Managing female stress incontinence: considerations since the suspension of vaginal mesh implants, by Mohammed Belal, consultant urologist.

Mr Mohammed Belal

Since the suspension of all procedures to implant vaginal mesh in July 2018, we are often contacted by patients and professionals for advice and help. For some patients, this involves surgery to remove mesh for female stress incontinence because it is causing pain, discomfort and/or urinary problems. I have carried out about 30 of these procedures currently.

The other issue that we are seeing, increasingly, is very conservative management of female urinary incontinence resulting, for some women, in very poor control of urinary symptoms. Few surgeons are trained in the alternative approach to creating a female sling, known as pubovaginal suspension or autologous sling which avoids the use of TVT mesh and the problems associated with it.

The autologous pubovaginal sling uses the patient’s own tissue (usually this is taken from the lower abdomen). This was the original approach to surgery to support weak tissues by using a ‘sling’ or ‘hammock’ that sits just beneath the vagina and above the urethra and was the gold standard before TVT mesh was introduced.

TVT mesh for vaginal implants first emerged about 20 years ago. Because this was a less invasive operation for the patient and simpler operation for the surgeon, it became the first line option in most cases and an operation carried out on a wide scale: more than 92,000 women received a vaginal mesh implant between April 2007 and March 2015 in England alone.

This meant surgical skill in the autologous pubovaginal sling procedure was depleted. Within the West Midlands region, I was the single surgeon who would receive referrals for any patients who would be better suited to an autologous sling, while other urologists within the region specialising in the treatment of stress urinary incontinence would carry out mesh implant operations only (which was the choice for the majority of patients).

The suspension of mesh operations has left us with a gap in surgical options for women with moderate to severe stress incontinence and prolapse. I am now involved in training a number of colleagues in the autologous approach, but this will take time. While more surgeons train in the autologous approach, very conservative management is common. Other interventions may not suit the woman with moderate to severe incontinence: colosuspension (surgical lifting of the bladder) is major surgery and using urethral bulking agents will not be effective for some patients. We also increasingly are asked for advice and guidance by women with mesh implants. I emphasise that if you are asymptomatic (no pain, no difficulties passing urine or repeated infections), it is best to continue as you are. It is understandable that the suspension of mesh implants and accounts in the media may make you feel anxious. Do seek help if symptoms arise, but we would not remove mesh unless you were symptomatic.