Mid-urethral slings have become the most common method to treat stress urinary incontinence (SUI). They are typically placed in under 30 minutes in an outpatient setting and are popular with both physician and patients due to the high cure rate, relative ease of placement, low complication rate and quick recovery.
The prototype of modern day slings is the TVT (tension-free vaginal tape), and many similar ones exist on the market that are placed in a similar fashion, but ultimately perform the same function. TVT has been around for approximately 15 years and is used worldwide.
The sling is made of a thin strip of polypropylene mesh weave, a common and safe type of mesh used for surgery in a variety of body locations. The width is 1 cm and the length left in the body is usually between 6-8 inches long. There are various methods for placing slings, but ultimately, it must rest under the mid-urethra.
It is placed through a small incision in the vagina, usually under general anesthesia, and women can go home the same day without a urinary catheter after urinating in recovery. Vaginal stitches to close the skin dissolve, but the sling is permanent. It becomes incorporated into the body tissue. The body lays new collagen and scar within the sling and around it, and it becomes a new firm ligament under the urethra replacing the one that had become weak. The sling acts like a backboard and supports the urethra during straining maneuvers such as coughing, sneezing, laughing, jumping and exercise. It prevents it from descending, thereby preventing urine loss.
Slings are durable to about 10-15 years but longer term data does not exist simply because it hasn’t been around that long. It is less invasive than the next most popular procedure for SUI, the Burch colposuspension, which requires a bikini line abdominal incision and then the bladder neck is raised up and stitched close to the back part of the pubic bone. Despite equivalent cure rates, surgery time and recovery time is longer. It has generally fallen out of favor as a modern approach to curing SUI. If a woman is undergoing other pelvic surgery such as a hysterectomy or bladder lift (cystocele), a sling can be done concomitantly and adds only a few extra minutes to these procedures.
For those women who desire cosmetic vaginal surgery, sling surgery can be done as well at the same time.
The expected cure rate for slings is approximately 89-91% where the female patient is dry. There is about a 2% failure rate, and the rest can be considered improved. Improvement from soaking 6 pads a day to 2 thin liners is a success for severe cases of incontinence.
Durability is important and most (85%) will still be dry in the long term. There is an expected drop off (recurrence) rate which is inevitable given changes that occur to the body with age, menopause, weight loss or gain, etc. Women who are still considering another pregnancy should not undergo a sling till childbearing is complete.
Preoperative evaluation with a history, physical exam, urinalysis, and urodynamics help to make the appropriate decision as to whether: 1. A sling is appropriate and, 2. which type of sling to use. Other factors taken into consideration when deciding if/when/and how to place the sling include age, prior surgeries, body habitus, overall health, and other considerations. Bladder function, capacity, and sphincter function as determined by urodynamics helps to tailor the sling to the individual patient.
Common risks include: infection (low), bleeding (low), injury to bladder (low), mesh exposure in the vagina (low), and post operative urinary dysfunction. Vaginal spotting is expected for 1-2 weeks after the surgery.
Recovery is usually straightforward. Typically, being a “couch potato” for 72 hrs is recommended. Women can return to work thereafter (if non-physical). Exercise and exertion should be delayed about 2-3 weeks, but no pools, baths or sex for six weeks.
Slings will usually work right away even though most scarring isn’t complete for several months. In the first several weeks, occasionally the stream may seem a little slower than usual, or may split or deflect. These usually self correct after a few weeks.
There are women who experience leakage of urine with penetration during sex, and others who experience leakage of urine with orgasm. Several studies have shown that penetration-related leakage is treatable with TVT type slings. Orgasm-related leakage can be treated with overactive bladder medication, but one study did show TVT to help this as well. Urodynamic evaluation is important to verify the correct type of sex-related incontinence prior to treatment.
Despite the fact that TVT and other slings are placed in the vagina under the urethra, it has an overall beneficial effect on female sexual dysfunction when it is related to incontinence. Women may be embarrassed to have sex if they fear a urine leak or odor, and will avoid it or have decreased pleasure. Surgical correction of SUI with TVT has been shown to improve sexual function domains such as desire, arousal, lubrication, orgasm, satisfaction, and pain. As a result of the surgery, women report reacquiring self confidence and greater sexual interest after resolution of sex-related incontinence. The consensus in the literature concludes that there is a positive, not negative, impact on female sexual health.
