Innovation Breeds Innovation: How Pelvic Floor Ultrasound Filled the Diagnostic Gap for Vaginal Mesh Kit Complications

  • Jonia Alshiek
  • S. Abbas ShobeiriEmail author


The use of vaginal mesh kits in urogynecologic and urologic practice increased rapidly in the past two decades, followed by a high rate of previously unencountered complications for most practicing urologists and urogynecologists. Defining the problem in such instances is crucial for formulating a treatment plan. Ultrasound was becoming slowly popular with urogynecologists for diagnosis of vaginal birth-related pelvic floor trauma at the time vaginal mesh kits were introduced to the market. Because MRI and CT scans were unable to see the mesh, ultrasound filled this niche as the only modality that could see the mesh clearly. Further innovations in ultrasound technology such as the introduction of 3D endovaginal probes revolutionized the imaging and management of vaginal mesh kit complications.

This chapter will introduce the reader to the history of various vaginal meshes, with a brief overview of ultrasound methodology, and a rich collection of ultrasound images illustrating how ultrasound can augment regular physical examination to provide an accurate diagnoses and better therapeutic management of mesh complications.


Endovaginal ultrasound (EVUS) Endoanal ultrasound (EAUS) Ultrasound Instrumentation Mesh Kits Mesh complications 


  1. 1.
    Schuettoff S, Beyersdorff D, Gauruder-Burmester A, Tunn R. Visibility of the polypropylene tape after tension-free vaginal tape (TVT) procedure in women with stress urinary incontinence: comparison of introital ultrasound and magnetic resonance imaging in vitro and in vivo. Ultrasound Obstet Gynecol. 2006;27(6):687–92.CrossRefGoogle Scholar
  2. 2.
    Fischer T, Ladurner R, Gangkofer A, Mussack T, Reiser M, Lienemann A. Functional cine MRI of the abdomen for the assessment of implanted synthetic mesh in patients after incisional hernia repair: initial results. Eur Radiol. 2007;17(12):3123–9.CrossRefGoogle Scholar
  3. 3.
    Manonai J, Rostaminia G, Denson L, Shobeiri SA. Clinical and ultrasonographic study of patients presenting with transvaginal mesh complications. Neurourol Urodyn. 2016;35(3):407.CrossRefGoogle Scholar
  4. 4.
    Tunn R, Picot A, Marschke J, Gauruder-Burmester A. Sonomorphological evaluation of polypropylene mesh implants after vaginal mesh repair in women with cystocele or rectocele. Ultrasound Obstet Gynecol. 2007;29(4):449–52.CrossRefGoogle Scholar
  5. 5.
    Denson L, Shobeiri SA. Three-dimensional endovaginal sonography of synthetic implanted materials in the female pelvic floor. J Ultrasound Med. 2014;33(3):521.CrossRefGoogle Scholar
  6. 6.
    Velemir L, Amblard J, Fatton B, Savary D, Jacquetin B. Transvaginal mesh repair of anterior and posterior vaginal wall prolapse: a clinical and ultrasonographic study. Ultrasound Obstet Gynecol. 2010;35(4):474–80.CrossRefGoogle Scholar
  7. 7.
    Santoro GA, Wieczorek AP, Dietz HP, Mellgren A, Sultan AH, Shobeiri SA, et al. State of the art: an integrated approach to pelvic floor ultrasonography. Ultrasound Obstet Gynecol. 2011;37(4):381–96.CrossRefGoogle Scholar
  8. 8.
    Dietz HP. Mesh in prolapse surgery: an imaging perspective. Ultrasound Obstet Gynecol. 2012;40(5):495–503.CrossRefGoogle Scholar
  9. 9.
    Svabík K, Martan A, Masata J, El-Haddad R, Hubka P, Pavlikova M. Ultrasound appearances after mesh implantation–evidence of mesh contraction or folding? Int Urogynecol J. 2011;22(5):529–33.CrossRefGoogle Scholar
  10. 10.
