my bleeding? How likely is it that the bleeding is related to my prior hysterectomy or the mesh? What else could it be related to? Do I need to be concerned about cancer?
You had pelvic organ prolapse surgery using abdominally placed mesh to help shore up the pelvic floor tissues which had relaxed. While this is an excellent procedure to repair prolapse, there are complications that can develop afterwards. One of those complications (the one you are experiencing) involves erosion of the mesh through the vaginal wall. This may not occur for sometime after surgery, and can occur years after placement of the mesh. In fact, the risk of mesh erosion goes up as women's estrogen levels fall around the time of menopause. That's because on of estrogen's many roles in the body is to maintain the vaginal lining, keeping it thick and healthy and allowing it to heal quickly if the tissue is injured.
Based on my review of your records, you have undergone an appropriate evaluation and testing. The only testing you need now is a good clinical examination. In the office setting, exams can sometimes be limited by discomfort, and at times, an examination under anesthesia is required. A thorough exam will reveal areas where mesh may be eroding through the vaginal wall and ensure that all erosions are identified. Typically the exposed mesh is removed, and the vaginal tissue is mobilized and closed over the open wound to allow the area to heal better.
Based on your records and medical history, your bleeding is almost certainly from the exposed mesh — not cancer. Because you have undergone a hysterectomy, you don't have a uterus to bleed from, eliminating the possibility that you have uterine cancer. Also, ovarian cancer does not typically present with vaginal bleeding and your imaging studies show that your ovaries are normal. If there is any concern that you may be bleeding from your rectum, you should be evaluated with a colonoscopy; however, if the bleeding is vaginal, the source is most likely the mesh erosion.
A gynecologist told me was that mesh implants held in place better when women took additional estrogen. Should I be on hormones? If so, can you please explain why?
Please be assured that vaginal estrogen therapy is not the same thing as hormone replacement therapy. Hormone replacement therapy implies the use of oral estrogen pills to help with the symptoms of menopause such as hot flushes. Oral hormone replacement therapy does not help with healing of vaginal mesh erosion or help women who experience vaginal dryness with intercourse. Vaginal estrogen supplementation is appropriate for the initial management of exposed vaginal mesh; it can also be used to help the vagina heal better after the removal of exposed vaginal mesh. It is safe and used in women with vaginal symptoms associated with menopause, such as dryness and pain with intercourse. Vaginal estrogen supplementation acts locally in the pelvic area and there are negligible effects on other parts of the body. The only concern associated with using it is that it may — at very high dose and with prolonged use — stimulate endometrial hyperplasia, or overgrowth of the lining of the uterus. For women who have had a hysterectomy such as yourself, this is not a concern and so it is even more acceptable to use for a prolonged amount of time as necessary.
My doctor has suggested that I have surgery to remove the exposed mesh. I just want to know if I'm having the right surgery. Do you agree with what my doctor has proposed? Do I have any other options? What would happen if I do nothing? Will my problem gradually get worse and could I develop other complications?
I have reviewed the plan of care your doctor has recommended and it is entirely appropriate. Some women who have mesh erosion choose to cautiously observe the erosion and not undergo further surgery. This may be an option if you are not sexually active and the small spotting or light bleeding is not bothersome to you. If you choose to go the conservative route and simply monitor the erosion (which is entirely acceptable), it is safe and appropriate to use vaginal estrogen supplementation to help the vagina heal. If this fails and you are still bothered by the exposed mesh — either from discomfort with intercourse or bleeding/spotting from the vagina — surgical removal of the exposed mesh would be the appropriate next step.
The only recommendation I would make in addition to what your doctor has suggested is to also perform a cystoscopy (a procedure used to see inside your urinary bladder and urethra — the tube that carries urine from your bladder to the outside of your body) at the time of your exam; this will help ensure the mesh is not causing problems with your bladder and lower urinary tract.
As I have already mentioned, if you are not having pain with intercourse and are minimally bothered by the spotting, you can observe the mesh erosion and have periodic clinical exams by your gynecologist, such as every six months or as needed. There is no way to predict how the mesh erosion will evolve as you move further along in menopause. It may resolve (especially if you try using vaginal estrogen supplementation), stay the same or get bigger over time. There is always a risk that the mesh could erode into other organs but this is very unlikely. If it is eroding into the vagina, the likelihood that it will erode into other organs such as the bladder is very, very low and I would not worry about this. You had an appropriate prolapse surgery. All surgical procedures come with risks — but small ones. Vaginal mesh erosion is a known complication of prolapse surgery with mesh. It is typically successfully managed with vaginal mesh removal and the use of vaginal estrogen.
Summary of Next Steps
Thank you, PATIENT NAME, for allowing me to participate in your care. In summary:
- If the spotting you are experiencing is bothersome or if you are sexually active, I would recommend that you undergo surgery to remove the mesh and repair the vaginal cuff. I suggest that you use vaginal estrogen before and after your surgery to help improve healing.
- If you are not sexually active, I recommend that you use vaginal estrogen supplementation to allow the area to heal and to minimize the risk of progression of the mesh erosion.
I hope that you find these recommendations helpful and that they serve as the basis for a productive conversation with your treating team. I wish you good fortune with your health.
Links for the Patient
The American Urogynecologic Association has a discussion board for women who have concerns about pelvic floor disorders including mesh related information.