Polypropylene Mesh
Polypropylene (PP) is a permanent synthetic mesh used in midurethral slings for stress urinary incontinence (SUI) and abdominal sacrocolpopexy for apical pelvic organ prolapse (POP). A sling, an abdominal prolapse mesh and a transvaginal POP mesh are different devices and procedures. Their evidence and regulatory status differ and are discussed separately here.[1]
This is the material hub. For selection and operative management, see Female SUI, Prolapse Repair and Mesh Complications.
Material Properties
PP is a semi-crystalline synthetic thermoplastic. Modern pelvic-floor PP devices commonly use macroporous monofilament mesh (Amid type I); NICE specifies type 1 macroporous PP for retropubic midurethral slings.[2][15] Porosity, filament structure, weight, stiffness and deformation all affect the tissue response.[2][3]
| Amid type | Structure | Example | Use in pelvic-floor surgery |
|---|---|---|---|
| I | Macroporous, monofilament | Polypropylene | Current standard for slings and sacrocolpopexy |
| II | Microporous | ePTFE (Gore-Tex) | Historical |
| III | Macroporous with multifilament or microporous components | Polyester (Mersilene) | Historical |
| IV | Submicronic | Silastic | Not used |
Amid's classification comes from hernia surgery.[15]
In animal models, PP evoked a host response that was less inflammatory than, or similar to, that of other synthetic and biologic meshes, and a lightweight, large-pore structure fared best.[17] The vaginal niche has a distinct hormonal, immune and microbial environment, which has been proposed to amplify the inflammatory response to transvaginal mesh.[3]
Mesh deformation after tensioning has been proposed as a mechanism of complications. In a 12-week rhesus macaque sacrocolpopexy model, exposure occurred in 3/10 animals with unstable pores, 3/10 with intentionally collapsed and wrinkled mesh, and 1/9 in the stable-pore group after an unintended wrinkle.[23] All exposures occurred where pores collapsed and mesh wrinkled; myofibroblast counts exceeded sham in all three mesh groups, highest in the predeformed group. Uniform, open-pore geometry after tensioning is therefore a design goal ("effective porosity").[23][5]
PP is not biologically inert: implantation produces a tissue response, and the vaginal environment differs from the abdominal wall. Claims that PP degradation has been definitively disproved are too strong. One explant study attributed apparent surface cracking to removable protein or fixation artifacts, whereas subsequent materials literature continues to describe possible in-vivo degradation.[3][4][5]
Page's 2023 sacrocolpopexy study compared consecutive prospective cohorts, including a lightweight partially absorbable PP/poliglecaprone product. At a median follow-up of about 8 years, graft-related complications were 13/178 (7.3%) with lightweight (28 g/m²) versus 23/101 (22.8%) with heavier-weight (more than 44 g/m²) PP; graft-related reinterventions were 5/238 (2.1%) versus 19/101 (18.8%). Subjective improvement (PGIC 4 or higher) and anatomical failure did not differ between groups.[6] The audit was supported by Ethicon.[6]
Evidence by Operation
| Application | Clinically useful interpretation |
|---|---|
| Midurethral sling for SUI | AUA/SUFU recommends counseling index patients considering SUI surgery on the efficacy and safety of midurethral slings, autologous fascia pubovaginal slings, Burch colposuspension and bulking agents . For index patients selecting a midurethral sling, retropubic, transobturator or single-incision slings may be offered . Discuss permanent-mesh risks and alternatives before selection.[7] |
| Retropubic versus transobturator sling | The 2017 Cochrane review found broadly similar short-term subjective cure. Reported subjective cure at up to 1 year ranged from 71% to 97% with retropubic and 62% to 98% with transobturator slings; beyond 5 years the ranges were 51% to 88% and 43% to 92%. Retropubic placement had more bladder perforation (4.5% vs 0.6%) and voiding dysfunction; transobturator placement had more groin pain (6.4% vs 1.3%). Repeat incontinence surgery was more likely after transobturator placement (4 trials, low-certainty evidence).[8] |
