Women’s Health

The Truth About Mesh in Female Pelvic Medicine and Reconstructive Surgery

Amos Adelowo, MDPolypropylene mesh material has been used in most surgical subspecialties and in millions of patients for over five decades. In my field of Female Pelvic Medicine and Reconstructive Surgery, the use of permanent mesh material is often used for the treatment of pelvic organ prolapse, which is when the pelvic organs drop due to weakened pelvic muscles, and stress urinary incontinence, which is the involuntary leakage of urine after physical activity, such as sneezing, coughing, and laughing.

In July 2011, the U.S. Food and Drug Administration (FDA) released an advisory on the safety and effectiveness of surgical mesh in the treatment of pelvic organ prolapse. In addition, there has been significant media attention surrounding this issue, and lawyers have targeted women who have had mesh placed, promising big payouts for their pain and discomfort.

Because of these developments, many women are confused, fearful, and may not seek treatment for bothersome pelvic floor conditions that significantly impact their quality of life. As a care provider in the Division of Female Pelvic Medicine and Reconstructive Surgery at Emory, my goal is to provide patients with the best information and care for their conditions. Here are some things you should know about mesh and pelvic floor disorders before making any health decisions.

Not All Mesh is the Same

Mesh is used in the mid-urethral sling surgery commonly used for the treatment of stress urinary incontinence for women who leak urine after coughing, sneezing, laughing, running, etc. This surgery is the leading treatment option and current gold standard for stress incontinence surgeries. The FDA has clearly stated that the polypropylene mid-urethral sling is safe, effective and it is not the subject of the 2011 FDA safety communication on the use of vaginally placed mesh for pelvic organ prolapse surgery.

The way we place the mesh is also a factor. Abdominally placed mesh with the option of a minimally invasive approach to placement has been used over many years with excellent results. The FDA’s communication focused on transvaginal placement of mesh products for treatment of pelvic organ prolapse.

Transvaginal Mesh is Not the Only Option

Some women don’t seek help for pelvic floor disorders because they are worried about transvaginal mesh, but we have many other options for treating prolapse and incontinence. These include non-surgical options, including physical therapy or a support device known as a pessary, as well as other surgical options that do not include the use of transvaginal mesh. We also offer minimally invasive surgical options that result in quicker post operative recovery, less blood loss and shorter hospital admission after surgery.

Transvaginal Mesh is Still a Good Option for Some Patients

Some of our surgical options use materials that aren’t permanent, so the results may not last as long as repairs made using permanent mesh. Studies show that using mesh can significantly lower the failure rate of these surgeries. Based on the current available information, many patients undergoing pelvic organ prolapse surgery with the use of mesh augmentation will heal well and have no problems. They will experience relief from their symptoms and improvement in function of the lower urinary tract.

Removing Transvaginal Mesh

In our practice, we care for women referred to us from other institutions with mesh complications. We occasionally have to “revise” a surgical mesh by either releasing the tension or excising a small exposed area. We do have the experience and training to remove mesh, as we have done so in patients with complications from their mesh surgery.

Our Team Understands and Can Manage the Risks

The risks associated with transvaginal mesh surgeries as well as other prolapse surgeries include pain, infection, urinary problems, bleeding, and painful sexual intercourse. Many of these complications can be treated and resolved in most patients, with management ranging from an in-office visit to another surgery. There is a small but significant group of patients who experience permanent complications from the use of transvaginally placed mesh.

For this reason, our team at Emory provides extensive counseling on the choice of surgical approach and the materials that will be used. We also work to ensure that patients understand what signs and symptoms should concern them after surgery. We provide an open line of communication and access for our patients to be seen and evaluated in a timely fashion if they are concerned.

We also believe in the importance of a multidisciplinary care team for all of our patients with pelvic floor dysfunction, including those with mesh. At Emory, our team includes urogynecologists, urologists, colorectal surgeons, radiologists, gastroenterologists, and pelvic floor physical therapists. We believe this approach provides optimal care with best outcome, and it gives our patients the benefit of receiving input from different subspecialists without multiple client visits.

