Section Four: Treatment Protocols - Chronic Pelvic Pain with Synthetic Vaginal Mesh

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Treatment protocols for chronic pelvic pain, associated with use of synthetic vaginal mesh begin with a pudendal MRI, often performed in a hospital setting. During that visit, the patient sees a physical therapist who performs an assessment of the patient’s pelvic floor muscles and the pelvic nerves. On the following day, the patient is seen by the physician who has the results of the MRI and the assessment by physical therapist.
If the patient has demonstrated significant pelvic floor muscle spasm, she is scheduled the patient for Botox injection. She is also given vaginal suppositories with Valium and baclofen, which seem to work well for relieving pelvic floor muscle spasms.
“After waiting two weeks for the Botox to really start working, if the patient has relief of pain, then we do not do anything else.”
-Michael Hibner, M.D.
Pelvic Pain Specialist
If a woman does not have a relief of pain with Botox treatments, then the next step in treatment protocol can be three CT-guided pudendal nerve blocks. These are performed by interventional radiologist, under local anesthetic and a steroid. The goals of this procedure is to diagnose pudendal neuralgia to deliver steroid to treat the pain.
“If a woman only has a relief of pain maybe a week or two, then that’s not good enough. But I do have women where they had months of pain relief. In those women I would not offer them surgery. I would just say come here twice a year and get your pudendal nerve block.”
-Michael Hibner, M.D.
Pelvic Pain Specialist
For a woman suffering with chronic pelvic pain following the use of synthetic mesh or sling, If nothing else has helped, in terms of a pudendal nerve block or Botox injections, treatment protocol calls for surgical removal of the mesh, a procedure that can last 6 to 8 hours.
“I strongly believe that the entire mesh has to be removed meaning not only the part that is in the vagina but also the arms of the mesh that go deep into the body. And that can only be achieved if the surgery is done both vaginally and intra-abdominally. “
-Michael Hibner, M.D.
Pelvic Pain Specialist
In addition to removal of the mesh, in this surgery, treatment protocols include a procedure for urinary incontinence. It is called a Burch Procedure, which is a traditional anti-incontinence surgery.
“(This procedure) was almost abandoned when the meshes came on the market. I do this to prevent the patient from having urinary leakage.”
-Michael Hibner, M.D.
Pelvic Pain Specialist
If the chronic pelvic pain continues, following mesh removal, nerve blocks and botox injections, treatment protocol addresses nerve compression. Evaluation and treatment involves surgery and the use of ultrasound-guided selective blocks of the branches of the pudendal nerve.
“We can block the perineal branch or the clitoral branch. We’re not that good blocking the rectal branch. So if based on those selective blocks, which of the blocks gives a woman pain relief, we then proceed with surgical decompression.”
-Michael Hibner, M.D.
Pelvic Pain Specialist
Selective terminal branch blocks of the pudendal nerve are performed to determine where decompression needs to take place.
“We do a nerve wrap at the end of the surgery to prevent the nerve from scarring.
-Michael Hibner, M.D.
Pelvic Pain Specialist
Activated platelet plasma can also be introduced that contain growth factors to promote the growth of nerve cells that produce myelin, which is the outside coating of the nerve.
“We use the activated platelets to again speed up or promote nerve healing.”
-Michael Hibner, M.D.
Pelvic Pain Specialist
With this procedure, treatment protocol recommends the placement of a Marcaine pain pump next to the nerve. It drips Marcaine on the nerve for about two weeks after surgery. Its purpose is to desensitize the nerve and spinal cord.
“I believe that patients that have severe neuropathic pelvic pain, they can develop a central sensitization phenomenon in the spinal cord, which is somewhat like a
a phantom pain or program pain.”
-Michael Hibner, M.D.
Pelvic Pain Specialist
During this procedure, treatment protocal includes ketamine infusions, which is a medication that is known to reverse the central sensitization of the nervous system.
“I think the neuropathic pelvic pain is like having CRP, the complex regional pain or a reflex sympathetic dystrophy of the pelvis. That’s why the patients get ketamine infusion. We usually keep them in the hospital for a day or two on fairly high-dosed ketamine infusion to reduce that RSD symptoms.”
-Michael Hibner, M.D.
Pelvic Pain Specialist
In cases of continued chronic pelvic pain after synthetic mesh use following mesh removal, nerve blocks, botox injections, nerve decompression, and ketamine infusions, treatment protocol focuses on periodic ketamine infusions.