Male Sling Procedure

The male sling procedure is a minimally invasive surgical treatment for stress urinary incontinence in men, typically post-prostatectomy, involving placement of a synthetic sling to elevate and compress the urethra—restoring continence by enhancing urethral support and outlet resistance.

Introduction

Stress urinary incontinence (SUI) in men is a distressing condition, often resulting from damage or weakening of the urinary sphincter. This can occur following prostate surgery, pelvic trauma, or as a result of certain neurological conditions. The leakage of urine, especially during physical activity, coughing, or sneezing, can significantly impact quality of life and self-esteem. Among the various interventions developed to address this issue, the male sling procedure has emerged as a promising, minimally invasive, and effective surgical option.

Understanding Male Stress Urinary Incontinence

Before delving into the specifics of the male sling procedure, it is crucial to understand the underlying condition it treats. Stress urinary incontinence in men commonly arises after prostate surgery, such as radical prostatectomy for prostate cancer or transurethral resection for benign prostatic hyperplasia. The urinary sphincter, responsible for keeping the bladder closed, may lose its strength or be damaged, leading to involuntary urine leakage.

Symptoms of SUI include:

• Leakage of urine during activities that increase abdominal pressure (e.g., lifting, coughing, laughing, or exercising).
• Frequent use of pads or protective garments.
• Social embarrassment or withdrawal from activities.

While conservative measures such as pelvic floor muscle training (Kegel exercises), medications, and lifestyle modifications may benefit some, persistent or severe cases often require surgical intervention for meaningful relief.

What is the Male Sling Procedure?

The male sling procedure is a surgical technique designed to support and reposition the urethra and sphincter, thus improving continence. It is tailored primarily for men with mild to moderate SUI who have enough sphincter function remaining. The sling, made from synthetic mesh or biological material, acts as a hammock under the urethra, providing gentle compression and elevating the urethra into a more favorable position for continence.

Types of Male Slings

Several types of male slings have been developed, each with their specific materials and methods of placement:

• Transobturator Slings: These are placed via small incisions in the perineum (between the scrotum and anus) and the groin, threading the sling through the obturator foramen (an opening in the pelvic bone), providing firm support and moderate compression.
• Adjustable Slings: These allow post-operative adjustment of tension, enabling customization to the patient’s continence needs.
• Bone-Anchored Slings: These are anchored directly to the pelvic bone, offering a fixed point of support for the urethra.

Indications for the Procedure

The male sling is most suitable for:

• Men with mild to moderate stress urinary incontinence following prostate surgery.
• Patients who have not achieved sufficient improvement with conservative therapy.
• Individuals with adequate residual sphincter function (as determined by urodynamic studies and clinical assessment).
• Patients who prefer a less complex procedure than the artificial urinary sphincter.

Contraindications

The procedure may not be appropriate for:

• Men with severe SUI or complete sphincter deficiency.
• Active urinary tract infection.
• History of pelvic radiation (increased risk of complications).
• Previous urethral surgery or strictures in some cases.

The Surgical Technique

Pre-Operative Preparation

Preparation includes:

• Comprehensive evaluation (history, physical examination, urodynamics, cystoscopy).
• Discussion of expectations, alternatives, and potential risks.
• Pre-operative urine culture to exclude infection.
• Instructions to stop certain medications (anticoagulants, for example) days before the surgery.

The Procedure Itself

The male sling is typically implanted under general or regional anesthesia. The standard steps are:

• The patient is positioned in lithotomy (legs elevated and spread).
• A small incision is made in the perineum.
• The urethra is exposed, and the sling is placed beneath it.
• The ends of the sling are brought out through the groin or fixed to the pelvic bone, depending on the system used.
• Once appropriately tensioned to provide gentle urethral compression, the sling is secured in place.
• The incision is closed, and a catheter may be placed temporarily for urinary drainage.

The entire procedure usually takes 60–90 minutes, and many patients are discharged the same or next day.

Recovery and Post-Operative Care

Immediate Post-Op Care

• Patients are monitored for bleeding, infection, and urinary retention.
• Pain at the incision site is common but generally well-controlled with oral analgesics.
• A urinary catheter may remain in place for a short period (usually removed within 24 hours).
• Most men can return to light activities within a week and resume normal life within 2–4 weeks.