| Single-incision sling | FDA's April 2024 assessment found comparable effectiveness and adverse-event types and rates to traditional MUS through 36 months.[1] The 2023 Cochrane review found similar patient-reported cure or improvement at 12 months versus transobturator slings after excluding TVT-Secur, but dyspareunia and repeat continence surgery or mesh revision remained uncertain; retropubic comparisons and longer-term outcomes were less certain.[9] In the SIMS randomized trial, three-year patient-reported success ('much' or 'very much improved') was noninferior for adjustable anchored mini-slings versus conventional MUS (177/246 versus 157/235); dyspareunia at 36 months was reported by 17/145 (12%) versus 7/145 (4.8%) women assigned direct dyspareunia questions.[25] |
| Abdominal sacrocolpopexy | Remains a distinct mesh application outside the FDA transvaginal POP order. In the CARE trial, the Kaplan-Meier estimate of mesh erosion at 7 years was 10.5% (95% CI 6.8–16.1%), with 126/215 (59%) of extended-CARE enrollees completing 7-year follow-up. Product, concomitant procedures and length of follow-up affect exposure risk.[1][6][16] |
| Transvaginal permanent mesh for POP | In the 2024 Cochrane review, lower prolapse awareness and repeat prolapse surgery were offset by more total repeat surgery for prolapse, SUI or exposure (RR 1.56, 95% CI 1.07–2.26), bladder injury and de novo SUI. Exposure was 11.8%, with 6.1% undergoing exposure surgery.[10] |
A large English administrative cohort of 95,057 women found estimated 9-year risks of 3.3% for sling removal, 4.5% for further SUI surgery and 6.9% for either.[11] Nine-year removal risk was 2.7% after transobturator and 3.6% after retropubic insertion.[11] In a New York State cohort of 36,195 women, estimated 7-year risks were 3.7% for erosion and 6.7% for reoperation.[19]
Safety and Complication Assessment
AUA/SUFU states that clinicians should not place a mesh sling if the urethra is inadvertently injured during planned midurethral sling surgery , or use a synthetic midurethral sling during concomitant stress incontinence surgery with urethral diverticulectomy, urethrovaginal fistula repair, or urethral mesh excision . Clinicians should strongly consider avoiding mesh with radiation injury, substantial scarring or poor tissue quality .[7]
Potential problems include vaginal exposure, urinary-tract perforation, infection, voiding dysfunction, recurrent incontinence, urgency, pain and dyspareunia. Mesh removal may itself cause injury or recurrent prolapse or incontinence and may not resolve pain.[2][8]
Exposure. Reported exposure rates depend on the operation. After transvaginal POP mesh, the Cochrane review found exposure in 11.8% and surgery for exposure in 6.1%.[10] After retropubic and transobturator slings, Cochrane reported tape exposure in 21 and 24 per 1000 respectively.[8] A 2026 meta-analysis of six studies (n = 3068; fixed-effects pooling) reported mesh-erosion prevalence from 1.3% to 13.7% after MUS, and associated prior pelvic surgery (OR 10.37, 95% CI 6.70–16.07), diabetes (OR 4.63), smoking (OR 3.38), obesity (OR 2.79) and postmenopausal status (OR 2.34) with mesh erosion.[20] In the New York cohort, prior hysterectomy was associated with higher and high-volume facilities with lower erosion risk.[19]
Pain and dyspareunia. In a retrospective multicenter series of 347 women referred to four tertiary centers for mesh complications, 42.7% had mesh erosion, 34.6% pelvic pain and 30% dyspareunia; 77% had a grade 3 or 4 complication and 60% needed two or more interventions.[18] These are referral-center data. Pain associated with mesh may not resolve after removal. Peripheral nerve neuromodulation has been described in a single case report of refractory retropubic sling pain.[18][22]
NICE's management framework includes:[2]
- For a single vaginal exposure smaller than 1 cm², discuss topical vaginal estrogen and review within 3 months.
- For vaginal mesh exposure or extrusion, consider partial or complete removal of the vaginal portion when topical estrogen is declined, a sling exposure is 1 cm² or larger, mesh is extruded, or nonsurgical treatment has not helped after three months; discuss the removal decision, its extent and risks with the patient and a regional multidisciplinary team.
