Bladder Sling Surgery: Complete Guide to Treatment for Stress Incontinence

Bladder sling surgery has become the gold standard treatment for stress urinary incontinence in women. If you’re experiencing urine leakage when you cough, sneeze, laugh, or exercise, a bladder sling procedure may offer a long-term solution. This comprehensive guide explores everything you need to know about bladder sling surgery to help you make an informed decision about your treatment options.

What Is a Bladder Sling?

A bladder sling, also known as a urethral sling, is a surgical procedure designed to support the urethra and prevent involuntary urine leakage. The sling acts like a hammock beneath the urethra or bladder neck, providing the support needed to keep the urethra closed during activities that put pressure on the bladder.

During the procedure, a surgeon places a strip of material under the urethra to provide additional support. This material can be synthetic mesh (typically made from polypropylene) or natural tissue taken from your own body. The sling creates a supportive layer that prevents the urethra from opening when pressure is applied to the bladder.

Understanding Stress Urinary Incontinence

Stress urinary incontinence (SUI) occurs when physical movement or activity puts pressure on your bladder, causing involuntary urine leakage. This happens when the muscles and tissues supporting the urethra weaken, allowing urine to escape during moments of increased abdominal pressure.

Common triggers include:

• Coughing or sneezing
• Laughing
• Physical exercise or sports activities
• Lifting heavy objects
• Standing up from a seated position
• Sexual intercourse

Stress incontinence differs from urge incontinence (overactive bladder), where you feel a sudden, intense urge to urinate. Some women experience mixed incontinence, which combines both types.

Who Is a Candidate for Bladder Sling Surgery?

Bladder sling surgery is typically recommended for women who:

• Have moderate to severe stress urinary incontinence that significantly affects quality of life
• Have not found relief with conservative treatments such as pelvic floor exercises, lifestyle modifications, or pessary devices
• Are in good overall health and able to undergo surgery
• Have completed childbearing or do not plan to have more children
• Have realistic expectations about surgical outcomes

Your healthcare provider will conduct a thorough evaluation, including a physical examination, bladder function tests, and possibly urodynamic studies to confirm that stress incontinence is your primary problem and that you’re a good candidate for surgery.

Types of Bladder Sling Procedures

Tension-Free Vaginal Tape (TVT) – Retropubic Approach

The retropubic sling is one of the most commonly performed bladder sling procedures. During this minimally invasive surgery, the surgeon makes a small incision inside the vagina near the urethra and two tiny incisions just above the pubic bone.

Using a special needle, the surgeon threads a mesh tape through the vaginal incision and brings each end up through the small abdominal incisions. The tape sits under the mid-urethra like a supportive hammock. The mesh is positioned without tension, allowing it to provide support only when pressure is applied to the bladder.

The body’s natural tissue grows into and around the mesh over time, securing it permanently in place. This procedure typically takes 30-45 minutes and can often be performed as outpatient surgery.

Transobturator Tape (TOT) Sling

The transobturator approach is similar to the retropubic method but follows a different path. Instead of passing through the abdominal wall, the sling is threaded through the obturator foramen (a hole in the pelvic bone) on each side.

The surgeon makes one small incision in the vagina and two small incisions in the groin creases. The mesh tape is guided from the vaginal incision through the groin incisions using a needle. This approach avoids the space behind the pubic bone, potentially reducing the risk of bladder injury.

Both the retropubic and transobturator approaches have high success rates, though studies suggest the retropubic approach may be slightly more effective for some women. Your surgeon will recommend the best approach based on your anatomy and specific condition.

Single-Incision Mini-Sling

This newer, less invasive option involves only one small vaginal incision. The surgeon places a shorter piece of mesh that attaches to pelvic tissues on either side of the urethra, avoiding the need to pass needles through the groin or abdomen.

Advantages include shorter operating time and potentially faster recovery. However, long-term effectiveness data is still limited compared to traditional mid-urethral slings. This approach may be suitable for women with milder incontinence or those who prefer a less invasive option.

Autologous Fascial Sling

An autologous or conventional sling uses tissue from your own body rather than synthetic mesh. The surgeon harvests a strip of fascia (connective tissue) from your abdomen or thigh to create the sling.

This approach requires a larger incision and typically a longer recovery period. The surgeon places the sling at the bladder neck and secures each end to the abdominal wall with sutures. Because it uses your own tissue, there’s no risk of mesh-related complications.

This procedure is often reserved for women who have had previous incontinence surgery that failed, those who prefer to avoid synthetic materials, or women with specific anatomical considerations that make synthetic slings less suitable.

