The bladder and urethra play a key role in pelvic organ prolapse and stress urinary incontinence. The most frequent cause of SUI is early bladder prolapse.
Figure 1. Illustration from patent application 2004. “u” is called a urethra. “B” is called a bladder.
As we age, the bladder loses support from neighboring fascia, muscles, ligaments and tendons and drops down, folding itself over supporting structures underneath (and over slings or sutures after surgeries). The folding narrows the outlet or urethra. Imagine you are holding a rolled up throw rug under one arm to carry it, it folds over and the hole inside it narrows and flattens.
Figure 2. Offset oil funnel.
Mesh illustrations in journal articles, public information handouts, and patent applications are inaccurately show the urethra as a straw-shaped tube through which urine flows. See example in Figure 1. It is really a sideways funnel — “offset” like the photo of the oil funnel in Figure 2. Figure 3. is a healthy bladder.
Figure 3. Healthy non-prolapsing bladder.
How in the world did the patent office and the FDA clear this product, a mesh tape with wing-like extensions for treating female urinary incontinence US 8047982 B2, when the illustration clearly shows a tube and the device is designed to fit a straight tube?
It is no wonder patients become confused.
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If you’ve ever bent your straw and tried to keep sipping your drink anyway, even though you hate the way your delicious milkshake comes up in dribs and drabs, fits and starts, you can imagine what is happening to your urethra when you have mesh-related urinary retention. It is an extremely painful condition and, if it is left untreated, it can cause extensive damage to your kidneys and urinary tract. Yet another mesh trouble.
“I really miss the way I used to “tinkle!” When I had to go, I could sit down and have a good, steady flow that came out fast. And I would be done. Now, I can’t seem to get it out like I used to. It’s almost like an unsatisfying feeling. I have the urge, but it won’t come out right. And I need to stand up and squat over the toilet to get the last part out. It seems I always have to urinate now…the more I push, the less it flows.”
“I really don’t enjoy urinating anymore! Before, it was such a relief to go to the bathroom! Now, it’s annoying.”
“I have trouble with pain while walking and sitting.”
“Ever since the sub-urethral sling I have had some voiding dysfunction.”
“I saw a really good urologist and he said he would never have used the sling I got and it was a ‘little’ tight. This has caused me lots of pain, some erosion, etc. He recommended removal for me.” – personal accounts
The women above can describe what urinary retention due to bladder mesh better than any medical author. The problem lies in the very design of the transobturator tape. Surgeons are human and human skills vary. No two human pelvis’s are shape alike and fitting one product to all means that some slings will be placed so tight they squeeze off the flow of urine. One study found 3.7 percent of mesh implants result in urinary retention requiring additional surgeries.
Why? A transbobturator tape (TOT or TVT-O) is inserted by hanging polypropylene woven mesh like a hammock— not too tight and not too loose—with exactly the right tension. Trouble is, the patient is asleep when she gets her implant and can’t say, “Ouch! A little too tight!” Or, “Can you loosen it up a bit?” Surgeons have to estimate how tight to make it using techniques that other surgeons have found successful or that they took a weekend course operating on an motionless cadaver. Even the surgeon’s handedness* affects the angle at which they punch the trocar through and how much tension gets applied to each side of the sling. By the time you wake up with that indubitable feeling that its too tight, it’s too late.
While your surgeon is stringing your hammock, you are tipped with your head down in a position you would not assume for a longer than a few minutes because all the blood rushes to your head. To put you in the Trendelenburg position, your sleeping body is placed on the operating table, your legs strapped in stirrups and your head is lowered as much as 30 degrees.
When you first stand up after surgery, the full weight of all the organs above push against the mesh sling below putting pressure on your urethra. If the sling is too tight, your urethra becomes pinched, or kinked. You are about to enter a personal learning curve of discovery–more than you ever wanted to know about urinary retention.
Retention is definitely not fun: Some women with retention are able to trickle their urine slowly, some have to finish emptying their bladders by standing up and bending forward, some must place their head below their knees, and others end up with catheters or urostomies. Imagine that. You are forced to bow down in supplication, privately humiliated with every bathroom trip while the profiteers of the defective device you just received are sunning themselves on yachts on the Mediterranean. Even the surgeons who put in yours and now are refusing to say the mesh caused your problem, are sitting in the deck chairs.
Catheters: Some women cannot, no matter what they try, get their urine out—not being able to start a stream or to finish emptying due to the angle of the crimp in their urethras. Indwelling (Foley) catheters are often placed but the length of time they can be used is limited because they result in urinary tract infections nearly 100% of the time a few days time. Some women are taught to use intermittent cathaterization (IC) to empty their own bladders. Those smaller catheters are inserted and removed each time and can be rinsed and reused. Learning how to use them is extremely difficult and the inside of your urethra is extremely sensitive to damage and can swell causing more retention. Try laying down in the bathtub the first few times you insert one or lay on a shower curtain on your floor so you won’t get tired as you learn how to insert the catheter very slowly and carefully. Once you learn the shape of your own urethra, it’ll be easier.
Supra-pubic catheters and urostomy: In rare cases, catheters fail or the bladder is so distended that a catheter won’t work so a supra-pubic catheter is inserted. It is a simple surgical procedure where a small hole is cut above your pubic bone and a catheter is inserted to drain your urine until your urethra is healed. The amount of time it is left in varies from patient to patient. If the bladder or urethra is permanently damaged a major surgery is performed to drain urine from your kidneys through a small hole in your abdomen, a urostomy, or radical cystectomy.
