The short version
Three different problems can come from the same place — the pelvic floor:
If you read nothing else on this page, these are the six things that matter. Everything below explains each one in plain language.
- 1Three problems, one pelvic floor. They share the same anatomy, so treating one can change the others — sometimes for the better, sometimes not. That isn't a complication of surgery. It's the nature of the pelvic floor.
- 2Repairing prolapse can uncover leaking you didn't have before. The bulge can act like a kink in a garden hose, holding it back. Depending on what testing shows, somewhere between 15 and 40 out of 100 women leak afterward.
- 3Bladder testing tells us which problem you actually have. Stress leaking and urgency are genuinely easy to confuse, even from the inside. Testing separates them, and narrows your risk from a wide range to a useful one.
- 4Mesh and a sling are two separate decisions. Your prolapse repair may or may not use mesh. A sling is a different piece, in a different place, treating a different problem. Declining one doesn't change the other.
- 5A sling doesn't have to be decided forever, today. It can be placed during your prolapse surgery, or later as a much smaller procedure if you turn out to need it.
- 6A sling treats leaking well, and may worsen urgency. Roughly a third of women improve, a third stay the same, a third get worse. Which of those matters more to you is genuinely yours to weigh.
Who this page is for
Surgery usually isn't the first step, and it isn't the only option. Many women improve a great deal with pelvic floor physical therapy, bladder training, or medication for urgency. A pessary — a removable support placed in the vagina — can hold the prolapse up and reduce leaking at the same time, with no operation at all.
This page picks up after those conversations. It's written for the woman who has already worked through her options with her physician, and decided surgery is the right next step. That's the point where these decisions get complicated.
If you're earlier than that, start with our prolapse page, or simply call us. There's no rush to get to surgery, and plenty worth trying first.
First: two different bladder problems, easily confused
This trips up almost everyone, and it matters, because the two are treated in completely different ways. What separates them isn't how much you leak — it's what your bladder is doing.
You cough, laugh, sneeze, lift something, or exercise — and you leak right then. There's no warning and often no urge at all.
This is stress incontinence. A sling is the main surgical treatment.
You get sudden, strong urges to go that are hard to put off. You may go often, or wake up at night to go. You may or may not leak with those urges — either way, it's the same underlying problem.
This is overactive bladder. When leaking comes with the urges, it's called urge incontinence — still overactive bladder, just with leaking. Treated with medication and nerve therapies, not a sling.
Where are you starting from?
Pick the one that best matches when your symptoms happen. You'll see just the part that applies to you.
Repairing the prolapse can uncover leaking that was hidden
This is the situation that surprises people most, so it's worth understanding well. When prolapse pushes the vaginal walls out of position, it can press on the urethra and hold back leaking that would otherwise happen. Once the prolapse is repaired, that pressure is gone.
Bladder testing before surgery helps us tell where you sit. If you don't leak during the test, your risk sits at the lower end of the range. Most women in your position never need anything further. If you do leak during the test, it's at the higher end, and adding a sling at the same time is worth a real discussion.
Either way, a sling can be added later if you turn out to need one. Waiting is a legitimate choice here, not a gamble.
Many women choose to address both at once
You're not weighing a hypothetical here — both the prolapse and the leaking are already affecting your life. In this situation, many women decide to treat both in the same operation, so there's one surgery and one recovery instead of two.
Adding a sling typically adds about 20–30 minutes to the end of an operation you're already having, and folds into the same recovery period. We'll still do bladder testing first. It confirms that effort-related leaking is what's driving your symptoms, and gives us a clear record of where you started.
Repairing the prolapse may improve urgency on its own
Urgency is the hallmark of an overactive bladder. Whether or not you actually leak with those urges, it's the same underlying condition — and the approach is the same. That distinction matters here because a sling is not the treatment for it.
Prolapse can press on the bladder, and relieving that pressure sometimes calms urgency considerably. That's a genuine possibility worth knowing about before adding anything else. When urgency doesn't improve, there are effective treatments for it on their own — medication, nerve therapies, and others we can walk through. It doesn't have to be solved in the same operation.
A sling carries some chance of making urgency worse. So when urgency is the dominant problem, and testing confirms an overactive bladder, we'd generally talk through leaning away from adding one.
This is where bladder testing matters most
Having both patterns together is very common. They're genuinely hard to tell apart from the inside. If you landed here because you weren't sure, that's a completely reasonable place to be. Testing is how we sort out which one is actually driving your symptoms, and that answer changes the recommendation.
