Commentary

The relationship between parents and pediatricians is unique. More than any other field of medicine, there is a level of trust that develops because of the consistent and ongoing interaction for several years. But as the child grows older and enters the adolescent years, the relationship shifts from catering to the desires of the parent to the needs of the child.

When a strong relationship is established, the transition of trust is usually easy, and parents are very comfortable and welcoming of an independent relationship between the physician and the child. But there are many issues that come up in adolescence that may be very difficult for a child to discuss with the parent despite having a good relationship, putting the physician directly in the middle.

The issue of minor consent is complex, and because it differs from state to state, it becomes even more complex. Of course, the best approach is to have a conversation with the parent to determine their views on various issues and ask for consent to address them should their child present to you for treatment, but new patients present, and time to establish a relationship is not always possible. The American Academy of Pediatrics statement on treatment of adolescents requires that every attempt is made to encourage inclusion of the parent in any decision making.

Understanding the laws that govern the state in which you practice is imperative. The state policies and laws can be found at www.Guttmacher.org. Although there has not been a physician held liable for nonnegligent care given to a minor who gave consent, it is important for parents to understand what their child can consent to or against. It also is important for the physician to be explicitly clear as to what their limitations are by law.

A minor status is defined by age under 18 years of age. An emancipated minor is someone who attained legal adulthood because of marriage, military service, or living separately from parents and managing one’s financial affairs (Understanding Legal Aspects of Care, in “Adolescent Health Care: A Practical Guide,” 5th ed [Philadelphia Lippincott Williams & Wilkins, 2008]). These laws are very clear and do not usually cause much confusion. Where the situation becomes very grey is in the case of the mature minor. This category is recognized in some states as an exception to the rules requiring parental consent for medical care (Int. J. Gynaecol. Obstet. 1998;63:295-300). The mature minor is defined as being at least 14 years old, having the ability to understand risk and benefits, and having the ability to provide informed consent. But this requires a subjective assessment of the adolescent, which could be argued by the parent.

Minors can consent to contraceptive services in most states. In 1977, the Supreme Court ruled that the right to privacy protects a minor’s access to nonprescriptive contraception, and although prescribed contraception is not included, it is generally considered to be included (Med. Clin. North Am, 1990; 74:1097-112). It is important to note that a pharmacist under the Pharmacist Conscience Clause, in some states, can refuse to fill the prescription without parental consent at their discretion (Arch. Pediatr. Adolesc. Med. 2003;157:361-5). Although this not a common issue, it may present a larger issue if the patient requested confidentiality.

Diagnosis and treatment of sexually transmitted disease also can be done with the consent of a minor, but the age of the patient, usually greater than 14 years, is required in most states. A careful assessment must be done for abuse regardless of whether the minor admitted to consensual sex or not. The laws regarding statutory rape are clearly defined state to state and may present a larger problem if disputed by the parent.

Elective abortion is always a topic of debate. States require at least one parent to consent when a minor is seeking an abortion, but a minor also can seek a judicial bypass, which is a request from a minor to not have parental consent for an abortion if they believe that notification will bring harm to the minor. Conversely, an adolescent also can refuse to consent to an abortion that the parent requests.

Immunizations also can be given with the consent of the minor, but extra precaution should be given to documentation of clear explanation of risk and benefits. Despite there being no federal law requiring parental consent, some states do require it, and it is prudent to obtain it.

Parents don’t often realize the limitations of their ability to prevent or demand treatment. So although the abortion itself falls outside the scope of care of a pediatrician, educating parents on the laws can help them navigate the situation better. Parents also may request drug, sexually transmitted infection, or pregnancy testing without the knowledge of the minor. Whether it is done is left to the discretion of the physician but the AAP advises that this only be done as a rare exception (Pediatrics 2007;119:627-30).

Now a larger consideration for physicians is financial liability. Parents are not obligated to pay for treatment and procedures for which they did not consent. The financial responsibility falls on the minor who requested it. Obviously, this could be costly for the facility, and therefore a decision has to be made to either disrupt continuity of care and refer to an outside facility or absorb the cost. This can be a challenging decision. Disclosing to the minor that payment sent through the insurance might unintentionally breach the confidentiality of the treatment is also an important consideration if the minor’s desire is to keep the parent uninformed.

The issue of consent to treatment when it comes to minors is multifaceted. Maintaining the trust of the parent and gaining the trust of the adolescent is tricky when the lines of communication between them are limited. Establishing early a relationship of trust with the parent to advise and treat the child appropriately in the event he or she does present with complex issues will settle many of the issues. More importantly, as pediatricians our goal is to establish a relationship with the adolescent so that he or she knows where to go to get good sound advice and treatment to ensure good health and prevent avoidable consequences.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Scan this QR code to view similar columns or go to pediatricnews.com.

The relationship between parents and pediatricians is unique. More than any other field of medicine, there is a level of trust that develops because of the consistent and ongoing interaction for several years. But as the child grows older and enters the adolescent years, the relationship shifts from catering to the desires of the parent to the needs of the child.

When a strong relationship is established, the transition of trust is usually easy, and parents are very comfortable and welcoming of an independent relationship between the physician and the child. But there are many issues that come up in adolescence that may be very difficult for a child to discuss with the parent despite having a good relationship, putting the physician directly in the middle.

The issue of minor consent is complex, and because it differs from state to state, it becomes even more complex. Of course, the best approach is to have a conversation with the parent to determine their views on various issues and ask for consent to address them should their child present to you for treatment, but new patients present, and time to establish a relationship is not always possible. The American Academy of Pediatrics statement on treatment of adolescents requires that every attempt is made to encourage inclusion of the parent in any decision making.

Understanding the laws that govern the state in which you practice is imperative. The state policies and laws can be found at www.Guttmacher.org. Although there has not been a physician held liable for nonnegligent care given to a minor who gave consent, it is important for parents to understand what their child can consent to or against. It also is important for the physician to be explicitly clear as to what their limitations are by law.

A minor status is defined by age under 18 years of age. An emancipated minor is someone who attained legal adulthood because of marriage, military service, or living separately from parents and managing one’s financial affairs (Understanding Legal Aspects of Care, in “Adolescent Health Care: A Practical Guide,” 5th ed [Philadelphia Lippincott Williams & Wilkins, 2008]). These laws are very clear and do not usually cause much confusion. Where the situation becomes very grey is in the case of the mature minor. This category is recognized in some states as an exception to the rules requiring parental consent for medical care (Int. J. Gynaecol. Obstet. 1998;63:295-300). The mature minor is defined as being at least 14 years old, having the ability to understand risk and benefits, and having the ability to provide informed consent. But this requires a subjective assessment of the adolescent, which could be argued by the parent.

Minors can consent to contraceptive services in most states. In 1977, the Supreme Court ruled that the right to privacy protects a minor’s access to nonprescriptive contraception, and although prescribed contraception is not included, it is generally considered to be included (Med. Clin. North Am, 1990; 74:1097-112). It is important to note that a pharmacist under the Pharmacist Conscience Clause, in some states, can refuse to fill the prescription without parental consent at their discretion (Arch. Pediatr. Adolesc. Med. 2003;157:361-5). Although this not a common issue, it may present a larger issue if the patient requested confidentiality.

Diagnosis and treatment of sexually transmitted disease also can be done with the consent of a minor, but the age of the patient, usually greater than 14 years, is required in most states. A careful assessment must be done for abuse regardless of whether the minor admitted to consensual sex or not. The laws regarding statutory rape are clearly defined state to state and may present a larger problem if disputed by the parent.

Elective abortion is always a topic of debate. States require at least one parent to consent when a minor is seeking an abortion, but a minor also can seek a judicial bypass, which is a request from a minor to not have parental consent for an abortion if they believe that notification will bring harm to the minor. Conversely, an adolescent also can refuse to consent to an abortion that the parent requests.

Immunizations also can be given with the consent of the minor, but extra precaution should be given to documentation of clear explanation of risk and benefits. Despite there being no federal law requiring parental consent, some states do require it, and it is prudent to obtain it.

Parents don’t often realize the limitations of their ability to prevent or demand treatment. So although the abortion itself falls outside the scope of care of a pediatrician, educating parents on the laws can help them navigate the situation better. Parents also may request drug, sexually transmitted infection, or pregnancy testing without the knowledge of the minor. Whether it is done is left to the discretion of the physician but the AAP advises that this only be done as a rare exception (Pediatrics 2007;119:627-30).

