Outpatient management of an infected retropubic sling-a case report

Stress urinary incontinence affects 30-80% of women, with synthetic midurethral slings being the preferred surgical treatment for their high success rate and low complication profile. Although infection rates are low (0.7%), there are limited data on managing surgical site infections following retropubic sling placement. Existing reports recommend mesh removal as the primary treatment for mesh infections. This case describes the first known instance of successful conservative management of infected midurethral sling tracts using oral antibiotics and hydrogen peroxide irrigation, offering a potential alternative to more invasive treatments.

We report a case of a 55-year-old female with a history of well-controlled diabetes mellitus who underwent retropubic midurethral sling and concomitant robotic prolapse repair in October 2022. On postoperative day 11, she developed abdominal pressure, discomfort and malodorous urine followed by a fever of 101.9 F the next day. She was empirically treated with ciprofloxacin 500 mg twice daily and metronidazole 500 mg three times daily for coverage of uropathogens and anaerobes given her symptoms and proximity to surgery. Computed tomography (CT) scan demonstrated two small abscesses within the inferior pelvis. On exam, erythematous vaginal tissue surrounding the sling incision was noted and white purulent discharge was expressed from the incision. Given physical exam and CT scan findings, mesh infection was suspected. As no mesh exposure was noted, the decision was made to pursue conservative management. In addition to the oral antibiotics, vaginal estrogen cream three times per week and vaginal irrigation to the sling site three-times daily with a dilute hydrogen peroxide mixture (50/50 hydrogen peroxide/water) were initiated. On postoperative day 24, the patient exhibited decreased drainage, non-erythematous, non-tender tissue, resolution of fever and abdominal pain. By her 2-month follow-up, all signs of infection had resolved, and the sling incision site was fully healed with no mesh exposure.

This case highlights the successful conservative management of an infected midurethral sling using oral antibiotics and hydrogen peroxide irrigation, presenting an alternative to mesh removal. It highlights the importance of early recognition and appropriate treatment, contributing valuable insights to the management of surgical site infections in synthetic sling procedures.