FEMALE UROLOGY

Groin pain after a tension-free vaginal tape or similar suburethral sling: management strategies
Duckett JR, Jain S
Department of Obstetrics and Gynaecology, Medway Maritime Hospital, Windmill Road, Gillingham, Kent ME7 5NY, UK
BJU Int. 2005; 95: 95-7

• Objective: To review different treatment strategies for women with groin pain after tension-free vaginal tape (TVT) or similar suburethral sling procedures.
• Patients and Methods: The series comprised 450 women who had a TVT procedure, with a follow-up of 3-50 months. Five women (1%) reported significant groin pain and were offered further treatment. In addition, one woman was referred from another centre and received treatment.
• Results: Women with pain were initially treated conservatively, and in most the pain resolved and required no further treatment. Persistent or severe discomfort was treated with a combined steroid (methyl prednisolone, 2 mL, 80 mg) and local anaesthetic (bupivacaine, 10 mL, 0.5%) injection in four women. There were no side-effects from the treatment. One woman was relieved of her pain and required no further treatment. In one woman the local injections failed to improve her symptoms but the pain was not severe enough to warrant further treatment. Two women developed recurrent pain after an initially successful injection, and in these women the TVT was excised. One woman referred from another centre was primarily treated with TVT excision. In the three women treated with distal tape excision, the mean pain scores decreased from 8.7 before excision to 0.7 afterward. One woman is awaiting tape excision.
• Conclusion: If conservative management fails to relieve the symptoms of groin pain it can be treated by injecting a mixture of steroid and local anaesthetic. However, local injection failed to provide long-term relief in three of four women. More severe symptoms might require TVT mesh dissection and excision, which provided significant pain relief.
  
  
• Editorial Comment
  The authors report on the incidence and management of clinically significant groin pain following a tension-free vaginal tape procedure. Findings noted a 1% rate of postoperative pain after the TVT procedure. Their study group of 5 women included 4 who were initially treated with an injection of methylprednisolone and bupivacane. Of those 4 women who were treated, one woman achieved an acceptable response and one woman had her pain reduced to a point that no further treatment was needed. The remaining 3 (2 of which underwent initial infiltration of the anesthetic solution) underwent distal tape excision. All 3 of those women had an excellent clinical response with regards to diminution in the pain score.
  This report provides an excellent commentary on the presence of groin pain after the tension free vaginal tape procedure and its incidence in their surgical population. In addition, it provides a very workable algorithm of management for these patients. Key points to consider from this paper would be when the pain originally presented: Immediately after surgery or during the postoperative convalescence as adhesions would develop? In addition, it would have been of great value to know the change in pain scores after the injection therapy and to compare them to the change in pain scores after the TVT excision. The paper brings up further cogent points including whether pain after a tension-free vaginal tape has a greater incidence than reported and is the current reported incidence merely reflective of the vigorousness of the interviewing consultant. In summary, this is an excellent paper with regards to both discussing the presence of pain after tension-free vaginal tape as well as describing a straight forward treatment algorithm. That these surgeons had an excellent response in pain to the excision of the distal end of the tape should be noted and remembered.

Dr. Steven P. Petrou
Associate Professor of Urology
Mayo Clinic College of Medicine
Jacksonville, Florida, USA