An Exploration of Sexual and Relational Impacts of Vaginal Mesh Injury: A Systematic Review using Thematic Synthesis

An Exploration of Sexual and Relational Impacts of Vaginal Mesh Injury: A Systematic Review using Thematic Synthesis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review An Exploration of Sexual and Relational Impacts of Vaginal Mesh Injury: A Systematic Review using Thematic Synthesis Natasha Beer, Danielle De Boos, Mark Gresswell This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8918556/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Surgical mesh used to treat Pelvic Organ Prolapse and Stress Urinary Incontinence has caused substantial injury to a growing number of women. The impact of mesh injury is far-reaching, significantly disrupting women’s lives. Whilst there is a growing body of literature examining the impacts, there is little research that specifically aims to understand the sexual and relational implications of mesh injury. This study aimed to systematically review evidence regarding the impacts of mesh injury reported by women in relation to sexual and relational functioning. Methods A systematic search of four databases (MEDLINE, CINAHL, PubMed, and ProQuest Dissertations and Theses) and a grey literature search was conducted in July 2025. Studies reporting qualitative data about women’s experiences of mesh injury where sexual and relational impacts were reported were included. The quality of each study was assessed using the qualitative CASP checklist. The data was thematically synthesised. (PROSPERO registration: CRD420251077730). Results A total of eight studies were included, with upwards of 639 participants identified; however, two of the reports included did not specify the number of participants. Of the eight studies included, five were rated high quality with three rated as moderate. Seven overlapping themes were developed from the data: 1) Sexual functioning: changes due to pain, 2) Changes to sexuality, 3) Relational activity: changes due to pain, 4) Changes to relationship satisfaction, 5) Identity: changing sense of self navigating life with mesh injury, 6) Changes in relational roles and a seventh central theme of disrupted embodied sexual-relational self. Conclusion Women with mesh injury experience significant sexual and relational disruption as a result of chronic pain, contributing to psychological distress. Psychological flexibility appears to be a protective mechanism for relational distress. Further research that seeks to understand these impacts is needed, which may inform the development of appropriate psychological interventions. Women’s health chronic pain vaginal mesh injury complications sexual functioning relationships embodiment Figures Figure 1 Figure 2 1. Background Vaginal mesh injury is an example of iatrogenic harm experienced by women ( 1 ). For decades, surgical mesh was commonly used in the treatment of Pelvic Organ Prolapse and Stress Urinary Incontinence ( 2 ). National inquiries, including the Australian Parliament Senate Community Affairs References Committee ( 3 ) report and Cumberlege’s ( 2 ) ‘First Do No Harm’ report, found widespread failings in relation to the identification and response to the harmful effects of mesh devices. The inquiries and subsequent studies have identified that women’s experiences were dismissed at multiple levels across the system ( 2 , 4 ), with radical changes required concerning the communication of patient-reported outcomes when evaluating treatment outcomes ( 1 , 4 ). A recent systematic literature review focusing on women’s accounts of the harm caused by surgical mesh indicates that the effects have caused significant, far-reaching and long-lasting disruption to women’s lives ( 5 ). Mesh injury disrupts personal lives, relationships, careers, and social lives, resulting in psychological harm ( 4 , 6 ). Whilst there is a growing body of evidence aimed at understanding the physical, psychological and sociological impacts of mesh injury ( 6 – 11 ), there is little focusing on the impact of mesh injury on sexual and relational functioning for mesh-injured women. The only existing paper that specifically examines the sexual impact of mesh injury focuses on the male experience of sexual intercourse with a mesh-injured female partner ( 12 ). This research was conducted whilst women were still campaigning for recognition of the serious complications associated with the use of surgical mesh. Understanding the differential challenges faced by both women and men is central to achieving transformative change ( 13 ). Therefore, this review focuses on the sexual and relational impacts reported by women. Sexual functioning is an important factor when considering overall quality of life ( 14 ). Whilst biological determinism posits that sexual behaviours are a set of biological processes ( 15 ), the psychological mechanisms underpinning sexual behaviours are broad and complex ( 16 ). Broad factors as motivators for sexual activity include physical reasons, goal attainment, emotional reasons, and insecurity reasons ( 16 ). Sexual functioning is therefore a complex interplay of both biological and psychological factors ( 17 ), which is further complicated by the presence of chronic pain. Sexual relations not only support the development of new relationships but are an important factor in the maintenance of relationships ( 18 ). Several studies have demonstrated that relational satisfaction is influenced by sexual satisfaction ( 19 ), although some studies have demonstrated that this is a stronger predictor for men ( 20 ). Women have been identified as engaging in sexual intercourse to achieve bonding and emotional closeness ( 21 ); therefore, the implications of not having sex are broader than the achievement of physical intimacy and have relational implications. Sexual pleasure for women is now recognised as an important consideration within their overall sexual health ( 22 ). However, the lack of recognition of the importance of sexual satisfaction for women as a surgical outcome may have contributed to the lack of sexual outcome measures following surgical mesh interventions ( 2 ). Moore and Sitron ( 23 ) posit that women experiencing chronic pain during intimacy experience a cognitive dissonance, whereby their painful sexual experiences do not align with desired or expected sexual selves, contributing to their overall suffering. Consequently, sexual satisfaction cannot be understood in isolation, as the existing literature demonstrates that relationships and sexuality are both influenced by sexual satisfaction and influence sexual satisfaction. Additionally, women experiencing chronic vaginal pain during intercourse are more likely to experience sexual self-discrepancies, which in turn is associated with lower sexual satisfaction ( 23 ). Whilst a decrease in relationship satisfaction was not identified in this study ( 23 ), several studies have identified a relationship between sexual dysfunction and decreased relationship satisfaction ( 24 – 26 ). Therefore, gaining an understanding of both women’s sexual and relational satisfaction in the context of mesh injury is important. Chronic pain exists within a complex interplay of biopsychosocial processes ( 27 ), and has been found to contribute to changes in relationship satisfaction ( 28 ). The mechanisms underpinning changes in relational satisfaction are a influenced by chronic pain itself and contextual variables within the couple ( 29 ). Patient pain adjustment may be complicated by spousal pain-reinforcing behaviours; therefore, pain management interventions that seek to understand relational factors may support pain adjustment and relationship satisfaction ( 27 ). Reese et al. ( 30 ) posit that the affective emotional experience of pain may be influenced by the quality of the marital relationship. Women in happy unions that identify their partner as highly responsive to their needs have been found to have capacity to adopt adaptive coping strategies which increase positive affect and functioning during episodes of pain ( 31 ). In contrast, people in relationships with poor adjustment are at increased risk of higher levels of pain and psychological disability ( 32 ). Additionally, partners caring for spouses with chronic pain have been found to experience feelings of burden and poor marital adjustment ( 33 ), which may further contribute to changes in relational roles and thus relationship satisfaction. Due to the lack of research specifically into mesh-injured women’s sexual and relational experiences, the foci of the literature drawn upon relate to organic rather than iatrogenic pain processes, such as rheumatoid arthritis ( 32 ) chronic vaginal pain ( 23 ), and Vestibulodynia ( 34 ). This may limit the generalisability of the findings in the context of women who have suffered iatrogenic harm. Whilst not the primary aim of the study, the findings may highlight the differential experiences and needs reported by mesh-injured women. Although the significant sexual, relational and psychological impacts of vaginal mesh injury are documented, there remains a lack of research examining effective psychological interventions for this population. Limitations have been identified in applying established chronic pain models to mesh-injured women’s experiences ( 5 ). A systematic literature review of mesh-injured women’s experiences found a lack of compatibility with the approach in the standard model of chronic pain disability ( 5 ). Due to the differential needs of mesh-injured women, this approach increases the risk of the dismissal and invalidation of the physical suffering experienced, thereby perpetuating harm for this population ( 5 ). Acceptance and Commitment Therapy (ACT) is recommended by National Institute for Health and Care Excellence as a psychological therapy for the management of chronic pain ( 35 ), with a growing evidence base for chronic pain management ( 36 – 39 ). ACT is an empirically supported transdiagnostic psychological therapy, aimed at fostering psychological flexibility as opposed to symptom reduction ( 40 ), adopting the position that the avoidance of pain contributes to the overall experience of pain and psychological distress ( 41 , 42 ). Therefore, ACT offers a theoretical framework for understanding mesh injured women’s health related psychological distress. ACT interventions aim to increase psychological flexibility and utilise cognitive defusion techniques to support individuals to re-engage with valued activities and build a meaningful life even with the presence of pain ( 41 , 42 ). The ACT definition of psychological flexibility refers to the coping, acceptance and adjustment to stressors in a way which facilitates valued goal pursuit ( 43 ). Psychological inflexibility in chronic pain cohorts has been identified as a predictor of pain-related dysfunction and distress ( 42 ). In addition to the evidence base for chronic pain, ACT has an emerging evidence base for sexual and relational difficulties ( 44 , 45 ). There are arguments that there are limitations to the approach as ACT is not specifically designed to target areas such as conflict resolution ( 45 ). However, ACT may increase feelings of compatibility in couples, with ACT interventions supporting couples to adopt a team mentality when considering experiences and actions against their joint values ( 46 ). The discussion considers the findings of the review through the lens of psychological flexibility in line with the ACT approach ( 41 ). 