Which specialist should I refer a female patient with suspected transvaginal mesh erosion, recurrent urinary infections, and possible bladder or urethral fistula to for evaluation and management?

Specialist Referral for Transvaginal Mesh Complications

Refer this patient to a urologist with specialized training and experience in mesh complications, or to a Female Pelvic Medicine and Reconstructive Surgery (FPMRS) specialist for comprehensive evaluation and surgical management. 1, 2, 3

Primary Referral Pathway

Urologist as First-Line Specialist

• Urologists with mesh complication expertise should be the primary referral for suspected mesh erosion into the bladder or urethra, as these complications require endoscopic evaluation and often transurethral resection of exposed mesh material 2, 3, 4
• The combination of recurrent UTIs, suspected mesh erosion, and possible fistula formation represents mesh-related complications that typically require surgical intervention best suited to urologists trained in this specific area 3
• Mesh encountered within the urinary tract must be fully excised, which requires urologic surgical expertise 3

FPMRS Specialist as Alternative or Co-Management

• FPMRS specialists are board-certified in managing complex pelvic floor complications including mesh-related problems 5
• These subspecialists can provide comprehensive multicompartment assessment, as mesh complications often involve multiple pelvic compartments simultaneously 6
• FPMRS specialists manage the full spectrum of mesh complications including vaginal exposure, persistent pain, and urinary tract erosion 3

Diagnostic Evaluation Required

Imaging Studies

• Transvaginal ultrasound (TVUS) has high sensitivity for detecting implanted mesh and slings, with studies showing only 72% of mesh visible on TVUS was detected on physical examination alone 1
• TVUS can identify mesh extrusion and assess the relationship of mesh to anatomic structures that may be causing symptoms 1
• MRI pelvis provides optimal soft-tissue contrast for evaluating vesicovaginal fistulae and complex mesh complications, with equal sensitivity to CT and superior surgical planning information 1

Endoscopic Evaluation

• Cystourethroscopy is mandatory to visualize mesh erosion into the bladder or urethra, assess for bladder calculi formation (which develop in >3 months if mesh exposed), and plan surgical approach 4, 7
• Comprehensive urethroscopy in addition to cystoscopy is essential, as urethral erosions can present with atypical symptoms including recurrent stress incontinence 7

Clinical Presentation Patterns

Mesh Erosion Symptoms

• Vaginal discharge, dyspareunia, pelvic pain, recurrent UTIs, hematuria, dysuria, frequency, and urgency are the most common presenting symptoms 3, 4
• Patients may be completely asymptomatic despite significant mesh exposure 3
• Bladder calculi develop on exposed mesh material in nearly all cases when mesh has been present >3 months, typically visible on plain X-ray 4

Fistula Considerations

• Vesicovaginal and urethrovaginal fistulae represent severe mesh complications requiring specialized surgical repair 1
• MRI is equally sensitive to CT for evaluating these fistulae and provides superior multiplanar imaging for surgical planning 1

Management Algorithm

Initial Conservative Approach (Limited Applicability)

• Small asymptomatic mesh exposures (<0.5 cm) may be treated conservatively with observation 3
• However, this patient's presentation with recurrent UTIs and suspected fistula indicates symptomatic disease requiring surgical intervention 3

Surgical Management Pathway

• Most patients ultimately require partial or complete mesh excision 3
• Endoscopic management includes cystoscopy with cystolithopaxy for bladder stones, followed by transurethral resection of visible mesh into the detrusor muscle 4
• Some patients require multiple endoscopic procedures or subsequent open surgery for complete mesh removal, particularly for persistent pain 4
• All intravesical tape must be removed endoscopically; intraurethral mesh may require specialized techniques including urethral speculum-assisted direct vision excision 4

Critical Clinical Pitfalls

Delayed Recognition

• Unrecognized tape perforation or erosion must be considered in any woman with persistent urinary symptoms, infection, or pain after mid-urethral sling procedures 4
• Presentation can occur from 8 weeks to 18 months (or longer) after initial mesh placement 4
• Multiple perforation sites are common—in one series, 6 of 9 women had perforations at more than one site 4

Incomplete Evaluation

• Physical examination alone is insufficient—72% of mesh visible on ultrasound was not detected clinically 1
• Cystoscopy without comprehensive urethroscopy may miss urethral erosions 7

Specialist Selection

• Primary care physicians commonly refer mesh complications to general urology (29%) or general Ob/Gyn rather than FPMRS specialists (25%), despite FPMRS training specifically addressing these complications 5
• Evidence supports that mesh complications are best managed by urologists or FPMRS specialists with specific training and experience in this area 3

Post-Excision Expectations

• Recurrent stress urinary incontinence occurs in essentially all patients after tape division or excision 4
• Persistent pain may continue in up to 50% of patients even after complete mesh excision 3
• Patients require counseling about these outcomes before surgical intervention 3, 4