Introduction
Millions of people struggle with urinary incontinence worldwide. This common issue can deeply affect daily life. For women with stress urinary incontinence (SUI), midurethral slings offer hope. These small mesh strips have changed how doctors treat leakage.
The procedure is quick, minimally invasive, and highly effective. This guide explains everything you need to know about midurethral slings.
What Is a Midurethral Sling?
A midurethral sling is a thin strip of mesh placed under the middle part of the urethra. It works like a hammock to support the urethra and stop leaks.
When you cough, sneeze, or exercise, pressure builds in your abdomen. This pressure can push urine out if your urethra lacks support. The sling prevents this by keeping your urethra in place during these activities.
How They Developed
Midurethral slings represent a major breakthrough in treating incontinence:
- 1990s: Dr. Ulf Ulmsten from Sweden created the tension-free vaginal tape (TVT) procedure.
- Early 2000s: Doctors developed the transobturator tape (TOT) approach to reduce certain risks.
- 2010 onwards: Single-incision mini-slings emerged as even less invasive options.
This progress marked a shift from complex surgeries to simple outpatient procedures with faster recovery.
Types of Midurethral Slings
Doctors use three main types of slings:
1. Retropubic Slings (TVT)
How it’s placed: Through a small vaginal cut and two tiny belly incisions. The mesh goes behind the pubic bone.
Good points:
- Long-term data shows lasting results
- Success rates of 80-90% after 5-15 years
- Considered the gold standard for comparison
Things to consider:
- Slightly higher risk of bladder injury during surgery
- Rare chance of blood vessel or bowel injury
2. Transobturator Slings (TOT/TVT-O)
How it’s placed: Through a vaginal cut and two small groin incisions. The mesh passes through the obturator foramen (a space in your pelvic bones).
Good points:
- Avoids the space behind the pubic bone
- Success rates similar to TVT (75-85%)
- May cause fewer bladder emptying problems
Things to consider:
- More likely to cause groin pain
- Possible injury to nerves or blood vessels in the groin
3. Single-Incision Mini-Slings
How it’s placed: Through just one vaginal cut with no exit points.
Good points:
- Less invasive with quicker recovery
- Can use local numbing instead of general anesthesia
- Shorter surgery time
Things to consider:
- Less long-term data available
- Success rates vary by device
- Not all mini-slings work equally well
The Surgery Explained
Here’s what happens during a midurethral sling procedure:
- Numbing: You’ll receive local, regional, or general anesthesia. Most people go home the same day.
- Small Cut: The surgeon makes a tiny cut (1-2 cm) in your vaginal wall under your urethra.
- Placing the Sling: Using special tools, the surgeon positions the sling under your mid-urethra.
- Adjusting: The surgeon ensures the sling sits “tension-free” – not too tight but supportive enough.
- Closing: The cut is closed with dissolving stitches.
The whole process typically takes just 20-30 minutes.
How Well Do They Work?
Midurethral slings show impressive results:
- Short-term: 80-90% of patients see major improvement or complete cure
- Long-term: 70-80% of women still report benefits after 10+ years
- Compared to other surgeries: Results match or beat more invasive procedures
A major review in 2017 looked at 81 studies with over 12,000 women. It found that midurethral slings remain effective for 5+ years with few complications. This confirms they’re an excellent first surgical option for SUI.
Who Should Get a Midurethral Sling?
Not everyone with bladder leakage needs a sling. Before surgery, you’ll need:
- Urodynamic testing: Confirms you have stress urinary incontinence
- Cough test: Shows leakage when pressure increases
- Bladder emptying check: Makes sure you can empty your bladder fully
- Medical history review: Identifies risk factors
- Pelvic exam: Checks for other pelvic floor issues
Good candidates usually:
- Have proven stress urinary incontinence
- Tried other treatments without success
- Empty their bladder well
- Have no active infections
- Ideally have completed childbearing (though this isn’t mandatory)
Possible Complications
While generally safe, midurethral slings can cause problems:
Short-term Issues
- Trouble emptying bladder: Affects 2-10% of patients
- Bladder injury: Happens in 3-5% of retropubic cases, less than 1% with transobturator
- Infection: Occurs in 0.7-4.5% of cases
- Bleeding: Usually minimal
Long-term Issues
- Mesh exposure: In 1-6% of patients, mesh may poke through vaginal tissue
- Ongoing pain: 1-5% report lasting groin, leg, or pelvic pain
- New urgency: 5-15% develop sudden, strong urges to urinate
- Pain during sex: Affects 1-2% of women
FDA Warnings and Mesh Concerns
In 2008 and 2011, the FDA issued safety alerts about transvaginal mesh. These mainly focused on larger mesh products for pelvic organ prolapse—not the narrow strips used for slings. Many patients didn’t understand this difference.
