A recent published joint statement by the American Urogynecologic Society (AUGS) and the International Urogynecological Association (IUGA) on the management of mesh-related complications in women who have been treated for pelvic organ prolapse (POP) or stress urinary incontinence (SUI) highlighted multiple gaps in evidence related to the evaluation and management of mesh exposure and mesh-related pain.[1] The detection of vaginal mesh exposure can be challenging due to intolerable pain, distorted anatomy such as a long and narrow vagina, or subtle findings that may go unnoticed. Imaging such as translabial ultrasonography (TLUS) and magnetic resonance imaging (MRI), while excellent for determining the type and course of the mesh material, or any associated complications, are not reliable modalities to detect mesh exposure.[2,3] 

Our group has used vaginoscopy – an office-based evaluation of the vaginal walls and apex with a flexible scope – as a simple and easily tolerated outpatient procedure to inspect the vagina in cases of suspected mesh/suture exposure without need for anesthesia.  Because there is a paucity of data on the use of vaginoscopy in general, and none on its use in mesh-related complications, we present our experience with this technique along with corroborative findings at the time of mesh-related surgical repairs.

An IRB-approved review of an electronic medical record database at a tertiary care center provided the list of all vaginoscopy procedures performed by a single FPMRS specialist since 2014. Demographics, indications for vaginoscopy, and findings were collected by a neutral investigator not involved with the care of these patients. Duplicates, unattainable medical records due to death, incomplete vaginoscopy results, and cases with lack of documented operative room corroborative information were excluded. Detected exposures were further reviewed for type/location of exposure, surgical approach, additional imaging (TLUS and MRI), and intraoperative findings for corroboration. All surgical procedures were performed by a FPMRS-certified surgeon. 

The procedure was performed with a flexible cystoscope, frequently after a concurrent cystoscopy but can be done independently. Vaginal compartments are sequentially evaluated and all findings including exposures are photographed and documented into the patient’s medical chart. Example findings are depicted in Figure 1. The entire procedure is typically performed in 1-2 minutes without any complications.

From 2014 to 2020, 178 vaginoscopy report were queried. Of those, four were duplicates, four were incomplete, one was unattainable, and ten were for other indications such as confirming a vesico-vaginal fistula site. The final study group consisted of 159 vaginoscopies that were conducted in 138 women. The majority of patients were Caucasian (87%) with a median age of 59 years and median BMI of 27.4. The majority of patients were post-menopausal (88%) and status-post hysterectomy (89%). Presenting symptoms prompting vaginoscopy included dyspareunia (46), hispareunia (6), vaginal bleeding or discharge (24), or pelvic pain (31). Multiple symptoms were present in 63%. 

The total yield in detecting mesh/suture exposure was 32% (51/159): 33% (23/71) without prior removal attempts and only vaginal complaints, 37% (18/49) with history of prior surgical mesh/suture removal, 38% (10/26) with history of prior office mesh removal and none (0/13) to when evaluating bladder mesh complications. The median years since mesh placement was 7.5 years and prior removal (n = 28) was 2.8 years. Nearly half of patients also had TLUS and/or MRI as part of their evaluation for mesh-related complications. Amongst those, only 3 exposures were suspected – all by TLUS and all involved a mesh sling. The apex was the most common site of exposure (63%). Mesh/suture removal was mostly performed via a vaginal approach (90%), with 93% corroboration with office-based findings. Figure 2 depicts the findings, imaging, and approach to management.

In this study, we observed the yield of vaginoscopy in detecting mesh/suture exposure not identified during routine examination due to pain or anatomical limitations to be 32% with 93% surgical corroboration. These findings indicate that vaginoscopy is useful to determine the location and type of mesh/suture exposed prior to surgery and can influence both patient counselling and surgical planning. 

Our findings suggest that women who present with vaginal symptoms (such as pain/dyspareunia, bleeding/discharge, or hispareunia) with a history of mesh implantation (regardless of the initial date of placement) may benefit from vaginoscopy to evaluate the possibility of mesh or suture exposure. In addition, when presented with a prior history of mesh/suture excision or removal of up to three years, vaginoscopy may be useful to verify healing of prior exposure as well as evaluate for possible new sites of exposure. However, in patients with exposed bladder mesh, our findings suggest that concurrent vaginoscopy will not yield findings unless other indications exist.
 
The predominant site of exposure detected by vaginoscopy was the vaginal apex. Depending on the length of the vagina and the prior procedure performed, this area can be the most difficult one to thoroughly assess during a routine pelvic examination. Mesh sacrcocolpopexy procedures can stretch the vaginal length and exposures often occur high at the apex. Some sutures are just abutting the surface and may be difficult to identify with a speculum examination. While transvaginal mesh exposures usually occur along the vaginal walls, pain is often times the limiting factor during attempted pelvic exam. Our findings suggest that vaginoscopy can overcome these limitations of pain and anatomical constraints.

Office-based vaginoscopy is a quick and easily tolerated procedure to exclude, detect, or confirm mesh or suture exposure in selected women, especially those with vaginal symptoms (pain, narrow vagina, and difficult exam) or prior mesh-removal attempts with apical exposures. By locating the site, nature, and extent of the exposure, vaginoscopy aids in surgical planning and patient counselling of mesh-related complications.

Developed by the Joint Writing Group of the American Urogynecologic Society and the International Urogynecological Association. Joint position statement on the management of mesh-related complications for the FPMRS specialist. Int Urogynecol J. 2020;31(4):679-694.
Staack A, Vitale J, Ragavendra N, Rodríguez LV. Translabial ultrasonography for evaluation of synthetic mesh in the vagina. Urology. 2014;83(1):68-74.
Khatri G, Carmel ME, Bailey AA, et al. Postoperative Imaging after Surgical Repair for Pelvic Floor Dysfunction. Radiographics. 2016;36(4):1233-1256.