Surgical repair: Urinary retention makes it necessary to undergo a battery of urodynamic tests and new sling implant recipients are often told to wait a few months to see if it will somehow magically stretch out. Mesh material is designed not to stretch and making a patient wait months ignores the amount of unimagined agony and personal distress that a tight sling causes. A urologist or uro-gynecologist often will perform a “ligation” or “revision” in which they cut the sling in two. We do not recommended revisions or partial removals as they allow the two ends of the sling to snap away, shred, and grab onto any healthy tissue around—leading to future revision or very long and complicated removal surgeries.
Despite the fact that waiting only prolongs your agony, in order to keep you from having more complications, mesh troubles, be sure to learn all you can about the difference between revisions and complete removals before deciding who will treat you and what procedures to agree to.
Yikes! If you’ve ever had to wait way too long to go pee, you know what a bladder infection feels like—only it feels like that all the time, even after you pee, until it is healed. If you’ve had a urinary tract infection (UTI), you know the kind of pain that ruins your life for a few days. If you have pelvic mesh, you may have one bladder infection after another and you find yourself saying, “Hey, this is a lot worse than what took me to the doctor in the first place.”
There is a whole lot of information about UTIs on the internet, but we’re talking a bit about mesh-related bladder infections today. The urinary system contains the delicate structures urine passes through—the kidneys, ureters, bladder and urethra. Put a bit of woven polypropylene (like the screen in your window) in there, and you stir up a whole mesh of trouble. For some, it’s frequent UTIs. Causes: As we age, we lose collagen and supportive structures begin to lose elasticity, even those holding up the pelvic organs like the bladder, the uterus and the rectum. In women, the tube from the bladder to the outside (urethra) begins to change shape under the weight of those organs and bends like a paper straw causing the urine flow to slow down and sometimes stop before your bladder is empty. When some urine stays behind, your warm bladder behaves like a petri dish. Bacteria grows. The most common culprit, E. coli lives around your anus and can wander up your urethra in several ways: from wiping, from, pardon the expression, “skid marks” on your underpants, from sexual activity, especially if you wear a diaphragm, or along the side of a urinary catheter. Flushing your urinary tract by drinking water is one of the best ways to prevent and cure UTI’s.
Symptoms: Sometimes it is difficult for a woman with a pelvic mesh implant, or sling, to determine if her bladder pain is from an infection or because mesh by itself is irritating her bladder. Ordinarily, signs of a bladder infection include a frequent urge to urinate, pain and burning while urinating, increased night-time urination, lower abdominal pain, cloudy urine with a foul odor, or blood in urine. If she has mesh, she may have many of these symptoms. If the infection travels up to the kidneys, symptoms include fever, nausea, and chills as well as flank pain on either side. Kidney infections, like pyelonephritis, can become a very serious very quickly. If you have kidney symptoms, see a physician immediately.
Transvaginal mesh can become brittle and crack in the body, slicing nearby organs and may move from where it was implanted to the lower urinary tract where it can introduce infections. The sling or tape creates and ideal hiding place for bacteria, sometimes rare bacteria which is hard to treat. People who take antibiotics frequently for UTI’s are at risk of developing antibiotic-resistant bacterial infections. Self care: You can buy a kit to test your own urine if you think you have a UTI and want to be sure. Knowing how to recognize an oncoming UTI and treating it conservatively can help you avoid the use of repeated antibiotics.
Flushing is your first line of defense. “The solution to pollution is dilution.” Flushing dilutes the numbers of bacteria and allows you body’s normal defenses a chance to work. Drink at least 8 glasses of water every day—not soda, fruit juice (other than cranberry) or milk of coffee—water. There is one important exception to this: If your physician put you on a strict fluid restriction because of kidney disease, please follow his/her instructions because your body handles fluids differently.
Cranberry juice is recommended because it has been proven to make an environment in your urine where bacteria can’t thrive. Putting a cup of unsweetened cranberry juice into 2 quarts of water will take care of both the flushing and infection. If you can’t tolerate the taste, pharmacies and some grocery stores sell cranberry capsules.
If your condition worsens or lingers more than a few days, it is important to see your health care provider about appropriate medications including antibiotics. UTIs when left untreated can escalate quickly and cause kidney damage or kidney failure. Prevention: To prevent future infections, be diligent about making sure your bladder is fully empty, flush it with water all the time, wipe from front to back and, if you have fecal incontinence (those stained panties), use baby wipes or feminine cleansers to be sure you are completely clean after moving your bowels, minimize the use of catheters, and try not to take antibiotics unless it is absolutely unnecessary. Non-bacterial UTI’s: Sutures and parts of mesh slings have been found inside the bladder after pelvic surgeries, causing stones to form and creating symptoms identical to UTI but the urine had no bacteria in it. In most cases, when the foreign material was removed, the symptoms went away.
Mesh removal: When mesh causes structural damage to the urinary tract, removal may be required, along with the appropriate organ repair.
Look forward to more information on antibiotic resistance, and other mesh related topics in upcoming blogs on MeshTroubles.com
This blog contains first-hand opinions about pelvic surgical mesh from a calliope of experience: from 8 years of meetings, phone calls, emails and social network with mesh victims, interviews with surgeons, years of front-line emergency nurse work and early work in biostatistics and medical research, to walking the mesh walk today. I’ve learned about the magnificent inner strength of women facing unparalleled and unimaginable pelvic injuries and, along with it physical, emotional, social and spiritual challenges that would buckle the knees of the bravest soldier. These women inspire me in their tenacity and unwillingness to let go of the true joy in their lives.
To those women, I dedicate this blog.