- Refer urinary-tract perforation or complex symptoms to a specialist mesh service. Persistent pain without an identified mesh abnormality can require pelvic-floor, pain and other multidisciplinary treatment rather than automatic complete excision.
ACOG Committee Opinion 694 advises examination for exposure or erosion in women with persistent vaginal bleeding, discharge or recurrent urinary tract infection after mesh placement, and states that asymptomatic women have no role for intervention. It lists observation, physical therapy, medication and surgery as management options.[21]
An asymptomatic recipient does not need preventive removal solely because a mesh product was withdrawn.[12] New bleeding, discharge, pain, dyspareunia, infection or voiding symptoms warrants evaluation.[12][21]
Regulatory Distinctions
| Jurisdiction | Scope |
|---|---|
| United States | FDA's April 2019 order stopped sale/distribution of the remaining transvaginal POP products. It did not remove SUI slings or abdominal POP mesh.[1] |
| Australia | TGA published its decision in December 2017 and cancelled transvaginal POP meshes and single-incision mini-slings from the ARTG in January 2018. Its current information distinguishes standard midurethral slings and abdominally placed prolapse mesh, which remain available. Australia did not ban every MUS.[13] |
| England / NICE guidance | The July 2018 high-vigilance restriction, which covered vaginally inserted mesh for both SUI and POP, allowed specified exceptions; it was not a permanent, uniform UK-wide ban on all mesh. NICE NG123 advises against transobturator placement unless the retropubic route should be avoided and restricts single-incision slings to clinical trials; current local restrictions also apply.[2][14] |
| FDA milestones | October 2008 Public Health Notification and July 2011 Safety Communication on transvaginal mesh; January 2016 reclassification of transvaginal POP mesh to class III (premarket approval); July 2018 order to stop selling the last posterior-compartment POP mesh; April 2019 order covering the remaining transvaginal POP products.[1] |
Record the exact implant and route.
Future Directions
- Lightweight, large-pore designs that keep their pore structure after tensioning are intended to reduce pore collapse and downstream complications.[5][23]
- Three-dimensionally printed patient-specific meshes based on pelvic imaging, electrospun scaffolds and bioabsorbable composites have been proposed.[24]
- Mandatory mesh registries and longitudinal surveillance have been proposed.[3]
See also: Absorbable Mesh, Coated / Hybrid Mesh, Autologous Rectus Fascia.
References
1. US Food and Drug Administration. FDA Activities: Urogynecologic Surgical Mesh. Includes April 2024 SUI mini-sling review and 2019 POP order.
2. NICE. Urinary incontinence and pelvic organ prolapse in women: management (NG123). Sections 1.5 and 1.11; current online recommendations accessed September 2026.
3. Abhari RE, Izett-Kay ML, Morris HL, Cartwright R, Snelling SJB. Host-Biomaterial Interactions in Mesh Complications After Pelvic Floor Reconstructive Surgery. Nature Reviews Urology. 2021;18(12):725-738. doi:10.1038/s41585-021-00511-y
4. Thames SF, White JB, Ong KL. The Myth: In Vivo Degradation of Polypropylene-Based Meshes. International Urogynecology Journal. 2017;28(2):285-297. doi:10.1007/s00192-016-3131-4
5. Jain T, Isayeva IS, Simon DD. Polypropylene Surgical Mesh Implants for Hernia and Pelvic Floor Disorders: A Materials Performance Perspective. Journal of Biomedical Materials Research Part A. 2025;113(8):e37970. doi:10.1002/jbm.a.37970
6. Page AS, Cattani L, Pacquée S, et al. Long-Term Data on Graft-Related Complications After Sacrocolpopexy With Lightweight Compared With Heavier-Weight Mesh. Obstetrics and Gynecology. 2023;141(1):189-198. doi:10.1097/AOG.0000000000005021
