Most women who have a mid-urethral sling for stress incontinence do well, but a minority develop pain, mesh exposure or erosion, trouble emptying the bladder, or new urgency. These problems are usually diagnosable with an examination, cystoscopy and bladder testing. Treatment ranges from vaginal estrogen and observation to partial or complete sling removal, chosen according to the specific complication.
What a mid-urethral sling is and why it can cause problems
A mid-urethral sling is a narrow strip of synthetic polypropylene mesh placed under the middle of the urethra through a small vaginal incision. The tape passes either behind the pubic bone (retropubic) or out through the groin (transobturator). When a woman coughs or lifts, the tape supports the urethra so urine does not leak.
The sling is one of the most studied operations in gynecology, and major professional societies continue to regard it as a standard treatment for stress urinary incontinence. Even so, it is a permanent implant. The tape sits close to the urethra, bladder, vaginal wall and nerves. Problems arise when the tape is too tight, sits in the wrong position, wears through tissue or triggers a chronic inflammatory or nerve-related pain response.
Common mid-urethral sling complications
The IUGA/ICS joint terminology classifies mesh complications by what happened, when it happened and where. In practical terms, the problems women report fall into a few groups:
- Vaginal mesh exposure: the tape becomes visible or palpable through the vaginal wall, often causing discharge, spotting or a partner feeling a scratchy edge during sex.
- Erosion or perforation into the urethra or bladder: less common but more serious, it can cause blood in the urine, recurrent urinary infections, stones on the mesh or persistent pain.
- Voiding dysfunction: a slow stream, straining, incomplete emptying or retention, usually because the tape is obstructing the urethra.
- New or worse urgency: sudden urges and urge leakage that were not present before surgery.
- Pain: groin, thigh, vaginal or suprapubic pain, and pain with intercourse (dyspareunia) for the woman or her partner.
- Recurrent leakage: the sling no longer controls stress incontinence.
Sling pain: groin, vaginal and pain with sex
Pain is the complication that worries women most and is often the hardest to sort out. Groin and inner-thigh pain is more often linked to the transobturator route, because the tape passes near muscles and nerves of the thigh. Retropubic slings more often cause suprapubic or vaginal pain.
Not every pain after a sling comes from the mesh itself. Pelvic floor muscle spasm, vulvodynia, vaginal atrophy, hip or back problems and bladder pain syndrome can produce similar symptoms. A careful examination tries to reproduce the pain by pressing along the course of the tape. Pain that is pinpoint, reproducible and located over the mesh suggests that the tape is contributing, while widespread pain may need a broader pain-management approach alongside any surgery.
Mesh exposure and erosion: signs and early treatment
Exposure means the mesh can be seen or felt in the vagina. It typically causes discharge, light bleeding or discomfort during intercourse, though small exposures may cause no symptoms. Erosion into the urethra or bladder is suspected with blood in the urine, recurrent infections or irritative bladder symptoms, and it is confirmed by looking inside with a cystoscope.
Small vaginal exposures without symptoms are sometimes managed conservatively with vaginal estrogen, which can help the vaginal skin heal over the tape, particularly after menopause. When exposure persists, is larger or causes symptoms, the exposed segment is usually trimmed and the vaginal wall closed in a short procedure. Mesh that has entered the urethra or bladder generally needs removal of that segment, either endoscopically in selected cases or through an open or vaginal operation with repair of the urinary tract.
Trouble emptying the bladder after a sling
Temporary difficulty voiding is common in the first days after surgery and usually settles. Persistent obstruction is different: a weak stream, needing to strain or lean forward, frequent infections and a large volume of urine left behind after voiding. When obstruction is clear, the usual treatment is sling incision, in which the tape is cut in the midline under the urethra to release tension. Done early, it often relieves obstruction while many women keep some continence benefit, although leakage can return.
How doctors evaluate a suspected sling complication
A structured assessment helps separate mesh problems from other causes and guides the choice of surgery. A typical evaluation includes:
- A detailed history: the date and type of sling, the operative note, when symptoms started and what makes them better or worse.
