Who you will see and what to expect at RAH Pelvic mesh clinic

You will initially be seen by the Gynaecologist in the Pelvic Mesh Clinic unless another urgent pathway is recommended during the triage process.

Our Gynaecologist is:

• Dr Carolyn Marlow

The gynaecologist may need to conduct a physical examination. This examination would consist of a gentle internal and external clinical examination including neurological and musculoskeletal tests of your legs, pelvis and perineum. Your informed consent will be required before proceeding and the PMC Nurse will be present at all times during an examination. If at any time you feel uncomfortable during the examination, please let the staff know.

When the relevant information has been assessed and evaluated, the Gynaecologist may recommend a referral to other members of the multi-disciplinary team for further evaluation of your treatment management plan.

A urologist is a specialist surgeon who manages problems of the kidneys, bladder and urethra.

Our Urologist is:

• Dr Ashani Couchman

During your initial consultation, the Urologist will review your symptoms and discuss what your treatment goals are. At that session, you will have further discussion about whether an evaluation of the inside of your bladder, to exclude the possibility of mesh erosion, may be required along with the assessment of your bladder function. You will have a discussion about these tests, what they entail and possible complications. Information sheets about the tests will be provided along with an introduction to the nursing team involved in undertaking them in collaboration with the urologist.

These tests, with your informed consent, can be completed without the need for a general anaesthetic and in one outpatient appointment. A separate appointment can be booked for you to return to undertake this test if you prefer; allowing you the opportunity to read the information provided and ask further questions you may have.

You will be required to complete a 2-day bladder diary prior to attending this appointment. This assessment will give the Urologist a better understanding of your regular bladder habits and fluid intake/output.

To view the inside your bladder, the doctor will perform a ‘Cystoscopy’. A small flexible camera will be gently inserted into your urethra and up into your bladder. The doctor will be able to view the walls of your bladder and evaluate any mesh erosion. The Urologist is also able to assess whether the mesh is close to any important structures in your bladder. If future surgery is required, this test better informs the surgeon of the severity of your condition prior to your operation and therefore a clear management plan can be made at the time. It also allows you to visualise the issue to improve understanding.

To assess your bladder function, the doctor will conduct ‘Urodynamic studies’. This study involves the insertion of two small catheters, one in the bladder and the other in the rectum. These slim catheters allow the bladder to be slowly filled to mimic the symptoms you experience at home. This test can take up to an hour as it is done slowly and is guided by you, with regard to bladder sensation and a feeling of fullness. Some women find this test a little embarrassing because it is invasive and we put your bladder under stress to see what may cause you to leak.

If at any time you feel uncomfortable during the tests, please let the staff know. You are welcome to bring a support person if you so wish. We endeavour to make these tests as comfortable and relaxed as possible. The team involved in undertaking them are two nurses and the urologist and all staff members are female.

At the end of one or both investigations, you will have the opportunity to review the results. If you would prefer to have a separate consultation for the discussion of results and possible treatment, we will facilitate a repeat appointment.

The specialised field of colorectal surgery manages disorders of the rectum, anus, and colon. Our Colorectal Surgeon is:

• Dr Michelle Thomas

The colorectal surgeon will assess for any potential mesh complications involving the bowel as well as your function. This usually includes questions about your bowel habit, bowel control, difficulty with toileting, bleeding and pain. It would be helpful to keep a diary of your bowel habits and dietary intake for the 2-3 weeks prior to your appointment. The ‘Bristol Stool Chart’ (found on Google) can help you easily and consistently assess your bowel habits.

The surgeon may need to examine you during the consultation. This may include a digital (finger) examination of your anus. If you feel uncomfortable at any time, please let the doctor know.

As a result of your initial consultation, your doctor may make another appointment to do further investigations. These may include a sigmoidoscopy, anorectal manometry or endo-anal ultrasound.

A sigmoidoscopy is a short scope examination of the anus and rectum. It is usually a brief examination and is only slightly uncomfortable, but can be done under sedation if desired.