Most women are motivated to cure SUI and will often first perform Kegel muscle exercises and restrict fluids, or urinate frequently to keep the bladder empty and avoid a leak. These can be successful strategies but are tedious and frustrating to many. Once these conservative options have been exhausted, evaluation for a sling can be performed.
Dr. Matthew Karlovsky is a urologist that specializes in female pelvic health in Phoenix, Ariz. For more information, visit www.urodoc.net or www.femaleurologyaz.blogspot.com/
Add a Comment56 Comments
I had mine done about 5 years ago- BEST thing I ever did for myself! Zero complications and zero leakage after surgery, I was able to be active again- sneezing, coughing, laughing, hiking, biking and anything else I want to do!February 27, 2020 - 11:43pm
No longer buying poise pads in bulk! Yay
That's encouraging thank you, I just had it done and I'm very nervousMarch 3, 2016 - 12:18am
I had the mid urethral sling op done jus over two weeks ago. All went fine, I don't even feel like I've had surgery! Does anyone know if it would do any harm if I started exercising again now? I'm itching to run again and get back to the gym!June 2, 2014 - 3:15pm
I appreciate postive comments on surgery as all you can really find is negative! What type of procedure did you have?September 23, 2014 - 8:27pm
Hello,September 9, 2014 - 5:09pm
I just had this procedure done yesterday along with a posterior repair and instructions are no strenuous activity for at least 6 weeks. I too feel great. If you start running again before the 6 weeks, the pounding impact might alter the healing process. You should relax and wait the 6 weeks.
I had the urethral sling done Feb 2014 and now it June 2014....and I have been in misery everyday since this was done. The constant urge to urinate is unbearable. Dr. has tried every medicine for overactive bladder. Nothing has worked. Its only getting worse. April he done another urodynamic test he said everything look good, and had me to try another medicine for overactive bladder. That didn't work either. I go back June 14 2014 for him to discuss botox injections in the bladder or interstim placement. I am terrified of trying anything.May 31, 2014 - 3:57pm
The other problems I am having since the sling is terrible pain in my urethrea, burning pain, and my vagina feels as if its stuff full of cotton balls.Also the only way now that I can have a BM is to take laxitives. I used to be a active, happy, outdoors woman, I am not that woman any more. I feel like I'm not living only existing. My whole family is suffering from me having this surgery.
The conclusion of my story :TO ALL WOMEN NEVER HAVE A SLING OF ANY KIND PLACED IN YOUR BODY
Please I need ur opinion because for the past year I been lifting weight, and now the doctor told me the that I'm not suppose to do after he told me that I feel scare please help me I want to continue my exercise I want to be fitnessApril 4, 2013 - 9:15pm
I had this surgery now on day 25 and it's brilliant, my only prob is that sometimes I feel like I have not emptied my bladder enough and I have to concentrate when at the loo to make sure I empty it properly. Thumbs up from me. I hope to go back to spin class tomorrow also so things are on the up!April 4, 2013 - 2:42pm
I am 52 not quite 3 weeks postop from a cystocele repair, mid urethral sling. I previously had a total hysterectomy at 30. (Ive had no gyn infections in 20+ years - the only exception, taking antibiotics and what would start out as feeling like a yeast infection would immediately move into my urinary tract). The first week after surgery, I felt a yeast infection. PA "looked" and said no but gave rx. (Fluco?something - 1 pill normally kicks, I took 2). Ive have generally not felt well. As week 2 finishes, I noticed a horrible odor , occasional slight red tinge discharge and then some stringy came off the tp yesterday and last night I see what looks like a tampon string hanging out of my vagina. I am one that does not like to call the dr, even to ask a question. I am getting hounded by family to call as i do not see them for 6 more days. deep down i do fear there is some infection, that something is coming out, but dread more being the paranoid patient.November 23, 2012 - 7:17am
So I have just noticed the string tonight and I am 2 weeks out. What did your doctor tell you??? I too do not want to bother them if this is normal and will go away.June 19, 2015 - 5:49pm