Conclusion

It’s important to know that the symptoms associated with pelvic floor disorders – urinary incontinence, fecal incontinence, prolapse, and sexual dysfunction – are not a normal part of aging and are treatable. We will work with patients to find a treatment option that improves their quality of life. If concerns about transvaginal mesh are holding you back from seeking treatment, please reconsider and talk to your health care provider.

About Dr. Adelowo

Amos Adelowo, MD, MPH, FACOG, is an Assistant Professor in the Department of Gynecology and Obstetrics at Emory University School of Medicine. He is a member of the Female Pelvic Medicine and Reconstructive Surgery division, also known as urogynecology. Dr. Adelowo sees patients at the Emory Clinic at Emory University Hospital Midtown, on the 8th floor. He completed medical school at Pennsylvania State College of Medicine and his residency in obstetrics and gynecology at the University of Massachusetts Memorial Hospital. He then completed his fellowship in Female Pelvic Medicine and Reconstructive Surgery at Mount Auburn Hospital and Harvard Medical School. To make an appointment with Dr. Adelowo or any of our urogynecologists, please call 404-778-3401.

National Infertility Awareness Week: You Are Not Alone

Infertility Awareness WeekThis week, April 19-25, is National Infertility Awareness Week. At the Emory Reproductive Center, we know well the pain that infertility causes those who are ready to grow their family. Infertility is extremely isolating – it can be difficult to share fertility struggles with friends who seem to conceive easily, or to face family members who continually ask about plans for a baby.

That’s why we’re happy that the theme “You Are Not Alone” has been chosen for this year’s National Infertility Awareness Week. Since infertility is rarely discussed, many people don’t realize just how common the issue is – in fact, infertility impacts 1 in 8 couples of reproductive age. What’s more, people who are unaware of how common infertility is may not realize just how many options we have to treat it.

In the spirit of raising awareness about infertility, we’d like to share some basic facts about this medical condition:

  • We define infertility as the inability to become pregnant after a certain period of time of unprotected intercourse. For women under age 35, that period of time is one year; for women over the age of 35, that period of time is six months. Some patients may have risk factors that make infertility more common, such as endometriosis, and those patients are encouraged to seek assistance before six months or a year has passed.
  • Infertility is not just a female problem – 30 percent of infertility cases are due to a female factor, 30 percent of infertility cases are due to a male factor, and in the rest of the cases, the cause is unknown or may be due to both a male and female issue.
  • We now have more options than ever for treating infertility, including everything from intrauterine insemination and in vitro fertilization to egg donation and surrogacy. And in vitro fertilization, or IVF, is safer than ever before, with a lower risk of multiple births compared to years earlier.

We take the theme “You Are Not Alone” seriously at Emory – once patients initiate treatment, we put together a team that supports them throughout their entire journey with us. All of our staff members are trained in the special needs of infertility patients, and from that initial work-up to the completion of treatment, we are our patients’ biggest cheerleaders.

In addition to providing our patients with a compassionate and respectful experience, we’re proud to say that our in vitro fertilization program consistently achieves success rates significantly above the national average. It’s extremely fulfilling to know that we have helped so many patients feel less alone by successfully helping them build their families.

RESOLVE, the National Infertility Association, has some wonderful resources for men and women seeking more information on infertility, as does the American Society for Reproductive Medicine. We also invite you to visit our website or to call 404-778-3401 to make an appointment and learn more about your options.

About the Emory Reproductive Center

The Emory Reproductive Center, located at Emory University Hospital Midtown, manages a range of conditions that affect reproductive health, including fibroids, endometriosis, abnormal bleeding, recurrent pregnancy loss, premature ovarian insufficiency, polycystic ovary syndrome, male infertility, and genetic disorders.