In 2019, the FDA stopped the sale of mesh for prolapse repair but stated that:
- Midurethral slings differ from prolapse mesh
- The benefits of properly placed slings outweigh the risks
- Strong evidence supports their continued use for SUI
Major medical groups still endorse midurethral slings as safe and effective when used correctly.
Recovery After Surgery
Most patients recover quickly:
- Hospital stay: Usually go home same day or next morning
- Return to activities:
- Light activities: 1-2 weeks
- Office work: 1-2 weeks
- Heavy lifting/exercise: 4-6 weeks
- Sex: 4-6 weeks
- Pain level: Mild to moderate, managed with pain pills
- Bladder function check: You must show you can empty your bladder before going home
Other Treatment Options
Midurethral slings aren’t the only way to treat stress urinary incontinence:
Non-surgical Choices
- Pelvic floor therapy: First treatment to try, helps 60-70% of women
- Vaginal devices: Support devices that help reduce leaks
- Lifestyle changes: Losing weight, managing fluids, scheduled bathroom trips
- Medications: Limited options for SUI (duloxetine in some countries)
Other Surgical Options
- Bulking agents: Injections to narrow the urethra
- Burch procedure: Traditional surgery through larger incision
- Pubovaginal sling: Uses your own tissue instead of mesh
- Artificial sphincter: For severe cases only
New Developments
The field keeps improving:
- Better meshes: Lighter materials that maintain support
- Tissue engineering: New materials that work better with your body
- Adjustable slings: Allow tension changes after surgery
- Less invasive techniques: Further reducing recovery time
- Better patient selection: Helping doctors match patients to the right procedure
Ongoing research focuses on long-term results, quality of life, and developing improved materials.
Expert Opinions
Dr. Emily Lukacz from UC San Diego Health says: “Midurethral slings are one of the most well-studied procedures for women. The data consistently shows they’re safe and effective when done by trained surgeons. While we take the risks seriously, the life-changing benefits for the right patients are clear.”
Dr. Roger Dmochowski from Vanderbilt adds: “Midurethral slings let us offer a quick procedure with excellent results. The keys are choosing the right patients, fully explaining the benefits and risks, and using proper surgical technique.”
Key Research Studies
Several important studies have shaped our understanding:
- The TOMUS trial (2010): Compared different sling approaches, finding similar success rates but different types of complications.
- The E-TOT study (2012-2022): Showed benefits lasting 10+ years.
- The ROSETTA trial (2019): Compared slings to Botox for mixed incontinence.
Current studies are looking at:
- Results beyond 15 years
- Impact on quality of life
- Comparison with newer treatments
- Factors that predict success or problems
Common Questions
How long does a midurethral sling last? Midurethral slings are permanent implants. Studies show 70-80% of women still see benefits after 10-15 years.
Will a midurethral sling affect my sex life? Most women report either no change or better sex after getting a sling because they no longer leak during intimacy. A small number (1-2%) may feel pain during sex.
Can I have an MRI with a midurethral sling? Yes, modern slings are MRI-safe.
What about pregnancy after a sling? Pregnancy might affect how well your sling works. Many doctors suggest completing childbearing before getting a sling, but it’s not strictly required.
Can a midurethral sling be removed if needed? Yes, though complete removal gets harder over time as tissue grows into the mesh. Partial removal for complications like mesh exposure is more common.
What’s the difference between slings for incontinence and mesh for prolapse? Incontinence slings are narrow strips (1 cm wide) placed under the urethra. Prolapse mesh is larger and supports pelvic organs. FDA warnings mainly concerned prolapse mesh, not the smaller slings.
Conclusion
Midurethral slings have transformed treatment for female stress urinary incontinence. They offer a minimally invasive option with high success rates and reasonable safety. While all procedures have risks, strong evidence supports midurethral slings as the standard surgical treatment for SUI.
Talk with your doctor about the benefits, risks, and options before deciding. For the right patients, midurethral slings can dramatically improve quality of life and end the burden of leaking urine.