Patel RS, Christie AL and Zimmern PE: Role of of fice-based vaginoscopy in a tertiary care center. Urol Pract 2021; 9: 80.

A 2020 joint statement from the American Urogynecologic Society and the International Urogynecological Association established evidence-based algorithms for managing transvaginal mesh-related complications in women who have been treated for pelvic organ prolapse or stress urinary incontinence.¹ The report identified multiple gaps in evidence regarding the evaluation and management of mesh exposure and mesh-related pain.

Currently, an office-based pelvic examination is the first step to evaluate for mesh-related complications by identifying areas of tenderness/discomfort and mesh exposure. However, if the vaginal examination is limited or not possible due to pain or a narrow introitus, it is recommended that patients undergo an examination under anesthesia if the presenting symptoms are consistent with a possible mesh complication.² Additionally, certain areas, such as the lateral fornices in those with prior transobturator sling placement, may be difficult to visualize during an office-based pelvic examination.³ Imaging such as translabial ultrasonography (TLUS) or magnetic resonance imaging, while excellent for determining the type and course of the mesh material or any associated complications, is not a reliable modality to detect mesh exposure.^4–6

Our group has used vaginoscopy–an office-based evaluation of the vagina with a flexible cystoscope–as a simple, safe, well-tolerated outpatient procedure to inspect for possible mesh/suture exposure without need for anesthesia. In our recent Urology Practice^® article, we review our experience with this technique along with corroborative findings at the time of transvaginal mesh removal surgeries.⁷

To accomplish this, we evaluated all outpatient vaginoscopy procedures and transvaginal mesh removal surgeries performed by a single female pelvic medicine and reconstructive surgery specialist. Vaginoscopy was typically performed in 4 groups of patients. The first group included any patient with a history of mesh sling or mesh prolapse (vaginal, open or robotic) presenting with vaginal complaints such as pressure, pain/dyspareunia, bleeding, discharge, recurrent vaginitis or a report of hispareunia (defined by the International Continence Society as male partner pain with intercourse after female reconstructive surgery). The second group included patients with a history of surgical mesh removal at our institution to verify no mesh exposure recurrence, especially at the apex. The third group of patients had a history of removal or office excision done before at outside institutions to verify that the area of mesh exposure had healed. In the fourth group, vaginoscopy was performed following the evaluation for exposed bladder mesh by cystoscopy to exclude a concurrent vaginal mesh exposure.

The procedure is performed with a flexible cystoscope, frequently after a concurrent cystoscopy, although it may be done independently. Vaginal compartments are sequentially evaluated and findings are photographed and documented in the patient’s medical chart. Examples of vaginoscopy findings are depicted in the figure. The entire procedure is typically performed in 1−2 minutes and is well tolerated, and no complications were observed in our series.

Figure. Examples of vaginoscopy findings confirming mesh surface exposure. a, exposed vaginal mesh sling in lateral sulcus behind granulation polyp causing dyspareunia and vaginal discharge. b, vaginal mesh exposure very high up at right apex after prior abdominal sacrocolpopexy causing episodes of unexplained recurrent vaginal bleeding. c, small mesh exposure at vaginal apex responsible for recurrent vaginitis.

From 2014 to 2020, 159 vaginoscopies were conducted in 128 women. Vaginoscopy was performed twice in 15 patients and 3 times in 8 patients. Presenting symptoms included dyspareunia (46 patients), hispareunia (6), vaginal bleeding (9), vaginal discharge (14) and pelvic pain (31). Many patients (63%) had more than 1 presenting symptom.

The total yield of exposed mesh/suture detection was 32% (51/159 patients), that is 33% of patients (23/71) had no prior transvaginal mesh removal attempts, 37% (18/49) had a history of surgical mesh/suture removal, 38% (10/26) had a history of office transvaginal mesh removal and no patient (0/13) with bladder mesh complications was found to have vaginal mesh exposure on vaginoscopy. Of note, 5/51 patients had a negative pelvic examination for transvaginal mesh exposure that was later found to be positive on vaginoscopy.

Median time was 7.5 years since initial transvaginal mesh placement and 2.8 years since prior removal (28 patients). Nearly half of patients also had TLUS and/or magnetic resonance imaging as part of their evaluation for mesh-related complications. Among those, only 3 exposures were suspected−all by TLUS and all involving a mesh mid urethral sling. The apex was the most common site of exposure (63%). Mesh/suture removal was mostly performed via a vaginal approach (90%), with 93% corroboration with office-based findings.

To our knowledge this is the first large study on the use of office-based vaginoscopy to evaluate transvaginal mesh/suture-related complications. We found that the yield of vaginoscopy to detect mesh or suture exposure not identified during routine examination due to pain or anatomical limitations was 32%, with 93% surgical corroboration.

Our findings suggest that women who present with vaginal symptoms (such as pain/dyspareunia, bleeding/discharge or hispareunia) with a history of transvaginal mesh implantation (regardless of the initial date of placement) may benefit from vaginoscopy to evaluate the possibility of mesh or suture exposure. In addition, when presented with a history of mesh/suture excision or removal within 4 years, vaginoscopy may be useful to verify healing of prior exposure as well as evaluate for possible new sites of exposure.

The apex remains a difficult area to visualize or palpate, especially in patients with a narrow introitus or long, tented-up vagina. Our findings indicate that exposures were detected commonly at the apex and after a median time frame of 7.5 years. Therefore, it is important for any practitioner to keep this timeline in mind and to consider a vaginoscopy in a symptomatic patient with a history of mesh placement for incontinence and/or prolapse when the examination findings are seemingly negative to carefully explore all vaginal walls, including the apex. The CPT® code for vaginoscopy is 57420, with a Medicare fee reimbursement of 1.60 relative value units and a nonfacility price between $118.11 and $166.58, depending on the geographic region.

Office-based vaginoscopy is a safe and simple tool to exclude or detect mesh/suture exposure in selected patients, as well as precisely locate the site/size of exposure to aid in surgical planning to address mesh/suture-related complications.