Now a larger consideration for physicians is financial liability. Parents are not obligated to pay for treatment and procedures for which they did not consent. The financial responsibility falls on the minor who requested it. Obviously, this could be costly for the facility, and therefore a decision has to be made to either disrupt continuity of care and refer to an outside facility or absorb the cost. This can be a challenging decision. Disclosing to the minor that payment sent through the insurance might unintentionally breach the confidentiality of the treatment is also an important consideration if the minor’s desire is to keep the parent uninformed.

The issue of consent to treatment when it comes to minors is multifaceted. Maintaining the trust of the parent and gaining the trust of the adolescent is tricky when the lines of communication between them are limited. Establishing early a relationship of trust with the parent to advise and treat the child appropriately in the event he or she does present with complex issues will settle many of the issues. More importantly, as pediatricians our goal is to establish a relationship with the adolescent so that he or she knows where to go to get good sound advice and treatment to ensure good health and prevent avoidable consequences.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Scan this QR code to view similar columns or go to pediatricnews.com.

The relationship between parents and pediatricians is unique. More than any other field of medicine, there is a level of trust that develops because of the consistent and ongoing interaction for several years. But as the child grows older and enters the adolescent years, the relationship shifts from catering to the desires of the parent to the needs of the child.

When a strong relationship is established, the transition of trust is usually easy, and parents are very comfortable and welcoming of an independent relationship between the physician and the child. But there are many issues that come up in adolescence that may be very difficult for a child to discuss with the parent despite having a good relationship, putting the physician directly in the middle.

The issue of minor consent is complex, and because it differs from state to state, it becomes even more complex. Of course, the best approach is to have a conversation with the parent to determine their views on various issues and ask for consent to address them should their child present to you for treatment, but new patients present, and time to establish a relationship is not always possible. The American Academy of Pediatrics statement on treatment of adolescents requires that every attempt is made to encourage inclusion of the parent in any decision making.

Understanding the laws that govern the state in which you practice is imperative. The state policies and laws can be found at www.Guttmacher.org. Although there has not been a physician held liable for nonnegligent care given to a minor who gave consent, it is important for parents to understand what their child can consent to or against. It also is important for the physician to be explicitly clear as to what their limitations are by law.

A minor status is defined by age under 18 years of age. An emancipated minor is someone who attained legal adulthood because of marriage, military service, or living separately from parents and managing one’s financial affairs (Understanding Legal Aspects of Care, in “Adolescent Health Care: A Practical Guide,” 5th ed [Philadelphia Lippincott Williams & Wilkins, 2008]). These laws are very clear and do not usually cause much confusion. Where the situation becomes very grey is in the case of the mature minor. This category is recognized in some states as an exception to the rules requiring parental consent for medical care (Int. J. Gynaecol. Obstet. 1998;63:295-300). The mature minor is defined as being at least 14 years old, having the ability to understand risk and benefits, and having the ability to provide informed consent. But this requires a subjective assessment of the adolescent, which could be argued by the parent.

Minors can consent to contraceptive services in most states. In 1977, the Supreme Court ruled that the right to privacy protects a minor’s access to nonprescriptive contraception, and although prescribed contraception is not included, it is generally considered to be included (Med. Clin. North Am, 1990; 74:1097-112). It is important to note that a pharmacist under the Pharmacist Conscience Clause, in some states, can refuse to fill the prescription without parental consent at their discretion (Arch. Pediatr. Adolesc. Med. 2003;157:361-5). Although this not a common issue, it may present a larger issue if the patient requested confidentiality.

Diagnosis and treatment of sexually transmitted disease also can be done with the consent of a minor, but the age of the patient, usually greater than 14 years, is required in most states. A careful assessment must be done for abuse regardless of whether the minor admitted to consensual sex or not. The laws regarding statutory rape are clearly defined state to state and may present a larger problem if disputed by the parent.

Elective abortion is always a topic of debate. States require at least one parent to consent when a minor is seeking an abortion, but a minor also can seek a judicial bypass, which is a request from a minor to not have parental consent for an abortion if they believe that notification will bring harm to the minor. Conversely, an adolescent also can refuse to consent to an abortion that the parent requests.

Immunizations also can be given with the consent of the minor, but extra precaution should be given to documentation of clear explanation of risk and benefits. Despite there being no federal law requiring parental consent, some states do require it, and it is prudent to obtain it.

Parents don’t often realize the limitations of their ability to prevent or demand treatment. So although the abortion itself falls outside the scope of care of a pediatrician, educating parents on the laws can help them navigate the situation better. Parents also may request drug, sexually transmitted infection, or pregnancy testing without the knowledge of the minor. Whether it is done is left to the discretion of the physician but the AAP advises that this only be done as a rare exception (Pediatrics 2007;119:627-30).

Now a larger consideration for physicians is financial liability. Parents are not obligated to pay for treatment and procedures for which they did not consent. The financial responsibility falls on the minor who requested it. Obviously, this could be costly for the facility, and therefore a decision has to be made to either disrupt continuity of care and refer to an outside facility or absorb the cost. This can be a challenging decision. Disclosing to the minor that payment sent through the insurance might unintentionally breach the confidentiality of the treatment is also an important consideration if the minor’s desire is to keep the parent uninformed.

The issue of consent to treatment when it comes to minors is multifaceted. Maintaining the trust of the parent and gaining the trust of the adolescent is tricky when the lines of communication between them are limited. Establishing early a relationship of trust with the parent to advise and treat the child appropriately in the event he or she does present with complex issues will settle many of the issues. More importantly, as pediatricians our goal is to establish a relationship with the adolescent so that he or she knows where to go to get good sound advice and treatment to ensure good health and prevent avoidable consequences.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Scan this QR code to view similar columns or go to pediatricnews.com.

A month ago the American Board of Internal Medicine sent a letter to diplomates saying they “got it wrong,” referring to the process of maintenance of certification or MOC, that the board required. They acknowledged that “parts of the new program are not meeting the needs of physicians like yourself.” Some of the things they proposed include changing the content of the Internal Medicine recertification exam to be “more reflective of what physicians in practice are doing,” with a promise that subspecialty recertification exams will follow suit. They also talk about “new and more flexible ways ... to demonstrate ... medical knowledge,” likely making room for the continuing medical education or CME credits that state licensures require.

While the letter was evidence that physician grievances were being heard, it was widely criticized for not having gone far enough. Questions remained about the financial and time cost of certification, the relevance of the exam, and the motivation of the board.

Well, the ABIM has written us again. Except it’s still not saying much. They simply say that they have been listening to feedback, and they list some points about what they’ve been hearing and are presumably going to take into consideration. In summary, they are recognizing that the while we all agree that we need a way for physicians to keep up on their medical knowledge, there is “a shared sense that defining ‘keeping up’ is the work of the whole community, including physicians, specialty societies, patient groups, and health care institutions.”

They proceed to outline what they’ve heard and will presumably consider, including the suggestion that the recertification exam be eliminated completely, and that CME units count toward recertification. Like I said, they didn’t say much. But this is promising. Particularly telling is the part where they acknowledge that the job of defining ‘keeping up’ does not fall solely on, as a friend put it, people that sit in their ivory towers and are removed from the daily grind of patient care.

Apropos of all this, I recently got my first 10 points toward MOC by taking a 30-question exam posted by the American College of Rheumatology. Each question comes with a list of references that you can review should you need or want to. To my great surprise, one of the references was in German. So what does that tell you about the people writing the questions and the process they use? What does that tell you about the validity of the questions as a measure of my competence and ability to treat people?

Exams like the boards are a measure of test-taking skills and retention, neither one of which is a true measure of what a capable, competent physician should be. The ABIM is imposing on us an onerous and ill-conceived tool, one that most physicians agree is irrelevant. I am glad this conversation is happening, because frankly the process was enough to make me want to quit being a doctor.

Dr. Chan practices rheumatology in Pawtucket, R.I.

A month ago the American Board of Internal Medicine sent a letter to diplomates saying they “got it wrong,” referring to the process of maintenance of certification or MOC, that the board required. They acknowledged that “parts of the new program are not meeting the needs of physicians like yourself.” Some of the things they proposed include changing the content of the Internal Medicine recertification exam to be “more reflective of what physicians in practice are doing,” with a promise that subspecialty recertification exams will follow suit. They also talk about “new and more flexible ways ... to demonstrate ... medical knowledge,” likely making room for the continuing medical education or CME credits that state licensures require.

While the letter was evidence that physician grievances were being heard, it was widely criticized for not having gone far enough. Questions remained about the financial and time cost of certification, the relevance of the exam, and the motivation of the board.

Well, the ABIM has written us again. Except it’s still not saying much. They simply say that they have been listening to feedback, and they list some points about what they’ve been hearing and are presumably going to take into consideration. In summary, they are recognizing that the while we all agree that we need a way for physicians to keep up on their medical knowledge, there is “a shared sense that defining ‘keeping up’ is the work of the whole community, including physicians, specialty societies, patient groups, and health care institutions.”