1.1 Aims The primary aim is the systematic identification, appraisal, and synthesis of the available evidence regarding the sexual and relational impacts that women experience as a result of vaginal mesh injury. The secondary aim is to identify gaps within the current literature to highlight areas for future research. Implications for clinical practice are considered in the discussion. 2. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) ( 47 ) guidelines were adopted to ensure consistency in reporting of the results. The review was registered on PROSPERO in June 2025 (ID: CRD420251077730). 2.1 Reflexive position The primary author is a trainee clinical psychologist with no personal experience of harm caused by surgical mesh or chronic pain. The author identifies as a female and as an intersectional feminist, which has influenced the choice of topic. Whilst this shapes the lens in which the findings have been interpreted, this offers valuable contributions to the understanding of gendered healthcare experiences. Research underpinned by feminist values creates space to critically examine the lived experiences of women, supporting exploration of marginalisation and power inequalities in a range of contexts ( 13 ). A feminist phenomenological position has been adopted, which operates with the key assumption that embodied experiences are shaped by discursive and structural contexts ( 48 ). This approach aims to uncover sedimented and hidden structures that influence those experiences, allowing for the interpretation of the subjective experiences of mesh-injured women whilst acknowledging structural explanations such as gender biases in medical research and institutions ( 48 ). Feminist standpoint research places women’s lived experiences at the centre of research, establishing a position in which knowledge can be built from ( 49 ). 2.2 Search strategy Four databases were searched: CINAHL, MEDLINE, PubMed, and ProQuest Dissertations and Theses. These databases were selected to allow for a broad search of publications relevant to the review. Additionally, the search strategy included a citation search and Google advanced search to capture relevant government inquiries. The inclusion of grey literature was important to capture global discourse and inquiries in relation to vaginal mesh injury. A date limit was applied, which restricted the search to published studies from 2008 onwards. This corresponds with the notification issued by the FDA indicating that there were serious complications associated with the transvaginal placement of surgical mesh (Cumberlege, 2020). Search terms were combined using the Boolean operators ‘AND’ and ‘OR’ to include terms from each of the four domains. The truncation asterisk (*) was utilised to broaden search results by searching for variations of the search terms. The search terms used are outlined in Table 1 . The corresponding thesaurus terms from each database were combined with the author's search terms. The full search strategy is included in the supplementary information in appendix 1. Table 1 Literature Review Search Terms Pelvic floor disorder Surgical intervention Surgical outcome Impact Pelvic Organ Prolapse Transvaginal Complications Sex* Stress Urinary Incontinence Vaginal surgical mesh Injur* Intima* Mesh Adverse effect Relation* Tension free vaginal tape Quality of life Transvaginal mesh QoL Vaginal mesh implant Personal li* Mesh injur* Social science Sub-urethral Sling 2.3 Eligibility criteria The population, exposure, and outcome (PEO) format was adopted to develop the research question and inclusion and exclusion criteria. Studies were selected based on the following criteria outlined in Table 2 . Table 2 Eligibility Criteria Included Excluded Participants Accounts of mesh-injured women reporting the sexual and relational impact of the injury Accounts of partners of mesh-injured women Exposure Surgical mesh used for the treatment of Pelvic Organ Prolapse and Stress Urinary Incontinence Surgical mesh used for treatment of other conditions, such as hernia Outcome Sexual and relational outcomes as a result of mesh injury Sexual and relational outcomes following mesh implants where mesh injury did not occur Study design Qualitative studies and government inquiries Quantitative reports and data Language and accessibility Studies published in English or studies that could be translated into English. Studies where a full-text copy was not available Studies that could not be translated Publication status Peer-reviewed research, grey literature, including Doctoral Theses and government inquiries Masters theses Date of publication Reports published before 2008 2.4 Screening and study selection Once the database searches were complete, the results were uploaded into Covidence. Initially, duplicate studies were removed, and the remaining reports were screened by the first author using the title and abstract to assess for suitability. The author then manually retrieved final reports for full-text screening against the eligibility criteria. Citation searching was conducted, and an advanced Google search was used to identify relevant government inquiries. 2.5 Data extraction All final reports included in the review were qualitative. Data pertinent to the research question was extracted from each report. Relevant data points from each government inquiry, such as inquiry submissions and key findings, were extracted. Data in relation to the characteristics of each report were extracted to include the author details, publication date, geographical location, study title, participant characteristics, research aim, data collection method, and data analysis method, outlined in Table 4 . 2.6 Data synthesis A thematic approach was adopted to synthesise the data ( 50 ). The results and discussion data from each study were coded by the first author, with an initial set of 55 codes. Codes were reviewed and grouped into descriptive themes, which were then analysed to develop analytical themes. First-order data in the form of quotations is included in the result sections to illustrate the themes. 3. Results The database search yielded 1220 results. Figure 1 illustrates the PRISMA ( 47 ) selection process. A total of 237 reports were duplicates and therefore excluded before screening. The titles and abstracts of 983 reports were screened, with a final 41 reports screened for eligibility using full-text review. In addition to the database search, three government inquiries were retrieved via advanced Google searching, with one excluded due to not meeting the inclusion criteria. One paper identified through citation searching was not retrieved. A total of eight reports, made up of six studies and two government inquiries, were included in the final review. 3.1 Study characteristics The characteristics of the included studies are presented in Table 3 with the corresponding identification number. The eight included studies were published between 2018 and 2024, reflecting the period in which changes in discourse around the use of surgical mesh occurred. The demographic characteristics were reported inconsistently across studies; therefore, sample size and age range are reported where available. The studies aimed to amplify the voice of mesh-injured women in research. The overall aim of each of the studies and reports was to gain an understanding of the impacts of vaginal mesh injury on women’s lives. Whilst the studies did not solely focus on the impacts of mesh injury in relation to women’s sex lives and relationships, this featured in each study to varying degrees. Sexual and relational impacts featured the most in study D. Studies F and A both reported sexual and relational impacts; however, the data was limited in these studies. The analysis in study D captured nuances in the different outcomes women experienced based on the severity of their injury, which was a strength of the study. This allowed for synthesis and analysis, which captured the different outcomes for women who had received timely diagnosis and treatment options versus women who had experienced protracted complications. The studies included were conducted in New Zealand (C), the United States of America (A), Australia (G, H), and the United Kingdom (UK; B, D, E, F). The pool of studies included in the review was conducted by a range of disciplines, including theological (C), sociological (D), political (F, G), (A, B, E), and psychological (H) perspectives. Study C was conducted by a researcher with lived experience. Studies G and H both provided analyses based on one set of data collected as part of the Australian Parliament Senate Community Affairs References Committee ( 3 ). Table 3 Characteristics of studies included Study ID Authors (year and country) Title Participants characteristics Methods (Collection and analysis) Research aim(s) A. Uberoi et al. (2020, USA) Listening to Women: A Qualitative Analysis of Experiences after Complications from Mesh Mid-urethral Sling Surgery Sample size (n = 19); age range (years): 39–76 Semi-structured focus groups and interviews; Inductive and deductive content analysis Aims : To gain a detailed understanding