Pubovaginal Sling Without Mesh: When Using Your Own Tissue May Be the Better Choice

Urine leakage during coughing, laughing, sneezing, exercising or lifting something heavy is usually a sign of stress urinary incontinence. For some women, the leakage is occasional and manageable. For others, it becomes disruptive enough to influence clothing choices, exercise, travel, work, intimacy and everyday confidence.

Pelvic floor exercises and lifestyle changes are usually tried first. When these measures do not provide adequate relief, surgery may be considered. One surgical option is a pubovaginal sling made from the patient’s own tissue, commonly called an autologous fascial pubovaginal sling.

Unlike a synthetic midurethral sling, this procedure does not use a strip of polypropylene mesh beneath the urethra. Instead, the surgeon harvests a strong piece of connective tissue, usually from the lower abdominal wall, and uses it to create a supportive hammock beneath the bladder neck and urethra.

This mesh-free approach can provide durable control of stress urinary incontinence, but it is a larger operation than most synthetic sling procedures. It also has its own potential complications, particularly temporary difficulty emptying the bladder and problems related to the abdominal incision.

Understanding who benefits most—and what recovery genuinely involves—can make the decision much clearer.

A pubovaginal sling is a strip of material positioned beneath the bladder neck and proximal urethra. Its job is to provide support when pressure rises inside the abdomen, such as during coughing, running or lifting.

In a mesh-free pubovaginal sling, the supporting material is usually autologous fascia, meaning tissue taken from the patient’s own body. The tissue is most commonly harvested from the rectus fascia, the strong covering over the abdominal muscles. In some cases, fascia may be taken from the outer thigh.

The strip of fascia is passed beneath the urethra, and sutures attached to its ends are brought upward behind the pubic bone. The surgeon adjusts the sling to provide enough support without compressing the urethra too tightly.

The sling does not act like a clamp that permanently closes the urethra. Instead, it improves urethral support and closure when abdominal pressure rises. Over time, the patient’s tissues heal around the fascial sling and help stabilise it.

The National Institute for Health and Care Excellence includes an autologous rectus fascial sling among the surgical options that may be offered when non-surgical treatment for stress urinary incontinence has failed. ^[1]

The two procedures have the same broad goal—supporting the urethra to reduce urine leakage—but they differ in several important ways.

A synthetic midurethral sling uses a narrow strip of manufactured mesh placed beneath the middle portion of the urethra. It can usually be inserted through small incisions and is commonly performed as a day-care or short-stay procedure.

An autologous pubovaginal sling uses the patient’s fascia and is generally positioned closer to the bladder neck. Because the fascia must first be harvested, the operation requires an abdominal incision in addition to a vaginal incision. Surgery and recovery therefore tend to be longer.

The expression “without mesh” refers to the material forming the sling. Surgeons may still use permanent or long-lasting sutures to hold and position the tissue, depending on the technique.

It is also important not to confuse mesh used for stress urinary incontinence with larger transvaginal mesh products previously used to repair pelvic organ prolapse. They are different procedures and involve different quantities and placements of material. Synthetic slings for stress urinary incontinence remain recognised treatment options, and the United States Food and Drug Administration continues to monitor their safety and effectiveness. ^[2]

There is no single profile that makes someone an ideal candidate. The decision depends on the type and severity of leakage, previous surgery, urethral function, tissue quality, overall health and personal preferences.

A good candidate usually has urine leakage associated with physical pressure rather than an uncontrollable urge to urinate.

Typical symptoms include leakage while:

• Coughing or sneezing
• Laughing
• Running or jumping
• Lifting heavy objects
• Standing from a seated position
• Exercising
• Having sexual intercourse

The operation is less likely to solve leakage caused primarily by an overactive bladder. Urgency, frequent urination and leakage before reaching the toilet may require different treatment.

Some women have mixed urinary incontinence, meaning both stress-related leakage and urgency-related leakage. A pubovaginal sling may improve the stress component, but urgency can remain, worsen or occasionally appear for the first time after surgery.

Surgery is generally considered after appropriate non-surgical treatment has been tried.

This commonly includes supervised pelvic floor muscle training for at least three months. Weight reduction, treatment of chronic constipation, management of persistent coughing, smoking cessation and changes in fluid or caffeine intake may also be recommended.

A sling may be reasonable when leakage remains sufficiently troublesome despite these measures or when a woman understands the non-surgical alternatives but prefers a more definitive treatment. The National Institute for Health and Care Excellence recommends discussing surgery after non-surgical management has failed and the patient wishes to consider an operation. ^[1]

Some women are uncomfortable with the idea of having a permanent synthetic implant. Others may have personal, medical or psychological reasons for avoiding mesh.

An autologous fascial sling allows the main supporting material to come from the patient’s own body. It therefore avoids complications that specifically require the presence of sling mesh, such as mesh exposure through the vaginal wall or erosion of mesh into the urethra or bladder.