They proceed to outline what they’ve heard and will presumably consider, including the suggestion that the recertification exam be eliminated completely, and that CME units count toward recertification. Like I said, they didn’t say much. But this is promising. Particularly telling is the part where they acknowledge that the job of defining ‘keeping up’ does not fall solely on, as a friend put it, people that sit in their ivory towers and are removed from the daily grind of patient care.

Apropos of all this, I recently got my first 10 points toward MOC by taking a 30-question exam posted by the American College of Rheumatology. Each question comes with a list of references that you can review should you need or want to. To my great surprise, one of the references was in German. So what does that tell you about the people writing the questions and the process they use? What does that tell you about the validity of the questions as a measure of my competence and ability to treat people?

Exams like the boards are a measure of test-taking skills and retention, neither one of which is a true measure of what a capable, competent physician should be. The ABIM is imposing on us an onerous and ill-conceived tool, one that most physicians agree is irrelevant. I am glad this conversation is happening, because frankly the process was enough to make me want to quit being a doctor.

Dr. Chan practices rheumatology in Pawtucket, R.I.

A month ago the American Board of Internal Medicine sent a letter to diplomates saying they “got it wrong,” referring to the process of maintenance of certification or MOC, that the board required. They acknowledged that “parts of the new program are not meeting the needs of physicians like yourself.” Some of the things they proposed include changing the content of the Internal Medicine recertification exam to be “more reflective of what physicians in practice are doing,” with a promise that subspecialty recertification exams will follow suit. They also talk about “new and more flexible ways ... to demonstrate ... medical knowledge,” likely making room for the continuing medical education or CME credits that state licensures require.

While the letter was evidence that physician grievances were being heard, it was widely criticized for not having gone far enough. Questions remained about the financial and time cost of certification, the relevance of the exam, and the motivation of the board.

Well, the ABIM has written us again. Except it’s still not saying much. They simply say that they have been listening to feedback, and they list some points about what they’ve been hearing and are presumably going to take into consideration. In summary, they are recognizing that the while we all agree that we need a way for physicians to keep up on their medical knowledge, there is “a shared sense that defining ‘keeping up’ is the work of the whole community, including physicians, specialty societies, patient groups, and health care institutions.”

They proceed to outline what they’ve heard and will presumably consider, including the suggestion that the recertification exam be eliminated completely, and that CME units count toward recertification. Like I said, they didn’t say much. But this is promising. Particularly telling is the part where they acknowledge that the job of defining ‘keeping up’ does not fall solely on, as a friend put it, people that sit in their ivory towers and are removed from the daily grind of patient care.

Apropos of all this, I recently got my first 10 points toward MOC by taking a 30-question exam posted by the American College of Rheumatology. Each question comes with a list of references that you can review should you need or want to. To my great surprise, one of the references was in German. So what does that tell you about the people writing the questions and the process they use? What does that tell you about the validity of the questions as a measure of my competence and ability to treat people?

Exams like the boards are a measure of test-taking skills and retention, neither one of which is a true measure of what a capable, competent physician should be. The ABIM is imposing on us an onerous and ill-conceived tool, one that most physicians agree is irrelevant. I am glad this conversation is happening, because frankly the process was enough to make me want to quit being a doctor.

Dr. Chan practices rheumatology in Pawtucket, R.I.

Earlier this week, an airplane headed from Barcelona to Dusseldorf crashed into the French Alps, leaving 150 people dead. The black box recorder indicated that the copilot was left alone in the cockpit, the pilot was locked out and attempted to gain re-entry, and the flight was reprogrammed to cruise at an altitude of 100 feet, causing the plane to crash after an 8-minute descent. The evidence indicates a deliberate action on the part of the 27-year-old co-pilot, Andreas Lubitz.

With nothing to point to terrorism at this point, the investigation will include the question of whether or not the copilot suffered from a mental illness as a way of explaining his unexplainable actions. In short, was this a combination mass murder/suicide? Was there any way to predict that such an atrocity might happen? Are there measures that can be taken to ensure that it doesn’t happen again?

In the United States, treatment with any psychotropic medication has been a reason to ground a pilot permanently. In April 2010, the Federal Aviation Administration’s rules changed such that a pilot could fly if he’d been treated for mild to moderate depression with a selective serotonin reuptake inhibitor after 12 months. At that time, the FAA announced a 6-month amnesty period where a pilot could come forward about a diagnosis of depression that he had not previously felt comfortable disclosing. Presumably, other countries also have rules that ground pilots for mental illness.

So far, some reports in the media indicate that the copilot was not obviously suffering from a psychiatric disorder; all those who have been interviewed for these reports have expressed shock that Lubitz might have deliberately crashed the plane.

There also has been speculation in the media that a break in the copilot’s training 6 years ago was due to depression, and the mother of a school mate reportedly said that Lubitz had been treated for depression. Finally, investigators found a doctor’s note excusing Lubitz from work. At this point, the Wall Street Journal is reporting that he was being treated for depression. Apparently, he had shredded the note and flew on Tuesday, despite the written work excuse.

Still, all discussion of the copilot’s mental state is purely speculation. The media is noted for sensationalist reporting – and in efforts to get information out quickly, the details are often confused or simply wrong, sometimes to a remarkable extent. We don’t know if the work excuse was written by a psychiatrist or another type of physician; we don’t know if it was for a psychiatric condition, cancer, or simply strep throat.

What we’ve been told is that a copilot who was cleared to fly did so despite a work excuse from a physician, he did not disclose this condition to his employer, and he crashed a plane killing 150 people.

We might assume that the pilot suffered from some type of psychic distress – whether he met criteria for a mental disorder or not, it’s not normal to kill 150 people. If the pilot did have a history of depression and was being treated at the time of this week’s flight, then we may be left with a very unsatisfactory answer.

The anti-psychiatry activists will say that psychotropic medications caused Lubitz to crash the plane. Psychiatrists will be left with no great answer with such a scenario and will be left to say that whatever treatment he was receiving, it wasn’t enough. Certainly, the physician who told Lubitz to take off from work was right: He didn’t belong in a cockpit that day. Presumably, that physician would have done more had he been aware that the patient was about to commit a mass murder.

If the copilot does have a history of depression, but his current work excuse was for an unrelated condition, we might wonder if an untreated recurrence of depression played some role in his actions. One might speculate that the copilot could have been afraid to seek care at this time, perhaps because of a fear that he would lose his vocation.

Still, major depression can hardly explain such an act, and it is unfortunate that the press has already begun to run headlines linking this man’s alleged psychiatric diagnosis to a catastrophic mass murder. Somehow, “mental illness” gets used as an endpoint explanation for why such things happen; and short of a severe psychotic delusional system, it’s a very unsatisfying answer for an unprecedented act of violence.

The facts will unfold and perhaps we’ll learn a little more. We’ll find out what condition the copilot was being treated for and whether there were other stresses going on in his personal life. But people get depressed, take antidepressants, and deal with stress all the time.

It’s possible, if not likely, that we’ll never understand why this copilot decided to end the lives of so many people along with his own.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work (Baltimore: The Johns Hopkins University, 2011).

Earlier this week, an airplane headed from Barcelona to Dusseldorf crashed into the French Alps, leaving 150 people dead. The black box recorder indicated that the copilot was left alone in the cockpit, the pilot was locked out and attempted to gain re-entry, and the flight was reprogrammed to cruise at an altitude of 100 feet, causing the plane to crash after an 8-minute descent. The evidence indicates a deliberate action on the part of the 27-year-old co-pilot, Andreas Lubitz.

With nothing to point to terrorism at this point, the investigation will include the question of whether or not the copilot suffered from a mental illness as a way of explaining his unexplainable actions. In short, was this a combination mass murder/suicide? Was there any way to predict that such an atrocity might happen? Are there measures that can be taken to ensure that it doesn’t happen again?

In the United States, treatment with any psychotropic medication has been a reason to ground a pilot permanently. In April 2010, the Federal Aviation Administration’s rules changed such that a pilot could fly if he’d been treated for mild to moderate depression with a selective serotonin reuptake inhibitor after 12 months. At that time, the FAA announced a 6-month amnesty period where a pilot could come forward about a diagnosis of depression that he had not previously felt comfortable disclosing. Presumably, other countries also have rules that ground pilots for mental illness.

So far, some reports in the media indicate that the copilot was not obviously suffering from a psychiatric disorder; all those who have been interviewed for these reports have expressed shock that Lubitz might have deliberately crashed the plane.