of women’s experiences of mesh complications B. Dibb et al. (2020, United Kingdom) When things go wrong: experiences of vaginal mesh complications Sample size (n = 18); age range (years): 40–67 Semi-structured interviews; Thematic analysis Aims : To explore the individual experiences of women who have had vaginal mesh complications and the impacts C. Brown (2019, New Zealand) The experiences of seven women living with pelvic surgical mesh complications Sample size (n = 7); age range (years): 43–69 Semi-structured interviews; Van Manen’s four Lifeworld Existential Aims : To understand women’s lived experience of pelvic surgical mesh complications D. Gregson (2024, UK) A sociological exploration into the experiences of ‘mesh-injured women’ Sample size (n = 25); age range (years): 37–70 Semi-structured interviews and diary entries; Narrative and thematic analysis Aims : To uncover the lived experience of women experiencing transvaginal mesh complications E. Toye et al. (2023, UK) The experience of women reporting damage from vaginal mesh: a reflexive thematic analysis Sample size (n = 15); age range (years): 48–78 Online and telephone semi-structured interviews; Reflexive thematic analysis Aims : To explore and understand the experience of living with complications attributed to vaginal mesh surgery so that this knowledge can contribute to improvements in care for those considering mesh, or mesh removal, surgery. F. Cumberlege (2020, UK) First Do No Harm Sample size: 517 participants in patient engagement events; Written and Oral evidence contributed: unclear; participant characteristics not reported Drop in events, letter and email submissions; Evidence gathering (government inquiry) Aims : To understand the harmful effects of medicines and medical devices used in the United Kingdom G. Australian Parliament Senate report (2018, Australia) Number of women in Australia who have had transvaginal mesh implants and related matters Sample size (n = 555); participant characteristics not reported Written submissions and oral submissions at committee hearing; Evidence gathering (government inquiry) Aims : To understand how many women in Australia have been adversely affected by surgical mesh implants, and to gain an understanding of the information provided to women and medical professionals undertaking vaginal mesh procedures H. McKinlay and Oxlad (2022, Australia) ‘I have no life and neither do the ones watching me suffer’: women’s experiences of transvaginal mesh implant surgery Sample size: 399; participant characteristics not reported Review of 555 written submissions from Australian inquiry; Reflective thematic analysis Aims : To explore women’s experiences of mesh surgery through a biopsychosocial lens analysing submissions to Australian Parliament Senate Inquiry Note: f = female, m = male, NP = Not provided 3.2 Quality appraisal The CASP Qualitative Studies Checklist ( 51 ) was utilised to appraise the quality of the research reports included in the review outlined in Table 3 . Each paper was allocated an identification number. Corresponding study identification numbers are denoted in brackets in the data synthesis. Table 4 Qualitative research appraisal using CASP Qualitative Studies Checklist (2023) Study ID Authors 1 2 3 4 5 6 7 8 9 10 Quality assessment A. Uberoi et al (2020) Y Y Y Y Y Y Y Y Y Y High B. Dibb et al (2020) Y Y Y Y Y U U Y Y Y Moderate C. Brown (2019) Y Y Y Y Y U U Y Y Y Moderate D. Gregson (2024) Y Y Y Y Y Y Y Y Y Y High E. Toye et al (2023) Y Y Y Y Y Y U Y Y Y High F. Cumberlege (2020) Y Y Y Y Y Y Y Y Y Y High G. Australian Senate report (201) Y Y Y Y Y U U U Y Y Moderate H. McKinlay and Oxlad (2022) Y Y Y Y Y Y Y Y Y Y High Note: CASP criteria for qualitative studies. 1. Was there a clear statement of the aims of the research? 2. Is a qualitative methodology appropriate? 3. Was the research design appropriate to address the aims of the research? 4. Was the recruitment strategy appropriate to the aims of the research? 5. Was the data collected in a way that addressed the research issue? 6. Has the relationship between researcher and participants been adequately considered? 7. Have ethical issues been taken into consideration? 8. Was the data analysis sufficiently rigorous? 9. Is there a clear statement of findings? 10. How valuable is the research? ( Y = Yes, N = No, U = Unclear) 3.3 Thematic synthesis of findings Three overarching themes were identified: changes in sexual functioning, changes in relational activity due to pain and changes to the embodied self. The three themes intersected with each other, creating three subthemes: changes in relationship satisfaction, changes in sexuality and changes in relational roles, with a central theme of disrupted embodied sexual-relational self. The overlapping relationship between the themes is illustrated in Fig. 2 . Sexual functioning : changes in sexual behaviour due to chronic pain Pain disrupting sexual activity featured in each of the data sets. Women described the painful implications of having penetrative sex and experienced an array of physical symptoms during sex, including vaginal dryness, sharp burning pain and spasms, bleeding, infections and offensive odour, and prolonged pain after sex (C, F, G, H). The pain was felt locally and in other areas of the body, including the abdomen, back, and bladder (H). As a result of the painful and unpleasant symptoms, women reported changes in libido and felt unable to want or enjoy sex (C). In study D participants were identified as being mildly, moderately, or severely injured by mesh. Regardless of the severity of their injury, women in each category experienced disruption to sexual intimacy. Study D reported pain interfering with the women’s ability to engage in sexual activity was similar regardless of the severity of mesh complications and injury. Women who were identified as having mild injury appeared to be more psychologically flexible and able to engage with other ways of bonding with their partner: “Instead, they reduced the disruption caused by their lack of, or reduced, sex lives by reevaluating and shifting the meanings they attached to their romantic relationships.” (D). Some women reported refraining from sexual relations completely (D) with no plans to have sex again (F). The loss of sexual intercourse ranged from months (D) to upwards of 10 years (F). The loss of sexual activity was associated with feelings of grief (G). However, some women reported feeling a sense of duty to continue to have sexual intercourse and regain their ability to function as a sexual partner despite the pain (A, B, D, E, H); this was sometimes related to factors such as maintaining financial security (D). Additionally, mesh erosion was also associated with physical injury to partners (A, D, F, G, H) which resulted in women avoiding sexual intercourse, and contributed to psychological distress including anxiety, guilt, grief, and depression (H). Changes in sexuality The embodied disruption meant women no longer felt able to physically want or enjoy sex, negatively impacting on their sexual identity (B, C, D, E, G, H). Women were left feeling as though they were not sexy (D) or attractive as a result of their mesh injury (B). “I think, the inability to … to have a sexual relationship you know, sort of is another sort of very, difficult journey you know, to deal with I think, because you feel unattractive you know, you feel … that there is a strain on the relationship because of it” (B). The physical harms caused by mesh implants and subsequent surgeries resulted in anatomical changes which felt incompatible with women perceiving themselves as a sexual being. One participant reported that they no longer had enough tissue to form a vagina (C) and another reported a comment made by their partner that they were a ‘cheese grater’ (G), leading to feelings of embarrassment. As a result of the ongoing complications and disruption to their sex lives, women reported reconciling with the idea that they would never function as a sexual partner again (D, G, H) and thus questioned if they would ever be able to maintain a relationship. This marked end to sexual intercourse represents the most severe sexual outcome for mesh-injured women. In contrast, women who were identified as mildly and moderately injured remained hopeful that they would be able to resume sexual intercourse and saw their injury as a temporary disruption to their sexual selves (D). Whilst the women in both these categories experienced severe symptoms in relation to sexual functioning, they either considered their symptoms to be manageable (mild) or expected that with treatment, they would be able to recover from the complications (moderate) (D). Changes in relational roles Changes in relation roles were reported across five studies (B, C, D, E, H). Women described feeling unable to be the partner they envisioned themselves being (H) and being reliant on partners who had transitioned into caring roles (C, D, H). Women also described their partners as friends, roommates, and platonic (B, D, E): A key contributor to the change in roles was the loss of relational and sexual activity, resulting in relational roles shifting. Activities of shared interest, which may have previously facilitated bonding and maintenance of a romantic relationship, were lost due to the continued experience of pain (B, D, G, H) “Me and my husband, we’re not a couple ...It’s more platonic than anything else... He’s in his room, and I just lay in here and listen to music because I can’t even concentrate on a TV programme because of pain...” (D). Relational activity : changes in relational activity due to chronic pain The pain experienced by women resulted in disruptions to other areas of their relationships, with women reporting they felt unable to participate in activities which they had previously enjoyed with their partners (D, G). There were, however, variations to this. Women who identified as having mild injury felt that with adjustments, they were able to maintain some level of their pre-injury functioning, limiting the embodied impact (D), again demonstrating psychological flexibility. However, women who were identified as moderately or severely injured in study D, were faced with a significant loss of relational activity or felt forced to forfeit activities with their