Your testing may show a bladder with normal capacity and no significant overactivity, but clear leaking when you cough or strain. If so, a sling may well be the right choice — even though you also have urgency symptoms. If testing shows genuine bladder overactivity, we'd generally talk through treating the urgency on its own track first.
This is the scenario nobody can reason through alone, and it's the one testing is most useful for.
If you've already had your urodynamics
Once your testing is done, the conversation shifts. It's no longer about what you think might be going on — we know. Your physician can pull up the finding that matches your study and walk through it with you.
Straightforward: repair the prolapse, and wait on the sling
Your testing didn't provoke leaking, and your bladder behaved normally as it filled. That puts your chance of developing stress leaking after prolapse repair at the lower end of the range — nearer 15%. Put another way, roughly 85 out of 100 women in your position don't go on to develop it.
For most women here, that makes repairing the prolapse alone the sensible plan. If leaking does turn up afterward, a sling can be added as its own shorter outpatient procedure. You'd be accepting a second recovery period only if you actually turn out to need one — rather than treating something you may well never develop.
Both findings point the same direction
Your testing showed leaking when you coughed or strained, and your bladder otherwise behaved normally. That combination is the most straightforward one we see: the stress leaking is confirmed, and there's no significant overactivity to worry about aggravating.
That matters because the main argument against adding a sling is its effect on urgency — and a calm bladder on testing makes that concern much smaller. Many women in this situation choose to have the sling placed at the same time as the prolapse repair: about 20–30 extra minutes, one recovery instead of two.
If urgency was part of what brought you in but your bladder tested calm, that's genuinely useful information. It suggests those symptoms are less likely to be coming from an overactive bladder than they seemed — which shifts the balance further toward addressing the stress leaking.
Repair the prolapse; treat the bladder on its own track
Your testing didn't provoke stress leaking, so your risk of developing it after prolapse repair sits at the lower end — which means the sling question largely recedes here. What the study did show is an overactive bladder, and that's the symptom most likely to still be bothering you.
There's a real possibility worth knowing: repairing the prolapse can relieve pressure on the bladder and calm urgency on its own. If it doesn't, urgency has good treatments of its own — medication, bladder retraining, Botox, and nerve therapies including sacral neuromodulation. None of those requires deciding anything today.
The real judgment call
Your testing showed both: leaking with effort, and an overactive bladder. Both problems are real. That makes this the situation where the tradeoff is most honest. A sling is the most effective treatment we have for stress leaking. It also carries roughly a one-in-three chance of making urgency worse.
When urgency is the more dominant complaint, we'd generally talk through treating the bladder first on its own track. We'd revisit the sling afterward, if stress leaking is still bothering you. When the stress leaking is clearly what's affecting your life most, adding a sling may still be the right call with that tradeoff understood.
There isn't a formula here. This is the one where what matters most to you genuinely decides it.
Why leaking can appear after prolapse surgery
Think of a garden hose with a kink in it. Turn the water on and nothing comes out — not because the water isn't there, but because the kink is holding it back.
When prolapse pushes the vaginal walls out of position, it can press on the urethra the same way. You may not leak, because the bulge is acting like that kink. Once we repair the prolapse, the kink straightens out — and leaking that was always possible can now happen.
This is called occult stress incontinence — "occult" simply meaning hidden. The surgery didn't create it. It uncovered something that was already there. Knowing this ahead of time is exactly why we test before surgery rather than after.
What bladder testing actually tells us
Bladder testing — urodynamics — is a short office study that measures how your bladder fills, holds, and empties. It does three useful things:
1. It tells us which problem you actually have
Stress leaking and urgency are easy to mix up, and many women have some of both in varying degrees. Testing separates them, which matters because they're treated differently.
2. It narrows your risk from a wide range to a useful one
If you don't leak during the test, your chance of developing stress leaking after prolapse repair is at the lower end. If you leak with coughing or straining, it's at the higher end. Same surgery, meaningfully different odds — and that's what makes a real decision possible.
3. It puts your starting point on the record
If a bladder symptom comes up a year or two from now, we can compare it against how your bladder actually behaved before surgery, rather than relying on memory.