We offer testing for male and female infertility issues and the latest in assisted reproductive technologies with excellent results – our in vitro fertilization (IVF) program consistently achieves success rates significantly above the national average.

Our fellowship-trained physicians are faculty members at the Emory University School of Medicine. Learn more about our team.

Fecal Incontinence: Talk to Your Doctor Today

fecal incontinenceFecal Incontinence (FI) is the accidental or involuntary loss of liquid or solid stool from the rectum. The two most important things to know about FI are:

  1. It is not a normal part of aging. And
  2. You are not alone.

Fecal incontinence affects nearly 18 million adults in the United States and has a profound impact on one’s quality of life. Still, many women are hesitant to talk to their doctors about this condition because they are embarrassed or think that there is nothing that can be done about it.

What Causes Fecal Incontinence?

There are many different factors within the body that have to all work together to keep us continent. These include intact mental function, normal volume and consistency of stool, and intact muscles, nerves, and reflexes within our colon and anal canal. A problem with any of these factors can lead to fecal incontinence.

Some examples of factors that can cause fecal incontinence include:

  • Neurologic conditions such as dementia, stroke, or multiple sclerosis
  • Diarrhea (from infection, irritable bowel, lactose intolerance, colitis, etc.)
  • Obstetric injury or trauma
  • Previous surgeries (hemorrhoids, fistulas)
  • Anatomic issues (tumors, hemorrhoids, fistula, rectal prolapse)
  • Medications
  • Radiation

Receiving Treatment for Fecal Incontinence:

The physicians of the Female Pelvic Medicine and Reconstructive Surgery division of Emory Clinic’s Department of Gynecology and Obstetrics are here to help you deal with this devastating condition. Your care with us often involves a team approach in which we collaborate with our colleagues from colorectal surgery and gastroenterology (GI), as well as a fantastic group of physical therapists.

What Can I Expect from My Visit?

During your visit you will have an in-depth conversation with your doctor, where we will review your medical history, including other medical conditions, surgeries, medications, etc. You will also undergo a full physical exam including a rectal and vaginal exam. Your doctor may order additional tests depending on your situation, including:

  • Endoanal ultrasound: This is done to see if your anal sphincter may have been torn or injured
  • Pelvic MRI or Defecography: This looks for possible anatomic causes and demonstrates how you eliminate stool during a bowel movement
  • Anal Manometry: This tests the reflexes, sensation and the function of your internal and external anal sphincter
  • Endoscopy: You may be asked to undergo a colonoscopy or another similar type of imaging procedure to rule out inflammatory conditions or cancers

Is There Hope? Treatment Options for Fecal Incontinence

Yes, there is hope. Treatment will be tailored to your specific cause of fecal incontinence as well as the severity of your symptoms. Our treatment approach will take into account your other medical conditions as well as your personal limitations or constraints. A large part of the treatment plan requires your participation, as it involves behavioral approaches and lifestyle changes. Some of these include:

  • Diet and fluid management
  • Bowel retraining/toileting techniques
  • Weight loss
  • Fiber supplements
  • Medications
  • Pelvic floor muscle exercises
  • Biofeedback

If these more conservative therapies fail, other more advanced treatment options your doctor may discuss with you include:

  • Anal injections with bulking agents
  • Sacral nerve stimulation (Interstim)
  • Posterior Tibial Nerve Stimulation (PTNS)
  • Anal sphincter repair
  • Colostomy

About Kristie Greene, MD

Kristie Greene, MDKristie Greene, MD, is an Assistant Professor in the Department of Gynecology and Obstetrics at Emory University School of Medicine. She is a member of the Female Pelvic Medicine and Reconstructive Surgery division, also known as urogynecology. Dr. Greene sees patients at the Emory Clinic at 1365 Clifton Road, in Building A on the 4th floor. She completed medical school at Loyola University’s Stritch School of Medicine and went on to complete both her residency and her fellowship in Female Pelvic Medicine and Reconstructive Surgery at the University of South Florida. To make an appointment with Dr. Greene or any of our urogynecologists, please call 404-778-3401.