wider social network to focus their efforts on maintaining activity with their partners. “We used to go walking in the Lake District [...] we used to go to football matches, gigs [...] I just can't stand for any length of time I get so much pain... even sitting here now I’m in pain [...] We still love each other but our relationship has changed. He’s one of those people who hates staying in, so we spend more time apart now.” (D) Changes in relationship satisfaction Relationship satisfaction appeared to change for many couples due to the sexual and relational impacts caused by mesh injury (B, D, E, G). Women reported feeling heartbroken and isolated by the changes in their relationship (E). Women who had been experiencing mesh injury complications for protracted periods of time appeared to be more likely to be negatively impacted in this domain (D, G), signalling the long-term effects of the pressure felt within the couple. In contrast, some relationships were able to withstand the effects of mesh injury. This appeared to occur when a timely diagnosis had been received (D). Timely diagnosis meant couples were able to attribute the difficulties to mesh injury and remained hopeful that treatment would mean they could resume their pre-injury relational activities, both sexually and leisurely. Thus, timely diagnosis acted as a protective mechanism. “I’m blessed to be in an incredibly strong marriage...I've got a lovely husband who understands that there's no pressure. We just love each other... There’s other ways of showing your affection and showing your love and kindness...” (D) In some couples, relationship satisfaction was closely related to sexual activity (A, D). Women felt that even though sexual activity was painful and presented physical harm to both them and their partners, they were obligated to engage in sexual activity to protect the satisfaction in the relationship (A, D). This carried an emotional and physical cost for the women. “It’s keeping our relationship alive in a way so that after the surgery there’s still a relationship to return to”. (D) For some the relational impacts of mesh injury were so severe that the relationship had not been able to withstand the stress. This resulted in a complete breakdown of the relationship leading to separation and divorce (A, C, D, G). Embodied self : changing sense of self, navigating life with mesh complications/injury and chronic pain Women have been faced with navigating a changing sense of identity as a result of mesh injury (C, G, H). Being unable to engage in activities that they were previously able to, such as social activities, household activities, and maintain the role they had previously held in their relationship led to changes in their sense of self (H). Women describe a loss of feeling whole, with mesh injury causing disruption to the unity between their body and their sense of self (C). Although only explicitly stated in one study, study G pointed to the impacts in communities of women where cultural practices and beliefs are impacted by mesh injury. This indicates that changing identity was not only felt by the participants but may be imposed on them by others in the community. “The impact of isolation on Indigenous women, you will find that if they have this mesh, they will be totally ostracised. When our women talk about sex, sex is not just sex; it encompasses a whole community and involves love, intimacy, touch deprivation—everything” (G) Disrupted embodied sexual-relational self The accounts provided by women in each of the studies demonstrate that each area was not impacted in silo (A, B, C, D, E, F, H). The women’s experiences of change to their sexual activity and sexual identity created changes in their relationships, as did the changes in the activities they could participate in with their partner. The women were left navigating changes in their role within their relationship, which impacted on their sense of self. This is captured in the final theme of disrupted embodied sexual-relational self which brings together the complex and multifaceted nature of mesh injury. 4. Discussion The purpose of the review was to locate and synthesise the accounts of women injured by surgical mesh implants, specifically in relation to their sexual and relational functioning. The available reports were critically appraised. The literature drawn upon in the discussion reflects different aetiological causes of chronic pain, which, although a limitation, increase understanding how chronic pain influences sexual and relational outcomes for women. Whilst the aims of each report examined the overall experience of mesh-injured women, painful intercourse as a result of mesh injury was a common theme across the studies, evidencing the significant disruption to women’s sexual functioning. The existing literature demonstrates that for women chronic pain and sexual dysfunction are often co-occurring difficulties ( 52 ). This review suggests that chronic pain as a result of mesh injury results in sexual dysfunction as identified in research other chronic pain conditions. Existing research demonstrates that sexual dysfunction as a result of chronic pain conditions results in lower levels of sexual satisfaction for women ( 23 , 52 ), which was reflected in the accounts of women included in the review. Sexual dysfunction has been described as a multifactorial problem, with multiple detrimental impacts creating psychological, interpersonal, intrapersonal, and economic difficulties ( 53 ). The findings of this review demonstrate the multifactorial nature and wider impacts of sexual dysfunction for mesh-injured women such as their perceived sexuality, relationship satisfaction and changing identity. Motivators for sexual relations change throughout the course of relationships ( 54 , 55 ), therefore changing the nature and frequency of sexual intimacy. For women with mesh injury, pain has severely disrupted their sexual activity in new ( 6 , 9 , 11 ) and established relationships ( 2 , 6 – 9 , 11 ). In line with Meston and Buss’ ( 16 ) findings, women’s motivators for intercourse varied, with women seeking emotional intimacy, role fulfilment and relational security. The impact of chronic pain extends beyond the sexual act, with pain interfering with women’s feelings of sexual desire ( 56 ). Sexuality is posited to be central to the human psychological experience ( 15 ). The impact of chronic pain extends beyond the sexual act, with pain interfering with women’s feelings of sexual desire ( 56 ). Painful sexual experiences significantly disrupted women’s experiences of sexuality. Sexuality encompasses perceptions of self as a sexual being, thereby influencing sexual activities and behaviours ( 57 ). This is consistent with the findings of the review, that women not only felt physically unable to engage in sexual activity due to pain but also reported a loss of libido and no longer viewed themselves as a sexual being. Sexual dysfunction was reported by women regardless of the severity of their mesh injury, indicating that sexual outcomes should be considered for all women experiencing mesh complications. Findings from the Cumberlege ( 2 ) review indicate that reporting on adverse outcomes of mesh devices was not representative of the risks and complications women have faced. Painful intercourse as a complication of the medical device was not reported as a risk. This may reflect a discrepancy in the importance women place on their ability to maintain a healthy sex life, compared to the manufacturers who did not perceive this as an important outcome. Sexual pleasure is a key aspect of women’s overall sexual health ( 22 ) and the Women’s Health Strategy for England ( 58 ) acknowledges current gender biases in healthcare, calling for the discrepancies to be addressed by healthcare providers. The development of individual identity, bonds, and intimate relationships are closely related to sexual functioning ( 18 , 56 ). Women’s sexual motivations encompass the desire for emotional intimacy ( 21 ). Thus, sexual dysfunction as a result of mesh injury cannot be understood solely as a physical complaint or in silo. This is reflected in the overlap of changes in sexual functioning and women’s reports of changing sexuality, identity and relationship satisfaction. The findings of the review indicate that relationships were damaged, sometimes irreparably by chronic pain. Whilst the review indicates changes in relationship satisfaction may relate to changes in sexual and relational activity, there may be other variables which are not accounted for which influence this domain. Spousal responses to their partners experience of pain directly impact relationship satisfaction ( 59 ), which has been replicated in more recent studies ( 27 , 28 ). Therefore, future research may incorporate partner responses in mesh-injured women’s experiences. Women who spoke positively about their relationship satisfaction appeared to demonstrate psychological flexibility in their approach to values-based relational activities. These women had identified new ways of bonding with their partner which may have acted as a protective mechanism for the relationship. The significant loss of valued activities in the relationship including both sexual and recreational activities that served as bonding experiences appeared to be related to not only relationship satisfaction, but higher levels of psychological distress. Pain as a barrier to quality time in couples has been found to have a detrimental impact on relationship satisfaction ( 60 ), which the findings of this review support. Couples engaging with interventions that promote relational flexibility and relationship rebuilding activities have been found to improve pain related distress within couples ( 60 ). ACT approaches to chronic pain acknowledge that the avoidance of activities provides short-term relief, however, have long-term detrimental impacts due to the loss of meaningful life activities ( 42 ). A recent meta-analysis ( 61 ) and systematic review ( 39 ) found that ACT reduced how much pain affects daily life with medium effect. Ye et al. ( 39 ) also found that ACT improved participants ability to function with moderate to large effect sizes. Therefore, supporting women to continue to engage with meaningful activities with their partners may positively