Introduction
Urinary incontinence means you leak urine when you don’t want to. Millions of people have this problem, especially women. It can make you feel embarrassed and limit your social life. It affects both your physical and emotional health.
Among the many treatments available, midurethral slings work very well for stress urinary incontinence. This article explains what midurethral slings are, how they work, their benefits and risks, and what to expect if you’re thinking about this treatment.
What Is a Midurethral Sling?
A midurethral sling is a minor surgery that treats stress urinary incontinence (SUI). SUI causes urine leaks during activities that put pressure on your bladder. These include coughing, sneezing, laughing, or exercising.
“The midurethral sling is one of the biggest breakthroughs in treating female stress urinary incontinence in recent decades,” says Dr. Rebecca Chen, a urogynecologist at Northeast Medical Center. “It’s changed how we treat this condition by offering a less invasive option with high success rates.”
The surgeon places a narrow strip of mesh (or sometimes natural tissue) under the middle part of your urethra. The urethra is the tube that carries urine out of your body. This sling acts like a hammock that supports your urethra, especially when pressure increases in your abdomen.
Historical Development
The idea of using a sling to treat urinary incontinence began in the early 1900s. But the modern midurethral sling we use today was developed in the 1990s.
Dr. Ulf Ulmsten introduced the tension-free vaginal tape (TVT) procedure in 1996. This marked the start of the midurethral sling era. His work was based on the “integral theory” which showed that SUI happens because the middle section of the urethra lacks support.
Dr. James Morrison, Professor of Urology at Western University Medical School, explains: “The midurethral sling completely changed how we understand female urinary incontinence. Before this, most procedures focused on supporting the bladder neck. Ulmsten’s work showed the crucial role of the midurethra in staying dry.”
Since then, doctors have developed many types and techniques. The transobturator tape (TOT) procedure came out in 2001 as another way to place the sling.
Types of Midurethral Slings
There are several types of midurethral slings. They differ mainly in how the surgeon places them:
Retropubic Slings (TVT)
This was the first technique for placing midurethral slings. The procedure works like this:
- The surgeon makes a small cut in the vagina under the urethra
- The sling goes through this cut and behind the pubic bone
- The ends of the sling come out through two tiny cuts in the lower abdomen
- The surgeon adjusts the sling to give the right support without too much tension
Transobturator Slings (TOT)
This method was developed as an alternative to the retropubic approach:
- It also uses a small vaginal cut
- The sling passes through the obturator foramen (a natural opening in the pelvic bone)
- The sling ends come out through small cuts in the groin area
- This approach avoids the retropubic space, which may reduce certain risks
Single-Incision Mini-Slings
These are the newest type of midurethral slings. They are even less invasive:
- They need only one vaginal cut
- They use shorter pieces of mesh
- They don’t require passing needles through the retropubic space or obturator foramen
- They can usually be done with local anesthesia as an outpatient procedure
“Each type of sling has its own benefits,” says Dr. Sophia Williams, Director of Female Pelvic Medicine at Southeastern University Hospital. “The choice depends on your anatomy, medical history, your surgeon’s expertise, and what you and your doctor decide together.”
How Midurethral Slings Work
Understanding how midurethral slings work helps explain why they help stress urinary incontinence.
In a healthy urinary system, the urethra stays closed when you’re not using the bathroom. This keeps urine from leaking out of your bladder. When you want to urinate, your urethral muscles relax to let urine flow. In people with stress urinary incontinence, the tissues around the urethra have weakened. This often happens because of childbirth, aging, or hormone changes. This weakness prevents the urethra from staying closed during activities that increase abdominal pressure.
The midurethral sling works by:
- Providing support: The sling creates a backboard under the urethra that stops it from dropping when abdominal pressure increases.
- Enhancing pressure transmission: When pressure increases (like during a cough), that pressure goes to both the bladder and urethra. The sling helps make sure the pressure keeps the urethra closed.
- Promoting tissue growth: Over time, your body’s tissues grow into and around the sling material. This creates stronger support.
“The sling doesn’t block the urethra,” Dr. Chen explains. “Instead, it restores the normal support that lets the urethra close properly during physical stress. You can still urinate normally when you want to.”
