Mid Urethral Sling Complications: Common Issues and Risks

Midurethral slings are among the most widely performed surgical treatments for stress urinary incontinence in women, and most recipients do well. But the procedure carries a real set of complications that range from temporary inconveniences to problems requiring further surgery. Reported rates of revision sit around 2–3% within five years, though individual complication types vary widely in frequency and severity. Understanding what can go wrong, and how surgeons manage each issue, helps you weigh the decision with more clarity than the typical pre-surgical pamphlet provides.

Bladder Perforation During Surgery

The most immediate risk happens on the operating table. During sling placement, the surgeon passes a trocar (a needle-like instrument) through tissue near the bladder. Sometimes the trocar punctures the bladder wall. In one study of 410 women undergoing midurethral sling placement, about 9% had bladder perforation detected on cystoscopy after trocar passage, with the rate substantially higher for retropubic slings (15%) compared to transobturator slings (2%).¹ A larger series of over 1,000 women found a lower overall rate of 3%, but confirmed the same pattern: nearly all perforations occurred during retropubic procedures, and 94% were associated with a less experienced surgeon.²

When a perforation is caught during surgery, the fix is usually straightforward. The trocar is removed and repositioned, and a catheter drains the bladder for a day or two while the small hole heals. The retropubic approach carries this risk because the trocar travels through the space behind the pubic bone, close to the bladder. The transobturator route avoids that space entirely, passing through the inner thigh instead, which is one reason it was developed.³ Other risk factors for perforation identified in the larger study included prior cesarean section, previous bladder-suspension surgery, and lower body mass index.²

Voiding Difficulty and Urinary Retention

After the sling is in place, some women find it hard to empty their bladder fully. The sling works by supporting the urethra so it doesn’t open under pressure (like coughing), but if the sling sits too tightly or the tissue swells, it can partially obstruct urine flow. In a large registry study of nearly 19,000 women, about 3% required some form of intervention for urinary retention after sling surgery.⁴ The good news is that most voiding difficulty is temporary and resolves on its own within days.⁵

When it doesn’t resolve, the usual first step is intermittent self-catheterization, where you use a thin tube to drain the bladder several times a day. If that isn’t enough, your surgeon can go back and loosen the sling (called mobilization) or, less commonly, cut it (transection). The registry data showed that women whose sling was mobilized early had outcomes at least as good as those who went through a catheterization period first, and they were less likely to eventually need the sling cut. Women who had the sling mobilized as the primary intervention were more often “very satisfied” with their overall treatment and more often had a negative stress test afterward, meaning their incontinence remained fixed.⁴

In another cohort, voiding dysfunction and urinary retention were the two leading reasons for sling revision surgery, together accounting for the majority of revision cases.⁶ The retropubic route appears to carry a higher risk of voiding problems requiring surgery compared to the transobturator route. In a major randomized trial, surgical intervention for voiding dysfunction was needed in about 2.7% of women who received a retropubic sling and 0% of those who received a transobturator sling.⁷

Mesh Erosion and Exposure

The sling is a strip of synthetic mesh, typically polypropylene, that is meant to stay permanently embedded in tissue. In some women, part of the mesh works its way through the vaginal wall so it becomes exposed. This is commonly called erosion (or, more precisely, exposure or extrusion). The exposed mesh can cause discharge, bleeding, pain, or discomfort during intercourse. One early study found the rate of polypropylene mesh erosion to be about 1.1%.⁸ Mesh erosion was also one of the indications for sling revision in roughly a fifth of revision cases in a separate cohort.⁶

Part of the problem is the material itself. Polypropylene is considerably stiffer than native vaginal and pelvic tissue. That stiffness mismatch means the rigid mesh can “shield” surrounding muscle from normal physiological forces, accelerating tissue degeneration over time. Researchers have also documented a chronic inflammatory response around mesh fibers, with immune cells called macrophages clustering around each fiber and elevated levels of enzymes associated with tissue breakdown.⁹¹⁰ This foreign-body reaction can smolder for years, which is one reason erosion sometimes shows up long after surgery rather than immediately.