There also has been speculation in the media that a break in the copilot’s training 6 years ago was due to depression, and the mother of a school mate reportedly said that Lubitz had been treated for depression. Finally, investigators found a doctor’s note excusing Lubitz from work. At this point, the Wall Street Journal is reporting that he was being treated for depression. Apparently, he had shredded the note and flew on Tuesday, despite the written work excuse.

Still, all discussion of the copilot’s mental state is purely speculation. The media is noted for sensationalist reporting – and in efforts to get information out quickly, the details are often confused or simply wrong, sometimes to a remarkable extent. We don’t know if the work excuse was written by a psychiatrist or another type of physician; we don’t know if it was for a psychiatric condition, cancer, or simply strep throat.

What we’ve been told is that a copilot who was cleared to fly did so despite a work excuse from a physician, he did not disclose this condition to his employer, and he crashed a plane killing 150 people.

We might assume that the pilot suffered from some type of psychic distress – whether he met criteria for a mental disorder or not, it’s not normal to kill 150 people. If the pilot did have a history of depression and was being treated at the time of this week’s flight, then we may be left with a very unsatisfactory answer.

The anti-psychiatry activists will say that psychotropic medications caused Lubitz to crash the plane. Psychiatrists will be left with no great answer with such a scenario and will be left to say that whatever treatment he was receiving, it wasn’t enough. Certainly, the physician who told Lubitz to take off from work was right: He didn’t belong in a cockpit that day. Presumably, that physician would have done more had he been aware that the patient was about to commit a mass murder.

If the copilot does have a history of depression, but his current work excuse was for an unrelated condition, we might wonder if an untreated recurrence of depression played some role in his actions. One might speculate that the copilot could have been afraid to seek care at this time, perhaps because of a fear that he would lose his vocation.

Still, major depression can hardly explain such an act, and it is unfortunate that the press has already begun to run headlines linking this man’s alleged psychiatric diagnosis to a catastrophic mass murder. Somehow, “mental illness” gets used as an endpoint explanation for why such things happen; and short of a severe psychotic delusional system, it’s a very unsatisfying answer for an unprecedented act of violence.

The facts will unfold and perhaps we’ll learn a little more. We’ll find out what condition the copilot was being treated for and whether there were other stresses going on in his personal life. But people get depressed, take antidepressants, and deal with stress all the time.

It’s possible, if not likely, that we’ll never understand why this copilot decided to end the lives of so many people along with his own.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work (Baltimore: The Johns Hopkins University, 2011).

Earlier this week, an airplane headed from Barcelona to Dusseldorf crashed into the French Alps, leaving 150 people dead. The black box recorder indicated that the copilot was left alone in the cockpit, the pilot was locked out and attempted to gain re-entry, and the flight was reprogrammed to cruise at an altitude of 100 feet, causing the plane to crash after an 8-minute descent. The evidence indicates a deliberate action on the part of the 27-year-old co-pilot, Andreas Lubitz.

With nothing to point to terrorism at this point, the investigation will include the question of whether or not the copilot suffered from a mental illness as a way of explaining his unexplainable actions. In short, was this a combination mass murder/suicide? Was there any way to predict that such an atrocity might happen? Are there measures that can be taken to ensure that it doesn’t happen again?

In the United States, treatment with any psychotropic medication has been a reason to ground a pilot permanently. In April 2010, the Federal Aviation Administration’s rules changed such that a pilot could fly if he’d been treated for mild to moderate depression with a selective serotonin reuptake inhibitor after 12 months. At that time, the FAA announced a 6-month amnesty period where a pilot could come forward about a diagnosis of depression that he had not previously felt comfortable disclosing. Presumably, other countries also have rules that ground pilots for mental illness.

So far, some reports in the media indicate that the copilot was not obviously suffering from a psychiatric disorder; all those who have been interviewed for these reports have expressed shock that Lubitz might have deliberately crashed the plane.

There also has been speculation in the media that a break in the copilot’s training 6 years ago was due to depression, and the mother of a school mate reportedly said that Lubitz had been treated for depression. Finally, investigators found a doctor’s note excusing Lubitz from work. At this point, the Wall Street Journal is reporting that he was being treated for depression. Apparently, he had shredded the note and flew on Tuesday, despite the written work excuse.

Still, all discussion of the copilot’s mental state is purely speculation. The media is noted for sensationalist reporting – and in efforts to get information out quickly, the details are often confused or simply wrong, sometimes to a remarkable extent. We don’t know if the work excuse was written by a psychiatrist or another type of physician; we don’t know if it was for a psychiatric condition, cancer, or simply strep throat.

What we’ve been told is that a copilot who was cleared to fly did so despite a work excuse from a physician, he did not disclose this condition to his employer, and he crashed a plane killing 150 people.

We might assume that the pilot suffered from some type of psychic distress – whether he met criteria for a mental disorder or not, it’s not normal to kill 150 people. If the pilot did have a history of depression and was being treated at the time of this week’s flight, then we may be left with a very unsatisfactory answer.

The anti-psychiatry activists will say that psychotropic medications caused Lubitz to crash the plane. Psychiatrists will be left with no great answer with such a scenario and will be left to say that whatever treatment he was receiving, it wasn’t enough. Certainly, the physician who told Lubitz to take off from work was right: He didn’t belong in a cockpit that day. Presumably, that physician would have done more had he been aware that the patient was about to commit a mass murder.

If the copilot does have a history of depression, but his current work excuse was for an unrelated condition, we might wonder if an untreated recurrence of depression played some role in his actions. One might speculate that the copilot could have been afraid to seek care at this time, perhaps because of a fear that he would lose his vocation.

Still, major depression can hardly explain such an act, and it is unfortunate that the press has already begun to run headlines linking this man’s alleged psychiatric diagnosis to a catastrophic mass murder. Somehow, “mental illness” gets used as an endpoint explanation for why such things happen; and short of a severe psychotic delusional system, it’s a very unsatisfying answer for an unprecedented act of violence.

The facts will unfold and perhaps we’ll learn a little more. We’ll find out what condition the copilot was being treated for and whether there were other stresses going on in his personal life. But people get depressed, take antidepressants, and deal with stress all the time.

It’s possible, if not likely, that we’ll never understand why this copilot decided to end the lives of so many people along with his own.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work (Baltimore: The Johns Hopkins University, 2011).

I’m not on Facebook, either professionally or personally.

My office doesn’t have a Twitter account.

In fact, my only nod to social media at all is a rarely updated LinkedIn page, which is really just a public CV.

Why, in this age of connectedness, do I hide from these things? One reason is time. There isn’t much of it in the course of a day. Between my practice (patients, dictations, forms, returning calls, reviewing tests, rinse, wash, repeat), my family (wife, kids, dogs, house), and all the other things that make up a day (driving, finances, bathing, sleep), I don’t have much extra time. I really have no desire to see what others had for breakfast, look at pictures of a distant cousin’s kids, or have an online political argument with in-laws.

Another reason is privacy. Most patients are good people, but there are scary ones, too. I don’t want them knowing my kids’ names, or what school they go to, or seeing their pictures. In this age trying to have a degree of personal privacy is hard enough. I don’t want to make it any easier for someone looking to cause trouble.

I have nothing against my patients. I like the majority of them. But I don’t want to be online friends with them, either. Practicing objective medicine requires a degree of emotional distance, and I don’t want to do anything to shorten that. Social media connections with someone may also clue you into their personal and political beliefs, and, as I’ve said before, I think knowing those about patients (and them knowing mine) can only make the relationship difficult.

And the last is from a medical-legal view. The definition of what constitutes medical advice seems to be quite vague, and I worry anything I innocuously post or tweet could be taken to mean that I had an established treating medical relationship with someone or that my malpractice carrier could raise my rates by saying I was doing online medicine.

There’s also the simple fact that anything can be interpreted in any way. I worry that something I might put up could be used against me in court. Let’s say a patient dies while I’m on vacation, and the family decides to sue. Pictures of me relaxing with my kids on the trip could be used to make me look like an uncaring, callous doctor, even if I had no idea what was going on back home.

I’ll keep my somewhat under-the-radar personal existence as it is. Others may feel I’m missing out on the wonders of the social age, but I’m happy with keeping my home life just that – at home.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m not on Facebook, either professionally or personally.

My office doesn’t have a Twitter account.

In fact, my only nod to social media at all is a rarely updated LinkedIn page, which is really just a public CV.

