Signs a sling has not worked
A sling is a narrow tape placed under the middle of the urethra to act as a backstop when pressure rises in the abdomen. A sling is usually described as having failed in one of four ways.
Persistent leaking means the stress leak never really went away after surgery. Recurrent leaking means you were dry for months or years and then the cough-and-sneeze leak returned. New urgency means you now feel sudden, hard-to-defer urges to urinate, sometimes with leaking on the way to the toilet. Obstruction means the sling is too tight: a slow or stop-start stream, straining, a feeling of incomplete emptying, or repeated urinary infections.
These four patterns have different causes and different fixes, so the first step is to work out which one you have. Pain in the groin or vagina, pain during sex, or a rough area you can feel in the vagina are also reasons to be seen, because they can indicate a mesh complication.
Why slings fail
Slings fail for several reasons, and often more than one is involved. The tape may have been positioned slightly too loose to support the urethra, or too tight so that it obstructs it. Tissue changes with time: menopause thins the tissues around the urethra, and weight gain, chronic coughing and heavy lifting raise the pressure the sling has to resist. Some women have a weak urethral closure mechanism from the start, sometimes called intrinsic sphincter deficiency, and a standard tape may not give it enough support.
A sling also treats only one part of the pelvic floor. If the bladder base, the uterus or the back wall of the vagina has also dropped, those changes can continue after the sling and can produce urgency, incomplete emptying or a return of stress leaking. The NICE guideline on urinary incontinence and prolapse in women treats these conditions as linked and recommends assessing both together. None of this means the original surgeon did something wrong. A sling that gave you several dry years did its job for that period; the question now is what the pelvic floor needs today.
What to do if a bladder sling fails: measure first
Guidelines in the UK and the US agree on one point: a woman who has already had surgery for stress incontinence should have formal testing before any further operation. NICE recommends multichannel urodynamic testing before surgery in women who have had previous incontinence surgery, and the American Urological Association guideline advises urodynamics when the picture is complex, including after a failed procedure.
A full assessment usually includes a bladder diary over a few days, a urine test to rule out infection, a cough stress test with a comfortably full bladder, a measurement of how much urine is left after you void, and urodynamics, which records bladder pressure and flow while the bladder fills and empties. An examination checks for prolapse of the bladder, uterus or rectum, for how mobile the urethra is, and for any exposed or tender tape. Ultrasound or other imaging may be used to see where the existing sling sits in relation to the urethra.
The result of this work-up decides everything that follows. Obstruction and urgency are not treated by adding support. A recurrent stress leak with a mobile urethra is a different problem from a fixed, scarred urethra that no longer closes.
Can a failed bladder sling be fixed? The options
Yes, in many cases, but the right procedure depends on the pattern found at assessment. For recurrent or persistent stress leaking, the options described in the NICE, NHS and AUA guidance are a repeat synthetic sling, a sling made from your own tissue (an autologous fascial sling, taken from the abdominal wall or thigh), colposuspension, which lifts and stitches the tissue beside the bladder neck to a ligament behind the pubic bone, and urethral bulking injections, in which a gel is injected around the urethra to help it close. Pelvic ligament suspension, which re-anchors the patient's own lax pelvic ligaments without synthetic mesh, is a further approach that is not covered by those guidelines. It is considered for women whose assessment shows loss of ligament support, and it can address prolapse at the same time.
For an obstructing sling, the usual treatment is to loosen or cut the tape, which often relieves the slow stream and the urgency that came with it; a stress leak may then return and need its own plan. For new urgency without obstruction, treatment typically starts with bladder training and medication rather than another operation. For pain or exposed mesh, the question becomes how much of the tape to remove.
Each option has its own risks, which the ACOG patient guidance on surgery for stress incontinence sets out: voiding difficulty, new urgency, infection, and, with synthetic material, exposure or erosion. Second procedures are generally harder than first ones because of scar tissue. Results and recovery vary from person to person, and only a surgeon who has seen your test results can say which option fits you.
Does the old sling have to come out?
Not always. A sling that causes no pain, no exposure and no obstruction is often left in place when a second procedure for leaking is done, because removing a well-healed tape means dissecting through scar near the urethra. When the sling is the problem, as with obstruction, pain or erosion, part or all of it may need to be removed. Partial removal takes out the segment under the urethra or the exposed piece; complete removal follows the arms of the tape toward the groin or behind the pubic bone and is a larger operation.
Mesh removal is a specialized area. In England, NICE advises that women with mesh complications are seen by a regional multidisciplinary team with surgeons experienced in mesh removal. Wherever you are treated, ask the surgeon how often they remove tape, what they recommend for your specific problem, and what happens to continence after removal. Whether an existing sling is removed, and how much of it, is decided at consultation after the assessment described above and is written into the surgical plan.