impact on the experience of chronic pain and relational distress. The implications of each overarching theme resulted in a central disruption to the embodied sexual-relational self. The concept of embodiment is rooted in philosophy but has been garnering increased attention within the realm of psychology ( 62 ). The self is a sum of traits that collectively inform an individual’s sense of being ( 63 ), with embodiment considering the combined experience of having a body and being a body, the synthesis of which is central to the development of self-identity ( 62 ). Disharmonious synthesis is associated with psychological distress ( 62 ). Mesh injury can be conceptualised as a significant event which creates disharmonious synthesis, inhabiting a body which no longer aligns with the ideal sense of self. Furthermore, social conditions and relationships are features of the embodied self ( 63 ). Feminist theories of embodiment consider the embodied experience within the discursive structures with shape women’s experiences ( 48 ). This was demonstrated in one study where women were at higher risk of being ostracised within their community as a result of their mesh-injury, highlighting the impact of the discursive structures that influence the embodied experience. Intrinsic to the embodied self is sexuality ( 15 ). Women who experience chronic pain are at increased risk of experiencing a cognitive dissonance, where their reality does not align with their desired sexual self ( 23 ), thereby disrupting the embodied self. The inability to have sexual intercourse is a threat to a sense of belonging and value, as women face pressures to comply with the heterosexual norms of intercourse ( 34 ). The development of sexual subjectivity without the end goal of achieving sexual intercourse allows for sexual intimacy and unexpected pleasure ( 64 ). This appears to fit with the ACT approach, as the development of psychological flexibility may promote the exploration of new approaches to achieving intimacy and relational activity, with the aim of increasing relationship satisfaction. 4.1 Strengths and limitations This is the first systematic review seeking to understand the sexual and relational impacts women experience as a result of surgical mesh injury. The inclusion of a reflexive statement allows the reader to position the research in the context of the author’s approach and positionality, increasing transparency. Whilst this does not eliminate any potential bias in the development and construction of the coding and themes, readers are able to assess the strengths and limitations of the author's interpretation of the findings. The review was conducted in accordance with the PRISMA guidelines, providing consistency and confidence in the reporting of the findings. Searching four databases allowed for broad inclusion of literature across a range of disciplines. The inclusion of grey literature supported minimisation of publication bias. The limited number of studies which report of sexual and relational outcomes for mesh-injured women creates a limitation in the conclusions that can be drawn, notwithstanding that the reports included in the review were not inherently focusing on sexual and relational outcomes after mesh injury. The methodological quality of the studies included in the review was generally high. However, none of the studies focused on sex and relationships, meaning important nuances may not have been captured and therefore not included in the discussion. The study samples were largely homogenous (age, gender, ethnicity), which limits the applicability to women living in countries not captured in the current research. The samples were however heterogeneous in terms of research field and discipline (theology, nursing, psychology, sociology, political). Drawing from multiple types of knowledge production supported in depth exploration of the lived experience of women. The common themes identified across disciplines indicate the significance of the findings, supporting the application of findings in a range of contexts, thereby enhancing the utility of the findings. The adoption of thematic synthesis accommodates for the disciplinary variation and tension in the interpretation of findings. 4.2 Implications for practice and future research Future research specifically aimed at understanding the impact of mesh injury on sexual functioning, sexuality and relational outcomes would be beneficial to further understand the needs of women in this group and capture nuances that may have been missed in this review. Outcomes that relate to women’s overall health are an important consideration and should be addressed by healthcare providers ( 58 ). The findings are an important consideration for complex mesh centres in the UK providing care for mesh-injured women. For women presenting with mesh complications, timely care that places importance on sexual and relational outcomes may mitigate some of the sexual and relational harms experienced by women. ACT has a developed evidence base for treatment of chronic pain. However, there is currently a general assumption that an ACT approach is applicable across pain types ( 65 ). Psychological flexibility was identified as a potential protective mechanism for mesh-injured women in relation to continued engagement with values-based actions such as sexual and relational activities. Therefore, further research in relation to ACT as an approach for mesh-injured women requires interventional studies to understand the effectiveness of the approach for this client group. Furthermore, research that seeks to understand adjustment to pain and the adaptive and maladaptive coping mechanisms within couples may inform couples-based ACT approaches to pain management where mesh injury is present. Abbreviations ACT Acceptance and Commitment Therapy CASP Critical Appraisal Skills Programme FDA Food and Drug Administration n Sample size / number of participants NP Not provided PEO Population, Exposure, Outcome PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses QoL Quality of Life UK United Kingdom USA United States of America Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials Data generated and analysed during the study is included in the article and is supplementary information file. Competing interests The authors declare that they have no competing interests. Funding This review did not receive funding. Authors' contributions NB acted as the primary author and developed the review, conducted the literature searches, screened studies, extracted and synthesised data and drafted the manuscript. DDB provided primary supervision of the review, including guidance on the analysis and interpretation of the results and revision of the manuscript. MG provided secondary supervision of the review, contributing to the development of the review and manuscript revision. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Ducey A, Donoso C, Ross S, Robert M. From anatomy to patient experience in pelvic floor surgery: Mindlines, evidence, responsibility, and transvaginal mesh. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8918556","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":606668635,"identity":"2673ac67-78c6-440d-bafd-c65224ca8230","order_by":0,"name":"Natasha Beer","email":"data:image/png;base64,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","orcid":"","institution":"University of Nottingham","correspondingAuthor":true,"prefix":"","firstName":"Natasha","middleName":"","lastName":"Beer","suffix":""},{"id":606668643,"identity":"5b1db28d-3f3c-4f9b-aac6-fa4c62f1bf0b","order_by":1,"name":"Danielle De Boos","email":"","orcid":"","institution":"University of Nottingham","correspondingAuthor":false,"prefix":"","firstName":"Danielle","middleName":"","lastName":"De Boos","suffix":""},{"id":606668657,"identity":"857ef46d-8f09-4722-bd14-221afbffdc5d","order_by":2,"name":"Mark Gresswell","email":"","orcid":"","institution":"University of Lincoln","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"","lastName":"Gresswell","suffix":""}],"badges":[],"createdAt":"2026-02-19 15:29:52","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8918556/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8918556/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105351987,"identity":"039f9426-bb5b-479e-804e-0345078b5696","added_by":"auto","created_at":"2026-03-25 06:01:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":304720,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePRISMA flow diagram illustrating study selection process (Page et al, 2021).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8918556/v1/2d715f938a327f0f308ea372.png"},{"id":105351986,"identity":"1f85433a-afdf-4215-a5da-b4a0dbfe5121","added_by":"auto","created_at":"2026-03-25 06:01:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":290681,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eDiagram representing the overlapping relationship between the key themes, emphasising the centrality of the changes that women experienced to their integrated sexual and relational self.