Your doctor has recommended a mesh sling to treat your stress urinary incontinence.
Before we talk about this surgical option, let’s review some information about the
female body and this medical condition.
The female bladder is behind the pubic bone and on top of the vagina.
It is in the pelvis, the lowest part of the body between the hips.
The bladder muscle squeezes to empty urine through a short tube called the urethra.
This tube lies under the pubic bone and in front of the vagina.
The urethral sphincter is a muscle at the opening to the bladder.
You control urination by relaxing and squeezing this muscle.
Stress urinary incontinence , SUI (say S-U-I) is uncontrolled urine leaking from pressure
on the bladder and urethra.
This pressure happens with sneezing, coughing, laughing and exercise.
SUI is a problem when the pelvic muscles that support the bladder and urethra, or the urethral
sphincter are weak.
Support problems can start from pressure on these muscles with pregnancy and childbirth,
chronic constipation, extra body weight, smoking, coughing and certain activities like heavy
lifting that are repeated often.
Other risks for female SUI include
low estrogen and menopause
genetics, meaning a woman can be born at risk for weak tissue
and it can be an occasional side effect of pelvic surgery
Some changes can make leaking better without surgery, drink smaller amounts at a time,
quit smoking if you smoke and work to get to a healthy weight if you are overweight.
Another way to help stop leaking without surgery is to make pelvic muscles stronger with Kegels,
also called pelvic floor exercise.
These exercises can help before and after incontinence surgery.
Physical therapists can help with these exercises.
They will sometimes use biofeedback therapy to test if you are exercising the right muscles.
Other tools for this therapy are electrical stimulation and vaginal weights.
If exercise and other changes have not helped stop the leaking then bulking agents may be
an option.
Silicone microbeads or another material is injected into the urethra to make the wall
thicker so that it closes more tightly.
Many patients are better after this but the leaking eventually returns for most.
The injection may be repeated.
Bulking agents are most helpful for people with mild SUI, for patients not ready for
surgery and patients that cannot or should not have surgery.
The sling procedure is a permanent surgical treatment option for women with problem leaking
from SUI.
A sling is a ribbon which can be made of human tissue or plastic fabric called mesh.
The ribbon is looped under the urethra during surgery, to create a sling or hammock.
This adds support for the weak tissues and urethral sphincter and helps stop leaking
for most patients.
Your surgeon has recommended a mesh sling for you.
This means that your sling will be made of a ribbon of plastic fabric called polypropylene
(say “poly-pro-pa-leen”).
The main benefits to using mesh instead of human tissue are
mesh slings are faster and easier to place
less time is spent in surgery
incisions are smaller
so healing is faster than if the sling was made from your own tissue.
Mesh slings have been used to treat SUI for over 15 years.
About 8 out of 10 women have no leaking or are drier after this procedure.
As with any surgery there can be problems or complications for some patients.
Mesh exposure in the vagina is one problem that can affect about 3 percent or 3 in 100
women after a mesh sling.
This is when a piece of the mesh is not completely covered by the vaginal wall after healing.
A small edge of the mesh can be felt by the patient or their partner as a screen or gritty
patch in the vagina.
This can usually be fixed with a minor procedure to trim and cover the mesh.
If the exposed mesh is not causing the patient any problems, it can be safe to leave untreated,
and repair if new problems develop.
Mesh exposure is more common in patients that have thin delicate vaginal tissue from low
estrogen.
You may be advised to use estrogen vaginal cream before or after surgery.
Rarely, the mesh causes painful scar tissue, erosion or damage to the bladder or urethra.
Some problems, especially pain are not able to be fixed with surgery.
There are three main types of mesh sling procedure: mini sling, retropubic and transobturator
(say trans-ob-tur-A-tor) . Each way of placing the mesh has its own risks and benefits.
Mini Slings are the newest procedure.
They use the smallest size mesh and only need one small vaginal incision to place.
But we are still learning about how well these work and the problems that patients may have.
The retropubic sling procedure guides the mesh using the pubic bone in front of the
bladder.
This has the highest risk of a small hole being poked in the bladder.
These injuries usually heal quickly if seen and treated at the time of surgery.
This type of sling is the best-studied with proven long-term benefits.
The transobturator procedure guides the mesh in from the side and bottom of the pubic bone.
This is away from the bladder so there is less risk of bladder damage.
Two small incisions are needed in the groin or leg crease to place this mesh.
A risk of this procedure is pain from these groin incisions for some patients.
Mesh is permanent.
During healing your tissues grow into the mesh.
Surgery to remove it can be difficult or impossible to do.
