This original clinical research is the first study to explore phenotyping of pain related to continence mesh devices. Mesh associated Pain Syndrome (MAPS) is the commonest complication of mesh devices. Research in this area has focused on management of MAPS however there has been little focus on defining the pain mechanism involved in MAPS which has limited treatment options available. The aim of this study is to explore pain mechanisms involved in MAPS in patients with continence devices, examine if differences exist in pain mechanisms of differing continence devices and to attempt to define the pain phenotype of MAPS to support better understanding of its management. The study explores the hypothesis that MAPS is not solely neuropathic-driven.

A cross-sectional study set within a quaternary-level mesh complications service. All women with MAPS related to a single continence device accessing the service between 26/01/2018 to 19/04/2024 were included.
Pain mechanism was determined using body-mapping of pain, the validated Pain DETECT questionnaire (PD-Q), and the validated Electronic Patient Assessment Questionnaire (e PAQ) to measure self-reported vagina, bladder and bowel pain together with dyspareunia. Quality of Life (QOL) and functional capacity was ascertained using the EuroQol group-5 Dimension (EQ5D). Mental well-being was measured using the WHO-5 wellbeing index. These assessments were compared in patients with retropubic and Trans-obturator (TOT) mesh devices and compared between subjects with nociceptive, ambiguous and neuropathic mediated pain as determined by the PD-Q score.

Over 5-years 280 women presented with MAPS. Subjects reported high levels of pre-existing pain-inducing conditions (n=146/280 52%). Body-mapping of pain identified localised pain suggestive of nociceptive pain mechanisms and neuro-anatomically plausible pain distributions suggestive of neuropathic pain origins in both mesh devices. However, 2% of patients reported distant pain consistent with nociplastic (Central Sensitization) mechanisms. PDQ identified most patients had neuropathic mediated pain (n=78/142 55%). Twenty-two percent (n=31/142) had nociceptive pain on PDQ and the remaining 23% (n=33/142) exhibited pain of ambiguous origin. Trans-obturator (TOT) devices were associated with a significantly higher mean PDQ score (p=0.04) of 20 compared to a mean of 17 in retropubic devices. There was a reported, ‘moderate’ impact in ability to perform usual activities of daily living and ‘moderate’ rates of anxiety and depression across the study group. Self-reported physical and mental well-being identified low scores in patients with MAPS of of 53/100 and 28/100 respectively. Subjects with neuropathic pain reported significantly higher vaginal pain on the e PAQ (p=0.03), significantly lower QOL related to bladder function (p=0.0005) and reduced ability to perform usual activities (p=0.01) than those with nociceptive pain.

Pain associated with MAPS appears to be predominately neuropathic mediated based on anatomical distribution and PDQ however the high levels of non-pain symptoms including anxiety and depression together with functional and mental impairment may indicate a nociplastic component to their pain.

MAPS appears to be of neuropathic phenotype with evidence of mixed origin including the nociplastic features found such as non-pain symptoms including functional disability and reduced mood and QOL. These exemplify the multidimensional impact and burden of chronic pain. These findings would suggest that surgery alone is not likely to be effective at resolving MAPS and that a multimodal approach directed at central nervous system rather than peripheral processes is likely to be more effective, specifically therapies addressing the tenants of the biopsychosocial model of chronic pain.