Sling Procedures for Stress Urinary Incontinence: What the Research Shows

Oct 19, 2026

If you leak when you cough, laugh, sneeze, lift or jump, you are dealing with stress urinary incontinence. At some point, someone may mention a “sling.” As a urogynecologist, I get a lot of questions about this surgery, and I think you deserve a clear, honest picture of what the research says, both the good and the not-so-good, so you can have a better conversation with your doctor.

How a sling procedure is done

The procedure most women are offered is a midurethral sling. A narrow strip of polypropylene mesh is placed under the middle of the urethra (the tube that carries urine out of the bladder) through a small vaginal incision, to give it support.

There are a few versions:

Retropubic (TVT): the mesh passes up behind the pubic bone.
Transobturator (TOT or TVT-O): the mesh passes out through the groin.
Single-incision mini-slings: placed through the vaginal incision only.

Most of these procedures are done as outpatient surgery.

How well do slings work?

The best summary we have is a Cochrane review (Ford, 2017) of 81 trials involving 12,113 women. In the short term, women reported being cured in 62–98% of cases with the transobturator approach and 71–97% with the retropubic approach. Beyond five years, those numbers were 43–92% and 51–88%.

Those ranges are wide, and that matters. How “success” is defined changes the answer. In the TOMUS trial (Richter, New England Journal of Medicine, 2010), which followed 597 women, one-year success on objective testing was about 81% for retropubic and 78% for transobturator slings. But when women were asked how they felt, success was 62% and 56%.

There is also long-term data. A 17-year follow-up of the TVT sling (Nilsson, International Urogynecology Journal, 2013) found that more than 90% of women were dry on testing, and 87% were cured or much improved.

So for many women, slings work well. But “dry on a test” and “happy with my bladder” are not always the same thing.

Short-term risks

Every surgery has risks. The Cochrane review found:

Bladder perforation in 4.5% of retropubic slings versus 0.6% of transobturator slings.
Groin pain in 6.4% of transobturator slings versus 1.3% of retropubic slings, usually short-lived.
Trouble emptying the bladder was about half as common with the transobturator approach.

Bleeding, a collection of blood (hematoma) and urinary tract infections are also possible.

Long-term risks and mesh

The concern most women have heard about is mesh. In the Cochrane review, the mesh became exposed or eroded through the vaginal wall in about 2.4% of transobturator and 2.1% of retropubic slings. Less often, mesh can erode into the bladder or urethra. Chronic pain, pain with intercourse and infection can also occur.

Large population studies help show how often women need more surgery later:

In England, a study of 95,057 women (Gurol-Urganci, JAMA, 2018) found 3.3% had the sling removed within nine years.
In Ontario, a study of 59,887 women (Welk, JAMA Surgery, 2015) found 3.29%, about 1 in 30, had removal or revision within ten years.
Another English study of 92,246 women over eight years (Keltie, Scientific Reports, 2017) found 5.9% were readmitted within five years for further mesh surgery or complications.

What a sling does not fix

This point surprises many women: a sling treats stress leakage. It does not treat urgency, that sudden “I have to go right now” feeling, and it does not prevent overactive bladder. Some women actually develop new urgency or overactive bladder symptoms after surgery. If you have both kinds of leakage, ask your doctor which symptoms the sling is expected to help.

Signs of erosion or infection

If you have had a sling, know these warning signs and see your doctor if you notice them:

Vaginal discharge or bleeding
Pain, including a partner feeling the mesh during intercourse
Recurrent urinary tract infections
Blood in the urine
Pain with urination

Treatment often means more surgery to trim, revise or remove the mesh. Complete removal can be difficult because tissue grows into the mesh, and leakage can come back.

Where the regulators stand

In 2018, England paused the use of vaginal mesh for stress incontinence, and it is now tightly restricted there. In the United States, you may have heard that the FDA stopped vaginal mesh. On April 16, 2019, the FDA ordered a stop to transvaginal mesh for prolapse. That order did not apply to slings for stress urinary incontinence.

Start with your pelvic floor

Here is what I want every woman to know: pelvic floor muscle training is first-line treatment for stress urinary incontinence, according to the American College of Physicians. In the UK, NICE guideline NG123 recommends at least three months of supervised pelvic floor training before considering surgery.

That is why I created PfilAtes™ (pronounced “Filates,” and it is not Pilates). It takes just 10 minutes a day. In our internal data, 74% of women improved their bladder symptoms.

The power is in the pulse. Each PfilAtes™ movement uses a small range of motion around a hold point, paired with percussive breathing and a voluntary pelvic floor contraction.

Good questions to ask your doctor

Have I tried at least three months of supervised pelvic floor training?
Is my leakage stress, urgency or both?
Which type of sling do you recommend for me, and why?
How many of these procedures do you perform, and how do you handle complications?
What happens if I need the mesh removed?

Surgery can be the right choice for some women. The best decision is an informed one.

Ready to strengthen your pelvic floor?

The PfilAtes™ Women’s Course gives you lifetime access to the program for $149, just 10 minutes a day, from home.

Start the PfilAtes™ Women’s Course →

Warmly, Dr. Bruce Crawford, Urogynecologist and Founder of PfilAtes™

This article is for education only and is not individual medical advice. Please talk with your own physician about your symptoms and treatment options.

References

Ford AA, et al. Mid-urethral sling operations for stress urinary incontinence in women. Cochrane Database of Systematic Reviews. 2017.
Richter HE, et al. Retropubic versus transobturator midurethral slings for stress incontinence (TOMUS). New England Journal of Medicine. 2010.
Nilsson CG, et al. Seventeen years’ follow-up of the tension-free vaginal tape procedure for female stress urinary incontinence. International Urogynecology Journal. 2013.
Gurol-Urganci I, et al. Long-term rate of mesh sling removal following midurethral mesh sling insertion among women with stress urinary incontinence. JAMA. 2018.
Welk B, et al. Removal or revision of vaginal mesh used for the treatment of stress urinary incontinence. JAMA Surgery. 2015.
Keltie K, et al. Complications following vaginal mesh procedures for stress urinary incontinence: an 8 year study of 92,246 women. Scientific Reports. 2017.
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 (FDA). Order to manufacturers of surgical mesh intended for transvaginal repair of pelvic organ prolapse. April 16, 2019.