However, choosing a mesh-free sling should not be based on the belief that it is risk-free. The trade-off is a larger incision, greater postoperative discomfort, a longer recovery and an increased possibility of temporary difficulty urinating.

A fully informed discussion should cover the benefits, limitations and uncertainties surrounding every suitable procedure—not only the risks associated with mesh. ^[1]

Some women leak because the urethral sphincter itself does not close effectively. This is sometimes called intrinsic sphincter deficiency.

Leakage may be severe and can occur with very little physical effort. A woman may leak while walking, changing position or simply standing. Examination may show that the urethra is relatively fixed rather than excessively mobile.

Because a traditional pubovaginal sling provides substantial support at the bladder neck and proximal urethra, it is often considered in women with severe sphincteric weakness. The 2024 Canadian Urological Association guideline identifies severe sphincteric deficiency as a situation in which an autologous bladder-neck fascial sling may be particularly relevant. ^[3]

A pubovaginal sling may be used as a salvage procedure when stress urinary incontinence continues or returns after:

• A previous synthetic midurethral sling
• A prior bladder-neck suspension
• Another continence procedure
• Removal or division of a previous sling

Recurrent leakage is more complicated than first-time stress urinary incontinence. Scar tissue, altered urethral mobility and existing mesh may influence which operation is safest.

Studies have reported that an autologous fascial pubovaginal sling can provide meaningful improvement after synthetic sling failure or mesh removal, although outcomes vary according to the reason for the original failure and the condition of the urethra. ^[4]

A woman who has required removal of a synthetic sling because of erosion, exposure, pain or infection may not wish to receive another synthetic sling.

Using autologous fascia can be considered either at the time of mesh removal or as a separate procedure after healing. Whether both operations should be performed together depends on the location of the mesh, tissue quality, infection, urethral damage and the surgeon’s judgement.

The operation should ideally be performed by a surgeon experienced in both mesh-complication surgery and reconstructive treatment of stress urinary incontinence.

Synthetic mesh may be unsuitable when continence surgery is being performed alongside procedures involving the urethra, such as:

• Repair of a urethrovaginal fistula
• Removal of a urethral diverticulum
• Excision of mesh from the urethra
• Reconstruction of significantly scarred urethral tissue

In these situations, placing synthetic material near a fresh urethral repair may increase concern about infection, erosion or poor healing. An autologous fascial sling can offer support without positioning synthetic mesh directly beneath the reconstructed area. The Canadian guideline specifically notes fistula and diverticulum repair among situations in which an autologous sling may be considered. ^[3]

Compared with a synthetic midurethral sling or urethral bulking injection, an autologous pubovaginal sling is more invasive.

A suitable candidate should understand that the operation usually involves:

• General or spinal anaesthesia
• An abdominal incision
• A vaginal incision
• A urinary catheter after surgery
• Possible hospital admission
• Several weeks of restricted activity
• A longer period before returning to strenuous work or exercise

The procedure may be a good choice for someone who values avoiding mesh and is comfortable accepting a more demanding recovery.

A pubovaginal sling is elective surgery, so conditions that substantially increase surgical or anaesthetic risk should be addressed beforehand.

Surgery may need to be postponed in the presence of an active urinary tract or vaginal infection. Poorly controlled diabetes, untreated bleeding disorders and severe heart or lung disease may also increase risk.

Pregnancy is a reason to delay the procedure. Women planning future pregnancies are usually advised to postpone continence surgery because pregnancy and childbirth can place renewed pressure on the pelvic floor and cause the leakage to return, even after caesarean delivery. ^[5]

A pubovaginal sling may also be unsuitable—or require particularly careful consideration—when a woman already has significant difficulty emptying her bladder. The operation intentionally increases urethral resistance, so pre-existing weak bladder contraction or obstruction could worsen after surgery.

Predominant urgency urinary incontinence is another reason to reconsider the diagnosis. A sling treats urethral leakage caused by physical pressure; it is not a primary operation for overactive bladder.

Previous abdominal surgery does not automatically rule out an autologous sling, but extensive scarring, abdominal wall hernias or inadequate fascia may require a modified approach or harvesting tissue from the thigh instead.

The evaluation begins with a detailed discussion of when leakage occurs, how frequently it happens and how much it interferes with daily life.

A clinician may ask the patient to complete a bladder diary recording fluid intake, urination, urgency and leakage episodes. A urine test is usually performed to exclude infection or blood in the urine.

During a pelvic examination, the clinician may assess vaginal tissue, pelvic organ prolapse, urethral mobility and pelvic floor strength. A cough stress test may be performed with a comfortably full bladder to confirm visible leakage.

The amount of urine remaining in the bladder after urination may be measured using ultrasound or a catheter. A high post-void residual could indicate impaired bladder emptying and may influence the choice of surgery.

