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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 the surgery about six months ago. No problems but now it seems like I constantly have UTI 's. Prior to the surgery, I did have UTI's but they were treated with antibiotics. Now nothing helps. The most symptom I have is my urine has a strong odor. The doctor said there is nothing they can do....it must be from the sling. I had a ultrasound done. The doctor said to drink lots of water (which i do) and possibly start taking cranberry pills. Any suggestions what the constant UTI symptoms could be from and also, what can I do to fix it?
October 19, 2012 - 12:13amThis Comment
I am very active and was looking forward to my sling surgery so I could get back to running and exercising without wearing big pads. My surgery was on June 18 by a well-respected UroGynecologist in Boston. Now, 1 month later, I have worse problems then before. I leak continually and when I tried to run for the first time today I soaked my pad. I am beyond disappointed and discouraged because I took 1 month off from work and have not been able to enjoy Summer with my children because I couldn't be active while I healed. It was very frustrating not being able to exercise when that is such an important part of my life (it's actually my career.) I have called the doctor's office and they tell me to wait, but so far, not impressed. I would urge anyone considering this to be aware that it may NOT be the magic bullet. I was hoping to not wear pads anymore but obviously I will need to invest in them even more now.
July 19, 2012 - 6:38amThis Comment
I had the original surgery in May 2010 My first CORRECTIVE surgery was in December 2011 with the 2nd one scheduled in 2 weeks. Never was I told about the FDA warning. No woman should consider this surgery. There are alternatives. The mesh was rushed through the FDA approval process orginially, I wish the FDA would rush the recall. Complaints are coming in exponential numbers. Recall is only a matter of time.
April 2, 2012 - 11:04amThis Comment
It may be a fluke of course, yet the safe thing to do is go for a vaginal exam, and make sure the bladder is emptying well at your GYN's office.
February 23, 2012 - 10:04pmThis Comment
I had the procedure in May of 2011, and it has been great. However, I recently have had 2 UTI's back to back. I have never had one in my life before this. Now I am concerned that it has something to do with the sling. After reading older posts and seeing all the lawsuits it scares me. I asked my GYN and he doesn't think it has anything to do with it. How do I know? I don't even want to think what would happen if it has to be removed
February 23, 2012 - 1:36pmThis Comment
Well, now I'm scared. Should I not have the procedure after all? It's scheduled for a week from Monday.
November 21, 2011 - 1:54pmThis Comment
Only if you are really certain you can live with the risk. When it works great, life is great. If something goes wrong, you will need to address that, too. I posted last year about my partial removal after it migrated into the vagina. Now, the other half is traveling and I am having pricks and pains that a reminiscent of the first half before it broke through. Am having to go for another evaluation. I am just thankful for good insurance since I could never been able to do this on my own without it. Good luck.
November 28, 2011 - 6:35pmThis Comment
I just had my mesh sling put in on 8/30/11. I had to have a catheter for about 6 days because I wasn't able to let anything out but had it taken out 5 days ago and have been doing better everyday. Have been sore off and on and my stitches on my legs ache sometimes but seem to be getting better everyday. I did notice I have a stitch or some mesh sticking out of my urethra. Doctor said it was probably a stitch but have an appt. on Weds to check it out and make sure everything is going okay. I pray that I don't have any of the problems other women have had. I do trust my doctor though and he went over all the mesh scary stuff with me on my first appt. I am looking forward to running and jumping and laughing, sneezing and coughing without leakage!!
September 11, 2011 - 9:01pmThis Comment
A second opinion will reassure you of the correct path to proceed. A look in the urethra and bladder is also necessary. If it's extruding thru the vagina , then the extruded portion will need to be removed.
August 19, 2011 - 10:25pmThis Comment
I had mid urethral sling done 5/31/11 from the beginning i was concerned that the mesh was protruding into the vagina and went back 2x to see the surgeon. she said it was stitches but i kept feeling(with my own finger) that it was not stitches but what i felt it had width- so now i just went back again and she is now saying i have eroded and she wants to make incision and trim the mesh- my concern is will it fray? it seems cutting anything which is woven will fray and then i'll have a bigger problem! am hoping to get second opinion asap. any advice? i live in nj.
August 19, 2011 - 1:21pmThis Comment