Case Report J Clin Gynecol Obstet.

2019;8(1):25-28

Treatment of Mesh-Associated Abscess Using an Incision-

Free Technique: A Case Series
Joseph Panzaa, b, Parisa Samimia, Carl Zimmermana

Abstract ing sinus tract eliminating the need for an incision.

Patients who undergo pelvic mesh placement are at risk for developing
infectious complications. In the case of an abscess associated with the
Case Reports
mesh, removal is often necessary for resolution of the infection. This
report describes two cases of delayed abscesses associated with mesh Case 1
for posterior compartment prolapse and stress urinary incontinence. De-
finitive treatment for both involved complete removal of the offending
portion of mesh without the need for an incision. In patients who de- Case description
velop infectious complications involving pelvic mesh, providers must
consider removal of the mesh as a method for source control. Here, ex- We first present the case of a 70-year-old G3P3003 with a com-
ploration of an existing sinus tract allowed for complete mesh removal plex surgical history involving multiple prolapse and incon-
without the need for extensive dissection. This is especially important tinence procedures, presenting with a recurrent right gluteal
in those with medical comorbidities resulting in poor wound healing. abscess. Her medical history includes hypertension, hyperlipi-
demia, and diverticulitis. In addition to an abdominal hysterec-
Keywords: Pelvic abscess; Pelvic mesh; Surgical technique tomy, her pelvic reconstructive surgical history includes a ret-
ropubic midurethral sling in 2005 followed by a laparoscopic
sacral colpopexy (Gynemesh, Ethicon Inc., Sommervile, NJ,
USA) and transobturator sling (TVT-O, Ethicon Inc., Somer-
Introduction ville, NJ, USA) a year later. She then underwent a rectocele
repair and Avaulta (C.R. Bard, Inc., Murray Hill, NJ, USA)
The use of polypropylene mesh is a mainstay in the treatment mesh procedure with excision of a previously placed sling (it
of stress urinary incontinence (SUI) and is one of the most well is unclear which sling was removed based on the operative
studied surgical modalities in women’s health since its intro- report) and placement of a pubovaginal sling.
duction in the mid-1990s [1, 2]. Mid-urethral slings and pelvic The patient had undergone transcutaneous incision and
mesh for prolapse have undergone a number of permutations drainage of a right ischioanal fossa abscess on two separate
all with the goal of improving surgical outcomes while de- occasions without mesh removal at an outside institution. After
creasing potential complications. Type I mesh remains in use the second procedure, vaginal mesh exposure was noted and
as the standard of care for treatment of SUI [3]. More recently, she was referred to our institution. Initial exam revealed a re-
concerns around the use of synthetic mesh for pelvic organ gion of scarring in the perianal area, to the right of the midline
prolapse (POP) have resulted in a decrease in use [4]. Spe- consistent with an intermittently draining buttock abscess. At
cific concerns include the risks of scaring, exposure, pain, and her initial visit, it was not fluctuant, with no acute inflamma-
infectious complications. In any patient with a foreign body, tion or tenderness. The scarred area was adjacent to one of the
there is risk of long-term infectious complications. We present posterior Avaulta insertion points. In the midline of the distal
two cases of mesh associated with abscess formation remote vagina there was a mesh exposure of approximately 2.0 × 2.0
from initial placement and removed through an existing drain- cm. No other mesh exposures were noted.
At that time, we recommended removal of all graft material
with possible exploration of the right pelvic side wall and right
Manuscript submitted March 1, 2019, accepted March 12, 2019 ischioanal fossa in order to treat and avoid additional recur-
rence of her right buttock abscess. The patient was counseled
aDepartment of Obstetrics and Gynecology, Vanderbilt University Medical that a staged procedure may be necessary to remove all mesh.
Center, Nashville, TN, USA
bCorresponding Author: Joseph Panza, Department of Obstetrics and Gyne-

cology, Vanderbilt University Medical Center, 1161 21st Ave. South B1100 Surgical course
MCN, Nashville, TN 37232-2521, USA. Email: joseph.r.panza@vumc.org

doi: https://doi.org/10.14740/jcgo538 The initial procedure used the exposed vaginal mesh as a start-

Articles © The authors | Journal compilation © J Clin Gynecol Obstet and Elmer Press Inc™ | www.jcgo.org
This article is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International License, which permits 25
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Treatment of Mesh-Associated Abscess J Clin Gynecol Obstet. 2019;8(1):25-28

Figure 2. Ultrasound image of mesh within the left groin abscess.