Experts haven’t agreed that any one sling procedure is the best.
The procedure recommended for you depends on your surgeon’s experience and training
and your individual situation.
Be sure you understand which procedure and sling material is planned for you.
Let’s talk about what happens during a Mesh sling procedure.
To start, you are given anesthesia to keep you free of pain during the procedure.
You are positioned carefully.
A thin soft tube, called a Foley may be placed in your bladder.
A tool called a retractor is gently used to enable the surgeon to reach and operate on
the front wall of the vagina.
Here an incision is made.
If you are having a mini mesh procedure, this will be the only incision.
The small piece of mesh is gently positioned under the urethra and the incision is closed.
If you are having a retropubic mesh procedure, the vaginal incision is made followed by 2
small skin incisions above the pubic bone.
If a trans-obturator procedure is done, the vaginal incision is made, followed by 2 small
skin incisions in the groin-crease of the upper-thighs.
For the retropubic and trans-obturator procedures special tools are used to guide the sling
into position under the urethra.
The tools and the way they are used vary for the different procedures and kits.
The mesh is gently positioned to support the urethra without crushing or pressing on it.
This is called tension free.
The ends of the mesh are cut to the needed length.
The mesh holds itself in position.
A cystoscope is gently placed thru the urethra to the bladder and the bladder is filled with
water or saline (pronounced say-leen)
This scope has a light and a camera, and is used to help the surgeon see the inside of
the urethra and bladder during the procedure and after the sling is placed.
The surgeon checks for bleeding, holes in the bladder and for mesh or tools where they
should not be.
At the end of the procedure a foley may be placed.
The vaginal incision and skin incisions are closed.
After surgery “speak-up” and tell your care-team if you have more than expected pain
or problems.
You may be able to go home the same day, but many patients stay overnight.
You may have a foley to drain your bladder.
This is usually taken out before you leave the hospital.
Sometimes the foley needs to stay in a while longer.
You may have vaginal packing.
This soft ribbon of gauze is pulled before you go home.
You will have some pain and soreness but this is usually very mild.
When you are home from surgery, follow your doctor’s instructions to have the best results.
The first week rest as much as possible and do not lift anything heavy.
Use Tylenol, Motrin, Aleve or any other pain medication as recommended by your physician.
The first 4 to 6 weeks you must not have sex.
Showering to stay clean is important but don’t swim or use a hot tub unless your surgeon
says that it is safe for you to do.
You should not exercise or do any heavy lifting.
There is a very small risk of serious problems.
These can include internal bleeding, injury to the bladder, bowel, urethra or ureter.
More surgery is sometimes needed to correct some problems.
Call your doctor if you: cannot urinate, have a fever, worsening pain or bright red bleeding
that doesn’t stop.
Hospital admission, medication or surgery may be needed to fix some problems.
Signs of mesh exposure can be, vaginal discharge that doesn’t go away, bladder pain, bleeding
or pain with intercourse.
Be sure to tell your surgeon if you have these symptoms.
Some patients may have bladder side effects early after surgery.
There can be a problem called retention, if you can’t urinate or empty your bladder
on own.
If this happens, a catheter is needed for longer than originally planned.
A procedure to loosen the sling is sometimes needed.
Other possible bladder side effects include a new or worse feelings of urgency, or feeling
like you have to urinate because of bladder muscle spasm.
Or you may still have leaking.
You should not have a sling if you have bladder spasm causing overflow or urge incontinence
unless it is treated first because it can be made worse with a sling.
To help your body heal eat healthy foods.
Avoid junk food and sugary drinks and snacks.
If you are a smoker, don’t smoke.
And if you have diabetes, keep your blood sugar under control.
Both smoking and high blood sugar slow healing.
To avoid cancellation or complications from anesthesia or your procedure, your Job as
the Patient is to
not eat or drink anything after midnight, the night before surgery, not even a stick
of gum
take only medications you were told to on the morning of surgery with a sip of water
stop your aspirin or blood thinners before surgery as you are instructed
and arrive on time
You should be ready to verify or confirm your list of medical problems and surgeries, all
of your medications, including vitamins and supplements, your current smoking, alcohol
and drug use and all allergies, especially to medications, latex and tape
All surgery and anesthesia have a small but possible risk of serious injury, even some
problems very rarely leading to death.
It is your job to speak up and ask your surgeon if you still have questions about why this
surgery is being recommended for you, the risks and alternatives.
This video is intended as a tool to help you better understand the procedure that you are
scheduled to have or are considering.
It is not intended to replace any discussion, decision making or advice of your surgeon.