Neurological assessment, timely diagnosis and treatment for sling complications are important to prevent life-time physical disability or sexual dysfunction.
Retropubic slings causes ilioinguinal neuralgia and Complex Regional Pain Syndrome (CRPS) Type 1 or reflex sympathetic dystrophy (RSD). Transobturator (TOT) slings cause obturator neuralgia, pudendal neuralgia from injury to its main nerve at Alcock’s canal or to its peripheral branch to the clitoris, and CRPS Type 1 or 2. Careful neurological assessment, timely diagnosis and treatment of these pain disorders are important to prevent life-time physical disability and/or sexual dysfunction following sling placement for the surgical management of stress urinary incontinence (SUI).
The symptoms of Ilioinguinal neuralgia following retropubic sling implantation can be intense and debilitating pain due to mechanical compression and traction to the ilioinguinal nerve by the arms of the polypropylene mesh. Sometimes, the pain has been described as being ‘so intense and unbearable that the debilitated patients cannot resume normal daily activities.’ Accurate diagnosis requires careful sensory exam of the perineum and treatment includes mesh revision surgery with care not to sacrifice the nerve during mesh revision surgery, medication management, peripheral nerve injections, regional nerve blocks, cryoablation surgery, and peripheral nerve stimulator placement.
“Timely diagnosis and treatment of neurological complications is necessary to prevent life-time disability and sexual dysfunction.” – Dr. Greg Vigna
Complex Regional Pain Syndrome Type 1 or RSD has been observed in both abdominally placed hernia mesh and vaginal mesh. CRPS Type 1 produces severe pain, allodynia, and hyperalgesia. This pain is often described as burning. Although the precise etiology is not known, it is clear that persistent inflammatory activity has been demonstrated in numerous studies. CRPS Type 1 is also believed to be caused by the lack of oxygen or chronic hypoxia that is observed between the mesh and the body tissues which is referred as the hypoxic interface. This hypoxic interface maintains a perpetual inflammatory state that makes the nerves more prone to produce the spontaneous pain identified in CRPS Type 1. Treatment of mesh related CRPS Type 1 will likely require complete mesh removal, medication management, peripheral nerve blocks, and sometimes peripheral or spinal cord stimulation.
Pudendal neuralgia and obturator neuralgia are the recognized complications of the TOT slings, mini-slings, and the recently banned vaginal mesh devices used for pelvic organ prolapse (POP). These devices have a similar mechanism of injury to the obturator nerve and pudendal nerve in
that these designs require the arms of the devices to be blindly inserted into the obturator internus muscle in the groin which is in very close proximity to these nerves. Damage may occur acutely after surgery or years after implantation as the device degrades and contracts. Complications from the TVM devices previously used for the treatment of POP, in addition to implantation into the obturator internus, also require blind implantation of their arms upon the sacrospinous ligament which is where the pudendal nerve travels. Sacrospinous ligament fixation would acutely cause pudendal neuralgia and incapacitating buttock pain. The pain from obturator and pudendal neuralgia is a severe, life-changing, spontaneous pain and causes burning pain and lancing pain along with allodynia in the distribution of the nerve. This pain makes wearing tight pants nearly impossible. Treatment options for pudendal and obturator neuralgia include complete mesh removal, medication management, peripheral nerve blocks, and sometime peripheral or spinal cord stimulation. Surgery to decompress the obturator and pudendal nerve is sometimes required as well. Unfortunately only a few select physicians in North Carolina are trained to treat mesh related nerve compression.
Greg Vigna, MD, JD, a national pharmaceutical injury attorney says, “It is important for physicians who continue to implant TOT slings and retropubic slings in the treatment of SUI to understand the neuromuscular complications of these devices and provide a careful gynecological and neurological assessment for patients with mesh related nerve injuries as timely diagnosis and treatment of neurological complications is necessary to prevent life-time disability and sexual dysfunction in these women. Failure to timely diagnose ilioinguinal neuralgia after a retropubic sling or pudendal and obturator neuralgia following a TOT sling is unacceptable”.
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