The Surgical Procedure
Midurethral sling surgery is usually an outpatient procedure. This means you can go home the same day. The surgery generally takes 30-45 minutes.
Before the Procedure
Before having midurethral sling surgery, you’ll typically:
- Have a complete evaluation of your urinary symptoms, including urodynamic testing
- Get a physical exam to check your pelvic anatomy
- Discuss your medical history, medications, and previous surgeries with your surgeon
- Learn about the procedure, possible risks, benefits, and alternatives
During the Procedure
The surgical steps vary slightly depending on the type of sling, but generally include:
- Getting anesthesia (general, regional, or local with sedation)
- Being positioned for the best surgical access
- Having a small cut made in the vaginal wall beneath the urethra
- Creating a tunnel for the sling
- Inserting the sling using special surgical tools
- Adjusting the sling tension to provide support without blocking urine flow
- Closing the cut(s)
Recovery Period
Recovery from midurethral sling surgery typically involves:
- Initial recovery in a post-anesthesia area for a few hours
- Going home the same day in most cases
- Mild to moderate discomfort managed with pain medications
- Possible temporary difficulty urinating, requiring a catheter in some cases
- Gradual return to normal activities over 2-6 weeks
- Resuming sexual activity usually after 4-6 weeks
Dr. Michael Thompson, Chief of Urogynecology at Central Medical Center, advises: “Plan for about two weeks of reduced activity after surgery. Some women feel ready to return to desk work within days. But avoid heavy lifting and hard exercise for at least six weeks to allow proper healing.”
Benefits and Success Rates
Midurethral slings have become the gold standard for surgical treatment of stress urinary incontinence. They have high success rates and a good risk-benefit profile.
Effectiveness
Research consistently shows impressive success rates for midurethral slings:
- Short-term success rates (1-2 years) typically range from 85-90%
- Long-term studies show continued success rates of 70-80% at 5-10 years
- Patient satisfaction rates are generally high, with most reporting much better quality of life
A major 2020 analysis in the Journal of Urology looked at data from 36 controlled trials. It found that both retropubic and transobturator slings worked similarly well. They had cure rates between 85-90% at one year follow-up.
Advantages
Compared to older surgical approaches for treating stress urinary incontinence, midurethral slings offer several benefits:
- Less invasive: Smaller cuts mean less pain and faster recovery
- Shorter operating time: Usually done in less than an hour
- Outpatient procedure: No hospital stay needed in most cases
- Quicker return to normal activities: Most patients resume regular activities within 2-6 weeks
- Long-lasting results: Studies show benefits can last many years
- High patient satisfaction: Most patients report much better symptoms and quality of life
“Midurethral slings dramatically changed how we treat stress urinary incontinence,” says Dr. Williams. “Before these procedures, women faced more invasive surgeries with longer recovery times and more potential complications. Now, most of my patients return to their regular activities within weeks, often with complete resolution of their incontinence.”
Risks and Potential Complications
While midurethral slings are safe and effective for most patients, they do have some risks and complications. Your doctor should discuss these with you before surgery.
Common Side Effects and Complications
Some of the more common issues include:
- Pain: Most patients have some discomfort after surgery, usually managed with oral pain medications
- Urinary retention: Temporary difficulty emptying the bladder completely affects 5-10% of patients and may require short-term catheterization
- Urinary tract infection: Occurs in about 4-6% of patients
- New urgency: New or worse urge incontinence affects 5-15% of patients
- Groin pain: Particularly with transobturator slings, some patients experience pain in the groin area that usually goes away within weeks
Less Common but Serious Complications
More serious complications happen less often but may include:
- Mesh erosion or exposure: The mesh may become exposed in the vagina in 2-4% of cases
- Bladder or urethral injury: Occurs in less than 5% of procedures
- Blood vessel or bowel injury: Rare but potentially serious, especially with the retropubic approach
- Chronic pain: Ongoing pain affecting daily activities occurs in 1-2% of patients
- Need for revision surgery: Some patients need additional procedures to adjust or remove the sling
“Patients need to understand both the benefits and risks before having surgery,” emphasizes Dr. Thompson. “While serious complications are uncommon, they can significantly impact quality of life when they do occur. An informed patient can better participate in the decision-making process and have more realistic expectations about outcomes.”
