In our practice, we have seen many patients with pain originating after a mesh procedure develop pelvic floor myalgias, pelvic pain, and dyspareunia. A focally painful segment of hardened mesh due to shrinkage of the vaginal mesh implant may lead to primary vaginal pain syndromes and dyspareunia following vaginal mesh use [2]. A recent case series reported high incidence of pain along contracted mesh sites. Severe vaginal pain and focal tenderness are reported which can be reproduced by palpation of the mesh segment. The main clinical features include groin pain, suprapubic pain, dyspareunia, vaginal tightness, severe vaginal pain with movement, and vaginal shortening on vaginal examination. Over-tensioning of the mesh arms during implantation, and collagen deposition and contraction within the mesh pores are reported to be responsible for mesh hardening and nerve fiber entrapment [2]. This complication needs to be more robustly characterized and addressed in all studies reporting outcomes with synthetic transvaginal mesh-augmented prolapse repairs. However, it is difficult to characterize this complication, as the symptoms are often similar to other mesh-related complications or are compounded by chronic pain syndromes or myalgias. The pain syndromes related to mesh, like other pain syndromes, can be debilitating and have a profound adverse psychosocial effect in patients who suffer from it. Thus, treatment of pain related to mesh is typically multimodal and should be promptly recognized and instituted. Muscle relaxants and analgesics may improve pain in some individuals and are frequently first-line therapies. Physical therapy has been shown to improve some myalgias, as well as some neuropathies, and should be attempted prior to more aggressive intervention. In some situations, the mesh is clearly tight and tender, and the pain can be clinically reproduced by palpation of a tight band of mesh on vaginal examination. In these patients, surgical removal of the mesh may be preferred since the removal often has rates of improvement in pelvic pain and dyspareunia exceeding 70% [3]. Dyspareunia related to mesh exposure should typically be treated with surgical revision.

Although clinical examination and urodynamic study are the basic methods in the diagnostics of incontinent women, the significance of perineal pelvic floor ultrasound (pPFUS) is often mentioned in many more recent publications as the method enabling the assessment of the position of the urethra, its anatomical relations, mobility, and hyper-rotation. pPFUS is a widely available diagnostic method that may be performed by every clinician involved in pelvic floor diagnostics; it does not require special transducers and sophisticated scanners. The equipment used for pPFUS is widely accessible in obstetrics, radiology, gynecology, urology, surgery, and other specialties; thus, the access is easy and no extra investment is needed. Ultrasound has been used in the office or the operating room for drainage of hematomas and seromas. This anatomical access, however, does not allow for getting complete information about the complex anatomy of the urethra and its relations to the bladder, elements of the levator ani, and the vaginal walls, including pubocervical fascia. With this knowledge comes the ability to detect the cause of problems that have eluded us and to invent different ways of correcting the root cause of these problems. Two dimensional (2D) or three dimensional (3D) endovaginal ultrasound has become widely available. In a patient with vaginal tenderness and implanted vaginal mesh, one can use an endovaginal or an endoanal probe and map the vagina in a blinded fashion with a long Q-tip. With an endovaginal probe a long Q-tip is introduced along side the probe into the vagina. With an endoanal probe, the Q-tip is visualized vaginally (Fig. 15.2).