Urodynamic testing is not required before every first-time continence operation. It is more commonly considered when:

• The diagnosis is unclear
• Urgency symptoms are prominent
• The patient has difficulty emptying the bladder
• Previous continence surgery has failed
• Neurological disease affects bladder function
• Symptoms and examination findings do not agree

For repeat surgery or mixed symptoms, testing can help distinguish sphincter weakness, urethral hypermobility, involuntary bladder contractions and weak bladder muscle function. ^[6]

The operation is normally carried out under general anaesthesia, although spinal anaesthesia may sometimes be used.

The surgeon first makes an incision across the lower abdomen, often in the bikini line. A strip of strong fascia is removed from the abdominal wall. The remaining fascia is closed carefully to preserve abdominal strength.

A separate incision is made inside the vagina beneath the urethra. A passage is then created on each side of the bladder neck, behind the pubic bone.

The fascial strip is positioned beneath the bladder neck and proximal urethra. Sutures attached to the sling are brought through the retropubic space and secured above the pubic bone. The tension is adjusted so the sling supports the urethra without causing excessive obstruction.

Before completing the operation, the surgeon usually examines the bladder and urethra with a small camera. This cystoscopic examination helps identify an accidental bladder or urethral injury.

A catheter is left in place to drain the bladder, commonly for one or two days. It may occasionally be needed for longer when bladder emptying is slow. ^[6]

The lower abdominal incision usually causes more discomfort than the tiny incisions used for a synthetic midurethral sling. Pain is managed with oral medication, injections, local anaesthetic or other methods chosen by the surgical and anaesthetic teams.

Light vaginal bleeding or discharge may occur. Patients are usually encouraged to drink, eat and walk as soon as it is safe. Early movement reduces the risk of blood clots and helps bowel function recover.

When the catheter is removed, the care team will check whether the bladder empties adequately. This may involve measuring the amount passed and scanning the bladder afterward.

Some patients urinate normally immediately. Others have a weak stream or retain too much urine and need the catheter replaced for several days. A patient may occasionally be taught intermittent self-catheterisation until normal emptying returns.

Hospital stay varies considerably. Some centres discharge patients within one or two days, while others keep them for several days, particularly after complex or repeat surgery. Patient guidance from the British Society of Urogynaecology describes a typical hospital stay of approximately two to five days, although modern practice and local protocols may differ. ^[6]

Tiredness, abdominal soreness and mild vaginal spotting are common. Short walks are encouraged, but strenuous activity should be avoided.

Constipation should be prevented because repeated straining increases pressure on the healing sling and abdominal incision. Adequate fluids, fibre and any prescribed stool softener can help.

Patients should follow wound-care instructions and avoid tampons or vaginal douching.

Discomfort should gradually improve, although bending, prolonged standing and sudden movement may still pull on the abdominal incision.

Driving may resume when the patient is no longer taking sedating pain medication and can brake suddenly, turn comfortably and control the vehicle without pain. The exact timing should be confirmed with the surgeon.

Heavy lifting, vigorous exercise and sexual intercourse are generally restricted for approximately six weeks, but individual advice may differ.

Activity can usually be increased gradually after the postoperative review. Light office work may be possible sooner than physically demanding employment.

Abdominal healing often takes longer than vaginal healing. Patients whose jobs involve lifting, prolonged standing or manual labour may require eight to twelve weeks before returning fully.

Many people can return to unrestricted activity by approximately three months, provided healing is satisfactory and there are no bladder-emptying problems. ^[6]

Success can be defined in different ways. Some studies define success as complete dryness, while others include substantial improvement or reduced pad use.

Overall, autologous fascial slings are regarded as effective, durable operations. The National Institute for Health and Care Excellence concluded that there were no important differences in short- and medium-term effectiveness among autologous rectus fascial slings, colposuspension and retropubic midurethral mesh slings. ^[7]

Patient guidance from the British Society of Urogynaecology estimates that approximately 10 to 20 per cent of women may not obtain a cure and that stress urinary incontinence can later recur in about 10 per cent of cases. These numbers should be interpreted as broad estimates rather than guarantees because results depend on the definition of success, length of follow-up, previous surgery, severity of sphincter weakness and surgeon experience. ^[6]

A patient should ask the surgeon about personal outcomes for women with a similar medical and surgical history—not merely the overall success rate of the operation.

Bladder-emptying difficulty is one of the most important risks. The urine stream may become slow, and temporary catheterisation may be required.

The British Society of Urogynaecology patient information estimates that about one in ten patients may initially need additional catheterisation. Persistent emptying difficulty can occur in a smaller group. Occasionally, the sling must be loosened or surgically revised. ^[6]

Urgency, frequent urination or urgency incontinence may improve, remain unchanged or worsen after surgery. New overactive bladder symptoms are estimated to occur in approximately 10 per cent of patients in some patient-information data, though reported rates vary. ^[6]

Infection may involve the bladder, vaginal incision or abdominal wound. Antibiotics are normally given around the time of surgery to reduce this risk.