What the test is actually like
Most women are more anxious about this test than they need to be, so here's what to expect. It's done in the office, takes roughly half an hour, and no anesthetic is needed — it isn't a painful test, though it can be a little uncomfortable. You'll usually be asked to arrive with a comfortably full bladder, and to wear separates, since you'll change into a gown from the waist down.
You'll empty your bladder into a special toilet that measures how fast it empties. Then very fine, soft sensors are placed to measure pressure while your bladder is filled. You'll be asked how your bladder feels as it fills, and asked to do the things that normally trigger your symptoms — cough, strain, stand, sometimes hear running water. Then you'll empty your bladder one more time and the sensors come out.
Afterward, it's common for urination to sting a little for a day, and drinking extra water helps flush things through. There's a small chance of a bladder infection afterward, so let us know if you develop symptoms. We don't routinely give antibiotics after this test — most women don't need them. You can drive yourself home. Results are generally available right away, so we can go over them with you.
Mesh and slings are two separate things
This causes more confusion than almost anything else we discuss, so it's worth being very clear. Mesh can be part of a prolapse repair, and mesh can be part of a sling. They're different pieces, in different places, doing different jobs.
| Procedure | What it treats | Uses mesh? |
|---|---|---|
| Sacrocolpopexy | Prolapse — restores support to the top of the vagina | Yes |
| Native tissue repair (USLS, SSLF) |
Prolapse — restores support using your own ligaments | No |
| Midurethral sling | Stress leaking — supports the urethra so it stays closed under pressure | Yes |
| Urethral bulking | Stress leaking — an injection that helps the urethra seal | No |
Want an independent source? The American Urogynecologic Society and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction publish a question-and-answer sheet on mesh slings. It's written by specialists, not by us. It answers the questions patients most often bring us, including what the lawyer advertisements are about and how a sling differs from vaginal prolapse mesh. Read the AUGS–SUFU patient FAQs (PDF) →
And a note on "lifting the bladder"
Prolapse surgery isn't really lifting your bladder. It's rebuilding the support your vagina has lost — and your bladder benefits because it can no longer bulge down into the vagina. That's an important difference, because it explains why declining a sling doesn't take anything away from the repair itself.
If you'd rather avoid mesh entirely
Some women come in specifically wanting to avoid mesh. There is a complete path for that: native tissue prolapse repair, using your own ligaments, combined with urethral bulking for leaking if you need it.
We'll be straightforward about the tradeoffs. Urethral bulking is effective, but generally not as effective or as long-lasting as a sling, and it more often needs to be repeated. Native tissue repair is a well-established, perfectly reasonable prolapse operation. We've moved toward robotic sacrocolpopexy in many cases because recovery tends to be easier. The repair also tends to last longer, with less chance of the prolapse coming back. Both are real options, and which fits you is a conversation, not a default.
What happens to urgency
After prolapse repair: urgency often improves, thought to be from relieving pressure on the bladder. Sometimes it doesn't improve, and there are effective treatments for urgency on its own.
If a sling is placed: roughly a third of women find their urgency improves, a third find it unchanged, and a third find it worse.
What matters most to you?
There is no right answer here, and no score at the end. These are simply the things that tend to tip the decision one way or the other. Reading them through, and noticing which ones you feel strongly about, is often the most useful preparation you can do before your visit.
Now, or later if you need it?
If a sling is on the table, you don't have to decide it forever right now. A sling can be placed at the same time as your prolapse repair, or as its own procedure later if leaking develops.
| Sling at the same time | Wait, and only if needed | |
|---|---|---|
| Added surgery time | About 20–30 minutes onto an operation you're already having | A separate 20–30 minute outpatient procedure |
| Heavy lifting restriction | One 6-week period | A second 6-week period |
| Back to desk work | Same as your prolapse recovery | Usually within a few days |
| Repeat bladder testing | No | Possibly, if you didn't leak on your first test |
| The tradeoff | You may be treating something you would never have developed | A smaller second procedure, but a second recovery period |
What "waiting" actually looks like
It's a plan, not a shrug. We talk about your bladder at your post-operative visit — you may have no bothersome symptoms at all, or you may have leaking or urgency. At that point every option is open again. We'd typically give things a few months to settle before considering another procedure — unless the leaking is severe enough that waiting doesn't make sense for you.
The detailed version, with numbers For anyone who wants the specifics
Occult stress incontinence — the actual numbers
For a woman with prolapse and no stress leaking beforehand, the chance of developing stress leaking after prolapse repair runs roughly 15–40%. That range is wide because it depends on the individual, which is precisely why we test.
