Why people look for an alternative to a sling
Most women who search for sling alternatives are worried about mesh. In April 2019 the US FDA ordered manufacturers to stop selling surgical mesh intended for transvaginal repair of pelvic organ prolapse. That order did not cover mid-urethral slings for stress incontinence, which remain on the market in the United States. In the United Kingdom, NICE guideline NG123 still lists the retropubic mid-urethral mesh sling as a surgical option, and asks surgeons to explain that the sling is an implant that stays in the body and that complete removal may not be possible. In England the NHS has paused routine use of mesh slings since 2018 under a high-vigilance restriction.
Slings have not been banned. The real questions are different: do you want an implant, is your leaking severe enough for surgery at all, and does another operation fit your anatomy and your plans. The five options below run from no surgery to surgery with no synthetic material.
Option 1: Pelvic floor training and lifestyle changes
What it uses: your own muscles. Nothing is implanted.
How it works: a trained physiotherapist or nurse teaches you to contract and relax the pelvic floor correctly, often with feedback from a probe or a hand on the muscle. NICE recommends a supervised program of at least three months as the first treatment for stress or mixed incontinence. Lifestyle advice runs alongside: reducing caffeine, adjusting fluid intake, and losing weight if your body mass index is high.
What the evidence says: supervised training helps many women with mild to moderate leaking, and it is the first step in the NICE and NHS pathways. It cannot shorten a ligament that has stretched. If measurement shows that the supports of the bladder neck have failed, training alone is unlikely to be enough, and surgery enters the conversation. Our guide on exercises versus surgery explains how to tell which situation you are in.
Non-surgical options beyond training, including the radiofrequency and fractional laser vaginal treatments offered at Podo, are described on the non-surgical incontinence treatment page.
Option 2: Urethral bulking agents
What it uses: an injectable gel or paste placed in the wall of the urethra. No mesh and no cuts on the skin.
How it works: through a small telescope, the surgeon injects the material at two or more points around the urethra to thicken its wall and help it close. It is done under local or general anesthesia, usually as a day case.
What the evidence says: a Cochrane review of urethral injection therapy found the trials small and the evidence insufficient to guide practice, and injections appear to be less effective than surgery for cure. NICE lists bulking as an option when the other procedures are not suitable or not acceptable to the woman, and asks surgeons to explain that the effect reduces over time and that repeat injections may be needed. It suits women who want to avoid an operation or are not fit for one.
Availability at Podo: urethral bulking injections are offered at the clinic.
Option 3: Burch colposuspension
What it uses: your own tissue and stitches. No mesh.
How it works: through an abdominal incision or by laparoscopy, the surgeon places stitches from the tissue beside the bladder neck to a ligament on the back of the pubic bone. This steadies the bladder neck so it stays closed when pressure rises. It is done under general or spinal anesthesia. The open version usually means a hospital stay of a few days and a recovery of several weeks. The laparoscopic version should allow a quicker recovery, but the Cochrane review notes that its relative safety and long-term results are not yet known.
What the evidence says: Burch colposuspension was the standard operation before mesh slings. A Cochrane review of open retropubic colposuspension reports an overall continence rate of about 85 to 90 percent within the first year, falling to about 70 percent at five years. The same review notes that prolapse is more common after colposuspension than after sling operations, while voiding problems are less common. NICE NG123 notes that colposuspension involves a longer operation and hospital stay than a mid-urethral sling, and lists it alongside the autologous sling and the mesh sling.
Availability at Podo: Burch colposuspension is not performed at the clinic.
Option 4: Autologous fascial sling
What it uses: a strip of your own fascia, the firm tissue over the abdominal muscles, taken through a cut in the lower abdomen. No synthetic material.
How it works: the strip is passed under the bladder neck and its ends are fixed to the abdominal wall, forming a hammock of your own tissue. It is performed under general or spinal anesthesia. Because there are two wounds, recovery is longer than after a mesh sling, and a catheter may be needed for longer while the bladder settles.
What the evidence says: NICE lists the autologous rectus fascial sling as a standard surgical option for stress incontinence. It is often chosen by women who want a sling without an implant, and for women whose first sling has failed. The trade is a bigger operation for the absence of mesh.
Option 5: Pelvic ligament suspension
What it uses: the patient's own ligaments and sutures, without synthetic mesh.