    Wong V, Shek K, Goh J, Krause H, Martin A, Dietz H. Cystocele recurrence after anterior colporrhaphy with and without mesh use. Eur J Obstet Gynecol Reprod Biol. 2014;172:131–5.CrossRefGoogle Scholar
  11. 11.
    Lo T, Ashok K. Combined anterior trans-obturator mesh and sacrospinous ligament fixation in women with severe prolapse-a case series of 30 months follow-up. Int Urogynecol J. 2011;22(3):299–306.CrossRefGoogle Scholar
  12. 12.
    Babalola E, Bharucha A, Melton LJ, Schleck C, Zinsmeister A, Klingele C, et al. Utilization of surgical procedures for pelvic organ prolapse: a population-based study in Olmsted County, Minnesota, 1965–2002. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(9):1243–50.CrossRefGoogle Scholar
  13. 13.
    Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89(4):501–6.CrossRefGoogle Scholar
  14. 14.
    Whiteside JL, Weber AM, Meyn LA, Walters MD. Risk factors for prolapse recurrence after vaginal repair. Am J Obstet Gynecol. 2004;191(5):1533–8.CrossRefGoogle Scholar
  15. 15.
    Smith FJ, Holman CD, Moorin RE, Tsokos N. Lifetime risk of undergoing surgery for pelvic organ prolapse. Obstet Gynecol. 2010;116(5):1096–100.CrossRefGoogle Scholar
  16. 16.
    Margulies RU, Lewicky-Gaupp C, Fenner DE, McGuire EJ, Clemens JQ, Delancey JO. Complications requiring reoperation following vaginal mesh kit procedures for prolapse. Am J Obstet Gynecol. 2008;199(6):678.e1–4.CrossRefGoogle Scholar
  17. 17.
    Brincat C, Lewicky-Gaupp C, Patel D, Sampselle C, Miller J, Delancey JOL, et al. Fecal incontinence in pregnancy and post partum. Int J Gynaecol Obstet. 2009;106(3):236–8.CrossRefGoogle Scholar
  18. 18.
    Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013;30(4):CD004014.Google Scholar
  19. 19.
    U.S. Food and Drug Administration. Update on serious complications associated with transvaginal placement of surgical mesh for pelvic organ prolapse. FDA Safety Communication. 13 Jul 2011.Google Scholar
  20. 20.
    Murphy M, Holzberg A, van Raalte H, Kohli N, Goldman HB, Lucente V, Pelvic Surgeons Network. Time to rethink: an evidence-based response from pelvic surgeons to the FDA Safety Communication: “UPDATE on serious complications associated with Transvaginal placement of surgical mesh for pelvic organ prolapse”. Int Urogynecol J. 2012;23(1):5–9.CrossRefGoogle Scholar
  21. 21.
    Jakus S, Shapiro A, Hall C. Biologic and synthetic graft use in pelvic surgery: a review. Obstet Gynecol Surv. 2008;63(4):253–66.CrossRefGoogle Scholar
  22. 22.
    Horak TA, Guzman-Rojas RA, Shek KL, Dietz HP. Pelvic floor trauma: does the second baby matter? Ultrasound Obstet Gynecol. 2014;44(1):90–4.CrossRefGoogle Scholar
  23. 23.
    Fleischer AC, Harvey SM, Kurita SC, Andreotti RF, Zimmerman CW. Two−/three-dimensional transperineal sonography of complicated tape and mesh implants. Ultrasound Q. 2012;28(4):243–9.CrossRefGoogle Scholar
  24. 24.
    Rostaminia GMJ, Leclaire E, Omoumi F, Marchiorlatti M, Quiroz LH, Shobeiri SA. Interrater reliability of assessing levator ani deficiency with 360° 3D endovaginal ultrasound. Int Urogynecol J. 2014;25(6):761–6.CrossRefGoogle Scholar
  25. 25.
