Pain after vaginal prolapse repair surgery with mesh is a post‐surgical neuropathy which needs to be treated – and can possibly be prevented in some cases

Post‐surgical neuropathy leading to chronic pain is a recognised complication. It also can occur after surgery for pelvic organ prolapse repair involving mesh. Post‐surgical neuropathy needs to be identified and properly treated to minimise the occurrence of chronic pain. A treatment algorithm is put forward for discussion .

showing with objective testing, that chronic pain is present in 17% of patients at four months. 3 The incidence of post-operative neuropathy after caesarean section is estimated to be approximately 10%.
Nikolajsen first reported that 27 out of 220 (12.3%) women complained of abdominal pain three months after caesarean section, with 13 of them (5.9%) being significantly affected on a daily basis. 4 The natural history of post-surgical neuropathy is variable and poorly documented in the literature. Some patients improve over the course of a couple of years, with others continuing to struggle. 5 The main risk factors for developing post-surgical chronic pain are: (i) pre-existing pain and (ii) inadequate post-operative pain control. [2][3][4] Both these factors can and should be addressed when treating patients with pelvic organ prolapse.
Surgeons are ill-equipped to deal with chronic pain, mainly because they will rarely see patients beyond a couple of weeks after the intervention. If they do, they will often not know what approach to take. It is essential for the surgeon to recognise the early signs and symptoms of nerve trauma and to address the issues, in order to avoid chronic pain for these women.
Post-surgical pain is not necessarily due to a botched operation and surgeons should not feel defensive when a patient returns with complaints of pain. Moreover, in cases of immediate and severe pain, the most appropriate treatment may be surgical revision, to allow for the best chance of pain resolution. 6 Complications after prolapse repair surgery in women involving mesh have been extensively reported recently in the mainstream media as well as various social media outlets. Due to the severity of the complications and the suffering the women have endured, it is appropriate to briefly review the pathophysiology of this particular condition.
Surgery is in most cases a trauma involving predominantly only the soft tissues. There is vascular injury, transection of muscle and collagen fibres as well as terminal nerve fibres. During the healing phase the body will initiate neo-vascularisation, will remodel the collagen and the muscle fibres -nerve fibres will sprout and reconnect with their targets. 7 This is adaptive healing, quickly achieved in the young and a bit slower as we age. The presence of a foreign object in a wound is common, not the least through the The presence of pre-existing pain is listed as a major predisposing factor in the pathophysiology of chronic pain by most authors. 9 It is therefore crucial that the surgeon be cognisant and knowledgeable of perineal pain conditions.

AT THE TIME OF SURGERY
An important aspect in the prevention of chronic pain is adequate pain management at the time of surgery and during the days and weeks thereafter. 2 The key to pain control in the immediate hours post-intervention involves liberal use of local anaesthesia intra-operatively, and some form of patientcontrolled postoperative analgesia. In most hospitals, the anaesthesiologist is responsible for pain management during the first 24 h after the procedure. Patients typically stay a day or two in hospital and are then discharged with a script for oxycodone or similar narcotic. Post-surgical appointments are scheduled for several weeks later. This creates a 'no-man's land' of pain management for the patient. Who should they turn to when the oxycodone isn't holding the pain down? Adequate instructions, whichever form that takes, are required. Ideally, the patient's general practitioner takes the lead in this endeavour.
As stated before, the most vulnerable patients are those who were suffering from perineal or pelvic pain prior to the prolapse repair surgery. Even if these patients have an adequate pain management plan in place, there will be a need for close monitoring and -in most cases -adaptation of the plan.

FOLLOW-UP APPOINTMENT(S)
Many patients complain that there was no review of pain management during the follow-up consultation with their specialist.    The window of opportunity to remove the mesh before damage is irreversible is unknown -but it is reasonable to set a 24 h limit for the decision-making process, which leaves time to complete emergency imaging tests if required and involve colleagues for a second opinion.

PAIN MANAGEMENT IN THE EARLY WEEKS POST-SURGERY
Pain management in the early days and weeks after surgery is aimed at treating the soft tissue trauma and based predominantly on the use of anti-inflammatory as well as narcotic medications (Table 1). However, physical elements such as ice or heat packs and low-impact exercises are also important. The most effective allied health adjunctive treatment in the immediate

Injection of local anaesthetic (addition of cortisone is of uncertain value)
3 Topical oestrogen is resumed as soon as possible 4 Pain medication (tramadol, tapentadol, buprenorphen) -avoid codeine for its significant constipating effect, which will negatively impact pain management 5 Anti-neuropathic medications (tricyclic antidepressants, gabapentinoids, selective noradrenaline reuptake inhibitors) 6 Peripheral and regional blocks (caudal, pudendal) 7 Allied health in a supportive role Osteopathy: manipulation to address associated musculoskeletal dysfunction aftermath of surgery is acupuncture, thought to be a form of neuro-modulation . 11 As time goes on and pain persists, it is advisable to turn attention to the use of medications immediately impacting the transmission of the neural stimulus. The most effective medications are the so-called membrane stabilisers, such as local anaesthetics. It is not common practice or tradition to proceed with regional blocks, most likely because those who would recommend and perform the blocks are no longer involved in the management of the patient. However, the use of pudendal nerve and caudal blocks make a lot of sense, certainly for those patients who are not making any progress using a more established medical approach. It should be said at this stage that the traditional strong narcotic medications such as oxycodone have less and less a place in pain management as time goes by. When does one switch to one of the 'weak' products (tapentadol, buprenorphen, tramadol)? The clinician treating the patient is best placed to make the call. Experience will bring suspicion that a patient will need longer than expected pain management. Rather than renewing the oxycodone script, it might be an opportunity to switch.

PAIN MANAGEMENT IN THE MONTHS POST-SURGERY
When the three-month threshold is reached, the use of antineuropathic medications, if tolerated, becomes the mainstay of medical management (Table 2). Topical amitriptyline is no doubt a valuable element in the medium-to long-term management of post-surgical neuropathy in the perineal region.
Combination of topical and parenteral pharmaceuticals needs to be titrated to their optimal effectiveness with the lowest possible side-effect profile.
Allied health support, such as psychotherapy, physiotherapy and osteopathy become more interventional as opposed to supportive. Treatment of post-surgical neuropathy is tedious and takes several months. Frustration is common. Patients need to be encouraged to persevere. Treatment is recommended to continue a few weeks beyond resolution of symptoms and if symptoms recur, treatment is resumed as soon as feasible.
A few patients will need more aggressive pain management, even after complete removal of the mesh and suture material.
The modalities used, collectively termed neuro-modulation, are beyond the scope of this dissertation. However, it might be said that referral to a pain medicine specialist for more comprehensive management should not be delayed when patients are not making real progress in returning to normal daily functioning.