REVISED: Is a bladder sling necessary for 20% prolapse when getting a vaginal tightening procedure?

Question

REVISED QUESTION: Hi, I'm a 49 yo healthy woman planning on having vaginal tightening surgery. Having a perineoplasty and tightening the inside vaginal canal by cutting and tightening. My question is this, my surgeon says that in order to tighten the inside that i also have to install a sling for bladder support. Upon the exam has says that Im about 20% prolapse and in the future this may or may not get worse and if it does I could have urinary incontinence issues. However, I do not have any incontinence issues yet. I have had 2 vaginal birthed children. One when I was 18 yo and one when I was 20 yo. But he will not tighten inside without sling for bladder procedure. Why? Is it really necessary? I had to revise this question from the original post because I realized I should have said prolapse instead of incontinence. Understanding that one is a symptom of the other. I appreciate all responses to the original post. Thank you. Please help me to understand this before I make final decision on this procedure. It is very important to me.

Anna Chacon, MD, FAAD · Answer

As a physician, I want to reassure you first that a mild prolapse — such as about 20% — is quite common, and it does not automatically mean that a bladder sling is required when someone is considering a vaginal tightening procedure.

A bladder sling is typically recommended based on symptoms, not just the percentage of prolapse seen on exam. The key question is whether you are experiencing stress urinary incontinence — meaning leakage with coughing, sneezing, laughing, or exercise — or significant bladder support issues. If those symptoms are not present, a sling is often not necessary.

A vaginal tightening procedure (depending on the type — surgical vs. energy-based vs. cosmetic repair) focuses on the vaginal canal and tissue laxity, not primarily on bladder support. While some procedures may provide a small amount of additional support indirectly, they are not substitutes for a true anti-incontinence or prolapse repair surgery when that is clinically needed.

In real-world decision-making, these are the factors that usually guide whether a sling is added:

Presence of urine leakage with pressure or activity

Findings on pelvic exam and/or urodynamic testing

History of prior childbirth trauma or pelvic surgery

Degree and type of prolapse (anterior/bladder vs other compartments)

Your goals and tolerance for added surgical steps and risks

It’s also important to know that adding a sling when it isn’t clearly indicated can introduce unnecessary risks — such as urinary retention, urgency symptoms, or mesh-related complications — so most specialists prefer to be selective rather than automatic about placing one.

From a medical standpoint, a 20% prolapse alone does not automatically justify a sling. The decision should be symptom-driven and anatomy-specific, not percentage-based alone.

REVISED: Is a bladder sling necessary for 20% prolapse when getting a vaginal tightening procedure?

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