Erosion of mesh after repair of rectocele

Abstract

Genital prolapse is a common problem in women. Surgical repair is one of the management options. Traditional repair consists of midline plication of endopelvic fascia to reduce the prolapse and create support. A mesh has also been used to augment and repair such defects in the pelvic floor. Data on the efficacy and safety of mesh repair for genital prolapse are limited in literature. We present a rare case of mesh erosion 18 years after a rectocele repair.

Case report

A 64-year-old woman attended the gynaecological out-patient department with a history of vaginal soreness and discomfort for the last 3 months. She had no other symptoms. She gave a history of having had corrective surgery for a rectocele 18 years ago. She had no other significant medical problems.

On examination, the vulva looked atrophic but healthy. On separating the labia, the mesh from the previous repair along with prolene suture material could be seen protruding from the lower end of the vagina (Fig. 1). There was no genital prolapse. On vaginal examination, the uterus was small and retroverted. Fornices felt normal.

Fig. 1

Mesh with prolene suture protruding through vagina

The mesh of about 2-cm length was excised under general anaesthetic, and the vagina sewn over with absorbable sutures.

She was prescribed vaginal estrogen Pessary for 6 weeks.

At 6-week follow-up, the woman was comfortable and symptom free.

Discussion

Female genital prolapse is a common condition and may be present in up to 50% of women [1].Traditional techniques of repair of cystocele or rectocele are associated with high recurrence rates of up to 40% [2]. Rectocele repair is also associated with narrowing of the vagina and dysparunia. Meshes have been tried along the same principle of hernia repair to reduce recurrence rates and long-term complications like dysparunia.

Not much data are available about long-term efficacy and safety of mesh repair for rectocele. Erosion, stricture and infection are potential complications. Sola et al. in 2006 reported a series of repairs using the Tension Free Monofilament Macropore Polypropylene mesh with minimal intra-operative or short-term complications [3].

Mage [4] published a series of cases of genital prolapse repair using the mesh between 1994 and 1999 with a 5-year follow-up period. Forty-six patients were treated for genital prolapse by a vaginal approach using polyester mesh. There was only one case of mesh exposure 4 months after surgery. There were no cases of recurrence of prolapse or complaints of dysparunia.

Huebner in his article on the use of graft material in vaginal pelvic floor surgery concluded that there were few prospective randomised trials to prove the benefit of using grafts in vaginal pelvic floor surgery. Serious complications such as erosions were not mentioned, and quality of life measures such as dysparunia, urinary or bowel symptoms were ignored [5].

We present this rare case of mesh erosion 18 years after corrective surgery. Extensive literature search did not show any other such case reports. With mesh repair now being increasingly used by some gynaecologists, long-term complications such as the above could be used as part of counselling and consenting for the procedure.