- A pelvic examination to look for exposure, palpate the tape and check for tenderness, prolapse and atrophy.
- A urine test and, when indicated, a urine culture.
- Measurement of the post-void residual, usually by bladder ultrasound.
- Cystoscopy to check the urethra and bladder for mesh perforation or stones.
- Imaging such as translabial or transperineal ultrasound, which can often show the position of the tape, and occasionally MRI.
- Urodynamic studies when obstruction, urgency or recurrent stress leakage needs to be measured before planning revision.
Sling revision and removal surgery: what the options are
Revision is tailored to the problem rather than following a single formula. The main options are:
- Excision of an exposed segment: removing the visible tape and closing the vaginal wall.
- Midline sling incision or loosening: for obstruction and voiding difficulty.
- Partial vaginal removal: taking out the vaginal portion of the tape, often used for exposure and localized pain.
- Complete or near-complete removal: including the arms that pass behind the pubic bone or into the groin, sometimes requiring abdominal, laparoscopic or groin incisions.
- Repair of the urethra or bladder: when mesh has perforated these organs, sometimes with a tissue flap to support healing.
More extensive removal is not automatically better. Evidence on whether complete excision relieves pain more reliably than partial excision is limited and mixed, and larger operations carry higher risks of bleeding, nerve injury, urethral damage and recurrent incontinence. A frank discussion of goals, such as pain relief, normal voiding or simply removing all mesh, helps decide how far to go.
What happens to continence after revision
Removing or cutting the tape can bring back stress incontinence in a meaningful number of women. Some stay dry, some leak mildly, and others later choose another procedure. Alternatives that avoid synthetic mesh include a sling made from the woman's own fascia (autologous fascial sling), colposuspension, and urethral bulking injections.
Choosing a surgeon and recovering after revision
Mesh revision is more complex than the original sling, so it is reasonable to ask how often a surgeon performs these operations. Pain can improve gradually over months rather than immediately, and pelvic floor physical therapy is frequently part of the plan.
Frequently asked questions
Are mid-urethral slings still considered safe?
Professional organizations in many countries continue to regard the synthetic mid-urethral sling as an effective, well-studied option for stress urinary incontinence. Regulators in some countries have restricted or paused its use, so availability differs. The key is full informed consent about benefits, alternatives and possible complications.
Can sling pain start years after surgery?
Yes. Some women develop pain, exposure or erosion long after an uneventful recovery. New pain, bleeding, discharge or urinary symptoms at any time after a sling deserve evaluation rather than being dismissed.
Will removing the sling cure my pain?
Many women improve after targeted removal, especially when pain is clearly localized over the tape. However, relief is not guaranteed, and pain that involves nerves or pelvic muscles may persist and need additional treatment.
Will my incontinence come back if the sling is removed?
It may. The chance depends on how much tape is removed and how the original leakage behaved.
Should I get my operative records before seeing a specialist?
Yes. The operative note and the name of the sling product help the surgeon know the route and type of tape, which affects planning for imaging and removal.
References
- Haylen BT, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint terminology and classification of the complications related directly to the insertion of prostheses (meshes, implants, tapes) and grafts in female pelvic floor surgery. Neurourology and Urodynamics, 2011.
- Ford AA, Rogerson L, Cody JD, Ogah J. Mid-urethral sling operations for stress urinary incontinence in women. Cochrane Database of Systematic Reviews, 2017.
- American Urogynecologic Society and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction. Position statement on mesh midurethral slings for stress urinary incontinence.
- National Institute for Health and Care Excellence (NICE). Urinary incontinence and pelvic organ prolapse in women: management (NG123), 2019.
- U.S. Food and Drug Administration. Information on urogynecologic surgical mesh implants and mesh used for stress urinary incontinence.
This article is for general education and does not replace an examination by a qualified gynecologist. Individual results vary, and every procedure carries risks.