Controversies and FDA Notifications
It’s important to know that synthetic mesh slings have been subject to regulatory scrutiny and legal actions in recent years.
In 2008 and 2011, the U.S. Food and Drug Administration (FDA) issued safety communications about complications with transvaginal mesh for pelvic organ prolapse repair. However, these warnings mainly addressed mesh used for prolapse repair, not the smaller mesh slings used for stress urinary incontinence.
In April 2019, the FDA ordered manufacturers to stop selling mesh products intended for transvaginal repair of pelvic organ prolapse. This order did not apply to midurethral slings for stress urinary incontinence. The FDA and major medical organizations continue to support these as safe and effective when properly used.
Dr. Morrison clarifies: “People often confuse the larger mesh sheets used for prolapse repair with the narrow strips used for midurethral slings. The larger sheets had higher complication rates and were removed from the market. The scientific evidence continues to support the safety and effectiveness of midurethral slings when used appropriately for stress urinary incontinence.”
Major professional organizations support the continued use of midurethral slings as an appropriate treatment option for stress urinary incontinence.
Patient Selection and Considerations
Not all patients with stress urinary incontinence are ideal candidates for a midurethral sling procedure. Careful patient selection is crucial for the best outcomes.
Ideal Candidates
The best candidates for midurethral sling surgery typically:
- Have documented stress urinary incontinence
- Have tried and aren’t satisfied with conservative treatments
- Are healthy enough for surgery
- Have realistic expectations about outcomes
- Are not planning future pregnancies
- Have completed childbearing (though this isn’t absolutely required)
Contraindications and Cautions
Factors that might make a midurethral sling inappropriate or require special consideration include:
- Urinary retention or significantly weakened bladder function
- Plans for future pregnancy
- Ongoing or repeated urinary tract infections
- Previous radiation to the pelvic area
- Significant pelvic organ prolapse requiring simultaneous repair
- Certain connective tissue disorders
- Previous unsuccessful anti-incontinence surgery
“Choosing the right patients is critical for good outcomes with midurethral slings,” states Dr. Chen. “A thorough evaluation before surgery, including urodynamic testing when appropriate, helps identify patients who will benefit most from the procedure while minimizing risk of complications.”
Alternative Treatments
While midurethral slings work well for many patients with stress urinary incontinence, they aren’t the only treatment option. A comprehensive approach typically starts with conservative measures before considering surgery.
Non-Surgical Options
Patients may benefit from trying these approaches before or instead of surgery:
- Pelvic floor physical therapy: Special exercises to strengthen the pelvic floor muscles
- Behavioral changes: Bladder training, timed voiding, and fluid management
- Pessaries: Removable devices inserted into the vagina to support pelvic organs
- Lifestyle changes: Weight loss, quitting smoking, and managing chronic cough can reduce symptoms
- Medications: Certain drugs may help with mixed incontinence symptoms
“I believe in a step-by-step approach to treating stress urinary incontinence,” says Dr. Williams. “Many women can see significant improvement with non-surgical approaches, particularly pelvic floor physical therapy with a specialized therapist. Surgery should generally be considered when these more conservative options haven’t provided enough relief.”
Alternative Surgical Approaches
For patients who aren’t candidates for midurethral slings or prefer other options, other surgical procedures include:
- Bulking agents: Injectable materials to support the urethral tissues
- Burch colposuspension: A procedure that lifts and supports the bladder neck
- Autologous fascial sling: Uses the patient’s own tissue rather than synthetic mesh
- Artificial urinary sphincter: A mechanical device that controls urine flow
Dr. Thompson notes: “While midurethral slings have become our most common surgical intervention for stress incontinence, having alternative approaches remains important for patients with specific contraindications or preferences. A personalized approach to treatment selection is always best.”
Living with a Midurethral Sling
Most patients experience much better quality of life after successful midurethral sling surgery. However, understanding what to expect in the days, weeks, and years after the procedure is important for long-term satisfaction.