Why, in this age of connectedness, do I hide from these things? One reason is time. There isn’t much of it in the course of a day. Between my practice (patients, dictations, forms, returning calls, reviewing tests, rinse, wash, repeat), my family (wife, kids, dogs, house), and all the other things that make up a day (driving, finances, bathing, sleep), I don’t have much extra time. I really have no desire to see what others had for breakfast, look at pictures of a distant cousin’s kids, or have an online political argument with in-laws.

Another reason is privacy. Most patients are good people, but there are scary ones, too. I don’t want them knowing my kids’ names, or what school they go to, or seeing their pictures. In this age trying to have a degree of personal privacy is hard enough. I don’t want to make it any easier for someone looking to cause trouble.

I have nothing against my patients. I like the majority of them. But I don’t want to be online friends with them, either. Practicing objective medicine requires a degree of emotional distance, and I don’t want to do anything to shorten that. Social media connections with someone may also clue you into their personal and political beliefs, and, as I’ve said before, I think knowing those about patients (and them knowing mine) can only make the relationship difficult.

And the last is from a medical-legal view. The definition of what constitutes medical advice seems to be quite vague, and I worry anything I innocuously post or tweet could be taken to mean that I had an established treating medical relationship with someone or that my malpractice carrier could raise my rates by saying I was doing online medicine.

There’s also the simple fact that anything can be interpreted in any way. I worry that something I might put up could be used against me in court. Let’s say a patient dies while I’m on vacation, and the family decides to sue. Pictures of me relaxing with my kids on the trip could be used to make me look like an uncaring, callous doctor, even if I had no idea what was going on back home.

I’ll keep my somewhat under-the-radar personal existence as it is. Others may feel I’m missing out on the wonders of the social age, but I’m happy with keeping my home life just that – at home.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m not on Facebook, either professionally or personally.

My office doesn’t have a Twitter account.

In fact, my only nod to social media at all is a rarely updated LinkedIn page, which is really just a public CV.

Why, in this age of connectedness, do I hide from these things? One reason is time. There isn’t much of it in the course of a day. Between my practice (patients, dictations, forms, returning calls, reviewing tests, rinse, wash, repeat), my family (wife, kids, dogs, house), and all the other things that make up a day (driving, finances, bathing, sleep), I don’t have much extra time. I really have no desire to see what others had for breakfast, look at pictures of a distant cousin’s kids, or have an online political argument with in-laws.

Another reason is privacy. Most patients are good people, but there are scary ones, too. I don’t want them knowing my kids’ names, or what school they go to, or seeing their pictures. In this age trying to have a degree of personal privacy is hard enough. I don’t want to make it any easier for someone looking to cause trouble.

I have nothing against my patients. I like the majority of them. But I don’t want to be online friends with them, either. Practicing objective medicine requires a degree of emotional distance, and I don’t want to do anything to shorten that. Social media connections with someone may also clue you into their personal and political beliefs, and, as I’ve said before, I think knowing those about patients (and them knowing mine) can only make the relationship difficult.

And the last is from a medical-legal view. The definition of what constitutes medical advice seems to be quite vague, and I worry anything I innocuously post or tweet could be taken to mean that I had an established treating medical relationship with someone or that my malpractice carrier could raise my rates by saying I was doing online medicine.

There’s also the simple fact that anything can be interpreted in any way. I worry that something I might put up could be used against me in court. Let’s say a patient dies while I’m on vacation, and the family decides to sue. Pictures of me relaxing with my kids on the trip could be used to make me look like an uncaring, callous doctor, even if I had no idea what was going on back home.

I’ll keep my somewhat under-the-radar personal existence as it is. Others may feel I’m missing out on the wonders of the social age, but I’m happy with keeping my home life just that – at home.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Large-scale randomized trials have not only documented the efficacy of minimally invasive midurethral slings for stress urinary continence, they have also provided more adequate data on the incidence of complications. In practice, meanwhile, we are seeing more complications as the number of midurethral sling placements increases.

Often times, complications can be significantly more impactful than the original urinary incontinence. It is important to take the complications of sling placement seriously. Let patients know that their symptoms matter, and that there are ways to manage complications.

With more long-term data and experience, we have learned more about what to do, and what not to do, to prevent, diagnose, and manage the complications associated with midurethral slings. Here is my approach to the complications most commonly encountered, including bladder perforation, voiding dysfunction, erosion, pain, and recurrent stress urinary incontinence.

I will not address vascular injury in this article, but certainly, this is a surgical emergency that needs to be handled as such. As described in the February 2015 edition of Master Class on midurethral sling technique, accurate visualization toward the ipsilateral shoulder during needle passage is an essential part of preventing vascular injuries during retropubic sling placement.

Bladder perforation

Bladder perforation has consistently been shown to be significantly more common with retropubic slings than with transobturator slings. Reported incidence has ranged from 0.8% to 34% for tension-free vaginal tape (TVT) procedures, with the higher rates seen mainly in teaching institutions. Most commonly, the reported incidence is less than 10%.

Bladder perforation has no effect on the efficacy of the treatment, and no apparent long-term consequences, as long as the injury is identified. Especially with a retropubic sling, cystoscopy should be performed after both needles are placed but prior to advancing the needles all the way through the retropubic space. Simply withdrawing a needle will cause little bladder injury while retracting deployed mesh is significantly more consequential.

I recommend filling the bladder to approximately 300 cc, or to the point where you can see evidence of full distension such as flattened urethral orifices. This confirms that the bladder is under enough distension to preclude any mucosal wrinkles or folds that can hide a trocar injury.

The first step upon recognition of a perforation is to stay calm. In the vast majority of cases, simply withdrawing the needle, replacing it, and verifying correct replacement will prevent any long-term consequences. On the other hand, you must be fully alert to the possibility that the needle wandered away from the pubic bone, and consequently may have entered a space such as the peritoneum. Suspicion for visceral injury should be increased.

Courtesy of Dr. Charles Rardin

Resist the temptation to replace the needle more laterally. This course correction is often an unhelpful instinct, because a more lateral replacement will not move the needle farther from the bladder; it will instead bring it closer to the iliac vessels. Vascular injuries resulting from the surgeon’s attempts at needle replacement are unfortunate, as a minor complication becomes a major one. The key is to be as distal as possible – as close to the pubic bone as possible – and not to replace the needles more laterally.

Postoperative drainage for 1-2 days may be considered, but there is nothing in the literature to require this, and many surgeons do not employ any sort of extra catheterization after surgery where perforation has been observed.

Voiding dysfunction

Some degree of voiding dysfunction is not uncommon in the short term, but when a patient is still unable to void normally or completely after several days, an evaluation is warranted. As with bladder perforation, reported incidence of voiding dysfunction has varied widely, from 2% to 45% with the newer midurethral slings. Generally, the need for surgical revision is about 2%.

There are two reasons for urinary retention: Insufficient contraction force in the bladder or too much resistance. If retention persists beyond a week – in the 7-10 day postop time period – I assess whether the problem is resulting from too much obstruction from the sling, some form of hypotonic bladder, other surgery performed in conjunction with sling placement, medications, or something else.

Difficulty in passing a small urethra catheter in the office may indicate excessive obstruction, for instance, and there may be indications on vaginal examination or through cystoscopy that the sling is too tight. A midurethral “speed bump,” or elevation at the midpoint, with either catheterization or the scope is consistent with over-correction.

Courtesy of Dr. Charles Rardin

Do not dilate or pull down on the sling with any kind of urethra dilator. The sling is more robust than the urethral mucosa, and we now appreciate that this practice is associated with urethral erosion.

If the problem is deemed to be excessive obstruction or over-resistance, and it is fewer than 10 days postop, the patient may be offered a minor revision; the original incision is reopened, the sling material is identified, and the sling arms (lateral to the urethra) are grasped with clamps. Gentle downward traction can loosen the sling.

The sling should be grasped laterally and not at the midpoint; some sling materials will stretch and fracture where the force is applied. A little bit of gentle downward traction (3-5 mm) will often give you the needed amount of space for relieving some of the obstruction.

Beyond 10 days postop, tissue in-growth makes such a sling adjustment difficult, if not impossible. At this point, I recommend transecting the entire sling in the midline.There is differing opinion about whether a portion of the mesh should be resected; I believe that such a resection is usually unnecessary, and that a simple midline release procedure is the best approach.

A study we performed more than a decade ago on surgical release of TVT showed that persistent post-TVT voiding dysfunction can be successfully managed with a simple midline release. Of 1,175 women who underwent TVT placement for stress urinary incontinence and/or intrinsic sphincter deficiency, 23 (1.9%) had persistent voiding dysfunction. All cases of impaired emptying were completely resolved with a release of the tape, and the majority remained cured in terms of their continence or went from “cured” to “improved” over baseline. Three patients (13%) had recurrence of stress incontinence (Obstet. Gynecol. 2002;100:898-902).

