Although sub-urethral slings are highly effective in treating stress urinary incontinence (SUI), they can sometimes lead to sling-related pain, a very bothersome complication that may ultimately necessitate sling excision. Numerous studies have explored the causes and clinical presentations of sling-related pain, but the potential role of sling colonization in pain development remains largely unexplored. This case series aims to provide some of the first clinical evidence suggesting that infection may be a contributing factor in sling-related pain.

We report four cases of patients who underwent sling excision due to severe and persistent sling-related pain. The cohort included three women and one man, aged 55 to 79, all of whom initially received a sling for persistent SUI. Bacterial cultures were made from the excised slings; in the three patients with sling exposure, care was taken to culture only the non-exposed portions to avoid contamination and minimize the risk of detecting bacteria introduced through exposure.

The excised slings were found to be colonized by a diverse range of bacteria, including but not limited to: Staphylococcus lugdunensis, Streptococcus constellatus (part of the Staphylococcus anginosus group), Cultibacterium (Propionibacterium) avidum, Peptostreptococcus sp., and Prevotella bivia.

Numerous studies have explored the causes and clinical presentations of sling-related pain. Proposed mechanisms include sling extrusion, postoperative hematoma formation, direct surgical trauma, nerve irritation due to the tape's proximity to neural structures or local tissue tethering, and idiosyncratic reactions — particularly in patients with pre-existing pain syndromes such as fibromyalgia [1,2]. However, the potential role of sling colonization in pain development remains largely unexplored. 

Most of the identified microorganisms are not typically found within the genital or urinary systems, and some have even been associated with implant-related infections [3]. Given all the identified bacteria’s ability to become pathogenic when translocated to an inappropriate site, we hypothesize that their presence may contribute to sling-related pain.

It remains unclear whether, or to what extent, there really is causal link between sling colonization and sling pain, especially given the sling exposure also observed in most of our patients. However, we are among the first to propose sling colonization as a potential etiology for post-surgical pain, introducing a novel perspective in a field where mechanical factors—such as nerve injury and sling extrusion—have been the primary explanations.

Sling-related pain is a significant complication of sub-urethral sling placement, traditionally attributed to mechanical factors. Our findings suggest that bacterial colonization may also play a role, as multiple pathogens were identified in excised slings from symptomatic patients. While the causal relationship remains unclear, these results highlight the need for further research on the potential infectious contribution to sling-related pain. Future studies should explore larger cohorts and targeted strategies to improve patient outcomes.

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