New-Onset Urgency and Overactive Bladder

Some women who went into surgery only needing to worry about leaks with coughing or sneezing come out with a new problem: urgency, the sudden and hard-to-control need to urinate. This is sometimes called de novo overactive bladder (OAB). Estimates of how often it happens vary. One review placed the range at 5% to 25% for persistent, worsening, or new OAB symptoms after sling surgery.¹¹ A more recent analysis of over 6,700 women found that about 6% developed de novo OAB within the first year, with urgency being the dominant symptom.¹² Separately, de novo and persistent urgency with urge urinary incontinence has been reported at around 15% and 30%, respectively.¹³

Why a sling designed to prevent leaks would trigger urgency is not entirely settled. The leading theory is that partial urethral obstruction, even if too mild to cause obvious voiding difficulty, irritates the bladder and makes the muscle overactive. Treating the urgency usually starts with behavioral strategies and medications (anticholinergics or beta-3 agonists). If obstruction is suspected, loosening or releasing the sling can resolve the issue.

Chronic Pain and Nerve Problems

Persistent pain is one of the complications patients find most distressing, in part because it’s harder to diagnose and treat than mechanical problems like retention or erosion. The type and location of pain depend on which surgical route was used. Transobturator slings pass through the inner thigh near the obturator nerve, and groin or thigh pain is a recognized complication. Case reports have documented the mesh tape entrapping or cutting through peripheral branches of the obturator nerve.¹⁴ The differential diagnosis for persistent groin pain after a transobturator sling is broad, including muscle strain, inflammation around the pubic bone, abscess formation, and structural adhesions, not just nerve entrapment.¹⁵

In the major randomized trial comparing the two approaches, neurologic symptoms (including numbness and tingling) occurred in about 9.4% of the transobturator group versus 4% of the retropubic group.⁷ Those numbers illustrate a recurring theme with these two approaches: the retropubic route trades higher bladder-injury and voiding-dysfunction risk for lower nerve-symptom risk, while the transobturator route does the reverse.

Pre-existing pain conditions also matter. A retrospective analysis of women undergoing sling revision surgery found that preoperative narcotic use was a strong risk factor for persistent postoperative pain, with roughly seven times the odds compared to women not using narcotics beforehand.¹⁶

Sexual Function and Dyspareunia

Many women considering sling surgery worry about what it will do to their sex life, and the answer is surprisingly reassuring for most. Over the long term, sexual-function scores generally do not change after midurethral sling placement. One study following women for three years found no significant differences in any domain of a validated sexual-function questionnaire before and after surgery.¹⁷ At the 10-year mark, a large Scandinavian study showed that the negative impact of incontinence on sexual life dropped substantially, from about 31% preoperatively to around 6% at 10–20 years of follow-up, suggesting the benefits of being continent far outweigh any direct sexual side effects of the sling for most women.¹⁸

That said, a minority do experience painful intercourse (dyspareunia) or pelvic pain after surgery. A decade-long comparison between retropubic and transobturator techniques found no difference between the two, with about 15–17% of women in each group reporting dyspareunia and a similar proportion reporting pelvic pain.¹⁹ When pain is present and linked to mesh, it was one of the less common but still meaningful indications for revision, accounting for about 8% of revision cases in one cohort.⁶ In the Scandinavian long-term study, roughly 3–4% of women reported persistent pain after the sling that they attributed to the procedure itself.¹⁸

Who Is at Higher Risk

Complications are not evenly distributed. A Taiwanese retrospective study tracking five-year outcomes found that women who developed surgical complications were older on average (about 60 versus 53 years), were more likely to have diabetes, and had slower preoperative urine flow rates and longer voiding times. After adjusting for other factors, hormone replacement therapy stood out as a significant independent risk factor, roughly doubling the hazard of five-year complications.²⁰

Surgeon experience is another major variable. As noted, the large bladder-perforation study found that the vast majority of intraoperative injuries were tied to less experienced surgeons.² A review of 25 years of midurethral sling use emphasized that complications arise from an interaction of multiple factors, including mesh properties, surgical technique, the surgeon’s anatomic knowledge, and the thoroughness of follow-up care.²¹

When the Sling Needs to Come Out

If complications are severe enough, the mesh may need to be partially or fully removed. The tradeoff is real: taking out the sling often means the stress incontinence returns. A systematic review comparing partial and total mesh removal found that partial removal led to lower rates of recurrent stress incontinence. Women who had only the problematic portion excised had about a 19% rate of postoperative stress incontinence, compared to roughly 49% for total removal.²² Both approaches were similarly effective at relieving pain, obstruction, and erosion, so surgeons generally try to remove as little mesh as necessary.