We used to wait longer before revising the sling out of fear of losing the entire benefit of the sling. As it turns out, a simple midline release (leaving most, if not all, of the mesh in place) is usually just enough to treat the new complaint while still providing enough lateral support so that the patient retains most or all of the continence achieved with the sling.

Complaints of de novo urge incontinence, or overactive bladder, should be taken seriously. Urge incontinence has even more significant associations with depression and poor quality of life than stress incontinence. In the absence of retention, usual first-line therapies for overactive bladder can be employed, including anticholinergic medications, behavioral therapies, and physical therapy. Failing these interventions, my assessment for this complaint will be similar to that for retention; I’ll look for evidence of too much resistance, such as difficulty in passing a catheter, a “speed bump” cystoscopically, or an elevated pDet on pressure-flow studies, for instance.

If any of these are present, I usually offer sling release first. If, on the other hand, there is no evidence of over resistance in a patient who has de novo urge incontinence or overactive bladder and is refractory to conservative measures, a trial of sacral neuromodulation or botox injections is considered the next step.

Erosion

Erosion remains a difficult complication to understand. Long-term follow-up data show that it occurs after 3%-4% of sling placements, rather than 1% as originally believed. Data are inconsistent, but there probably is a slightly higher incidence of vaginal erosion with a transobturator sling, given more contact between the sling and the anterior vaginal wall.

There are hints in the literature that erosion may be related to technique – perhaps to the depth of dissection during surgery – but this is difficult to quantify. Moreover, many of the reported cases of erosion occur several years, or longer, after surgery. It is hard to blame surgical technique for such delayed erosion.

As we’ve seen with previous generations of mesh, there does not appear to be any window of time after which erosion is no longer a risk. We need to recognize that there is a medium- and long-term risk of erosion and appreciate its presenting symptoms: Recurrent urinary tract infection, pain with voiding, urgency, urinary incontinence, and microscopic hematuria of new onset.

Prevention may well entail preoperative estrogenization. The science looking at the effect of estrogen on sling placement is becoming more robust. While there are uncertainties, I believe that studies likely will show that topical estrogen in the preoperative and perioperative phases plays an important role in preventing erosion from occurring. Personally, I am using it much more than I was 10 years ago.

I like the convenience of the Vagifem tablet (Novo Nordisk Inc., Plainsboro, N.J.), and am reassured by data on systemic absorption with the 10-mcg dose, but any vaginal cream or compounded suppository can be used. I usually advise 4-6 weeks of preoperative preparation, with nightly use for 2 weeks followed by 2-3 nights per week thereafter. Smoking is also a likely risk factor. Data are not entirely consistent, but I believe we should provide counseling and encourage smoking cessation before the implant of mesh.

Management is dependent on when the erosion occurs or is recognized. When erosion occurs within 6 weeks post operatively, primary repair is an option. When erosion is detected after the 6-week window and is causing symptoms, a conservative trim of bristles poking through the vaginal mucosa is worth a try. I do not advise more than one such conservative trim, however, as repeated attempts and series of small resections can make the sling exceedingly difficult to remove if more complete resection is ultimately needed. After one unsuccessful trim, I usually remove the whole sling belly, or most of the vaginal part of the sling.

For slings made of type 1 macroporous mesh, resection of the retropubic or transobturator portions of the mesh usually is not required. In the more rare situation where those pelvic areas of the mesh are associated with pain, I favor a laparoscopic approach to the retropubic space to facilitate minimally invasive removal.

Postop pain, sling failure

Groin pain, or thigh pain, sometimes occurs after placement of a transobturator sling. As I discussed in the previous Master Class on midurethral sling technique, I have seen a significant decrease in groin pain in my patients – without any reduction in benefit – with the use of a shorter transobturator sling that does not leave mesh in the adductor compartment of the thigh and groin.

For persistent groin pain, I favor the use of trigger point injection. Sometimes one injection will impact the inflammatory cycle such that the patient derives long-term benefit. At other times, the trigger point injection will serve as a diagnostic; if pain returns after a period of benefit, I am inclined to resect that part of the mesh.

Pain inside the pelvis, especially on the pelvic sidewall (obturator or puborectalis complex) usually is related to mechanical tension. In my experience, this type of discomfort is slightly more likely to occur with the transobturator slings, which penetrate through the muscular pelvic sidewall and lead to more fibrosis and scar tissue formation.

In most cases of pain and discomfort, attempting to reproduce the patient’s symptoms by putting tension on particular parts of the sling during the office exam helps guide management. If I find that palpating or putting the sling on tension recreates her complaints, and conservative injections have provided temporary or inadequate relief, I usually advocate resecting the vaginal portion of the mesh to relieve that tension.

In cases of recurrent stress urinary incontinence (when the sling has failed), a TVT or repeat TVT is often warranted. The TVT sling has been demonstrated to work after nearly every other previous kind of anti-incontinence procedure, even after a previous retropubic sling. There is little data on mesh removal in such cases. I believe that unless a previously placed but failed sling is causing symptoms, there is no need to resect it. Mesh removal is significantly more traumatic than mesh placement, and in most cases it is not necessary.

Dr. Rardin reported that he has no relevant financial disclosures.

Large-scale randomized trials have not only documented the efficacy of minimally invasive midurethral slings for stress urinary continence, they have also provided more adequate data on the incidence of complications. In practice, meanwhile, we are seeing more complications as the number of midurethral sling placements increases.

Often times, complications can be significantly more impactful than the original urinary incontinence. It is important to take the complications of sling placement seriously. Let patients know that their symptoms matter, and that there are ways to manage complications.

With more long-term data and experience, we have learned more about what to do, and what not to do, to prevent, diagnose, and manage the complications associated with midurethral slings. Here is my approach to the complications most commonly encountered, including bladder perforation, voiding dysfunction, erosion, pain, and recurrent stress urinary incontinence.

I will not address vascular injury in this article, but certainly, this is a surgical emergency that needs to be handled as such. As described in the February 2015 edition of Master Class on midurethral sling technique, accurate visualization toward the ipsilateral shoulder during needle passage is an essential part of preventing vascular injuries during retropubic sling placement.

Bladder perforation

Bladder perforation has consistently been shown to be significantly more common with retropubic slings than with transobturator slings. Reported incidence has ranged from 0.8% to 34% for tension-free vaginal tape (TVT) procedures, with the higher rates seen mainly in teaching institutions. Most commonly, the reported incidence is less than 10%.

Bladder perforation has no effect on the efficacy of the treatment, and no apparent long-term consequences, as long as the injury is identified. Especially with a retropubic sling, cystoscopy should be performed after both needles are placed but prior to advancing the needles all the way through the retropubic space. Simply withdrawing a needle will cause little bladder injury while retracting deployed mesh is significantly more consequential.

I recommend filling the bladder to approximately 300 cc, or to the point where you can see evidence of full distension such as flattened urethral orifices. This confirms that the bladder is under enough distension to preclude any mucosal wrinkles or folds that can hide a trocar injury.

The first step upon recognition of a perforation is to stay calm. In the vast majority of cases, simply withdrawing the needle, replacing it, and verifying correct replacement will prevent any long-term consequences. On the other hand, you must be fully alert to the possibility that the needle wandered away from the pubic bone, and consequently may have entered a space such as the peritoneum. Suspicion for visceral injury should be increased.

Courtesy of Dr. Charles Rardin

Resist the temptation to replace the needle more laterally. This course correction is often an unhelpful instinct, because a more lateral replacement will not move the needle farther from the bladder; it will instead bring it closer to the iliac vessels. Vascular injuries resulting from the surgeon’s attempts at needle replacement are unfortunate, as a minor complication becomes a major one. The key is to be as distal as possible – as close to the pubic bone as possible – and not to replace the needles more laterally.

Postoperative drainage for 1-2 days may be considered, but there is nothing in the literature to require this, and many surgeons do not employ any sort of extra catheterization after surgery where perforation has been observed.

Voiding dysfunction

Some degree of voiding dysfunction is not uncommon in the short term, but when a patient is still unable to void normally or completely after several days, an evaluation is warranted. As with bladder perforation, reported incidence of voiding dysfunction has varied widely, from 2% to 45% with the newer midurethral slings. Generally, the need for surgical revision is about 2%.

There are two reasons for urinary retention: Insufficient contraction force in the bladder or too much resistance. If retention persists beyond a week – in the 7-10 day postop time period – I assess whether the problem is resulting from too much obstruction from the sling, some form of hypotonic bladder, other surgery performed in conjunction with sling placement, medications, or something else.