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8918556/v1/51156dd8af8f6cac79784ddb.png"},{"id":105569841,"identity":"a7d9e929-df61-4580-84ad-6b408046e4b0","added_by":"auto","created_at":"2026-03-27 13:13:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1627904,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8918556/v1/f41473de-69f1-4754-8e76-d36d35162235.pdf"},{"id":105565569,"identity":"720a8d1a-fa2e-4078-bea9-70e669cc7c17","added_by":"auto","created_at":"2026-03-27 12:53:37","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13962,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8918556/v1/79ef1b9cb450f71e13423c2b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"An Exploration of Sexual and Relational Impacts of Vaginal Mesh Injury: A Systematic Review using Thematic Synthesis","fulltext":[{"header":"1. Background","content":"\u003cp\u003eVaginal mesh injury is an example of iatrogenic harm experienced by women (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). For decades, surgical mesh was commonly used in the treatment of Pelvic Organ Prolapse and Stress Urinary Incontinence (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). National inquiries, including the Australian Parliament Senate Community Affairs References Committee (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) report and Cumberlege\u0026rsquo;s (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) \u0026lsquo;First Do No Harm\u0026rsquo; report, found widespread failings in relation to the identification and response to the harmful effects of mesh devices. The inquiries and subsequent studies have identified that women\u0026rsquo;s experiences were dismissed at multiple levels across the system (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), with radical changes required concerning the communication of patient-reported outcomes when evaluating treatment outcomes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA recent systematic literature review focusing on women\u0026rsquo;s accounts of the harm caused by surgical mesh indicates that the effects have caused significant, far-reaching and long-lasting disruption to women\u0026rsquo;s lives (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Mesh injury disrupts personal lives, relationships, careers, and social lives, resulting in psychological harm (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Whilst there is a growing body of evidence aimed at understanding the physical, psychological and sociological impacts of mesh injury (\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), there is little focusing on the impact of mesh injury on sexual and relational functioning for mesh-injured women. The only existing paper that specifically examines the sexual impact of mesh injury focuses on the male experience of sexual intercourse with a mesh-injured female partner (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This research was conducted whilst women were still campaigning for recognition of the serious complications associated with the use of surgical mesh. Understanding the differential challenges faced by both women and men is central to achieving transformative change (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Therefore, this review focuses on the sexual and relational impacts reported by women.\u003c/p\u003e \u003cp\u003eSexual functioning is an important factor when considering overall quality of life (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Whilst biological determinism posits that sexual behaviours are a set of biological processes (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), the psychological mechanisms underpinning sexual behaviours are broad and complex (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Broad factors as motivators for sexual activity include physical reasons, goal attainment, emotional reasons, and insecurity reasons (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Sexual functioning is therefore a complex interplay of both biological and psychological factors (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), which is further complicated by the presence of chronic pain.\u003c/p\u003e \u003cp\u003eSexual relations not only support the development of new relationships but are an important factor in the maintenance of relationships (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Several studies have demonstrated that relational satisfaction is influenced by sexual satisfaction (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), although some studies have demonstrated that this is a stronger predictor for men (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Women have been identified as engaging in sexual intercourse to achieve bonding and emotional closeness (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e); therefore, the implications of not having sex are broader than the achievement of physical intimacy and have relational implications.\u003c/p\u003e \u003cp\u003eSexual pleasure for women is now recognised as an important consideration within their overall sexual health (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). However, the lack of recognition of the importance of sexual satisfaction for women as a surgical outcome may have contributed to the lack of sexual outcome measures following surgical mesh interventions (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Moore and Sitron (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) posit that women experiencing chronic pain during intimacy experience a cognitive dissonance, whereby their painful sexual experiences do not align with desired or expected sexual selves, contributing to their overall suffering. Consequently, sexual satisfaction cannot be understood in isolation, as the existing literature demonstrates that relationships and sexuality are both influenced by sexual satisfaction and influence sexual satisfaction.\u003c/p\u003e \u003cp\u003eAdditionally, women experiencing chronic vaginal pain during intercourse are more likely to experience sexual self-discrepancies, which in turn is associated with lower sexual satisfaction (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Whilst a decrease in relationship satisfaction was not identified in this study (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), several studies have identified a relationship between sexual dysfunction and decreased relationship satisfaction (\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Therefore, gaining an understanding of both women\u0026rsquo;s sexual and relational satisfaction in the context of mesh injury is important.\u003c/p\u003e \u003cp\u003eChronic pain exists within a complex interplay of biopsychosocial processes (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), and has been found to contribute to changes in relationship satisfaction (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The mechanisms underpinning changes in relational satisfaction are a influenced by chronic pain itself and contextual variables within the couple (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePatient pain adjustment may be complicated by spousal pain-reinforcing behaviours; therefore, pain management interventions that seek to understand relational factors may support pain adjustment and relationship satisfaction (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Reese et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) posit that the affective emotional experience of pain may be influenced by the quality of the marital relationship. Women in happy unions that identify their partner as highly responsive to their needs have been found to have capacity to adopt adaptive coping strategies which increase positive affect and functioning during episodes of pain (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). In contrast, people in relationships with poor adjustment are at increased risk of higher levels of pain and psychological disability (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Additionally, partners caring for spouses with chronic pain have been found to experience feelings of burden and poor marital adjustment (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), which may further contribute to changes in relational roles and thus relationship satisfaction.\u003c/p\u003e \u003cp\u003eDue to the lack of research specifically into mesh-injured women\u0026rsquo;s sexual and relational experiences, the foci of the literature drawn upon relate to organic rather than iatrogenic pain processes, such as rheumatoid arthritis (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) chronic vaginal pain (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), and Vestibulodynia (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). This may limit the generalisability of the findings in the context of women who have suffered iatrogenic harm. Whilst not the primary aim of the study, the findings may highlight the differential experiences and needs reported by mesh-injured women.\u003c/p\u003e \u003cp\u003eAlthough the significant sexual, relational and psychological impacts of vaginal mesh injury are documented, there remains a lack of research examining effective psychological interventions for this population.\u003c/p\u003e \u003cp\u003eLimitations have been identified in applying established chronic pain models to mesh-injured women\u0026rsquo;s experiences (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). A systematic literature review of mesh-injured women\u0026rsquo;s experiences found a lack of compatibility with the approach in the standard model of chronic pain disability (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Due to the differential needs of mesh-injured women, this approach increases the risk of the dismissal and invalidation of the physical suffering experienced, thereby perpetuating harm for this population (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAcceptance and Commitment Therapy (ACT) is recommended by National Institute for Health and Care Excellence as a psychological therapy for the management of chronic pain (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), with a growing evidence base for chronic pain management (\u003cspan additionalcitationids=\"CR37 CR38\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). ACT is an empirically supported transdiagnostic psychological therapy, aimed at fostering psychological flexibility as opposed to symptom reduction (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), adopting the position that the avoidance of pain contributes to the overall experience of pain and psychological distress (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Therefore, ACT offers a theoretical framework for understanding mesh injured women\u0026rsquo;s health related psychological distress.