    Rostaminia G, White D, Quiroz L, Shobeiri SA. Is a new high-resolution probe better than the standard probe for 3D anal sphincter and levator ani imaging? Ultrason Imaging. 2015;37(2):168–75.CrossRefGoogle Scholar
  26. 26.
    Rostaminia G, White DE, Quiroz LH, Shobeiri SA. Visualization of periurethral structures by 3D endovaginal ultrasonography in midsagittal plane is not associated with stress urinary incontinence status. Int Urogynecol J. 2013;24(7):1145–50.CrossRefGoogle Scholar
  27. 27.
    Rostaminia G, Peck JD, Quiroz LH, Shobeiri SA. How well can levator ani muscle morphology on 3D pelvic floor ultrasound predict the levator ani muscle function? Int Urogynecol J. 2015;26(2):257–62.CrossRefGoogle Scholar
  28. 28.
    Shobeiri SA, Leclaire E, Nihira MA, Quiroz LH, O’Donoghue D. Appearance of the levator ani muscle subdivisions in endovaginal three-dimensional ultrasonography. Obstet Gynecol. 2009;114(1):66–72.CrossRefGoogle Scholar
  29. 29.
    Shobeiri SA, Rostaminia G, White DE, Quiroz LH. The determinants of minimal levator hiatus and their relationship to the puborectalis muscle and the levator plate. BJOG. 2012;120(2):205–11.CrossRefGoogle Scholar
  30. 30.
    Rogowski A, Bienkowski P, Tosiak A, Jerzak M, Mierzejewski P, Baranowski W. Mesh retraction correlates with vaginal pain and overactive bladder symptoms after anterior vaginal mesh repair. Int Urogynecol J. 2013;24(12):2087–92.CrossRefGoogle Scholar
  31. 31.
    Staack A. Translabial ultrasonography for evaluation of synthetic mesh in the vagina. Urology. 2014;83(1):68–74.CrossRefGoogle Scholar
  32. 32.
    Khatri G, Carmel ME, Bailey AA, Foreman MR, Brewington CC, Zimmern PE, Pedrosa I. Postoperative imaging after surgical repair for pelvic floor dysfunction. Radiographics. 2016;36(4):1233–56.CrossRefGoogle Scholar
  33. 33.
    Maher CM, Feiner B, Baessler K, Glazener CM. Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. Int Urogynecol J. 2011;22(11):1445–57. ReviewCrossRefGoogle Scholar
  34. 34.
    Barski D, Otto T, Gerullis H. Systematic review and classification of complications after anterior, posterior, apical, and total vaginal mesh implantation for prolapse repair. Surg Technol Int. 2014;24:217–24. ReviewPubMedGoogle Scholar
  35. 35.
    Haylen BT, Freeman RM, Swift SE, Cosson M, Davila GW, Deprest J, International Urogynecological Association; International Continence Society, Joint IUGA/ICS Working Group on Complications Terminology, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint terminology and classification of the complications related directly to the insertion of prostheses (meshes, implants, tapes) and grafts in female pelvic floor surgery. Neurourol Urodyn. 2011;30(1):2–12.CrossRefGoogle Scholar
  36. 36.
    Miklos J, Chinthakanan O, Moore R, Mitchell G, Favors S, Karp D, et al. The IUGA/ICS classification of synthetic mesh complications in female pelvic floor reconstructive surgery: a multicenter study. Int Urogynecol J. 2016;27(6):933–8.CrossRefGoogle Scholar
  37. 37.
    Feiner B, Maher C. Vaginal mesh contraction: definition, clinical presentation, andmanagement. Obstet Gynecol. 2010;115(2 Pt 1):325–30.CrossRefGoogle Scholar
  38. 38.