Activity Restrictions

To protect the sling as tissues heal:

• Avoid strenuous activity, heavy lifting, or cycling for several weeks.
• Refrain from sexual activity until cleared by the surgeon (usually about 4–6 weeks).
• Follow up with the surgical team as scheduled for assessment.

Outcomes and Effectiveness

Numerous studies report:

• Success rates of 70–90% for men with mild to moderate SUI.
• Significant reduction or elimination of pad use for most patients.
• Improved quality of life, confidence, and social participation.

Long-term durability is generally good, though some decline in efficacy may occur over several years.

Comparison with Other Treatments

The male sling is less invasive than an artificial urinary sphincter (AUS), has a lower complication rate, and does not require manual dexterity for operation (unlike the AUS, which uses a pump). It is, however, best suited to those with milder forms of incontinence.

Potential Risks and Complications

As with any surgical intervention, the male sling procedure carries risks:

• Bleeding and infection at the surgical site.
• Urinary retention (inability to urinate).
• Sling erosion or migration (rare).
• Persistent or recurrent incontinence.
• Pain or discomfort, especially when sitting.
• Need for further surgery if the procedure is not successful or complications arise.

Nursing Care of Patients Undergoing Male Sling Procedure

The success of the male sling procedure is not solely dependent on surgical technique but also on holistic nursing care that encompasses preoperative assessment, intraoperative assistance, and vigilant postoperative management.

Preoperative Nursing Care

1. Patient Assessment and Education

• Comprehensive Assessment: Obtain a detailed history, including the cause and severity of incontinence, previous treatments, comorbidities (especially diabetes and cardiovascular disease), and any allergies.
• Psychosocial Evaluation: Assess the patient’s expectations, understanding of the procedure, and emotional readiness. Address anxieties and provide reassurance.
• Preoperative Investigations: Confirm completion of all necessary investigations such as urinalysis, urine culture, urodynamic studies, and imaging as ordered by the physician.
• Patient Instruction: Explain the procedure, potential risks, benefits, expected outcomes, and the recovery pathway. Instruction should cover activity restrictions, catheter care, wound care, and signs of complications.

2. Preoperative Preparation

• Consent: Ensure that informed consent is obtained and documented.
• Fasting: Follow hospital protocol for preoperative fasting (usually nothing by mouth 6–8 hours before surgery).
• Skin Preparation: Assist with or instruct on preoperative showering with antiseptic solution. Shaving or clipping the perineal area should be done as per hospital policy to minimize infection risk.
• Bladder Management: Catheterization may be required preoperatively for bladder emptying; follow physician’s orders.

Intraoperative Nursing Care

1. Patient Positioning and Comfort

• Positioning: Assist in positioning the patient in lithotomy position, ensuring adequate padding to prevent nerve injury or pressure ulcers.
• Safety Checks: Verify all equipment is functioning (e.g., cautery units, suction, lighting) and all necessary surgical supplies are present.

2. Aseptic Technique

• Maintain strict aseptic technique to prevent surgical site infection.
• Assist the surgical team with instrument handling and ensure sterile field integrity throughout the procedure.

3. Intraoperative Monitoring

• Monitor patient’s vital signs (heart rate, blood pressure, oxygen saturation) and report any abnormalities immediately.
• Document fluids administered, blood loss, and any intraoperative events.

Postoperative Nursing Care

1. Immediate Postoperative Care

• Monitoring: Observe for airway patency, breathing adequacy, and circulation upon recovery from anesthesia. Monitor vital signs frequently as per protocol.
• Pain Management: Assess pain using appropriate scales and administer prescribed analgesics. Encourage non-pharmacological pain relief measures as appropriate.
• Urinary Output: Monitor for adequate urinary output. Temporary catheterization is common, but early removal is often encouraged to minimize infection risk.
• Wound Assessment: Inspect the surgical site for bleeding, hematoma, excessive swelling, or signs of infection (redness, warmth, discharge).

