A bladder sling is a surgical implant designed to support the urethra and the bladder neck, which are the structures responsible for maintaining urinary control. This procedure is most commonly performed to treat stress urinary incontinence (SUI), characterized by involuntary urine leakage during physical activities like coughing, sneezing, or lifting. The sling, often a strip of synthetic mesh or the patient’s own tissue, acts like a hammock to prevent the urethra from descending under pressure. While highly successful for most patients, a small percentage of slings may fail to function correctly over time.
Recognizing the Symptoms of Bladder Sling Failure
Failure of a bladder sling often presents as either a return of the original problem or the onset of new pelvic issues. The most common sign is the recurrence of stress urinary incontinence (SUI), where the patient experiences leakage again during exertion. This indicates the sling is no longer providing adequate support to the urethra, possibly due to loosening or shifting.
Other indications involve the development of new lower urinary tract symptoms. Patients may report difficulty emptying their bladder, known as urinary retention, or an unusually slow or weak urine stream. This obstruction suggests the sling is too tight or has shifted to constrict the urethra, preventing normal voiding.
Complications can also arise from issues related to the implant material, particularly synthetic mesh slings. Symptoms of mesh erosion, where the material wears through the vaginal wall or nearby structures, include chronic pelvic or groin pain, discomfort during sexual intercourse (dyspareunia), or unusual vaginal discharge or bleeding. These symptoms warrant prompt medical attention, indicating a foreign body reaction or structural compromise.
The onset of de novo urgency symptoms is also a sign of potential malfunction. This involves a sudden, compelling need to urinate that is difficult to defer, sometimes accompanied by urge incontinence. These new storage symptoms can be triggered by irritation or obstruction caused by the implant.
Underlying Causes of Bling Sling Malfunction
The reasons a bladder sling may fail fall into three categories: technical issues during the initial surgery, long-term physiological changes, or problems related to the sling material. Technical failure often relates directly to the tension applied during placement. If the sling is too loose, it will not adequately support the urethra, leading to the early or late recurrence of stress incontinence.
If the sling is placed with excessive tension, it can create an obstruction at the bladder neck or urethra, resulting in difficulty voiding and urinary retention. Scar tissue formation around the mesh can cause it to contract or tighten further, contributing to this problem over time. This is a common cause for the need for surgical revision soon after the initial procedure.
Long-term physiological changes are another contributing factor to late failure. Significant weight gain, the natural aging process, or chronic conditions that involve straining, such as chronic obstructive pulmonary disease (COPD), place excessive pressure on the pelvic floor. This added strain can overwhelm a previously successful sling, causing it to fail by stretching or losing its stabilizing position.
Material-related issues, such as mesh erosion or exposure, occur when the synthetic material wears through the vaginal lining, or into the bladder or urethra. This complication is related to the body’s inflammatory response, the size and porosity of the mesh, and the technique used during placement. Erosion can lead to chronic pain and infection, requiring specialized intervention.
Medical Assessment and Confirmation of Failure
When a patient presents with symptoms suggesting sling malfunction, a specialized medical assessment is necessary to confirm the failure and determine its cause. The initial step involves a thorough physical examination, including a pelvic exam to visually inspect the vaginal wall for signs of mesh erosion or exposure. The physician will also check the sling’s position and tension by having the patient cough or strain.
A crucial part of the evaluation is urodynamic testing, which objectively measures bladder and urethral function. This testing helps differentiate between recurrent SUI (poor support) and bladder outflow obstruction (excessive tension), guiding the treatment path. Key metrics, such as bladder pressure and flow rates, help the physician understand the mechanism of the patient’s symptoms.
To investigate potential erosion into the urinary tract, a cystoscopy may be performed. During this procedure, a thin tube with a camera is inserted through the urethra to visualize the inside of the bladder and urethra directly. This allows for the detection of mesh material that has penetrated the bladder wall or is visibly exposed.
Imaging studies like pelvic ultrasound or magnetic resonance imaging (MRI) are used to visualize the sling’s position relative to the surrounding pelvic organs. These images can confirm whether the sling has migrated, is pressing on the urethra, or is causing an inflammatory reaction. Combining these results confirms the nature of the sling failure.
Management and Treatment Options Following Failure
Once a bladder sling failure is confirmed, the management approach is individualized based on the specific cause of the malfunction. For patients experiencing mild recurrence of SUI, non-surgical management is often the first course of action. This may include focused pelvic floor physical therapy to strengthen the surrounding musculature, which can compensate for a slightly loosened sling.
Lifestyle modifications, such as weight reduction and avoiding high-impact activities, can significantly reduce leakage episodes. A physician may also recommend a pessary, a removable device inserted into the vagina that physically supports the bladder neck and urethra.
When failure is due to obstruction, characterized by severe difficulty voiding, surgical revision is necessary to relieve the tension. This procedure, called sling lysis or division, involves surgically cutting the sling material where it constricts the urethra. This is typically a minor outpatient procedure with a high success rate for relieving obstruction symptoms, though releasing the tension carries a risk of recurrent SUI.
For complications involving mesh erosion or chronic pain, treatment involves surgical removal of the material. Partial mesh removal, where only the exposed segment is excised, is common for erosion into the vaginal wall. Total sling removal is reserved for cases of deep erosion into the urinary tract, severe pain, or persistent infection.
If the primary failure was the recurrence of SUI, the patient may be a candidate for a subsequent re-operation. The most common salvage procedure is a repeat midurethral sling, placed through a different surgical route than the original. Studies show this procedure has subjective success rates ranging from 50% to 77% for recurrent SUI.
Alternative surgical procedures that do not rely on synthetic mesh are available for re-operation, particularly if the initial failure related to mesh complications. A pubovaginal sling (PVS) using the patient’s own tissue (autologous fascia) is one option, offering cure rates in the 60% to 80% range. Another option is the Burch colposuspension, a non-sling procedure that lifts the tissue around the urethra and bladder neck using sutures. The choice among these options is determined by the patient’s specific anatomy, the reason for the initial failure, and the surgeon’s expertise.