The Bladder Sling Procedure: What to Expect

Before Surgery

Preparation for bladder sling surgery typically includes:

• Comprehensive medical evaluation and discussion of your symptoms
• Urodynamic testing to assess bladder function and confirm diagnosis
• Review of current medications (you may need to stop blood thinners)
• Discussion of anesthesia options (general, spinal, or local with sedation)
• Instructions about eating and drinking before surgery
• Arranging transportation home after the procedure

During the Procedure

Most bladder sling surgeries take 30 minutes to an hour. The specific steps vary depending on the type of sling used, but generally include:

1. Administration of anesthesia
2. Placement in the lithotomy position (similar to a gynecological exam)
3. Small incision(s) made in the vagina and possibly the groin or lower abdomen
4. Placement of the sling material under the urethra
5. Adjustment of sling tension to provide support without being too tight
6. Closure of incisions with absorbable stitches or surgical glue

Many women go home the same day, though some may require an overnight hospital stay depending on the specific procedure and individual circumstances.

Recovery and Postoperative Care

Immediate Recovery (First Few Days)

After bladder sling surgery, you can expect:

• Mild to moderate discomfort at incision sites
• Some vaginal bleeding or discharge (normal for several weeks)
• Burning sensation during urination
• Possible temporary difficulty emptying your bladder completely
• Need to avoid heavy lifting, strenuous exercise, and sexual activity

Your surgeon may send you home with a catheter if you have difficulty urinating initially. Most women can urinate normally within a few days, but some require temporary catheterization for one to two weeks.

Short-Term Recovery (Weeks 1-6)

During the first six weeks after surgery:

• Rest as much as possible, gradually increasing activity
• Avoid lifting anything heavier than 10 pounds
• Refrain from sexual intercourse for 4-6 weeks or as directed
• Don’t insert anything into the vagina (tampons, douches)
• Avoid activities that increase abdominal pressure
• Attend follow-up appointments to monitor healing
• Stay well-hydrated and prevent constipation

Most women return to work within 1-2 weeks for desk jobs, while those with physically demanding jobs may need 4-6 weeks off.

Long-Term Recovery

Full recovery typically takes 2-3 months. During this time, the sling becomes incorporated into your body’s tissues. Once fully healed, you should be able to resume all normal activities without restrictions.

Success Rates and Effectiveness

Bladder sling surgery has high success rates for treating stress urinary incontinence:

• Approximately 80-90% of women experience significant improvement or complete resolution of symptoms
• Retropubic and transobturator mid-urethral slings show similar long-term effectiveness
• Success rates remain stable for many years after surgery
• Patient satisfaction rates are generally very high

However, effectiveness can vary based on factors such as:

• Severity of incontinence before surgery
• Type of sling procedure performed
• Surgeon experience and technique
• Patient age and overall health
• Presence of other pelvic floor disorders
• Whether you’ve had previous incontinence surgery

Potential Risks and Complications

While bladder sling surgery is generally safe, potential complications include:

Common Complications (Usually Temporary)

• Difficulty urinating: Some women experience temporary urinary retention requiring catheterization
• Urinary tract infections: More common in the first few weeks after surgery
• Pain or discomfort: Usually resolves within weeks but can occasionally persist
• Urgency or frequency: New or worsening urge to urinate frequently

Less Common Complications

• Bladder perforation: Rare injury during needle passage, usually heals without lasting problems
• Mesh exposure or erosion: Mesh material protrudes into the vagina, may require surgical removal
• Overactive bladder symptoms: New onset of urgency and frequency after surgery
• Painful intercourse (dyspareunia): May occur if the sling is too tight or mesh erodes
• Chronic pelvic or groin pain: Rare but can significantly impact quality of life
• Sling failure: Incontinence returns due to sling loosening or breaking

Mesh-Related Concerns

Synthetic mesh used in bladder slings has received significant attention due to complications reported with other types of mesh used for pelvic organ prolapse. It’s important to note that mid-urethral slings use much less mesh and have a different complication profile.

The FDA has not restricted the use of mesh slings for stress incontinence, as the benefits generally outweigh the risks. However, you should discuss mesh concerns thoroughly with your surgeon and consider whether an autologous (your own tissue) sling might be appropriate for your situation.

Alternative Treatment Options

Before considering surgery, most healthcare providers recommend trying conservative treatments:

Behavioral and Lifestyle Modifications

• Pelvic floor muscle training (Kegel exercises)
• Weight loss if overweight or obese
• Bladder training and scheduled voiding
• Avoiding bladder irritants (caffeine, alcohol, acidic foods)
• Treating chronic cough or constipation
• Smoking cessation

Medical Devices

• Pessaries: Devices inserted into the vagina to support the bladder
• Urethral inserts: Small disposable devices inserted before activities that trigger leakage

Other Surgical Options

• Bladder neck suspension (Burch procedure): Stitches support the bladder neck without using a sling
• Bulking agents: Injectable materials added around the urethra to improve closure
• Artificial urinary sphincter: Implanted device that controls urination (rarely used for women)

If you’re interested in medications for managing symptoms, consult your healthcare provider to discuss appropriate options and potential side effects before starting any treatment.