scopic bilateral salpingo-oophorectomy, retropubic mid-ure-

thral sling (Align, C.R. Bard, Inc., Murray Hill, NJ, USA) in
October 2010 for persistent pelvic pain and SUI. In 2015, she
Figure 1. MRI of left groin abscess with associated inflammation.
presented to her provider at that time for persistent pelvic pain
and was found to have a partial mesh exposure. Approximately
ing point. With gentle traction and a combination of sharp and 4 mm of exposed mesh was excised immediately beneath the
blunt dissection, the mesh was debrided from the surrounding mid-urethra.
tissue to the ischioanal fossa. All visible mesh was removed She presented to our institution with left groin and upper
from the vagina following the procedure. thigh cellulitis. On magnetic resonance imaging (MRI), she
At the patient’s 3- and 6-week post-operative visits, a pus- was found to have a multi-loculated abscess and myositis in
tule over the scarred perianal area was noted. The decision was the left groin involving the left adductor magnus, brevis, and
made to proceed with surgical removal of graft material from longus muscles (Fig. 1). The patient was treated with broad-
the ischioanal area using a transgluteal approach to prevent spectrum antibiotics, but continued to experience left groin
and treat recurrent abscess formation. and thigh pain with persistent abscess. She remained afebrile
Using a bile duct dilation probe, the right buttock abscess with negative blood and urine cultures. On ultrasound imag-
was traced through the ischioanal fossa to the right lateral as- ing, an echogenic structure in the left groin measuring 3.2 ×
pect of the vagina. The tract was opened using a tonsil clamp. 0.6 cm was thought to be consistent with residual transobtura-
Cultures of the area revealed Streptococcus constellatus. The tor mesh. A 3.0 × 3.4 × 2.7 cm abscess was also seen (Fig. 2).
tonsil clamp was then used to explore the sinus tract and easily No mesh could be visualized on internal exam, but a pin point
grasp and remove a 3-cm piece of mesh remaining in the fatty area of friable granulation tissue with purulent drainage was
tissue of the buttock. The area was probed and irrigated and palpated on the left lateral vaginal wall, which was tender on
there was felt to be no more remaining mesh. The tract was exam. A firm mass was palpated in the left groin, consistent
then packed with iodoform packing. with the abscess seen on imaging.
The wound packing was removed in the clinic 2 days after Given the persistent nature of the infection despite intra-
surgery. She was instructed to probe the wound daily with a venous (IV) antibiotics, the patient was taken for exam under
sterile cotton swab to facilitate healing from the base up. At her anesthesia and removal of left graft material.
3-week post-operative visit the wound had healed.

Surgical course
Case 2

Exam under general anesthesia revealed a 0.5-cm area of ul-

Case description cerated tissue on the left lateral vaginal wall. The overlying
epithelium was gently denuded revealing a scant area of white
Similarly, we present the case of a 50-year-old G2P2002 with mesh, which was removed with gentle traction. The entirety
a history of multiple pelvic and incontinence procedures pre- of the left arm of the trans-obturator mesh was believed to be
senting with left thigh myositis, cellulitis, and groin abscess. removed intact (Fig. 3). The operative site was copiously ir-
Her medical history is significant for type 2 diabetes mellitus, rigated.
hepatitis C infection, and active tobacco use. Her pelvic recon- The groin abscess was drained. A small, central fluctuant
structive surgical history involves laparoscopic-assisted vagi- area could be appreciated in the left groin. Approximately 8
nal hysterectomy, transobturator mid-urethral sling (Align, mL of purulent discharge was aspirated. The vaginal epithe-
C.R. Bard, Inc., Murray Hill, NJ, USA), and cystoscopy in lium was not closed, in order to prevent re-accumulation of
March 2010 for symptomatic uterine prolapse, abnormal uter- purulent material, as there was presumed to be a connecting
ine bleeding, and SUI. She subsequently underwent a laparo- tract to the abscess given its location around the graft material.

26 Articles © The authors | Journal compilation © J Clin Gynecol Obstet and Elmer Press Inc™ | www.jcgo.org
Panza et al J Clin Gynecol Obstet. 2019;8(1):25-28

examination. Chronic infection and biofilm formation had

prevented or reversed tissue ingrowth into the polypropyl-
ene netting allowing easy extraction simply by following
the sinus tract. We suggest considering tract exploration in
similar cases before more invasive dissection techniques are
employed.

Acknowledgments

None to declare.

Figure 3. Removed transobturator sling mesh.

Financial Disclosure
Abscess cultures demonstrated mixed bacterial growth,
with no single species isolated. None to declare.

Discussion Conflict of Interest

While the use of transvaginal mesh for POP has decreased, The authors have no conflict of interest or disclosures.
there remains a large cohort of women who have had this
material placed and are at risk for complications in the fu-
ture. The cases presented here highlight the importance of Informed Consent
considering mesh-related infections in patients found to have
a pelvic abscess, specifically in the setting of a draining si- Not applicable.
nus.
Interestingly, both cases involved the use of type 1 mesh,
which historically has less infectious complications due to its Author Contributions
macroporous design and ability to integrate into host tissue. It
is thought that vaginal exposure is the primary risk factor for JP and PS contributed to drafting the article. CZ revised the
infectious complications. Two other case reports were identi- article for critically important content and gave final approval
fied as involving abscesses associated with type 1 mesh. The for submission.
first was associated with a Safyre T adjustable kit (Promedon,
Cordoba, Argentina), which has silicone arms. The patient in
this case had additional risk factors of immunocompromising References
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28 Articles © The authors | Journal compilation © J Clin Gynecol Obstet and Elmer Press Inc™ | www.jcgo.org