Anorectal manometry is an investigation that measures how effectively the rectum and anal sphincter muscles are working. This test is commonly recommended to people who have faecal incontinence or constipation. It involves placing a very narrow lead into the anus. The test can take 10-20 minutes and is performed by a specialist technician. There may or may not be an assistant in the room. If you would prefer a chaperone be present, please let the staff know in advance.

An endo-anal ultrasound is a medical imaging test which views the structures of the anal canal. It is used in the investigation of some anorectal symptoms such as faecal incontinence. The examination will be performed using a specialised ultrasound probe placed just within the anal canal (finger size) and usually takes about 5 minutes. The live ultrasound picture will allow the identification ofthe muscles in the anal canal and their current functional status.

If future surgery is required, these tests better inform the surgeon of the severity of your condition prior to your operation and therefore a clear management plan can be made at the time.

If at any time during the examination or investigation you feel uncomfortable or do not wish to proceed, please let the staff know.

The Pain Specialists recognise that every woman has individual mesh complications and this includes their pain experiences, pain sources and pain types. They work closely with the other members of the multidisciplinary team to identify the best possible timing for the management of pain prior to procedures or surgery.

Our Pain specialist is:

• Dr Sharon Keripin

To help the Pain Specialists understand what is individual to you, you will be required to complete a pain triage assessment. This subjective assessment will be used to determine the first steps towards a management plan and treatment of your pain. It is likely that you will require multiple consultations as we work with you to determine what does or does not work for your pain. Whilst certain medications or procedures may be recommended, the pain specialists also recommend that you try a range of behavioural options in collaboration with these medications or procedures.

Our Psychologist has specialised knowledge and skills in the field of women’s mental health. They can offer you psychological support relating to the preparation for medical procedures, adjustment to medical diagnoses and treatments, pain management, sexual health problems and managing social isolation, anxiety or depression.

Our Psychologist is:

• Michelle Martin

Every session is tailored to your individual needs and on-going therapy is provided with your informed consent. During your consultation an assessment of your current mental health, your personal goals for your mental health as well as any relevant background history will be discussed. Our Psychologist is happy to support you with short to medium term psychological therapy, monitoring of mental health symptoms and emotional support including any required telephone follow up. They can also refer you to community services and resources as necessary

When it comes to pelvic mesh management, standard pelvic floor exercises are not appropriate and may lead to increased pain or further damage. Our expert physiotherapist specialises in pelvic health and in particular bladder/bowel dysfunction and relaxation of the pelvic floor muscles.

Our Physiotherapist is:

• Fiona Roney

During your consultation, our physiotherapist will support you and develop a management plan with you in regard to any bladder or bowel problems, pain management, relaxation techniques,sexual difficulties, vaginal symptoms and day-to-day exercise or physical activity and mobility concerns.

With your informed consent, hands-on treatment may be offered to you. This treatment may include an assessment of your pelvic floor muscles which would then require a gentle internal examination. If at any time during the treatment and examination you feel uncomfortable, please let the physiotherapist know.

Referral to the social work team is available through the Royal Adelaide Hospital. The PMC Nurse can refer you to a gynaecology social worker.

Social workers can assist you by identifying triggers which impact your wellbeing, encouraging support networks and linking you with relevant services and assist you to gain lost control and have the best possible quality of life. A social worker may want to conduct a psychosocial assessment to help better understand how your values, beliefs, hopes, emotions and history impact you and therefore on how the mesh has impacted your quality of life and ability to function.

The whole team will regularly collaborate together along your journey to ensure the highest standard of quality, personal healthcare is provided.

All of the information gathered during your various consultations will help to determine a diagnosis and work out if your symptoms are caused by the mesh implant or by something else. Due to the complexity of mesh implants, this information may need to be discussed with all the members of the multidisciplinary team, at once, in a multidisciplinary meeting (MDM). You will not be required to attend these meetings, but the outcomes of the discussion will be discussed with you, on the phone, soon afterwards.