Difficulty in passing a small urethra catheter in the office may indicate excessive obstruction, for instance, and there may be indications on vaginal examination or through cystoscopy that the sling is too tight. A midurethral “speed bump,” or elevation at the midpoint, with either catheterization or the scope is consistent with over-correction.

Courtesy of Dr. Charles Rardin

Do not dilate or pull down on the sling with any kind of urethra dilator. The sling is more robust than the urethral mucosa, and we now appreciate that this practice is associated with urethral erosion.

If the problem is deemed to be excessive obstruction or over-resistance, and it is fewer than 10 days postop, the patient may be offered a minor revision; the original incision is reopened, the sling material is identified, and the sling arms (lateral to the urethra) are grasped with clamps. Gentle downward traction can loosen the sling.

The sling should be grasped laterally and not at the midpoint; some sling materials will stretch and fracture where the force is applied. A little bit of gentle downward traction (3-5 mm) will often give you the needed amount of space for relieving some of the obstruction.

Beyond 10 days postop, tissue in-growth makes such a sling adjustment difficult, if not impossible. At this point, I recommend transecting the entire sling in the midline.There is differing opinion about whether a portion of the mesh should be resected; I believe that such a resection is usually unnecessary, and that a simple midline release procedure is the best approach.

A study we performed more than a decade ago on surgical release of TVT showed that persistent post-TVT voiding dysfunction can be successfully managed with a simple midline release. Of 1,175 women who underwent TVT placement for stress urinary incontinence and/or intrinsic sphincter deficiency, 23 (1.9%) had persistent voiding dysfunction. All cases of impaired emptying were completely resolved with a release of the tape, and the majority remained cured in terms of their continence or went from “cured” to “improved” over baseline. Three patients (13%) had recurrence of stress incontinence (Obstet. Gynecol. 2002;100:898-902).

We used to wait longer before revising the sling out of fear of losing the entire benefit of the sling. As it turns out, a simple midline release (leaving most, if not all, of the mesh in place) is usually just enough to treat the new complaint while still providing enough lateral support so that the patient retains most or all of the continence achieved with the sling.

Complaints of de novo urge incontinence, or overactive bladder, should be taken seriously. Urge incontinence has even more significant associations with depression and poor quality of life than stress incontinence. In the absence of retention, usual first-line therapies for overactive bladder can be employed, including anticholinergic medications, behavioral therapies, and physical therapy. Failing these interventions, my assessment for this complaint will be similar to that for retention; I’ll look for evidence of too much resistance, such as difficulty in passing a catheter, a “speed bump” cystoscopically, or an elevated pDet on pressure-flow studies, for instance.

If any of these are present, I usually offer sling release first. If, on the other hand, there is no evidence of over resistance in a patient who has de novo urge incontinence or overactive bladder and is refractory to conservative measures, a trial of sacral neuromodulation or botox injections is considered the next step.

Erosion

Erosion remains a difficult complication to understand. Long-term follow-up data show that it occurs after 3%-4% of sling placements, rather than 1% as originally believed. Data are inconsistent, but there probably is a slightly higher incidence of vaginal erosion with a transobturator sling, given more contact between the sling and the anterior vaginal wall.

There are hints in the literature that erosion may be related to technique – perhaps to the depth of dissection during surgery – but this is difficult to quantify. Moreover, many of the reported cases of erosion occur several years, or longer, after surgery. It is hard to blame surgical technique for such delayed erosion.

As we’ve seen with previous generations of mesh, there does not appear to be any window of time after which erosion is no longer a risk. We need to recognize that there is a medium- and long-term risk of erosion and appreciate its presenting symptoms: Recurrent urinary tract infection, pain with voiding, urgency, urinary incontinence, and microscopic hematuria of new onset.

Prevention may well entail preoperative estrogenization. The science looking at the effect of estrogen on sling placement is becoming more robust. While there are uncertainties, I believe that studies likely will show that topical estrogen in the preoperative and perioperative phases plays an important role in preventing erosion from occurring. Personally, I am using it much more than I was 10 years ago.

I like the convenience of the Vagifem tablet (Novo Nordisk Inc., Plainsboro, N.J.), and am reassured by data on systemic absorption with the 10-mcg dose, but any vaginal cream or compounded suppository can be used. I usually advise 4-6 weeks of preoperative preparation, with nightly use for 2 weeks followed by 2-3 nights per week thereafter. Smoking is also a likely risk factor. Data are not entirely consistent, but I believe we should provide counseling and encourage smoking cessation before the implant of mesh.

Management is dependent on when the erosion occurs or is recognized. When erosion occurs within 6 weeks post operatively, primary repair is an option. When erosion is detected after the 6-week window and is causing symptoms, a conservative trim of bristles poking through the vaginal mucosa is worth a try. I do not advise more than one such conservative trim, however, as repeated attempts and series of small resections can make the sling exceedingly difficult to remove if more complete resection is ultimately needed. After one unsuccessful trim, I usually remove the whole sling belly, or most of the vaginal part of the sling.

For slings made of type 1 macroporous mesh, resection of the retropubic or transobturator portions of the mesh usually is not required. In the more rare situation where those pelvic areas of the mesh are associated with pain, I favor a laparoscopic approach to the retropubic space to facilitate minimally invasive removal.

Postop pain, sling failure

Groin pain, or thigh pain, sometimes occurs after placement of a transobturator sling. As I discussed in the previous Master Class on midurethral sling technique, I have seen a significant decrease in groin pain in my patients – without any reduction in benefit – with the use of a shorter transobturator sling that does not leave mesh in the adductor compartment of the thigh and groin.

For persistent groin pain, I favor the use of trigger point injection. Sometimes one injection will impact the inflammatory cycle such that the patient derives long-term benefit. At other times, the trigger point injection will serve as a diagnostic; if pain returns after a period of benefit, I am inclined to resect that part of the mesh.

Pain inside the pelvis, especially on the pelvic sidewall (obturator or puborectalis complex) usually is related to mechanical tension. In my experience, this type of discomfort is slightly more likely to occur with the transobturator slings, which penetrate through the muscular pelvic sidewall and lead to more fibrosis and scar tissue formation.

In most cases of pain and discomfort, attempting to reproduce the patient’s symptoms by putting tension on particular parts of the sling during the office exam helps guide management. If I find that palpating or putting the sling on tension recreates her complaints, and conservative injections have provided temporary or inadequate relief, I usually advocate resecting the vaginal portion of the mesh to relieve that tension.

In cases of recurrent stress urinary incontinence (when the sling has failed), a TVT or repeat TVT is often warranted. The TVT sling has been demonstrated to work after nearly every other previous kind of anti-incontinence procedure, even after a previous retropubic sling. There is little data on mesh removal in such cases. I believe that unless a previously placed but failed sling is causing symptoms, there is no need to resect it. Mesh removal is significantly more traumatic than mesh placement, and in most cases it is not necessary.

Dr. Rardin reported that he has no relevant financial disclosures.

Large-scale randomized trials have not only documented the efficacy of minimally invasive midurethral slings for stress urinary continence, they have also provided more adequate data on the incidence of complications. In practice, meanwhile, we are seeing more complications as the number of midurethral sling placements increases.

Often times, complications can be significantly more impactful than the original urinary incontinence. It is important to take the complications of sling placement seriously. Let patients know that their symptoms matter, and that there are ways to manage complications.

With more long-term data and experience, we have learned more about what to do, and what not to do, to prevent, diagnose, and manage the complications associated with midurethral slings. Here is my approach to the complications most commonly encountered, including bladder perforation, voiding dysfunction, erosion, pain, and recurrent stress urinary incontinence.

I will not address vascular injury in this article, but certainly, this is a surgical emergency that needs to be handled as such. As described in the February 2015 edition of Master Class on midurethral sling technique, accurate visualization toward the ipsilateral shoulder during needle passage is an essential part of preventing vascular injuries during retropubic sling placement.

Bladder perforation

Bladder perforation has consistently been shown to be significantly more common with retropubic slings than with transobturator slings. Reported incidence has ranged from 0.8% to 34% for tension-free vaginal tape (TVT) procedures, with the higher rates seen mainly in teaching institutions. Most commonly, the reported incidence is less than 10%.

Bladder perforation has no effect on the efficacy of the treatment, and no apparent long-term consequences, as long as the injury is identified. Especially with a retropubic sling, cystoscopy should be performed after both needles are placed but prior to advancing the needles all the way through the retropubic space. Simply withdrawing a needle will cause little bladder injury while retracting deployed mesh is significantly more consequential.

