A vaginal sling is a surgical procedure that places a strip of material under the urethra to stop urine from leaking when you cough, sneeze, laugh, or exercise. It’s the most common surgery for stress urinary incontinence in women, with success rates above 80% at five years and patient satisfaction exceeding 90% even after ten years. The sling works like a hammock, providing a firm backstop so the urethra stays closed when pressure hits your abdomen.
How the Sling Stops Leaking
Stress urinary incontinence happens when the muscles and tissues supporting your urethra and bladder neck weaken, often after childbirth, hormonal changes, or aging. Without that support, any spike in abdominal pressure (a cough, a jump, lifting something heavy) can force the urethra open and let urine escape.
The sling sits beneath the urethra at its midpoint, acting as a platform. When pressure rises in your abdomen, the urethra compresses against the sling instead of dropping open. Over the weeks after surgery, your body grows scar tissue in and around the sling material, anchoring it in place without the need for permanent stitches. The result is a stable, passive support structure that only activates when it needs to: during moments of physical stress.
Types of Sling Procedures
There are two main approaches to placing a midurethral sling, and they differ primarily in the path the sling takes through your body.
The retropubic sling passes the tape from a small vaginal incision up behind the pubic bone, exiting through two tiny cuts near the bikini line. This was the original technique, sometimes called TVT (tension-free vaginal tape). The transobturator sling takes a different route, threading the tape through openings in the pelvic bone on either side of the groin. This approach was developed specifically to reduce the small risk of bladder or bowel injury that comes with passing instruments through the space behind the pubic bone.
A newer, shorter version called a mini-sling uses a single small incision and a shorter piece of tape. The FDA completed an evaluation of mini-slings in 2023 and found their effectiveness and complication rates comparable to traditional midurethral slings through at least three to five years of follow-up.
Synthetic Mesh vs. Your Own Tissue
Most slings today use a lightweight synthetic polypropylene mesh. It’s durable, readily available, and allows for a shorter operation. But slings can also be made from your own tissue, typically a strip of the tough connective tissue (fascia) harvested from your abdominal wall or thigh.
The choice between the two depends on your history. If you’ve had problems with mesh in a previous surgery, or if you have vaginal thinning that raises the risk of the mesh wearing through tissue, your surgeon may recommend using your own fascia instead. On the other hand, conditions that impair wound healing, like diabetes or obesity, or a history of previous abdominal surgery, sometimes make synthetic mesh more practical. This is a decision shaped by your specific anatomy and medical background.
Who Is a Candidate
A vaginal sling is considered when stress incontinence is bothersome enough to affect your quality of life and conservative options haven’t worked. Those first-line treatments include pelvic floor exercises (Kegels), weight loss, dietary changes, and quitting smoking. Only after these approaches fail, or if leaking is severe, does surgery come into the picture.
Before recommending a sling, your doctor will typically perform a pelvic exam, ask you to demonstrate the leaking (usually by coughing with a full bladder), check how well your bladder empties, and run a urine test. If you also experience a strong, sudden urge to urinate, or if you’ve had prior incontinence or prolapse surgery, additional testing called urodynamics may be needed. This test measures bladder pressure and function to confirm that stress incontinence is the primary problem. That distinction matters because a sling won’t fix urge incontinence, the type driven by involuntary bladder contractions. In fact, pure urge incontinence is a clear reason not to have sling surgery.
How Well It Works Long Term
The sling’s track record is strong. In long-term studies of retropubic slings, 97% of women met success criteria at one year, 81% at five years, and 70% at nine years. “Success” in these studies included significant improvement, not just complete dryness. The rates of being completely dry were lower, around 29% to 31% at five years and beyond. But patient satisfaction tells a more complete story: over 90% of women reported being satisfied with their results more than ten years after surgery. That gap between “completely dry” and “satisfied” reflects the reality that most women consider a major reduction in leaking to be a successful outcome, even if occasional, minor leaking persists.
Risks and Complications
Some degree of pain after surgery is normal and typically resolves within one to two weeks. If pain lingers beyond that window, it may point to nerve or muscle irritation from the sling placement, which your surgeon can evaluate.
Mesh erosion, where the synthetic material works its way through the vaginal wall, is the complication that gets the most attention. For erosion into the urethra specifically, the rate is less than 1%. The FDA continues to monitor reports of mesh-related complications and recommends that both patients and providers stay alert for signs of erosion or infection after surgery.
Difficulty emptying the bladder after the procedure occurs in about 1% to 2% of cases. This happens when the sling is slightly too tight, creating partial obstruction. In most cases, this is temporary. If it persists and you can’t empty your bladder adequately, a follow-up procedure to loosen or adjust the sling may be necessary.
Recovery Timeline
The surgery itself is typically outpatient, meaning you go home the same day. Afterward, you’ll be told to avoid lifting anything over 20 pounds and to skip high-impact exercise like running, aerobics, or sit-ups. You’ll also need to hold off on swimming, baths, and sexual activity for six weeks to allow the vaginal incision to heal.
How long you need to restrict physical activity is an area where practice is shifting. A randomized trial found that women who returned to normal activities at three weeks reported significantly higher satisfaction at six months compared to women who waited the traditional six weeks, with no difference in surgical success between the groups. That’s meaningful if you’re weighing time off work or have caregiving responsibilities. Your surgeon can help you decide what timeline fits your situation.
How Slings Compare to Bulking Injections
For women who want a less invasive option, urethral bulking injections are sometimes offered. These involve injecting a gel-like material around the urethra to help it seal more tightly. The procedure is done in an office or outpatient setting, with no incisions.
The two treatments work through fundamentally different mechanisms. A sling creates a firm platform that dramatically increases the pressure the urethra can withstand during coughing or straining. Bulking agents, by contrast, work by making the urethral lining plumper so it closes more completely. In direct comparisons, slings produced far greater increases in urethral pressure under stress. Bulking injections are generally reserved for the 10% to 15% of women whose incontinence stems from a weak urethral sphincter itself rather than a lack of support, or for women who aren’t good candidates for surgery.