Women with complications after pelvic mesh implants at increased risk of depression and suicide

Dr. Blayne Welk, a urologist at St. Joseph’s Health Care London, noticed that some of his patients were experiencing depression and other issues following complications related to pelvic mesh-based slings.

“A lot of patients were very emotional telling their story,” notes Dr. Welk.

“They told me about a lot of frustrations related to treatment options for complications. A lot of patients manage for years with problems and didn’t know the source of the issue, or that there is something that can be done to address it. Unfortunately, there are some cases where we can’t fix all the complications, but there are things that we can do to improve the situation. I think a lot of women get frustrated along the journey of finding that solution.” 

Women with stress urinary incontinence leak urine when they cough, sneeze, laugh or are physically active. Mesh slings are made of synthetic polypropylene, a type of plastic, which are surgically implanted in the vaginal wall to treat urinary leakage. Mesh-based incontinence slings account for more than 90 per cent of incontinence procedures in women, and are associated with uncommon but potentially significant complications.

Dr. Welk is also an adjunct scientist with ICES, associate scientist at Lawson Health Research Institute and assistant professor at Western University’s Schulich School of Medicine & Dentistry. Following his observations in the clinic, he led a research project to study the impact of the complications some women were facing. 

“There have been regulatory warnings and lawsuits related to significant transvaginal mesh complications. We wanted to quantify the serious psychological complications that can occur in women as a result of complications from transvaginal midurethral slings,” said Dr. Welk.

Complications are rare but when they happen they can be difficult and challenging to fix, as well as quite impactful for patient lives. They can experience chronic pain, new or changing urinary symptoms and erosions where some of the mesh becomes exposed in surrounding tissue. 

To determine whether women who experience midurethral sling mesh complications requiring surgical intervention have an increased risk of depression or self-harm behaviour, Welk's team tracked the number of Ontario women who needed a follow-up surgery to remove or fix a mesh implant and if they received treatment for depression or self-harm. The study, published in the journal JAMA Surgery, included almost 60,000 women who had the procedure January 2004 through December 2015.

The researchers found that 2. 8 per cent (1586 women) underwent a surgical procedure for a mesh complication. Of those women, 11 per cent (175 women) were treated for depression compared to eight per cent of women (4,470) who didn’t have corrective surgery. Of the women who needed corrective surgery, 2.77 per cent of women suffered from self-harm behaviour compared to only 1.15 per cent of women who did not need corrective surgery. These risks were highest in younger women, in particular those 46 years old and younger.

“Younger women are the ones who are most at risk of these mental health complications. We suspect that’s because of a stronger negative association between the complications and intimacy among this age group. They are also more likely to still be working full-time and raising children.”

The study reinforces some of the consequences that can occur from slings, and that those can be quite serious. 

“It is important to note that a lot of women are going into these operations to improve their quality of life. It’s not necessarily a dangerous condition when you have stress incontinence. There is a decision made to treat it. I think that in those rare cases when someone does experience severe complications, it can lead to decisional regret.”

There is often not an easy solution, with patients often requiring multiple different therapies to address the complications. This can include pain management, surgery, consultations with pain specialists and psychological support along the way. In some cases, removing the mesh does not resolve the pain and it can be very difficult to identify which individuals will benefit from what therapy, including surgery, notes Dr. Welk. 

The researchers add that when women experience midurethral sling complications, both they and their surgeons should be aware of the potential serious psychological impact of these complications.

The article “Midurethral sling complications and the risk of new onset depression or self-harm” is published in JAMA Surgery.

Author block: Blayne Welk, Jennifer Reid, Erin Kelly, You (Maria) Wu.