- No leaking on bladder testing: risk sits toward the lower end, nearer 15%. Put another way, roughly 85 out of 100 women in that position don't develop stress leaking.
- Leaking with effort on testing: risk sits toward the higher end, around 30–40%. Roughly 60–70 out of 100 still don't — but the odds have shifted enough to change the conversation.
What the numbers look like
Each dot is one woman out of 100.
About 15 of 100 develop stress leaking after prolapse repair. The other 85 do not.
About 30 to 40 of 100 develop it. Shown here as 35. Most still do not.
about 33 improve 34 unchanged 33 worse
Slings and urgency
Among women who have a midurethral sling placed, urgency symptoms divide roughly into thirds. About a third improve, about a third stay the same, and about a third get worse. There isn't a reliable way to know in advance which third you'll be in, which is part of why baseline urgency matters so much in the decision.
How the pieces interact
- Repairing prolapse fixes the bulge, often helps urgency, and can unmask stress leaking.
- Adding a sling treats stress leaking effectively, and may improve, not change, or worsen urgency.
- So the same operation can help one symptom while revealing or aggravating another. This is why we individualize rather than apply one formula.
What we weigh together
- Your symptoms now — what's actually bothering you, and how much.
- Your bladder testing — which problem is driving things, and where your risk sits.
- What you want — how you feel about mesh, about a possible second procedure, and which symptom you'd most want gone.
Recovery details
After prolapse surgery, or after a sling, we generally ask you to avoid heavy lifting for about six weeks. During recovery we also ask you to avoid soaking in a tub or pool, and to avoid putting anything in the vagina. Desk work is usually possible within a few days of a standalone sling; physically demanding work takes longer.
If you still have your uterus
Whether to remove the uterus is often part of this conversation as well. Our usual approach is to remove it at the same time if you're finished with childbearing, though uterine-sparing techniques are also an option. It doesn't change how we think through the decisions on this page, and we'll go over it with you directly.
Independent reading
These handouts are produced by the International Urogynecological Association, not by our practice. They're a useful second source on the two topics patients ask about most.
AUGS–SUFU patient FAQs on mesh slings (PDF) → AUGS–SUFU position statement on mesh slings → IUGA patient handout: Sacrocolpopexy (PDF) → IUGA patient handout: Uterosacral ligament suspension (PDF) → IUGA patient handout: Sacrospinous fixation (PDF) → IUGA patient handout: Urodynamics — a guide for women (PDF) → IUGA patient handout: Midurethral slings (PDF) → IUGA patient handout: Urethral bulking (PDF) →About this page
Who wrote it. This page was written by Dr. Christopher Ripperda and Dr. Kyle Norris of Fort Worth Urogynecology, the surgeons who perform these operations. It reflects the published literature together with our own experience caring for women with these conditions.
Funding. This page was developed and paid for by Fort Worth Urogynecology. It received no funding, sponsorship, or support of any kind from any device manufacturer, drug company, or other outside organization.
Our interest, stated plainly. We are the surgeons who perform the procedures described here, and we are paid for the care we provide. We have written this page to help you weigh the options honestly, including the reasons you might choose to do less, or nothing yet. We think you should know who is telling you this so you can judge it for yourself.
How it was developed. It was written by our physicians and reviewed within the practice. It has not yet been formally tested with patients — that work is planned, and this page will be revised in light of what we learn.
Where the numbers come from. The figures given here are drawn from the published surgical literature and from our own practice. They describe groups of women, not you specifically. We are preparing a full reference list for this page.
Last reviewed: August 2026 · Review schedule: at least once a year, and sooner if guidance from our professional societies changes.
Please read: This page is not medical advice. It is intended to help you, as a patient, understand a genuinely complicated clinical situation that we encounter routinely — so that when we sit down together, the conversation can start from a shared understanding rather than from scratch. Every woman's anatomy, symptoms, testing results, and priorities are different, and the right plan for you can only be decided with your own physician. Numbers given here are general ranges from clinical research and our own experience, not predictions about you specifically. If you have questions about anything here, please bring them to your visit — that's exactly what it's for.
Questions about your own situation?
This is a lot to take in, and you don't have to sort it out on your own. Call us and we'll talk it through.
Call (817) 923‑5559After your surgery
If you are already scheduled, or have had your operation, our nurses answered the questions they are asked most often on the floor — what to expect after surgery →