\u003c/p\u003e \u003cp\u003eACT interventions aim to increase psychological flexibility and utilise cognitive defusion techniques to support individuals to re-engage with valued activities and build a meaningful life even with the presence of pain (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). The ACT definition of psychological flexibility refers to the coping, acceptance and adjustment to stressors in a way which facilitates valued goal pursuit (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Psychological inflexibility in chronic pain cohorts has been identified as a predictor of pain-related dysfunction and distress (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn addition to the evidence base for chronic pain, ACT has an emerging evidence base for sexual and relational difficulties (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). There are arguments that there are limitations to the approach as ACT is not specifically designed to target areas such as conflict resolution (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). However, ACT may increase feelings of compatibility in couples, with ACT interventions supporting couples to adopt a team mentality when considering experiences and actions against their joint values (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe discussion considers the findings of the review through the lens of psychological flexibility in line with the ACT approach (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Aims\u003c/h2\u003e \u003cp\u003eThe primary aim is the systematic identification, appraisal, and synthesis of the available evidence regarding the sexual and relational impacts that women experience as a result of vaginal mesh injury. The secondary aim is to identify gaps within the current literature to highlight areas for future research. Implications for clinical practice are considered in the discussion.\u003c/p\u003e \u003c/div\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) guidelines were adopted to ensure consistency in reporting of the results. The review was registered on PROSPERO in June 2025 (ID: CRD420251077730).\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Reflexive position\u003c/h2\u003e \u003cp\u003eThe primary author is a trainee clinical psychologist with no personal experience of harm caused by surgical mesh or chronic pain. The author identifies as a female and as an intersectional feminist, which has influenced the choice of topic. Whilst this shapes the lens in which the findings have been interpreted, this offers valuable contributions to the understanding of gendered healthcare experiences. Research underpinned by feminist values creates space to critically examine the lived experiences of women, supporting exploration of marginalisation and power inequalities in a range of contexts (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA feminist phenomenological position has been adopted, which operates with the key assumption that embodied experiences are shaped by discursive and structural contexts (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). This approach aims to uncover sedimented and hidden structures that influence those experiences, allowing for the interpretation of the subjective experiences of mesh-injured women whilst acknowledging structural explanations such as gender biases in medical research and institutions (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Feminist standpoint research places women\u0026rsquo;s lived experiences at the centre of research, establishing a position in which knowledge can be built from (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Search strategy\u003c/h2\u003e \u003cp\u003eFour databases were searched: CINAHL, MEDLINE, PubMed, and ProQuest Dissertations and Theses. These databases were selected to allow for a broad search of publications relevant to the review. Additionally, the search strategy included a citation search and Google advanced search to capture relevant government inquiries. The inclusion of grey literature was important to capture global discourse and inquiries in relation to vaginal mesh injury. A date limit was applied, which restricted the search to published studies from 2008 onwards. This corresponds with the notification issued by the FDA indicating that there were serious complications associated with the transvaginal placement of surgical mesh (Cumberlege, 2020). Search terms were combined using the Boolean operators \u0026lsquo;AND\u0026rsquo; and \u0026lsquo;OR\u0026rsquo; to include terms from each of the four domains. The truncation asterisk (*) was utilised to broaden search results by searching for variations of the search terms.\u003c/p\u003e \u003cp\u003eThe search terms used are outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The corresponding thesaurus terms from each database were combined with the author's search terms. The full search strategy is included in the supplementary information in appendix 1.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eLiterature Review Search Terms\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic floor disorder\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgical outcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImpact\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic Organ Prolapse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransvaginal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSex*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStress Urinary Incontinence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVaginal surgical mesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInjur*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntima*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdverse effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRelation*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTension free vaginal tape\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQuality of life\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransvaginal mesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQoL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVaginal mesh implant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePersonal li*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMesh injur*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSocial science\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-urethral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Eligibility criteria\u003c/h2\u003e \u003cp\u003eThe population, exposure, and outcome (PEO) format was adopted to develop the research question and inclusion and exclusion criteria. Studies were selected based on the following criteria outlined in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eEligibility Criteria\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncluded\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcluded\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAccounts of mesh-injured women reporting the sexual and relational impact of the injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAccounts of partners of mesh-injured women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExposure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical mesh used for the treatment of Pelvic Organ Prolapse and Stress Urinary Incontinence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgical mesh used for treatment of other conditions, such as hernia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSexual and relational outcomes as a result of mesh injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSexual and relational outcomes following mesh implants where mesh injury did not occur\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy design\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative studies and government inquiries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative reports and data\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLanguage and accessibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudies published in English or studies that could be translated into English.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudies where a full-text copy was not available\u003c/p\u003e \u003cp\u003eStudies that could not be translated\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublication status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeer-reviewed research, grey literature, including Doctoral Theses and government inquiries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMasters theses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDate of publication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReports published before 2008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Screening and study selection\u003c/h2\u003e \u003cp\u003eOnce the database searches were complete, the results were uploaded into Covidence. Initially, duplicate studies were removed, and the remaining reports were screened by the first author using the title and abstract to assess for suitability. The author then manually retrieved final reports for full-text screening against the eligibility criteria. Citation searching was conducted, and an advanced Google search was used to identify relevant government inquiries.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data extraction\u003c/h2\u003e \u003cp\u003eAll final reports included in the review were qualitative. Data pertinent to the research question was extracted from each report. Relevant data points from each government inquiry, such as inquiry submissions and key findings, were extracted. Data in relation to the characteristics of each report were extracted to include the author details, publication date, geographical location, study title, participant characteristics, research aim, data collection method, and data analysis method, outlined in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Data synthesis\u003c/h2\u003e \u003cp\u003eA thematic approach was adopted to synthesise the data (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). The results and discussion data from each study were coded by the first author, with an initial set of 55 codes. Codes were reviewed and grouped into descriptive themes, which were then analysed to develop analytical themes. First-order data in the form of quotations is included in the result sections to illustrate the themes.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe database search yielded 1220 results. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the PRISMA (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) selection process. A total of 237 reports were duplicates and therefore excluded before screening. The titles and abstracts of 983 reports were screened, with a final 41 reports screened for eligibility using full-text review. In addition to the database search, three government inquiries were retrieved via advanced Google searching, with one excluded due to not meeting the inclusion criteria. One paper identified through citation searching was not retrieved. A total of eight reports, made up of six studies and two government inquiries, were included in the final review.