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 two slings placed..one mesh on my bladder and one TO Tape for urethra support...I am in constant pain/discomfort...had the surgery in 2009 along with a hysterectomy...don't do the slings/mesh girls...just DON'T DO IT! Pain...infections...UTI's...multiple medical visits/bills nonstop...incontinence...did I mention pain....leaking...frequency and lack of sleep associated...pressure...oh and did I mention pain...sexual discomfort...stinging...nausea...head aches...irritation inside and out. Your quality of life will drop considerably...DON'T DO IT to yourself or your loved ones.July 6, 2011 - 11:33am
It is terrible to hear all the issues you've had. If you are local to Phoenix or Arizona, you can certainly make an appointment to see what is going on and what can potentially be done, or if you tell me where you live I can direct to a doctor who can address these issues as well.July 12, 2011 - 1:30pm
I had a sling put in nine days ago and am so impressed with it. I felt great right after the surgery. My only problem is waiting. Waiting to get back to my normal life because I feel so great. I am walking but want to do more, but am doing my best not too. Remembering to not pick up too much or horse around with the kids and dogs too much because I feel great. It's going to be a long six weeks, but it's great to have results right away. I can sneeze and not have any leakage. It's the little things in life that add up to be great things!April 15, 2011 - 9:52am
I had a sling place on July 8, 2011. Came out of anesthesia without any issues, virtually stopped bleeding by that night and I feel terrific. I'm not swollen or sore and I haven't had to take any pain meds. I also want to do more than I should at this point since it's only been 3 full days since surgery, but I'm being careful not to lift or push or strain. I'm holding off walking until I get to the one-week mark just in case. Can't get wait to get back to my regular life! I would recommed this procedure to anyone with SUI. It's remarkable.July 12, 2011 - 12:18pm
Somebody help me please. I had a hysterectomy and sling surgery 3 weeks ago,I'm suffering with strong abdominal pain that goes all the way to the front part of my right leg,also I'm not voiding completely I have to go so many times and It's very painful.sometimes I feel like something is stuck in the left side of the abdomen. I hate this sling. Went to the doctor,he said It's normal give it time to recover.He said give it three months. But I want to remove it. Somebody can tell me What complications I'm going to have If They remove it?March 16, 2011 - 9:36am
I am 38 years old and had a sling placed, 2 weeks post OP. About a week ago I started experiencing some discomfot in my upper inner thigh area, just below the incision sites (more on the left side than the right). It sort of feels like my muscles are sore, but localized and somewhat swollen. I blew it off as sore muscles, but it is getting more tender and now I'm starting to worry that it might be an infection. Any suggestions?March 10, 2011 - 10:24pm
Make an appointment with the doctor who did it for an exam-
-Dr KMarch 11, 2011 - 7:57am
I had a "sling" procedure last year. While it has really helped with the stress incontinence I was having it has made the urinary "control" as a whole worse. Has anyone else had a similar experience?February 21, 2011 - 5:30pm
Here's my story....I had a TVT sling put in when I had my total hysterectomy done in April 2006. One year later, I had to have a tubal prolapse repair done. Then in 2008, I started getting UTI's after intercourse. The UTI's have persisted ever since. I also have pain on the lower right side of my abdomen. When I walk on the treadmill, I sometimes have a pinching pain in the uretha area. I have a hard time emptying my bladder. My primary doctor sent me to see a urologist. He did a test (I don't know the name of the test, but it involved looking at the inside of the uretha and bladder with a scope). Everything looked fine there. He did an ultrasound and he find that I wasn't emptying my bladder all the way. He put me on daily Macrobid and told me I would be fine. At a follow-up visit, I told him that my uretha was irriated all the time and it felt like I had to urinate all the time, but with little coming out. During the worst of the irritaion, my lower right abdomen (right of my bladder) and lower back would ache really bad. He then put me on Flomax and again told me I would be fine. The Flomax has helped a little (and I mean very little). I just feel like something isn't right with the sling. The meds I'm taking are making me sick (very queasy with each pill). My Obgyn put me on Premarin cream to see if that would help. Premarin caused a lot of water retention (to the point that it hurt to close my fingers) and I had a really hard time starting urination. Help me, please. I don't know what to do next with all this and it's not a way that I want to live the rest of my life (I'm 38 years old). Have also given up tub baths and swimming pools because of the UTI's.September 29, 2010 - 7:39am
Are you in Phoenix?
If not, you'll likley need to return to the urologist to be further evaluated. Sounds as if the sling may now be too tight. This was partially proved by the response to FLomax. Nevertheless, you'll likely need the urologist to order you a urodynamics test to confirm this finding (sling too tight), and you may need to have the sling cut to release the tension, and allow normal voiding and decrease bladder pressure.September 29, 2010 - 1:35pm