One point often causes confusion: the FDA's actions on transvaginal mesh concerned mesh for prolapse repair, and the FDA's urogynecologic mesh page explains that mid-urethral slings for stress incontinence were treated separately. The history of mesh in prolapse surgery is covered in the guide on cystocele repair with and without mesh.
What Podo offers
The clinic performs both operations for stress urinary incontinence: pelvic ligament suspension, which uses the patient's own ligaments without synthetic mesh, and the mid-urethral synthetic mesh sling. Which one suits you is decided after examination and measurement. Pelvic ligament suspension uses the patient's own ligaments and sutures, without synthetic mesh. It is used for stress urinary incontinence, cystocele, rectocele and uterine prolapse. How the technique compares with a sling is set out on the sling-versus-suspension page, and the technique itself is explained on its own page.
Vaginal laxity is measured numerically rather than judged by hand, and two ultrasound units are used for pelvic assessment. Pelvic ligament suspension surgery was developed by Dr. Mo Hyung-jin, the clinic's medical director, who was elected a Fellow of the International College of Surgeons (Korea Section) in obstetrics and gynecology in 2016. Consultations are available in English, and two of the clinic's three OB-GYN specialists are women.
Patients who have a sling or mesh from another clinic can be treated at Podo. If the existing mesh is well positioned, it is left in place and pelvic ligament suspension is performed. A sling or mesh that is poorly positioned can be removed at the clinic. Your records and an in-person examination decide which applies to you, and a revision is usually considered from 3 months after the original surgery, 2 months at the earliest. This page is general information and is not a diagnosis; a consultation is needed to decide whether a procedure suits you.
Records to send before a consultation
If you are considering traveling for a second opinion, the most useful documents are the operative report from your sling surgery, which names the device and the route, any urodynamic study with its tracings, imaging reports, a three-day bladder diary, and a short timeline of when you were dry and when the symptoms began. Send as many of these as you can. If your records are in another language, a plain summary written by you still helps.
Medical records and receipts from Podo are issued in English on request, which matters if you plan to claim from an insurer at home or need your home urologist to follow up. How to send records and how long international patients usually stay are covered on the booking page and the page for patients from the United States and Canada.
Questions
What does a failed bladder sling feel like?
Most often it feels like the leak you had before surgery: urine escaping with a cough, a sneeze, a laugh or a lift. Some women instead notice new urgency, a slow stream or a sense of incomplete emptying, which point to a sling that is too tight rather than too loose.
How long after sling surgery can a failure be diagnosed?
Leaking in the first weeks is often swelling and healing rather than failure, so surgeons usually wait for recovery to settle before judging. Leaking that persists after recovery, or that returns after a dry period, warrants assessment at any point. Cutting an obstructing sling is usually considered once the early post-operative period has passed, and the timing varies, so your own surgeon or a urogynecologist should say when testing or treatment is appropriate in your case.
Can a bladder sling be repeated?
A second synthetic sling is one recognized option after a failed first sling, alongside an autologous sling, colposuspension, bulking injections and ligament-based repair. Which is suitable depends on urodynamic findings, urethral mobility and whether prolapse is also present.
Can a bladder sling be reversed?
A sling can be cut, loosened or partly or wholly removed, but the tissue does not return to how it was before surgery. Removal is chosen when the sling itself causes obstruction, pain or exposure, and it is done by surgeons experienced in mesh removal.
Does Podo remove old slings or operate with a sling still in place?
Yes to both. If the existing mesh is well positioned, it is left in place and pelvic ligament suspension is performed. A sling or mesh that is poorly positioned can be removed at the clinic. Your records and an in-person examination decide which applies to you. Consultations are available in English.
Sources
- NICE NG123: Urinary incontinence and pelvic organ prolapse in women: management
- NICE NG123 recommendations: assessment, urodynamics and surgery for stress incontinence
- American Urological Association / SUFU: Surgical Treatment of Female Stress Urinary Incontinence guideline
- ACOG patient FAQ: Surgery for Stress Urinary Incontinence
- NHS: Urinary incontinence treatment, including non-mesh surgical options
- FDA: Urogynecologic Surgical Mesh Implants
About the reviewer
Dr. Mo Hyung-jin, MD, PhD, board-certified OB-GYN specialist, is the medical director of Podo Women's Clinic. He developed the pelvic ligament suspension technique used at the clinic for stress urinary incontinence and pelvic organ prolapse. Profile