    Letouzey V, De Tayrac R, Deffieux X, Fernandez H. Longterm anatomical and functional results after trans-vaginal cystocele repair using a tension-free polypropylene mesh. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:S82–S3.Google Scholar
  39. 39.
    Hammett J, Peters A, Trowbridge E, Hullfish K. Short-term surgical outcomes and characteristics of patients with mesh complications from pelvic organ prolapse and stress urinary incontinence surgery. Int Urogynecol J. 2014;25(4):465–70.CrossRefGoogle Scholar
  40. 40.
    Jeffery ST, Brouard K. High risk of complications with a single incision pelvic floor repair kit: results of a retrospective case series. Int Urogynecol J. 2014;25(1):109–16.CrossRefGoogle Scholar
  41. 41.
    Lee D, Bacsu C, Zimmern PE. Meshology: a fast-growing field involving mesh and/or tape removal procedures and their outcomes. Expert Rev Med Devices. 2015;12(2):201–16.CrossRefGoogle Scholar
  42. 42.
    Lee D, Zimmern PE. Management of complications of mesh surgery. Curr Opin Urol. 2015;25(4):284–91.PubMedGoogle Scholar
  43. 43.
    Pickett SD, Barenberg B, Quiroz LH, Shobeiri SA, OʼLeary DE. The significant morbidity of removing pelvic mesh from multiple vaginal compartments. Obstet Gynecol. 2015;125(6):1418–22.CrossRefGoogle Scholar
  44. 44.
    Araco F, Gravante G, Sorge R, De Vita D, Piccione E. Risk evaluation of smoking and age on the occurrence of postoperative erosions after transvaginal mesh repair for pelvic organ prolapses. Int Urogynecol J. 2008;19(4):473–9.CrossRefGoogle Scholar
  45. 45.
    de Tayrac R, Sentilhes L. Complications of pelvic organ prolapse surgery and methods of prevention. Int Urogynecol J. 2013;24(11):1859–72.CrossRefGoogle Scholar
  46. 46.
    Huffaker RK, Shull BL, Thomas JS. A serious complication following placement of posterior Prolift. Int Urogynecol J Pelvic Floor Dysfunc. 2009;20(11):1383–5.CrossRefGoogle Scholar
  47. 47.
    Firoozi F, Goldman H. Transvaginal excision of mesh erosion involving the bladder after mesh placement using a prolapse kit: a novel technique. Urology. 2010;75(1):203–6.CrossRefGoogle Scholar
  48. 48.
    Alvarez Garzon HJ, Jacquemet B, Mottet N, Kleinclauss F, Riethmuller D, Ramanah R. Endoscopic lithotripsy and vaginal excision of a calcified bladder-mesh extrusion. Int Urogynecol J. 2016;27(7):1113.CrossRefGoogle Scholar
  49. 49.
    Firoozi F, Goldman HB. Pure transvaginal excision of mesh erosion involving the bladder. Int Urogynecol J. 2013;24(6):925.CrossRefGoogle Scholar
  50. 50.
    Ostergard D, Azadi A. To mesh or not to mesh with polypropylene: does carcinogenesis in animals matter? Int Urogynecol J. 2014;25(5):569–71.CrossRefGoogle Scholar
  51. 51.
    Goldman H, Dwyer P. Polypropylene mesh slings and cancer: an incidental finding or association? Int Urogynecol J. 2016;27(3):345–6.CrossRefGoogle Scholar
  52. 52.
    King AB, Zampini A, Vasavada S, Moore C, Rackley R, Goldman H. Is there an association between polypropylene midurethral slings and malignancy? Urology. 2014;84(4):789–92.CrossRefGoogle Scholar
  53. 53.
    Linder B, Trabuco E, Carranza D, Gebhart J, Klingele C, Occhino J. Evaluation of the local carcinogenic potential of mesh used in the treatment of female stress urinary incontinence. Int Urogynecol J. 2016;27(9):1333–6.CrossRefGoogle Scholar
  54. 54.
