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
Thank you for responding. I'm in Northern Illinois. My gut feeling is that it's too tight, just from some of the posts that I've seen from other women with similar problems. Does releasing the sling ususally help with the UTI's? I figured that it would ease the urinating. Is it even possible to remove after 4 years?September 29, 2010 - 3:27pm
If you are emptying the bladder poorly because the sling is too tight, then releasing it will help voiding and lower your UTI risk. If looking in your bladder showed no mesh or sutures, then good, and releasing the sling is still possible and very doable. I have a colleague friend in Chicago area, Roger Goldberg, at North Shore, who is a urogynecologist. You will likely need urodynamics before any surgery is done. Go see him.September 29, 2010 - 4:08pm
As mentioned above by me, the physician has the responsibility to review with the patient the procedure/risks/benefits and complications of sling surgery. It is the gold standard and many women benefit from it, however it does have risks. As adults, all patients must do their due diligence and research the surgery they plan to have, ask the doctor questions (even if they may appear "stupid"), and get a second opinion, if not satisfied with your doctor's approach. Just because the doctor didn't exlpain it well is no reason to blindly go ahead with surgery, even if its minimally invasive. After all, it is your body, and ultimately, you are in control.September 27, 2010 - 10:28pm
I had a BioArc sling placed when I had my hysterectomy in December of 2006. Two years ago, I started having pain in my left lower abdomen, but no one could figure out what was causing it. Six weeks ago, we did. The left side of the mesh sling is now protruding into my vagina and I will have surgery this week to have it removed. NOT ONCE did the doctor who placed this (GYN) tell me that this was a possibility or even suggest that I should have this checked out. Now my family practitioner is convinced that the "phantom" pain was probably this! I had to go to a regional teaching hospital (OHSU) and consult with a urogynocologist who will do the surgery to remove this. The local urologist I consulted first said to put a little estogen cream on it and perhaps that would solve the problem! When I asked him how many of these he had seen and removed he became irritated with me and said "one or two." Then he told me to learn to live with a little pain! With a huge amount of these procedures resulting in injury (some cutting through to the baldder) from the slings coming out, this procedure should be approached with a great deal more caution than what I was led to believe would be the magic bullet for solving my UI issues.August 16, 2010 - 11:14am
I wanted to give a follow up to my last post. It is now almost 6 months since my surgery to remove the left side of the sling. The surgery was more invasive than originally thought, but went well. About one month after the surgery, I realized that I was pain free on my left lower flank. It has never returned. After about 3 months, my incontinence problems began to worsen (I was told this could happen). The Gyno-urologist advised that I could have a different procedure to help with this, but I am leery of having anything else done after my last experience. I'm now back to Poise pads. The Urologist who blew me off in the beginning, recently told an acquaintance that she probably wasn't experiencing sling issues, (her symptoms were similar to mine but no mesh protrusion, yet...). I told her that I firmly believe that unless a Dr. has experience with this, they probably won't recognize it and to get to someone who does FAST before it worsens. I do understand that the incidence of this happening with the BioArc sling is less common, but it DOES happen. I'm proof. I would advise anyone considering this procedure done to make sure that the doctor is experienced in placing this AND in removing it if necessary. ASK if they have ever removed one, or know of a physcian who has, just in case you develop problems. RUN if they deny knowing of any problems, it just proves that they do not have your best interests at heart. If the doctor doesn't discuss this with you honestly, and not just "oh, by the way", they aren't doing their job. I had more information on what could go wrong when I had a toenail removed! Final words, be informed, check out your doctor thoroughly, and if you are in a small area (as I am), go to a larger hospital if you can.March 11, 2011 - 8:33am
I had a tvt sling in place last August and was not informed about anything other then it will stop my leakage. It did do the trick and I was very happy until... After surgery I had pain, if my bladder was full or if I was a little constipated I was in unbelievable pain. This has not gone away and I have a dull pain all the time in my lower pelvic region. Have pain with sex and my incontinance has come back...So what has the sling offered me. Pain, incontinance, less sex, and the pending possiblility to have it removed. I would not recomend this for any woman. Look into them using your own skin, or pigs skin for support. If I knew this I think I would have went that way. It's not worth it.September 28, 2011 - 2:09pm
Anon - It both saddens and angers me to read about your experience. I'm glad you finally have the answers you need and are getting the specialized care you deserve. Women have been told to "live with" too many things for far too long. I'm glad you wrote in, and I hope you will continue to share what you learn with us and help other women. Best wishes for a solid and safe procedure at OHSU.August 16, 2010 - 5:17pm
Hi Anon - Thank you for writing and welcome to EmpowHER. The following links will provide you with more information about the urethral sling procedure.
I hope this addresses your concerns, will you let us know?March 10, 2010 - 6:05pm
Take care, Pat
Thank you Pat, I am finding your provided links very benificial.November 28, 2011 - 1:33am
I am a female who is almost 28 yrs of age and tested positive for UI, I am thinking about having a urethral sling put in, just want to know what I should be expecting afterwardsMarch 10, 2010 - 2:01pm