Vaginal tightening with incontinence surgery - is the bladder sling necessary?

Question

Hi, Im a 49 yo healthy woman planning to have vaginal tightening surgery. Having a perineoplasty and tightening the inside vaginal canal buy 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 urinary incontinece help. I had 2 children, one when i was 18 yo and one when i was 20. He says my bladder is about 20% towards the incontinence part. I dont have any symptoms and would rather not have that part done. But he will not tighten inside vagina without the sling for bladder. Why? Is it really necessary? Thank you

Oscar A. Aguirre, MD, FPMRS · Answer

Hello Tampalife,
While a sling is commonly performed at the time of a vaginal repair it should be reserved for women who are very symptomatic. Your primary complaint is laxity, looseness, and likely, decreased sensation and sexual/orgasm response. You should concentrate on improving these symptoms. Choose a surgeon who understands your goals and can explain all your treatment options. 
Following your vaginoplasty your bladder symptoms will likely be the as they are now, but if you were to develop stress incontinence in the future, whether it's at 1 or 10 years, there are great nonsurgical options available to address this symptom. To review some of these options go to the link below.
Best of luck,

Marco A. Pelosi III, MD, FACOG, FACS · Answer

Performing a sling on a patient without incontinence is a terrible idea unless you have severe prolapse and you leak urine when a pessary is placed. No competent surgeon would suggest this under any other condition because it sets you up for voiding dysfunction and mesh complications for no reason at all. Do yourself a favor and schedule a virtual consultation with an expert in vaginal tightening with perineoplasty and vaginoplasty. In over 27 years of doing these operations, I have yet to see a patient without urinary incontinence develop urinary incontinence as a result of vaginal tightening. To the contrary, it usually gets better if it was present beforehand.

Anna Chacon, MD, FAAD · Answer

I can understand why this feels confusing and a bit concerning — especially when you’re being told a second procedure is required even though you’re not having urinary leakage symptoms. Let me walk you through the reasoning in a clear, balanced way.

A perineoplasty and vaginal canal tightening procedure reshapes and tightens the posterior vaginal wall and perineal tissues. During this type of surgery, the anatomy and support structures of the pelvic floor are altered. In some women — particularly those who have had prior vaginal deliveries — tightening procedures can sometimes unmask or worsen underlying stress urinary incontinence that wasn’t obvious before surgery.

Your surgeon’s concern likely comes from this principle:
Some patients have occult (hidden) or borderline stress incontinence, meaning the bladder support is already somewhat weakened, even if symptoms are not yet noticeable. When the vaginal canal is tightened, pressure dynamics can change, and leakage may appear afterward. A sling is designed to provide additional urethral support to reduce that risk.

That said, whether a sling is automatically necessary is not the same for every patient.

Key points to consider:

A bladder sling is typically recommended when there is confirmed stress urinary incontinence or strong objective evidence of high risk.

If you truly have no symptoms — no leakage with coughing, sneezing, exercise, or urgency — many surgeons would at least discuss options rather than require it outright.

Some specialists prefer a preventive sling in higher-risk anatomy, while others prefer a staged approach (treat only if symptoms develop later).

A sling is generally safe and effective, but it is still an implanted support procedure with its own risks (voiding difficulty, urgency, mesh complications depending on type, need for revision in rare cases).

It’s reasonable to ask your surgeon:

What specific findings show I’m 20% toward incontinence?

Was this based on exam, imaging, or urodynamic testing?

What is my estimated risk of developing leakage if I do tightening without a sling?

Are there non-sling support options or a staged plan?

You’re asking exactly the right question. When you’re not experiencing symptoms, it’s appropriate to fully understand the risk–benefit balance before adding another procedure. A good surgical plan should feel medically justified and clearly explained — not rushed or automatic.

Vaginal tightening with incontinence surgery - is the bladder sling necessary?

Answers (3)

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