Postural perineal pain associated with perforation of the lower urinary tract due to insertion of a tension-free vaginal tape
Article first published online: 22 DEC 2003
BJOG: An International Journal of Obstetrics & Gynaecology
Volume 110, Issue 1, pages 79–82, January 2003
How to Cite
Hilton, P., Mohammed, K. A. and Ward, K. (2003), Postural perineal pain associated with perforation of the lower urinary tract due to insertion of a tension-free vaginal tape. BJOG: An International Journal of Obstetrics & Gynaecology, 110: 79–82. doi: 10.1046/j.1471-0528.2003.02056.x
- Issue published online: 22 DEC 2003
- Article first published online: 22 DEC 2003
- Accepted 21 August 2002
The tension-free vaginal tape operation was described by Ulmsten et al.1 in 1996, who found an 84% subjective and objective cure rate at two years, with no significant operative or post-operative complications. Preliminary results from a UK randomised comparative trial have been published2,3, and follow up studies up to five years have been published from Scandinavia4–7. All reports have described similarly encouraging results with few complications, and some 250,000 procedures have now been undertaken worldwide. Operative bladder injury has been reported in up to 9% of procedures, although this is generally held to be of little long term significance. If perforation is recognised by cystourethroscopy at the time of surgery, the tape may be repositioned and the bladder drained for 24–48 hours with minimal risk. If perforation goes unrecognised, considerable morbidity may be associated. We report two cases of overlooked operative perforation of the lower urinary tract, causing perineal pain related to posture.
A 48 year old parous woman complained of difficulty in voiding urine and vaginal pain, which had developed following insertion of a tension-free vaginal tape in July 1999. She was seen initially in July 1998 with a four-year history of stress incontinence. The tension-free vaginal tape operation was carried out apparently uneventfully under spinal anaesthesia. Cystoscopy was undertaken after each needle passage, with no sign of bladder injury. A Foley catheter was left in situ for six hours following her operation, until normal bladder sensation had returned. Following removal of the catheter, the woman was unable to void and complained of suprapubic pain and discomfort in the position of the vaginal incision. Intermittent catheterisation was carried out, and when she remained unable to void 48 hours later, she was taught clean intermittent self-catheterisation. Seven days post-operatively, cystoscopy was carried out. No abnormalities were identified in the vagina, bladder or urethra, although ‘a small ridge’ was palpable within the urethra; urethral dilatation to Hegar 11 was undertaken.
Over the next six weeks, she continued to complain of vaginal and perineal pain, dysuria, urgency and urge incontinence. Repeat urodynamic investigation was undertaken eight weeks post-operatively. There was considerable difficulty inserting the catheters. The bladder was stable on filling and on provocation, and no genuine stress incontinence was identified. The maximum voiding pressure was 55 cm H2O, the peak urine flow rate was 2 ml/s and the residual urine volumes were 220 and 320 ml.
Cystoscopy and urethral dilation was repeated 11 weeks after her initial operation. Again, the findings were reported as being normal. An incision was made in the anterior vaginal wall over the mid-urethra. A small section of tape, described as ‘a very tiny 0.5 cm piece of tape—barely recognisable as such’ was excised. The bladder was opened during this procedure and repaired using 2/0 chromic catgut sutures.
She was referred to our unit 12 months following insertion of the tension-free vaginal tape. She continued to complain of pain in the suburethral area. This was present all the time, but was maximal on standing, reduced to a slight ache on sitting and was minimal when supine. She and her partner both reported a sensation of discomfort in the region of the tape during intercourse. She experienced both urge and stress incontinence, but felt these were improving with time; there was still marked hesitancy and impairment of urinary stream. On vaginal examination, there was slight irregularity of the anterior vaginal wall, but there is no undue scarring, inflammatory change, or indication of erosion of the tape. Digital elevation of the urethra retropubically, particularly on the right side, replicated her pain.
Urine culture was negative, and X-rays of the pubic symphysis showed no indication of osteitis. After lengthy counselling, arrangements were made for a further examination under anaesthesia, cystourethroscopy, exploration of the suburethral area and possible further excision of the tape. On introduction of the cystoscope, a marked ‘catch’ was noted in mid-urethra; the urethra was injected, and, only with difficulty, the tension-free vaginal tape was found within the folds of the urethral wall, crossing the lumen from dorsal to ventral aspects. An inverted U-shaped incision was made in the anterior vaginal wall, and a posteriorly based flap was raised. The right para-urethral space was explored and the tape was located and divided laterally at the level of the inferior pubic ramus. The tape was traced medially to the point where it entered the dorsal aspect of the urethra. Having mobilised the tape, traction was applied, and the tape divided where it exited ventrally, to enter the left side of the retropubic space. The urethral wall was repaired with two layers of interrupted 2/0 polyglactin sutures, and a Martius graft, fashioned from the left labium majus, was passed subcutaneously to overly the site of the repair.