2. Ongoing Postoperative Management

• Catheter Care: If a catheter is in place, maintain patency, ensure securement, and monitor for signs of infection. Provide education on catheter care if the patient is discharged with one.
• Infection Prevention: Monitor for fever, chills, and wound complications. Reinforce the importance of hand hygiene and proper perineal care.
• Mobility: Encourage early, gentle ambulation as tolerated to reduce the risk of thromboembolism. Use sequential compression devices or administer prophylactic anticoagulants as prescribed.
• Bladder Training: Guide the patient in scheduled voiding when the catheter is removed. Monitor for urinary retention or difficulty voiding, which may indicate complications or obstruction.
• Continence Monitoring: Assess for improvement in incontinence, the presence of dribbling, or persistent leakage. Document progress and report concerns to the medical team.
• Patient Education: Teach the patient and family about wound care, signs of infection, activity restrictions (e.g., no heavy lifting or strenuous activity for several weeks), and when to seek medical attention.

3. Potential Complications and Nursing Interventions

• Infection: Promptly report any signs of infection. Administer antibiotics as ordered. Maintain a clean, dry surgical site.
• Urinary Retention: Assess for bladder distention and monitor post-void residuals. Teach double voiding techniques if mild retention occurs. Catheterization may be necessary if retention persists.
• Bleeding/Hematoma: Monitor for excessive drainage or swelling. Apply cold packs if prescribed and notify the physician of concerning findings.
• Dehiscence or Erosion: Observe for unusual discharge, pain, or sling exposure in the perineal area. Report findings immediately.
• Persistent Incontinence or Voiding Dysfunction: Document symptoms and collaborate with the urology team for further management, such as pelvic floor physical therapy or additional interventions.

Discharge Planning and Patient Follow-up

• Wound and Perineal Care: Instruct the patient in gentle perineal hygiene and keeping the area dry. Use mild soap and water, and avoid irritants.
• Activity Restrictions: Advise the patient to avoid heavy lifting, bicycling, or vigorous exercise for at least 4–6 weeks post-surgery or until cleared by the surgeon.
• Follow-up Appointments: Ensure the patient understands the schedule for follow-up visits, suture or staple removal (if required), and ongoing assessment of continence status.
• Signs to Report: Educate about symptoms that require prompt medical attention, including fever, chills, increased pain, difficulty urinating, or abnormal wound appearance.
• Psychosocial Support: Provide access to support resources, such as continence nurse specialists, counseling, or support groups for men dealing with urinary incontinence.

Patient and Family Teaching

Effective teaching empowers patients and their families, promotes recovery, and reduces complications. Key education points include:

• Purpose and expectations of the male sling procedure.
• Wound and catheter care techniques.
• Prevention and recognition of infection and complications.
• Importance of adherence to activity restrictions and follow-up visits.
• Lifestyle adaptations for managing incontinence as continence improves, such as scheduled voiding and pelvic floor exercises (as directed).

REFERENCES

1. Harrison WJ, Leslie SW, Desai D. Slings for Male Incontinence. [Updated 2024 Jan 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK599557/
2. Chung ASJ, Suarez OA, McCammon KA. AdVance Male Sling (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5583053/). Transl Androl Urol. 2017 Aug;6(4):674-681.
3. Comiter C, Dobberfuhl A. The Artificial Urinary Sphincter and Male Sling for Postprostatectomy Incontinence: Which Patient Should Get Which Procedure https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4778750/?Investig Clin Urol. Jan 2016; 57(1): 3-13.
4. Doudt AD, Zuckerman JM. Male Slings for Post-prostatectomy Incontinence. Rev Urol. 2018;20(4):158-169.
5. National Association for Continence (U.S.). Male Stress Incontinence Procedures https://nafc.org/male-stress-incontinence-procedures/.
6. Rizvi IG, Ravindra P, Pipe M, et al. The AdVance™ Male Sling: Does It Stand the Test of Time https://pubmed.ncbi.nlm.nih.gov/33517819/? Scand J Urol. 2021;55(2):155-160.

Stories are the threads that bind us; through them, we understand each other, grow, and heal.

JOHN NOORD

Connect with “Nurses Lab Editorial Team”

I hope you found this information helpful. Do you have any questions or comments? Kindly write in comments section. Subscribe the Blog with your email so you can stay updated on upcoming events and the latest articles.