Midurethral Sling (Female)

What is a midurethral sling?

A thin supportive strip is placed under the middle of the urethra through a small vaginal incision. When abdominal pressure rises, the sling provides a backboard that keeps the urethra closed. There are three approved, standard-of-care approaches: retropubic (passed behind the pubic bone, also called TVT), transobturator (passed through the natural openings on each side of the pelvis, also called TOT), and single-incision. Slings can be made from synthetic mesh or from your own fascia when preferred or when mesh is not appropriate.

Who may benefit from a sling?

• Women who leak with coughing, sneezing, laughing, lifting, or exercise.
• Women who have tried pelvic floor therapy without adequate improvement.
• Women having prolapse repair who also have stress leakage.

How is the procedure performed?

Under general anesthesia, a small vaginal incision is used to position the sling using one of the three approaches, and the sling is adjusted to support the urethra without tension. The procedure takes about 60 minutes. Most women stay one night with a catheter and go home the next day.

What are the benefits?

• High long-term cure and improvement rates for stress incontinence.
• Quick outpatient procedure with a small incision.
• Immediate improvement for most women.

What are the alternatives?

Pelvic floor physical therapy, a pessary or continence device, urethral bulking injection, and autologous fascial sling. Some women with mixed symptoms benefit more from bladder-directed therapy first.

What are the risks?

• Difficulty emptying the bladder, usually temporary.
• New or worsened urgency.
• Urinary tract infection.
• Bladder injury, which is uncommon.
• Mesh exposure or pain in a small number of patients, which can require revision.
• Recurrent or persistent leakage.

What should I expect before surgery?

• A pre-operative visit to review your history, medications, and goals.
• Instructions on blood thinners, supplements, and diabetes medications.
• A urine culture so any infection is treated before the procedure.
• Nothing to eat or drink after midnight unless told otherwise.
• A responsible adult to drive you home on the day of surgery.

What happens on the day of surgery?

The procedure is performed under general anesthesia. Most women stay one night with a catheter. The next morning the catheter is removed and a voiding trial is performed: if you urinate without difficulty, you go home without a catheter. If emptying is incomplete, the catheter is replaced and the voiding trial is repeated in the clinic about five days later.

Will I have a catheter?

Usually yes, overnight. The catheter placed during surgery is removed the next day, followed by the voiding trial described above. A small number of women go home briefly with a catheter or are taught intermittent catheterization for a few days.

What should I expect during recovery?

• Mild urgency, burning, and light spotting are expected in the first days and settle quickly.
• No lifting over ten pounds (about a gallon of milk) for six weeks.
• Nothing in the vagina for six weeks: no intercourse, tampons, or pelvic exams.
• A follow-up visit at about two weeks checks your symptoms and bladder emptying.
• A pelvic exam at about six weeks confirms healing.
• Most women return to desk work within a week.

When should I call the office?

• Fever above 101.5°F or shaking chills.
• Inability to urinate, or a catheter that stops draining.
• Heavy bleeding, or clots that do not clear with increased fluids.
• Pain that is not controlled by your prescribed medication.
• Redness, swelling, or drainage at an incision site.