Choosing the Right Surgeon

Selecting an experienced surgeon is crucial for optimal outcomes. Consider these factors:

• Board certification in urogynecology or urology
• Specific training and experience in incontinence surgery
• Number of bladder sling procedures performed annually
• Complication rates and patient outcomes
• Hospital quality ratings
• Communication style and willingness to answer questions
• Participation in continuing education and quality improvement

Don’t hesitate to get a second opinion, especially if you’re unsure about the recommended approach or have concerns about the procedure.

Questions to Ask Your Doctor

Before deciding on bladder sling surgery, discuss these important questions with your healthcare provider:

• What type of bladder sling do you recommend for my specific situation and why?
• How many of these procedures have you performed?
• What are your complication rates?
• What are my alternatives to surgery?
• What type of mesh will be used, or will you use my own tissue?
• What can I realistically expect in terms of improvement?
• How long will recovery take, and when can I return to normal activities?
• What are the long-term success rates?
• What happens if the sling fails or causes complications?
• How will this surgery affect future pregnancies if I plan to have children?
• Will my insurance cover this procedure?

Long-Term Outlook and Prognosis

Most women who undergo bladder sling surgery experience significant, lasting improvement in their stress incontinence symptoms. Long-term studies show that success rates remain high even 5-10 years after surgery.

However, some factors may affect long-term outcomes:

• Age: Younger women may have more durable results
• Future pregnancies: Childbirth after sling surgery can compromise results
• Weight gain: Significant weight increase may put additional stress on the sling
• Aging: Natural weakening of pelvic tissues continues over time
• Other health conditions: Chronic cough, constipation, or repeated heavy lifting may affect outcomes

Maintaining a healthy lifestyle, managing chronic conditions, and continuing pelvic floor exercises can help preserve surgical results long-term.

Special Considerations

Pregnancy Plans

If you plan to have more children, your doctor may recommend postponing bladder sling surgery until you’ve completed childbearing. Pregnancy and vaginal delivery can put stress on the pelvic floor and potentially undo the surgical repair.

If pregnancy occurs after sling surgery, discuss delivery options with your healthcare team. In some cases, cesarean delivery may be recommended to protect the surgical repair, though this decision should be individualized.

Mixed Incontinence

If you have both stress incontinence and overactive bladder (mixed incontinence), bladder sling surgery will only address the stress component. You may need additional treatments for urgency and frequency symptoms. Your healthcare provider might recommend addressing the overactive bladder component before or after sling surgery.

Previous Pelvic Surgery

Women who have had previous pelvic surgery, including failed incontinence procedures, may still be candidates for bladder sling surgery. However, outcomes may be less predictable, and the procedure may be more complex due to scar tissue.

Living with a Bladder Sling

Once fully recovered, most women with bladder slings can resume all normal activities without restrictions or special precautions. The sling becomes a permanent part of your body, incorporated into surrounding tissues.

You should:

• Attend regular follow-up appointments to monitor for any complications
• Report any new or worsening symptoms promptly
• Continue practicing healthy bladder habits
• Maintain a healthy weight
• Perform pelvic floor exercises as recommended
• Inform future healthcare providers about your sling if you need pelvic imaging or procedures

When to Seek Medical Attention

Contact your healthcare provider immediately if you experience:

• Inability to urinate or severe difficulty emptying your bladder
• Fever above 101°F (38.3°C) or chills
• Heavy vaginal bleeding (soaking through a pad per hour)
• Severe pain not controlled by prescribed medication
• Foul-smelling vaginal discharge
• Signs of infection at incision sites (redness, warmth, pus)
• New leg swelling or pain (possible blood clot)
• Visible mesh or suture material protruding from the vagina

Final Thoughts

Bladder sling surgery offers an effective solution for women struggling with stress urinary incontinence that hasn’t responded to conservative treatments. With high success rates and generally good long-term outcomes, it can significantly improve quality of life and restore confidence in daily activities.

However, like any surgical procedure, it carries risks that must be carefully weighed against potential benefits. The decision to proceed with surgery should be made after thorough discussion with your healthcare provider, considering your individual circumstances, treatment goals, and preferences.

Take time to research your options, ask questions, choose an experienced surgeon, and ensure you have realistic expectations about outcomes. With proper patient selection and skilled surgical technique, bladder sling surgery can provide lasting relief from stress incontinence and help you return to an active, confident lifestyle.

If you’re experiencing symptoms of stress urinary incontinence, don’t suffer in silence. Speak with your healthcare provider about whether bladder sling surgery might be right for you.

Sources:

• Mayo Clinic – Urinary Incontinence Surgery
• American College of Obstetricians and Gynecologists – Urinary Incontinence
• Urology Care Foundation – Stress Urinary Incontinence
• National Institute of Diabetes and Digestive and Kidney Diseases – Bladder Control Problems
• FDA – Surgical Mesh for Stress Urinary Incontinence