7. AUA/SUFU. Surgical Treatment of Female Stress Urinary Incontinence: 2023 guideline. Statements 10, 12–14 and 17–18.
8. Ford AA, Rogerson L, Cody JD, Aluko P, Ogah JA. Mid-Urethral Sling Operations for Stress Urinary Incontinence in Women. Cochrane Database of Systematic Reviews. 2017;7:CD006375. doi:10.1002/14651858.CD006375.pub4
9. Carter E, Johnson EE, Still M, et al. Single-Incision Sling Operations for Urinary Incontinence in Women. Cochrane Database of Systematic Reviews. 2023;10:CD008709. doi:10.1002/14651858.CD008709.pub4
10. Yeung E, Baessler K, Christmann-Schmid C, et al. Transvaginal Mesh or Grafts or Native Tissue Repair for Vaginal Prolapse. Cochrane Database of Systematic Reviews. 2024;3:CD012079. doi:10.1002/14651858.CD012079.pub2
11. Gurol-Urganci I, Geary RS, Mamza JB, et al. Long-term Rate of Mesh Sling Removal Following Midurethral Mesh Sling Insertion Among Women With Stress Urinary Incontinence. JAMA. 2018;320(16):1659-1669. doi:10.1001/jama.2018.14997
12. US Food and Drug Administration. Pelvic Organ Prolapse (POP). Advice for existing mesh recipients.
13. Therapeutic Goods Administration. About transvaginal surgical mesh devices. Updated December 19, 2023.
14. UK Department of Health and Social Care. Government announces strict rules for the use of vaginal mesh. July 2018.
15. Amid PK. Classification of Biomaterials and Their Related Complications in Abdominal Wall Hernia Surgery. Hernia. 1997;1(1):15-21. doi:10.1007/BF02426382
16. Nygaard I, Brubaker L, Zyczynski HM, et al. Long-Term Outcomes Following Abdominal Sacrocolpopexy for Pelvic Organ Prolapse. JAMA. 2013;309(19):2016-2024. doi:10.1001/jama.2013.4919
17. Kelly M, Macdougall K, Olabisi O, McGuire N. In Vivo Response to Polypropylene Following Implantation in Animal Models: A Review of Biocompatibility. International Urogynecology Journal. 2017;28(2):171-180. doi:10.1007/s00192-016-3029-1
18. Abbott S, Unger CA, Evans JM, et al. Evaluation and Management of Complications From Synthetic Mesh After Pelvic Reconstructive Surgery: A Multicenter Study. American Journal of Obstetrics and Gynecology. 2014;210(2):163.e1-8. doi:10.1016/j.ajog.2013.10.012
19. Chughtai B, Mao J, Matheny ME, et al. Long-Term Safety With Sling Mesh Implants for Stress Incontinence. The Journal of Urology. 2021;205(1):183-190. doi:10.1097/JU.0000000000001312
20. Priyatini T, Saputra AND, Meutia AP. Patient-Related Risk Factors for Mesh Erosion Following Midurethral Sling Procedures: A Systematic Review and Meta-Analysis. International Urogynecology Journal. 2026;37(7):1915-1927. doi:10.1007/s00192-026-06519-5
21. American College of Obstetricians and Gynecologists. Committee Opinion No. 694: Management of Mesh and Graft Complications in Gynecologic Surgery. Obstetrics and Gynecology. 2017;129(4):e102-e108. doi:10.1097/AOG.0000000000002022
22. Martin S, Han E, Peters KM. A Novel Approach to Managing Post Retropubic Vaginal Sling Pain. Urology. 2020;137:196-199. doi:10.1016/j.urology.2019.11.008
23. Knight KM, King GE, Palcsey SL, et al. Mesh Deformation: A Mechanism Underlying Polypropylene Prolapse Mesh Complications in Vivo. Acta Biomaterialia. 2022;148:323-335. doi:10.1016/j.actbio.2022.05.051
24. Farmer ZL, Domínguez-Robles J, Mancinelli C, Larrañeta E, Lamprou DA. Urogynecological Surgical Mesh Implants: New Trends in Materials, Manufacturing and Therapeutic Approaches. International Journal of Pharmaceutics. 2020;585:119512. doi:10.1016/j.ijpharm.2020.119512
25. Abdel-Fattah M, Cooper D, Davidson T, et al. "Single-incision mini-slings versus standard synthetic mid-urethral slings for surgical treatment of stress urinary incontinence in women: The SIMS RCT." Health Technol Assess. 2022;26(47):1-190. doi:10.3310/BTSA6148