Rectus Sheath Sling

What is a Rectus Sheath Sling?

A Rectus Sheath Sling also referred to as a Pubo-Vaginal Sling is an operation for the treatment of stress incontinence.

Pubovaginal Sling is considered by many as the operation of choice for women with Type III stress incontinence.

What is Stress Incontinence?

Stress incontinence refers to leakage of urine associated with activities like coughing, sneezing, laughing, lifting or even walking or standing.

How Does the Rectus Sheath Sling Work?

The Rectus Fascia is the tough covering over your abdominal muscle, Rectus Abdominis. (The fascial defect created is later sutured closed).The urethra is the tube from the bladder through which urine passes. 

It Sling works by allowing the urethra to be closed/supported both at rest, and also with straining. With straining or any rise in abdominal pressure, the sling pulls the urethra up and forward as the bladder is pushed down and back, preventing leakage of urine.

During the Procedure

The procedure involves both an abdominal and a vaginal incision (or cut). Through the abdominal incision, a strip (about 9 x 1cm) of your Rectus Fascia is removed to make the sling.  The sling is placed via the vaginal incision around the first part of the urethra (the bladder neck) and is suspended on strong sutures that are passed up internally through the pelvis (behind the pubic bone), and then tied together over the Rectus Fascia.

After the Procedure

The average hospital stay is 3 days. It is usual to have some wound pain post-operatively but this mainly resolves by 6 weeks. Pain management with paracetamol is typical (please ensure no more than 8 tablets are consumed per day). 

It is normal to have some spotting, bleeding or discharge from the vagina after surgery. This usually stops by about 3 weeks. When this has stopped and the vaginal wound has healed you can have sexual intercourse, as comfortable (usually by 3 weeks). Avoid using tampons until after this time.

Recover and Success

Following this operation, most patients with stress incontinence will be dry or significantly improved. The operation has a high success rate at 5-10 years.

Post Operative Care

You will be given a follow-up appointment, but if you experience any of the following problems after discharge you should seek medical attention;

• Severe pain not controlled with pain killers
• Bleeding
• Wound problems – infection or breakdown
• Inability to pass a catheter if required
• Or any other significant trouble.
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If at any stage your incontinence returns you should arrange a review visit.

Post Operative Side Effects

Some patients describe occasional discomfort from their abdominal wounds for up to 12 months following surgery. 

Up to a third of patients have some difficulty completely emptying their bladder initially. This is managed by learning to pass a small catheter via the urethra to empty the bladder, (Intermittent Self Catheterisation). You will be taught how to do this, usually before your operation. 

How often, and how long, this is required varies between patients. Most patients do not need to do this for more than 4 weeks but can be required for 12 weeks or longer.

It is important to do this and therefore prevents the bladder from becoming over-distended as this may delay the return of voiding to completion even more. Intermittent self-catheterisation is usually performed until the postvoid residual is < 100ml.

Uncommon Post Operative Issues

A small percentage of patients can have permanent or prolonged postoperative retention of urine. These patients may then require another minor operation to loosen or divide the sling and its sutures to be able to void again without passing a catheter.

The risk of permanent retention that cannot be reversed with further surgery requiring permanent catheterisation is very rare. Some patients with stress incontinence also have an urgency to pass urine. 



Urinary urgency can occur as a new symptom in some patients after stress incontinence surgery. The risk of making your incontinence worse after surgery is very rare.

What Are The Alternatives For Stress Incontinence?

Alternative treatments for stress incontinence include:

• bladder training
• pelvic floor exercises. 
• minor operations such as ‘injectables’. 
• Burch colposuspension or TVT tape (available for the treatment of Type II stress incontinence.)