Despite local discomfort in the graft site, she reported immediate relief of her perineal pain. When the suprapubic catheter was clamped on the 12th post-operative day, she voided spontaneously and reported marked improvement in her urine stream. The volumes voided were up to 520 ml, with residual urine volumes consistently less than 50 ml. At her follow up visit, the woman reported complete remission of her vaginal pain. She experienced occasional stress incontinence, although the urgency and urge incontinence had resolved.
A 40 year old parous woman was referred with recurrent urinary infection, persistent dysuria and perineal pain, which had all developed following insertion of a tension-free vaginal tape 15 months earlier. Her past history included a total abdominal hysterectomy and two anterior colporrhaphies, both carried out for concurrent urinary incontinence and vaginal prolapse. Urodynamic investigation had confirmed a diagnosis of genuine stress incontinence, with a stable bladder and normal voiding. The tension-free vaginal tape operation was carried under local anaesthesia with sedation. The procedure was uneventful and she was discharged the following day. At her follow up visit, she reported complete relief of her stress incontinence, but had had several episodes of urinary infection. After the fourth episode, antibiotic prophylaxis was instituted and cystoscopy was undertaken, with normal findings.
On referral to our department, she reported dysuria occurring during every act of micturition from the day of her operation and also perineal pain. The latter occurred specifically on sitting down and generally eased after a few minutes; she was pain-free in the erect position. On vaginal examination, there was no sign of erosion of the tape and no local swelling to suggest haematoma or infection. On palpation, there was an area just below the bladder neck, to the right of the midline, where she experienced exquisite tenderness; she reported this to be exactly the same as the discomfort she experienced on sitting.
Examination under anaesthesia and cystourethroscopy were undertaken. There was no sign of tape erosion within the vagina, although on cystoscopy, there was an area of perforation or erosion on the right lateral wall of the bladder, with the encrusted tension-free vaginal tape visible.
The woman was re-admitted for exploration, with a view to partial excision of the tension-free vaginal tape. The retropubic space was opened, dividing the rectus abdominis muscle from the pubis symphysis. The tape was identified on the right side, over the ileopectineal ligament, and traced down to where it entered the bladder (Fig. 1). The bladder was opened, and the tape along with the surrounding margin of bladder wall was excised; the tape was then divided below the level of the perforation. The bladder was closed with a single layer of continuous 2/0 polyglactin suture and drained by a urethral Foley catheter. Her post-operative course was uncomplicated. She passed urine normally when the catheter was removed on the fifth day and she reported immediate relief of her perineal pain. At her follow up visit, the woman did not complain of stress or urge incontinence and was voiding without difficulty. She had experienced no further perineal pain and no episodes of urinary infection.
The complications of surgery for genuine stress incontinence have recently been reviewed by Chaliha and Stanton8. Pain has been reported in 12% of women following colposuspension9–11 and 10% following needle suspension procedures. This is characteristically described in the site of the suspensory sutures and may be due to traction on muscle, nerve entrapment or local inflammatory change8,11. This phenomenon has not been previously reported in association with the tension-free vaginal tape. The site and quality of the pain and its mechanism in these cases appear to be different from that of the post-colposuspension syndrome9.
Most previous reports have suggested that the risk of erosion of the tension-free vaginal tape is extremely low, although a number of cases of both early and late transurethral migration of the tension-free vaginal tape have recently been recorded12–14. In both our cases, the women reported pain on the first day following their operation, which persisted until removal of the tape. This would seem to suggest that, in both women, the pain resulted from undetected operative injury rather than erosion. We can only speculate on the origin of the pain. In the first case, the tape penetrated the urethra and the pain occurred on standing, persisting until the woman changed her posture. In the second case, the tape penetrated the bladder and pain was reported on sitting, which eased after a few minutes, and settled completely on assuming the standing position. This would suggest that the pain might relate to traction or shearing effects of the tape against the wall of the lower urinary tract with changing intra-abdominal pressure. While late erosion of the tension-free vaginal tape cannot be excluded, we think that not only was urinary tract perforation likely to have arisen and been overlooked during surgery in these cases, but was also overlooked on at least one further endoscopic examination. The tension-free vaginal tape has been marketed as a simple, minimal access, ambulatory procedure. The assumption is often made that it is an easy operation for the generalist gynaecologist or urologist to perform. The introduction of the procedure in Scandinavia has been very carefully regulated, and this may contribute to the lack of reported complications. Similar regulation has not necessarily been applied in all parts of the world where the tension-free vaginal tape is now marketed. The operation is relatively straightforward for surgeons with experience of sling operations or needle suspension or of working in the retropubic space, with training in cystourethroscopy; but the operations may not be straightforward for surgeons without this experience. When cystourethroscopy is performed, either per-operatively or for the assessment of symptoms, the entire surface of the bladder should be inspected using a 70° telescope and the urethra should also be carefully visualised using a 0° or 12° telescope.
- 3A randomised trial of colposuspension and tension-free vaginal tape (TVT) for primary genuine stress incontinence—2 year follow-up [editorial]. Int Urogynecol J Pelvic Floor Dysfunct 12 3 Suppl 1 2001: S7., .