Sexual Dysfunction: When To See A Specialist

What is sexual dysfunction?

Sexual dysfunction is a general term that refers to a problem during sexual activity that interferes with an individual’s ability to enjoy the sexual experience. Sexual problems typically fall into one of four categories:

  1. Desire disorders
  2. Arousal disorders
  3. Orgasm disorders
  4. Pain disorders

What causes sexual dysfunction in women?

Many things, including physical or medical conditions as well as psychological causes, can contribute to sexual dysfunction. Some examples may include:

  • Medical problems, such as depression
  • Medications
  • Smoking, alcohol, and drugs
  • Stress and anxiety
  • Relationship problems
  • Prior negative sexual experiences
  • Hormone changes/menopause

What’s the link between sexual function and menopause?

Sexual function can affect both men and women of all ages. However, there are specific changes that occur around menopause that can impact a woman’s sexual experience. During menopause, declining hormone levels cause changes in our body that may affect our sexual function. For example, lower hormone levels may decrease your sex drive or cause changes in the vagina that may make intercourse uncomfortable.

What causes sex to be painful?

There are many reasons why sex may be painful. Some of the more common reasons include:

  • Vaginal atrophy: Loss of estrogen after menopause causes the vaginal lining to become thin and dry. We call this vaginal atrophy. Vaginal atrophy can make sexual intercourse uncomfortable or even painful. Although this is most commonly associated with menopause, a woman might also experience vaginal atrophy after surgical removal of her ovaries. Your doctor may treat this condition with vaginal estrogen in a cream, tablet, or ring form. Vaginal lubricants and moisturizers can also help.
  • Pelvic floor muscle spasms: Similar to a “Charley horse,” women can also develop muscle spasms or “trigger points” in their pelvic floor muscles. When this happens, it can make penetration difficult and painful. Treatment involves working with a pelvic floor physical therapist to help you rehab and appropriately relax these muscles.
  • Infections
  • Cysts
  • Endometriosis

When should you see a specialist about sexual dysfunction?

Most conditions can be managed with the help of your gynecologist or primary care physician. However, there are some conditions, like the ones listed below, that may require consultation with a specialist known as a urogynecologist, who has advanced training in these areas.

  • Pelvic organ prolapse: Pelvic organ prolapse is a weakening of the pelvic floor, which allows the vaginal walls along with some of your pelvic organs to herniate through the vaginal opening. This often presents as a vaginal bulge or an appearance that something is protruding outside of the vagina. Sometimes women describe a sensation of feeling like they are sitting on an egg. Although prolapse should not cause pain per se, the vaginal bulge may interfere with one’s ability to experience penetration and may cause discomfort during intercourse.
  • Previous surgeries: Sometimes women experience pain with intercourse after having undergone previous surgeries. This may be due to a complication of the surgery, distorted anatomy, or perhaps a residual foreign body in the vagina such as suture or mesh.

Talk to your health care provider

The good news is that most causes of sexual pain and sexual dysfunction are treatable. Treatment will depend on the underlying etiology and often requires a team approach including your partner, doctors, physical therapist and psychologists. Remember, communication is key. Talk to your health care providers today to see how they can help you with any concerns you are having.

About Kristie Greene, MD

Kristie Greene, MDKristie Greene, MD, is an Assistant Professor in the Department of Gynecology and Obstetrics at Emory University School of Medicine. She is a member of the Female Pelvic Medicine and Reconstructive Surgery division, also known as urogynecology. Dr. Greene sees patients at the Emory Clinic at 1365 Clifton Road, in Building A on the 4th floor. She completed medical school at Loyola University’s Stritch School of Medicine and went on to complete both her residency and her fellowship in Female Pelvic Medicine and Reconstructive Surgery at the University of South Florida. To make an appointment with Dr. Greene or any of our urogynecologists, please call 404-778-3401.