Symptoms such as fever, worsening pain, cloudy urine, painful urination, foul-smelling discharge or redness around the abdominal incision should be reported.

Because instruments pass behind the pubic bone near the bladder, accidental bladder injury can occur. It is usually recognised during cystoscopy and repaired or managed with prolonged catheter drainage.

Urethral, bowel, ureter or major blood vessel injuries are less common but potentially more serious.

Harvesting fascia creates risks that are not present with a small-incision synthetic sling. These include wound infection, fluid collection, persistent abdominal discomfort, separation of the wound and development of an incisional hernia.

The 2024 Canadian guideline notes that the distinctive risks of an autologous fascial sling arise mainly from fascial harvesting and the greater possibility of voiding dysfunction. ^[3] (PubMed Central (PMC))

Bleeding, blood transfusion and blood clots are possible after any pelvic operation. The risk is influenced by obesity, smoking, mobility, medical conditions and blood-thinning medications.

Patients should never stop aspirin, anticoagulants or other prescribed medication without instructions from the surgeon and prescribing clinician.

Temporary pelvic, vaginal and abdominal pain is expected during healing. Persistent pelvic pain, groin pain or painful intercourse is less common but can occur even though synthetic mesh has not been used.

The sling may improve leakage without eliminating it completely. Continence can also weaken over time because of ageing, chronic coughing, constipation, weight changes or further pelvic floor injury.

The strongest advantage of an autologous pubovaginal sling is that the sling itself is made from the patient’s tissue. There is no permanent strip of synthetic mesh beneath the urethra.

The disadvantages are equally real: a larger operation, an abdominal scar, more postoperative pain, longer recovery and a greater risk of temporary or persistent voiding difficulty.

A synthetic midurethral sling may still be appropriate for many women because it is less invasive and has well-established effectiveness. The Food and Drug Administration states that traditional midurethral slings have an established safety and effectiveness profile, and its review found comparable performance between approved mini-slings and traditional midurethral slings through the studied follow-up periods. ^[2]

The choice should therefore not be framed as “safe tissue versus unsafe mesh.” It is a comparison between different procedures, each with distinct benefits, complications and recovery demands.

Women considering mesh-free sling surgery should also be told about other appropriate options.

Continued pelvic floor muscle training may be reasonable when symptoms are mild or surgery is not desired. A continence pessary or other vaginal support device may reduce leakage during exercise in selected women.

Urethral bulking injections are less invasive and usually require less recovery, but improvement may be less complete and repeat injections may be necessary. The National Institute for Health and Care Excellence advises that bulking agents may be considered when other surgical procedures are unsuitable or unacceptable, while explaining that they are generally less effective and their benefit may diminish over time. ^[1]

Burch colposuspension is another mesh-free operation. It supports the bladder neck using sutures rather than creating a sling. It may be performed through an open or laparoscopic abdominal approach.

The best option depends on the severity and cause of leakage, previous operations, bladder-emptying function, pelvic organ prolapse, medical fitness and the patient’s priorities.

Before agreeing to the operation, it is reasonable to ask:

• Is my leakage definitely caused by stress urinary incontinence?
• Do I also have overactive bladder or difficulty emptying my bladder?
• Why do you recommend an autologous pubovaginal sling for me?
• Will the fascia be taken from my abdomen or thigh?
• How often do you perform this operation?
• What are your rates of complete dryness, urinary retention and sling revision?
• How long will I need a catheter?
• Could I go home with a catheter?
• How long should I avoid work, exercise, lifting and sex?
• What are my alternatives if I do not want either mesh or abdominal surgery?
• How would future treatment be managed if leakage continues?

The surgeon’s experience matters because the sling must be tensioned carefully. Too little support may leave persistent leakage, while too much tension may make bladder emptying difficult.

Pubovaginal sling surgery without mesh is a well-established treatment for stress urinary incontinence that uses the patient’s own connective tissue to support the urethra.

It may be especially suitable for women who want to avoid synthetic mesh, have severe urethral sphincter weakness, have experienced a failed or complicated previous sling, or require continence treatment alongside certain urethral reconstructive procedures.

The operation can provide long-lasting improvement, but it is more invasive than a synthetic midurethral sling or urethral bulking injection. Recovery takes longer, and temporary difficulty emptying the bladder is relatively common.

A good candidate is not simply someone who dislikes mesh. She is someone with a confirmed form of stress urinary incontinence who understands the benefits, limitations, recovery and risks of all reasonable alternatives and has chosen the procedure that best matches her anatomy, health and personal priorities.