I recommend filling the bladder to approximately 300 cc, or to the point where you can see evidence of full distension such as flattened urethral orifices. This confirms that the bladder is under enough distension to preclude any mucosal wrinkles or folds that can hide a trocar injury.

The first step upon recognition of a perforation is to stay calm. In the vast majority of cases, simply withdrawing the needle, replacing it, and verifying correct replacement will prevent any long-term consequences. On the other hand, you must be fully alert to the possibility that the needle wandered away from the pubic bone, and consequently may have entered a space such as the peritoneum. Suspicion for visceral injury should be increased.

Courtesy of Dr. Charles Rardin

Resist the temptation to replace the needle more laterally. This course correction is often an unhelpful instinct, because a more lateral replacement will not move the needle farther from the bladder; it will instead bring it closer to the iliac vessels. Vascular injuries resulting from the surgeon’s attempts at needle replacement are unfortunate, as a minor complication becomes a major one. The key is to be as distal as possible – as close to the pubic bone as possible – and not to replace the needles more laterally.

Postoperative drainage for 1-2 days may be considered, but there is nothing in the literature to require this, and many surgeons do not employ any sort of extra catheterization after surgery where perforation has been observed.

Voiding dysfunction

Some degree of voiding dysfunction is not uncommon in the short term, but when a patient is still unable to void normally or completely after several days, an evaluation is warranted. As with bladder perforation, reported incidence of voiding dysfunction has varied widely, from 2% to 45% with the newer midurethral slings. Generally, the need for surgical revision is about 2%.

There are two reasons for urinary retention: Insufficient contraction force in the bladder or too much resistance. If retention persists beyond a week – in the 7-10 day postop time period – I assess whether the problem is resulting from too much obstruction from the sling, some form of hypotonic bladder, other surgery performed in conjunction with sling placement, medications, or something else.

Difficulty in passing a small urethra catheter in the office may indicate excessive obstruction, for instance, and there may be indications on vaginal examination or through cystoscopy that the sling is too tight. A midurethral “speed bump,” or elevation at the midpoint, with either catheterization or the scope is consistent with over-correction.

Courtesy of Dr. Charles Rardin

Do not dilate or pull down on the sling with any kind of urethra dilator. The sling is more robust than the urethral mucosa, and we now appreciate that this practice is associated with urethral erosion.

If the problem is deemed to be excessive obstruction or over-resistance, and it is fewer than 10 days postop, the patient may be offered a minor revision; the original incision is reopened, the sling material is identified, and the sling arms (lateral to the urethra) are grasped with clamps. Gentle downward traction can loosen the sling.

The sling should be grasped laterally and not at the midpoint; some sling materials will stretch and fracture where the force is applied. A little bit of gentle downward traction (3-5 mm) will often give you the needed amount of space for relieving some of the obstruction.

Beyond 10 days postop, tissue in-growth makes such a sling adjustment difficult, if not impossible. At this point, I recommend transecting the entire sling in the midline.There is differing opinion about whether a portion of the mesh should be resected; I believe that such a resection is usually unnecessary, and that a simple midline release procedure is the best approach.

A study we performed more than a decade ago on surgical release of TVT showed that persistent post-TVT voiding dysfunction can be successfully managed with a simple midline release. Of 1,175 women who underwent TVT placement for stress urinary incontinence and/or intrinsic sphincter deficiency, 23 (1.9%) had persistent voiding dysfunction. All cases of impaired emptying were completely resolved with a release of the tape, and the majority remained cured in terms of their continence or went from “cured” to “improved” over baseline. Three patients (13%) had recurrence of stress incontinence (Obstet. Gynecol. 2002;100:898-902).

We used to wait longer before revising the sling out of fear of losing the entire benefit of the sling. As it turns out, a simple midline release (leaving most, if not all, of the mesh in place) is usually just enough to treat the new complaint while still providing enough lateral support so that the patient retains most or all of the continence achieved with the sling.

Complaints of de novo urge incontinence, or overactive bladder, should be taken seriously. Urge incontinence has even more significant associations with depression and poor quality of life than stress incontinence. In the absence of retention, usual first-line therapies for overactive bladder can be employed, including anticholinergic medications, behavioral therapies, and physical therapy. Failing these interventions, my assessment for this complaint will be similar to that for retention; I’ll look for evidence of too much resistance, such as difficulty in passing a catheter, a “speed bump” cystoscopically, or an elevated pDet on pressure-flow studies, for instance.

If any of these are present, I usually offer sling release first. If, on the other hand, there is no evidence of over resistance in a patient who has de novo urge incontinence or overactive bladder and is refractory to conservative measures, a trial of sacral neuromodulation or botox injections is considered the next step.

Erosion

Erosion remains a difficult complication to understand. Long-term follow-up data show that it occurs after 3%-4% of sling placements, rather than 1% as originally believed. Data are inconsistent, but there probably is a slightly higher incidence of vaginal erosion with a transobturator sling, given more contact between the sling and the anterior vaginal wall.

There are hints in the literature that erosion may be related to technique – perhaps to the depth of dissection during surgery – but this is difficult to quantify. Moreover, many of the reported cases of erosion occur several years, or longer, after surgery. It is hard to blame surgical technique for such delayed erosion.

As we’ve seen with previous generations of mesh, there does not appear to be any window of time after which erosion is no longer a risk. We need to recognize that there is a medium- and long-term risk of erosion and appreciate its presenting symptoms: Recurrent urinary tract infection, pain with voiding, urgency, urinary incontinence, and microscopic hematuria of new onset.

Prevention may well entail preoperative estrogenization. The science looking at the effect of estrogen on sling placement is becoming more robust. While there are uncertainties, I believe that studies likely will show that topical estrogen in the preoperative and perioperative phases plays an important role in preventing erosion from occurring. Personally, I am using it much more than I was 10 years ago.

I like the convenience of the Vagifem tablet (Novo Nordisk Inc., Plainsboro, N.J.), and am reassured by data on systemic absorption with the 10-mcg dose, but any vaginal cream or compounded suppository can be used. I usually advise 4-6 weeks of preoperative preparation, with nightly use for 2 weeks followed by 2-3 nights per week thereafter. Smoking is also a likely risk factor. Data are not entirely consistent, but I believe we should provide counseling and encourage smoking cessation before the implant of mesh.

Management is dependent on when the erosion occurs or is recognized. When erosion occurs within 6 weeks post operatively, primary repair is an option. When erosion is detected after the 6-week window and is causing symptoms, a conservative trim of bristles poking through the vaginal mucosa is worth a try. I do not advise more than one such conservative trim, however, as repeated attempts and series of small resections can make the sling exceedingly difficult to remove if more complete resection is ultimately needed. After one unsuccessful trim, I usually remove the whole sling belly, or most of the vaginal part of the sling.

For slings made of type 1 macroporous mesh, resection of the retropubic or transobturator portions of the mesh usually is not required. In the more rare situation where those pelvic areas of the mesh are associated with pain, I favor a laparoscopic approach to the retropubic space to facilitate minimally invasive removal.

Postop pain, sling failure

Groin pain, or thigh pain, sometimes occurs after placement of a transobturator sling. As I discussed in the previous Master Class on midurethral sling technique, I have seen a significant decrease in groin pain in my patients – without any reduction in benefit – with the use of a shorter transobturator sling that does not leave mesh in the adductor compartment of the thigh and groin.

For persistent groin pain, I favor the use of trigger point injection. Sometimes one injection will impact the inflammatory cycle such that the patient derives long-term benefit. At other times, the trigger point injection will serve as a diagnostic; if pain returns after a period of benefit, I am inclined to resect that part of the mesh.

Pain inside the pelvis, especially on the pelvic sidewall (obturator or puborectalis complex) usually is related to mechanical tension. In my experience, this type of discomfort is slightly more likely to occur with the transobturator slings, which penetrate through the muscular pelvic sidewall and lead to more fibrosis and scar tissue formation.

In most cases of pain and discomfort, attempting to reproduce the patient’s symptoms by putting tension on particular parts of the sling during the office exam helps guide management. If I find that palpating or putting the sling on tension recreates her complaints, and conservative injections have provided temporary or inadequate relief, I usually advocate resecting the vaginal portion of the mesh to relieve that tension.

In cases of recurrent stress urinary incontinence (when the sling has failed), a TVT or repeat TVT is often warranted. The TVT sling has been demonstrated to work after nearly every other previous kind of anti-incontinence procedure, even after a previous retropubic sling. There is little data on mesh removal in such cases. I believe that unless a previously placed but failed sling is causing symptoms, there is no need to resect it. Mesh removal is significantly more traumatic than mesh placement, and in most cases it is not necessary.

Dr. Rardin reported that he has no relevant financial disclosures.