How it works: the technique restores pelvic support by re-anchoring the patient's own lax pelvic ligaments. Where the other operations support the urethra from below, this one works on the ligaments that hold the bladder neck from above. It was developed by Dr. Mo Hyung-jin, the medical director of Gangnam Podo Women's Clinic. It is used for stress urinary incontinence, cystocele, rectocele and uterine prolapse, so leaking and a bulge that occur together can be assessed for one plan. When it is done for incontinence alone, it is performed under IV sedation with same-day discharge.
What the evidence says: this is a technique developed at one clinic, and it does not have the multi-center trial record of the mid-urethral sling or Burch colposuspension. The technique page explains the anatomy and the steps, and the comparison page sets it against the mid-urethral sling point by point. Results and recovery vary from person to person.
The five options side by side
Material. Only the mid-urethral sling uses synthetic mesh; the comparison page lists the materials of each operation.
Anesthesia and stay. Training needs none. Bulking is local or general, usually as a day case. Burch and the autologous sling are general or spinal, with a stay of one night or more. Pelvic ligament suspension for incontinence alone is done under IV sedation with same-day discharge.
Recovery. Training has no downtime. Bulking allows normal activity within days. Burch and the autologous sling need several weeks before lifting and exercise. For pelvic ligament suspension at Podo, lifting is limited to 10 kg (about 22 pounds) for 8 weeks, and a final check 5 to 10 days after surgery comes before you fly. Recovery after pelvic floor surgery is covered on our recovery page.
Evidence. The first four options each have published studies and a place in the NICE guideline. Bulking has the weakest and shortest-lived results in that group. Pelvic ligament suspension has a single-clinic record.
Availability at Podo. 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. Urethral bulking injections are offered, and Burch colposuspension is not performed. Radiofrequency and fractional laser vaginal treatments are offered as non-surgical options. For the autologous fascial sling, ask at consultation.
Do you need a sling at all?
Many women who search for this page are asking a prior question: is any operation worth it for me? The answer depends on two things. First, how much the leaking limits your life. Pads for a weekly run are a different problem from leaking on every cough. Second, what the supports of your bladder neck actually look like. A sling, a Burch or a ligament repair all treat a mechanical failure of support. If your supports are intact and the leaking is mild, the guideline answer is supervised training first, and no operation yet.
A measured assessment gets you to that answer faster than trial and error; our guide on exercises versus surgery explains what the measurement shows. Either way you leave with a written plan and the reasoning behind it.
How Podo assesses stress incontinence
Consultations are available in English. Two of the clinic's three OB-GYN specialists are women. Assessment of stress incontinence normally includes your history, a pelvic examination and a cough or stress test, as set out in the NICE guideline. At Podo vaginal laxity is measured numerically rather than judged by hand. You are told whether the leaking is stress, urge or mixed, because urge leaking is not treated by the four operations above and needs a different plan, usually bladder training and medication first.
If you are travelling for treatment, raise timing early so the plan fits your stay. This page is general information and is not a diagnosis; a consultation is needed to decide whether a procedure suits you.
Questions
Is a bladder sling the same thing as mesh?
A mid-urethral sling (TVT or TOT) is a narrow tape of synthetic mesh. The autologous fascial sling uses a strip of your own tissue instead, so the word sling does not always mean mesh. Ask which type is being proposed.
Did the FDA ban bladder slings?
No. The 2019 FDA order stopped the sale of mesh for transvaginal prolapse repair. It did not apply to mid-urethral slings for stress incontinence, which remain available in the United States.
Which alternative has the strongest evidence?
Burch colposuspension and the autologous fascial sling have the longest published records among the non-mesh operations and both appear in the NICE guideline. Bulking agents have weaker, shorter-lived results. Pelvic ligament suspension has a single-clinic record.
Can I try bulking first and have surgery later?
Yes. Bulking does not close off later options, and NICE describes it as a choice when other procedures are not suitable or acceptable. Discuss the sequence with your surgeon before the first injection.
Do I need surgery at all?
Not if your supports are intact and the leaking is mild; supervised training for at least three months is the guideline first step. Surgery is discussed when leaking limits your life or measurement shows the supports have failed.
Which of these options does Podo offer?
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. Urethral bulking injections are offered, and Burch colposuspension is not performed. Radiofrequency and fractional laser vaginal treatments are offered as non-surgical options. For the autologous fascial sling, ask at consultation.
Sources
- NICE guideline NG123: Urinary incontinence and pelvic organ prolapse in women
- NHS: Urinary incontinence, treatment
- US FDA: Urogynecologic surgical mesh implants
- Cochrane Review: Urethral injection therapy for urinary incontinence in women
- Cochrane Review (2017): Open retropubic colposuspension for urinary incontinence in women
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