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Urinary incontinence: To sling or not to sling? Mesh is the question – Read on for the answer

Many women are paying a high price for urinary incontinence without knowing all the facts behind a simple procedure that has been providing a permanent solution for decades.

That is largely attributed to a reluctance women have to talk with their doctors about their symptoms out of embarrassment, or the mistaken belief that leaking is something they have to live with due to aging or life after childbirth. Meanwhile the psychological and financial costs keep adding up. Routine care costs for sanitary supplies, dry cleaning and laundry for women with severe urinary incontinence ring up at $900 a year, according to a 2006 study published in Obstetrics & Gynecology. Other studies show an increase in depression among women with moderate to severe urinary incontinence.

What causes urinary incontinence?

There are two main types of urinary incontinence:

Urge incontinence (sometimes called “overactive bladder”), which causes a sudden, strong urge to urinate. It is often treated with medication or – in severe cases – neuromodulation therapies.

Stress incontinence, which causes women to leak urine when they laugh, cough, sneeze or during activities like lifting heavy items, exercising or having sex. This can be corrected, but because many women don’t discuss this with their doctors they may not realize there is a durable, minimally invasive treatment available.

A minor 15-minute out-patient surgery is now commonly used to correct the physical problem behind stress incontinence, which is caused by the weakening of the tissue and muscle that support the bladder. The urethra – the tube that carries urine from the bladder to the outside of the body – relies on a rigid backboard of connective tissue to help it compress and close to prevent leaks under pressure.

“If the tissue is weak, there’s nothing for it to compress against,” said Dr. Richard Farnam, director of the Texas Urogynecology and Laser Surgery Center. “It is like when you press on a straw that’s on a table it will flatten. But if you put that straw on top of Jell-O and you press on it, it’s not going to compress. It’s just going to push into the Jell-O.”

Front view of bladder. Weak pelvic muscles allow urine leakage (left). Strong pelvic muscles keep the urethra closed (right). Source:

The highest rates of Stress Urinary Incontinence (SUI) occur among women who have had children, but there is a long list of risk factors including hereditary defects, obesity, smoking and even high-impact exercise.

Treatments for Stress Urinary Incontinence

Lifestyle changes, exercises:

The first treatments for SUI are aimed at keeping symptoms from worsening. Behavioral changes like quitting smoking, losing weight and avoiding jumping or running may be recommended by physicians, along with pelvic floor muscle exercise.

“The exercises try to strengthen the muscles around the tissue and that will in some ways compensate for the weakness of the connective tissue.” Farnam explained. “Mainly it is a preventative strategy to try to prevent leakage from getting worse.”

Urethral bulking

This procedure – where a collagen-like substance is injected into the urethral lining – is generally only used in cases where other surgical options have failed because is not as effective or durable. It can distort the anatomy of the tissue and can complicate subsequent surgeries.

Surgical options:

Since exercise can’t restore the connective tissue, a surgical treatment may be recommended to correct the problem. Technological advances of robotic surgical systems have led to improved techniques in treating SUI using minimally invasive surgery for less scarring and faster recovery times.

Burch – One of the first highly effective procedures used to correct SUI was the Burch procedure, also known as retropubic urethropexy procedure or Burch colosuspension, which uses permanent sutures to suspend the bladder to a ligament behind the pubic bone to recreate a backboard for compression. This is an abdominal surgery, which can be done as an open surgery or performed by laparoscopy.

Slings – Next came a minimally invasive sling procedure which could be performed vaginally where a thin strap of material is placed under the bladder neck to provide support for the urethra. Studies have shown an 88 to 95 percent success rate in correcting urinary incontinence with the sling procedure.

Surgery to lift the bladder may use a web of strings (left) or a ribbon like sling (right) to support the bladder neck and urethra. Source:

There are two types of slings used to treat stress urinary incontinence:

  1. Midurethral sling – First performed in the early 1990s, this is now one of the most common types of surgery done to correct SUI. A narrow strap of woven polypropylene (the material used in permanent micro-sutures) is placed to create a hammock underneath the urethra for support. The procedure takes less than 30 minutes and is done on an outpatient basis. It has the quickest recovery time of SUI surgeries.
  2. Natural tissue sling – This type of surgery uses donor tissue from the patient, a cadaver, or a pig’s small intestine as the support strap. In the case of an autologous facial sling, tissue used in the operation can come from the patient’s abdomen or upper leg. This procedure can take 1 – 2 hours to perform and requires a hospital stay.

Millions of women have found permanent reliefwith a mid-urethral sling, which some consider one of the greatest innovations in the field of Urogynecology in the last 50 years.

“The brilliant thing about this is that it doesn’t require tissue harvesting or processing. There’s no risk of prion infection or other issues you’d potentially have to worry about from using donor tissue,” Dr. Farnam said.

Are midurethral slings safe?

The midurethral sling procedure is the most studied surgery to treat stress urinary incontinence, according to The American Urogynecologic Society (AUGS) and the Society of Urodynamics, Female Urology and Urogenital Reconstruction (SUFA). Studies show the procedure has a low complication rate and a high success rate.

But, because the midurethral sling uses mesh it is sometimes confused with transvaginal mesh (TVM) devices, which are used to repair Pelvic Organ Prolapse.  TVM devices were introduced in 2005, but complaints about placement issues attributed to a lack of consistency in surgical standards led the US Food and Drug Administration to recommend healthcare providers undergo specialized training and thoroughly inform patients about the benefits and risks of all potential treatment options.    

While the FDA continues to study outcomes for transvaginal mesh procedures, it determined no further study is necessary for the midurethral sling, noting in 2013 that “the safety and effectiveness of multi-incision slings is well established in clinical trials that followed patients up to one year.”

Midurethral sling surgery complications can include voiding issues and erosion. Voiding issues may often go away on their own or can be fixed easily with another short, minimally invasive procedure to adjust the mesh.

Board-certified urogynecologists see and treat these issues with greater frequency than non-specialists which results in the highest chance of long-term success.

If you have complications or other symptoms the FDA recommends you:

  • Discuss complications and treatment options with your health care provider. Only your health care provider can give you personalized medical advice. 
  • Consider getting a second opinion from a surgeon who specializes in female pelvic reconstruction if you are not satisfied with your discussion with your health care provider.