Treatment comparisons
Most pelvic floor problems have more than one good treatment, and the hard part is often choosing between two of them. Each page below takes one of those choices and puts the options side by side: how well each works, what recovery looks like, the main risks, and the kind of patient each one tends to suit. Each one also tells you how I think about the choice.
Find the problem you’re dealing with, then the decision you’re facing.
Pelvic organ prolapse
Prolapse decisions usually come in two steps. First, whether to treat it with surgery or without. Then, if you choose surgery, which operation. Prolapse treatments lays out the full range of options.
| The decision | What it comes down to |
|---|---|
| Pessary vs surgery | A device you manage and can stop anytime, or a one-time repair. Both are reasonable long-term choices. |
| Physical therapy vs surgery | PT improves how the prolapse feels. Surgery restores the support. They do different jobs, so PT is not a step you have to finish before surgery. |
| Native tissue repair vs sacrocolpopexy | Sacrocolpopexy tends to be a little more durable. A repair with your own tissue avoids mesh. This is one of the closer calls in my field. |
| Robotic vs vaginal surgery | Robotic surgery often fits when the top of the vagina has dropped and you want the most durable repair. Vaginal surgery often fits when several areas need repair or you want no incisions on your belly. |
The last two pages overlap. Robotic sacrocolpopexy is the mesh repair, and vaginal repair usually uses your own tissue. Read the native tissue page for the trade-off between durability and mesh, and the robotic page for the surgical approach and recovery.
Stress urinary incontinence
Stress incontinence is leaking when you cough, laugh, lift, or exercise. The procedure choices mostly come down to how much you want to stay dry for the long haul versus how much procedure you want. Urinary incontinence treatments covers the nonsurgical options too.
| The decision | What it comes down to |
|---|---|
| Sling vs bulking agents | The sling makes more women dry, but it is surgery and it uses mesh. Bulking is a quick injection with an easy recovery and a lower chance of staying completely dry. |
| Mesh vs non-mesh options | The mesh sling has a long track record. A sling made from your own tissue works about as well, with a longer operation and a harder recovery. |
Overactive bladder
Overactive bladder means urgency, going often, and sometimes leaking before you reach the toilet. Many women start with medication. When it doesn’t work or the side effects are too much, the choice usually moves to bladder Botox or sacral neuromodulation. The overactive bladder page covers the condition itself.
| The decision | What it comes down to |
|---|---|
| Botox vs medication | Medication is easy to try and easy to stop. Botox controls leaking about as well, more women become completely dry with it, and it avoids whole-body side effects. |
| Sacral neuromodulation vs Botox | They control symptoms about equally well over a couple of years. The choice is whether you’d rather have an implant that runs in the background or come back for an injection now and then. |
A note on mesh
Mesh comes up in half of these comparisons, and the word covers three different things:
- The midurethral sling for stress incontinence. A narrow strip of mesh sits under the urethra. It remains the standard surgical treatment for stress incontinence, and the FDA has not recalled it.
- Transvaginal mesh for prolapse. These were mesh kits placed through the vagina to repair prolapse. The FDA removed the last of them from the U.S. market in 2019.
- Mesh for sacrocolpopexy. It is placed through small incisions in the belly and attached to a ligament on the sacrum, the bone at the base of the spine. The 2019 order did not cover it.
Most of the news about mesh was about the second one. If mesh is what’s holding you back, tell me. We can talk through your risk with each option, and there is a mesh-free choice for every problem on this page.
How I use these pages
These comparisons are general guidance. At your visit I examine you, ask what bothers you most and what you want to get back to doing, and then we go through the options that fit. You make the choice. If you want my recommendation, I’ll give it. Bring the page for the decision you’re weighing, along with your questions.
References
- American Urogynecologic Society and SUFU. Joint Position Statement on Midurethral Slings for Stress Urinary Incontinence. Female Pelvic Med Reconstr Surg. 2021. doi:10.1097/SPV.0000000000001096
- Carberry CL, Tulikangas PK, Ridgeway BM, et al. American Urogynecologic Society Best Practice Statement: Evaluation and Counseling of Patients With Pelvic Organ Prolapse. Urogynecology. 2025. doi:10.1097/SPV.0000000000001641