Among women who had the mesh removed entirely, a substantial proportion needed a subsequent anti-incontinence procedure. One study found that within a year of total mesh removal, about 35–39% underwent another surgery for recurrent incontinence.²³ For those women, second-line options include procedures that avoid synthetic mesh altogether, such as a pubovaginal sling using your own tissue or a Burch colposuspension.²⁴

Imaging and Diagnosing Complications

When symptoms arise months or years after sling surgery, figuring out what is going on can be challenging. You can’t see the sling from the outside, and symptoms like pain or urgency have many possible causes. Pelvic floor ultrasound, in both two-dimensional and three-dimensional modes, has become a valuable diagnostic tool. It can confirm the sling’s presence, identify its position relative to the urethra, detect residual mesh after a prior excision, and even show mesh that has migrated into the bladder or urethra. Evidence of inflammation, folding, or abnormal sling shape on ultrasound can help explain pain or voiding problems and guide surgical planning.²⁵ For women with unclear symptoms, this kind of imaging can be the difference between targeted treatment and an exploratory approach.

Alternatives That Skip the Mesh

The complications above have driven interest in alternatives that avoid synthetic mesh. The oldest established option is the autologous fascial sling, where a strip of your own tissue (usually from the abdominal wall) replaces the synthetic tape. A comparison of autologous rectus fascia slings and synthetic transobturator slings found similar effectiveness and safety, with the autologous option eliminating the risk of mesh erosion entirely.²⁶

A 2024 meta-analysis pooling data across multiple trials, however, added important nuance. For retropubic routes, synthetic and autologous slings performed similarly in terms of continence rates. But in populations with recurrent stress incontinence, the synthetic retropubic sling was associated with higher subjective continence. Synthetic transobturator slings also scored higher on subjective satisfaction compared to autologous slings.²⁷ On the flip side, autologous sling procedures involve harvesting tissue from the abdomen, which means a longer incision, more operative time, and in one registry study, roughly three and a half times the odds of perioperative adverse events compared to synthetic mesh slings.²⁸ So the choice is a genuine tradeoff: autologous slings eliminate mesh-specific complications but carry higher short-term surgical risk and may not produce the same level of patient satisfaction in certain populations.

The Psychological Weight of Complications

What the clinical literature sometimes underrepresents is how mesh complications affect women’s overall well-being. Qualitative research interviewing women who experienced complications found that the effects rippled through every part of their lives. Participants described their experience as psychologically traumatic, reporting heightened anxiety, fears related to suicidal thoughts, and the erosion of intimate relationships due to pain and reduced sexual functioning.²⁹ A separate qualitative study echoed these findings, documenting impacts across psychological, social, sexual, and physical domains.³⁰

These studies are small and based on women who sought treatment for complications, so they represent the worst-case end of the spectrum. But they highlight something that complication-rate tables do not capture: for the minority who develop serious issues, the burden extends well beyond the physical symptoms. Women in these studies frequently described feeling dismissed by clinicians who attributed ongoing symptoms to other causes, delaying diagnosis and deepening frustration. If you develop persistent unexplained symptoms after sling surgery, seeking a specialist with experience in mesh complications (often a urogynecologist or female pelvic medicine specialist) is worth the effort, both for accurate diagnosis and for the validation that your experience is recognized and taken seriously.

Regulatory Context and What Changed

Midurethral slings for stress incontinence were never banned, but they got swept into the broader mesh controversy. After years of rising complication reports, the FDA issued multiple notifications and warnings about transvaginal mesh products.³¹ In 2019, the FDA ordered manufacturers to stop selling transvaginal mesh kits for pelvic organ prolapse, but it explicitly did not apply this order to midurethral slings for stress incontinence, which had a stronger evidence base and a different risk profile. Several countries, including the UK and Australia, imposed broader restrictions or pauses that did include slings, creating wide variation in access depending on where you live.

The upshot is that midurethral slings remain available in the United States and many other countries, and professional medical societies continue to endorse them as an effective first-line surgical option for stress incontinence. But the regulatory scrutiny tightened informed-consent requirements, encouraged more conservative surgical techniques, and elevated awareness of alternatives. If you are offered a sling today, your surgeon should be able to clearly walk you through the complication profile for the specific approach they plan to use, the alternatives available to you, and how their own outcomes compare to published benchmarks.