    Lone FW, Sultan AH, Stankiewicz A, Thakar R, Wieczorek AP. Vascularity of the urethra in continent women using colour doppler high-frequency endovaginal ultrasonography. 2015. Springerplus 2014;3:619.CrossRefGoogle Scholar
  55. 55.
    Javadian P, Quiroz LH, Shobeiri SA. In vivo ultrasound characteristics of vaginal mesh kit complications. Female Pelvic Med Reconstr Surg. 2017;23(2):162–7.CrossRefGoogle Scholar
  56. 56.
    Javadian P, Shobeiri SA. The disability impact and associated cost per disability in women who underwent surgical revision of transvaginal mesh kits for prolapse repair. Female Pelvic Med Reconstr Surg. 2017 Sept 13; [Epub ahead of print], 1.
  57. 57.
    Neville CE, Fitzgerald CM, Mallinson T, Badillo S, Hynes C, Tu F. A preliminary report of musculoskeletal dysfunction in female chronic pelvic pain: a blinded study of examination findings. J Bodyw Mov Ther. 2012;16(1):50–6.CrossRefGoogle Scholar
  58. 58.
    Abed H, Rahn DD, Lowenstein L, Balk EM, Clemons JL, Rogers RG, et al. Incidence and management of graft erosion, wound granulation, and dyspareunia following vaginal prolapse repair with graft materials: a systematic review. Int Urogynecol J. 2011;22(7):789–98.CrossRefGoogle Scholar
  59. 59.
    Thomson AJ, Jarvis SK, Lenart M, Abbott JA, Vancaillie TG. The use of botulinum toxin type A (BOTOX) as treatment for intractable chronic pelvic pain associated with spasm of the levator ani muscles. BJOG. 2005;112(2):247–9.CrossRefGoogle Scholar
  60. 60.
    Rao A, Abbot J. Using botulinum toxin for pelvic indications in women. Aust N Z J Obstet Gynaecol. 2009;49(4):352–7.CrossRefGoogle Scholar
  61. 61.
    Schnitzler A, Roche N, Denormandie P, Lautridou C, Parratte B, Genet F. Manual needle placement: accuracy of botulinum toxin a injections. Muscle Nerve. 2012;46(4):531–4.CrossRefGoogle Scholar
  62. 62.
    Shobeiri SA, White D, Quiroz LH, Nihira MA. Anterior and posterior compartment 3D endovaginal ultrasound anatomy based on direct histologic comparison. Int Urogynecol J. 2012;23(8):1047–53.CrossRefGoogle Scholar
  63. 63.
    Rostaminia G, White D, Hegde A, Quiroz LH, Davila GW, Shobeiri SA. Levator ani deficiency and pelvic organ prolapse severity. Obstet Gynecol. 2013;121:1017–24.CrossRefGoogle Scholar
  64. 64.
    Shobeiri SA, Rostaminia G, White D, Quiroz LH, Nihira MA. Evaluation of vaginal cysts and masses by 3-dimensional endovaginal and endoanal sonography. J Ultrasound Med. 2013;32(8):1499–507.CrossRefGoogle Scholar
  65. 65.
    Denson L, Shobeiri SA. Imaging of urethral bulking agents: a sonographer’s perspective. J Diagn Med Sonogr. 2013;29(6):255–9.CrossRefGoogle Scholar
  66. 66.
    Yune JJ, Quiroz L, Nihira MA, Siddighi S, O’Leary DE, Santiago A, et al. The location and distribution of transurethral bulking agent: 3-dimensional ultrasound study. Female Pelvic Med Reconstr Surg. 2016;22(2):98–102.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Obstetrics and Gynecology, Inova Women’s Hospital, Virginia Commonwealth UniversityFalls ChurchUSA
  2. 2.Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv UniversityTel AvivIsrael
  3. 3.INOVA Health SystemFalls ChurchUSA

Personalised recommendations