Short-Term Recovery and Expectations
In the first few weeks after surgery, you should:
- Take prescribed pain medications as needed
- Avoid strenuous activities, heavy lifting (over 10 pounds), and high-impact exercise
- Watch for signs of infection or unusual symptoms
- Stay hydrated but avoid excessive fluid intake
- Be prepared for possible temporary changes in urination patterns
- Attend all follow-up appointments with your healthcare provider
Long-Term Considerations
Over the longer term, patients with midurethral slings should:
- Maintain regular check-ups with their healthcare provider
- Continue pelvic floor exercises as recommended
- Report any new urinary symptoms promptly
- Understand that natural aging may affect urinary function over time
- Be aware that future pelvic surgeries may require special considerations
“I tell my patients that while midurethral slings last a long time, they are not necessarily a lifetime solution,” explains Dr. Chen. “The natural aging process continues, and some women may experience changes in their urinary function over time. Regular follow-up care remains important.”
Frequently Asked Questions (FAQ)
How do I know if I’m a good candidate for a midurethral sling?
You may be a good candidate if you have documented stress urinary incontinence that hasn’t improved with conservative treatments like pelvic floor physical therapy. A thorough evaluation by a urogynecologist or urologist specializing in female urology can help determine if this procedure is right for you.
How long does the surgery take?
The procedure typically takes 30-45 minutes but may vary depending on individual factors and whether other procedures are done at the same time.
Will the sling need to be replaced in the future?
Most midurethral slings are designed to be permanent. Studies show good durability with success rates of 70-80% even 5-10 years after surgery. However, a small percentage of patients may need revision or removal due to complications or returning symptoms.
Can I have an MRI with a midurethral sling?
Most synthetic slings used today are MRI-compatible. However, always tell healthcare providers about your sling before having any imaging studies.
Will a midurethral sling affect my sex life?
Most women report no negative impact on sexual function after recovery from surgery. Some studies even show improved sexual function, likely due to less anxiety about urine leakage during intimacy. A small percentage of women or their partners may experience discomfort, which should be reported to their healthcare provider.
What happens if I get pregnant after having a midurethral sling?
While it’s generally recommended to complete childbearing before having a midurethral sling placed, pregnancies after sling placement have occurred without significant complications. However, vaginal delivery may affect the results of the surgery, and some surgeons recommend considering cesarean delivery in this situation.
Can the sling be removed if I experience problems?
Yes, if necessary, the sling can be partially or completely removed. However, removal may result in a return of incontinence symptoms. The decision to remove a sling is made carefully, weighing the benefits against the risks.
How soon will I know if the surgery was successful?
Most patients notice improvement in their stress incontinence symptoms immediately or within the first few weeks after surgery. However, complete healing and final results may take 6-12 weeks.
Are there activities I should avoid permanently after having a midurethral sling?
Most patients can return to all normal activities, including exercise, after appropriate healing (typically 6 weeks). There are generally no permanent activity restrictions following successful midurethral sling surgery.
Does insurance cover midurethral sling surgery?
Most health insurance plans, including Medicare, cover midurethral sling surgery when it’s deemed medically necessary. However, coverage policies vary, and patients should check with their insurance provider about specific coverage and potential out-of-pocket costs.
Conclusion
The midurethral sling is one of the most important advances in treating female stress urinary incontinence. It uses a minimally invasive approach with high success rates and a good safety profile when properly used. It has dramatically improved quality of life for millions of women who previously suffered from the physical and emotional burden of urinary incontinence.
The best approach to treating stress urinary incontinence is highly personalized. Patients should have thorough discussions with their healthcare providers about their symptoms, goals, and treatment options. Understanding the benefits, risks, and alternatives to midurethral sling surgery allows for informed decision-making and appropriate expectations.
As research continues and surgical techniques improve, the management of stress urinary incontinence will likely see further innovations. However, the midurethral sling has established itself as a cornerstone therapy that effectively addresses the root causes of stress urinary incontinence while giving patients a minimally invasive option with lasting results.