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Study characteristics\u003c/h2\u003e \u003cp\u003eThe characteristics of the included studies are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e with the corresponding identification number. The eight included studies were published between 2018 and 2024, reflecting the period in which changes in discourse around the use of surgical mesh occurred. The demographic characteristics were reported inconsistently across studies; therefore, sample size and age range are reported where available. The studies aimed to amplify the voice of mesh-injured women in research.\u003c/p\u003e \u003cp\u003eThe overall aim of each of the studies and reports was to gain an understanding of the impacts of vaginal mesh injury on women\u0026rsquo;s lives. Whilst the studies did not solely focus on the impacts of mesh injury in relation to women\u0026rsquo;s sex lives and relationships, this featured in each study to varying degrees. Sexual and relational impacts featured the most in study D. Studies F and A both reported sexual and relational impacts; however, the data was limited in these studies.\u003c/p\u003e \u003cp\u003eThe analysis in study D captured nuances in the different outcomes women experienced based on the severity of their injury, which was a strength of the study. This allowed for synthesis and analysis, which captured the different outcomes for women who had received timely diagnosis and treatment options versus women who had experienced protracted complications.\u003c/p\u003e \u003cp\u003eThe studies included were conducted in New Zealand (C), the United States of America (A), Australia (G, H), and the United Kingdom (UK; B, D, E, F). The pool of studies included in the review was conducted by a range of disciplines, including theological (C), sociological (D), political (F, G), (A, B, E), and psychological (H) perspectives. Study C was conducted by a researcher with lived experience. Studies G and H both provided analyses based on one set of data collected as part of the Australian Parliament Senate Community Affairs References Committee (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eCharacteristics of studies included\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy ID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAuthors\u003c/p\u003e \u003cp\u003e(year and country)\u003c/p\u003e \u003cp\u003eTitle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMethods (Collection and analysis)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eResearch aim(s)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUberoi et al. (2020, USA)\u003c/p\u003e \u003cp\u003eListening to Women: A Qualitative Analysis of Experiences after Complications from Mesh Mid-urethral Sling Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSample size (n\u0026thinsp;=\u0026thinsp;19); age range (years): 39\u0026ndash;76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSemi-structured focus groups and interviews; Inductive and deductive content analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eAims\u003c/b\u003e: To gain a detailed understanding of women\u0026rsquo;s experiences of mesh complications\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDibb et al. (2020, United Kingdom)\u003c/p\u003e \u003cp\u003eWhen things go wrong: experiences of\u0026nbsp;vaginal mesh complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSample size (n\u0026thinsp;=\u0026thinsp;18); age range (years): 40\u0026ndash;67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSemi-structured interviews; Thematic analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eAims\u003c/b\u003e: To explore the individual experiences of women who have had vaginal mesh complications and the impacts\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrown (2019, New Zealand)\u003c/p\u003e \u003cp\u003eThe experiences of seven women living with pelvic surgical mesh complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSample size (n\u0026thinsp;=\u0026thinsp;7); age range (years): 43\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSemi-structured interviews; Van Manen\u0026rsquo;s four Lifeworld Existential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eAims\u003c/b\u003e: To understand women\u0026rsquo;s lived experience of pelvic surgical mesh complications\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGregson (2024, UK)\u003c/p\u003e \u003cp\u003eA sociological exploration into the experiences of \u0026lsquo;mesh-injured women\u0026rsquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSample size (n\u0026thinsp;=\u0026thinsp;25); age range (years): 37\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSemi-structured interviews and diary entries; Narrative and thematic analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eAims\u003c/b\u003e: To uncover the lived experience of women experiencing transvaginal mesh complications\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eToye et al. (2023, UK)\u003c/p\u003e \u003cp\u003eThe experience of women reporting damage from vaginal mesh: a reflexive thematic analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSample size (n\u0026thinsp;=\u0026thinsp;15); age range (years): 48\u0026ndash;78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOnline and telephone semi-structured interviews; Reflexive thematic analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eAims\u003c/b\u003e: To explore and understand the experience of living with complications attributed to vaginal mesh surgery so that this knowledge can contribute to improvements in care for those considering mesh, or mesh removal, surgery.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCumberlege (2020, UK)\u003c/p\u003e \u003cp\u003eFirst Do No Harm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSample size: 517 participants in patient engagement events; Written and Oral evidence contributed: unclear; participant characteristics not reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDrop in events, letter and email submissions; Evidence gathering (government inquiry)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eAims\u003c/b\u003e: To understand the harmful effects of medicines and medical devices used in the United Kingdom\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eG.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralian Parliament Senate report (2018, Australia)\u003c/p\u003e \u003cp\u003eNumber of women in Australia who have had transvaginal mesh implants and related matters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSample size (n\u0026thinsp;=\u0026thinsp;555); participant characteristics not reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWritten submissions and oral submissions at committee hearing; Evidence gathering (government inquiry)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eAims\u003c/b\u003e: To understand how many women in Australia have been adversely affected by surgical mesh implants, and to gain an understanding of the information provided to women and medical professionals undertaking vaginal mesh procedures\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMcKinlay and Oxlad (2022, Australia)\u003c/p\u003e \u003cp\u003e\u0026lsquo;I have no life and neither do the ones watching me suffer\u0026rsquo;: women\u0026rsquo;s experiences of transvaginal mesh implant surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSample size: 399; participant characteristics not reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReview of 555 written submissions from Australian inquiry; Reflective thematic analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eAims\u003c/b\u003e: To explore women\u0026rsquo;s experiences of mesh surgery through a biopsychosocial lens analysing submissions to Australian Parliament Senate Inquiry\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: f\u0026thinsp;=\u0026thinsp;female, m\u0026thinsp;=\u0026thinsp;male, NP\u0026thinsp;=\u0026thinsp;Not provided\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Quality appraisal\u003c/h2\u003e \u003cp\u003eThe CASP Qualitative Studies Checklist (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e) was utilised to appraise the quality of the research reports included in the review outlined in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Each paper was allocated an identification number. Corresponding study identification numbers are denoted in brackets in the data synthesis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eQualitative research appraisal using CASP Qualitative Studies Checklist (2023)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy ID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAuthors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eQuality assessment\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUberoi et al (2020)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDibb et al (2020)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eU\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eU\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrown (2019)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eU\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eU\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGregson (2024)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eToye et al (2023)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eU\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCumberlege (2020)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eG.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralian Senate report (201)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eU\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eU\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003eU\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMcKinlay and Oxlad (2022)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003eNote: CASP criteria for qualitative studies. 1. Was there a clear statement of the aims of the research? 2. Is a qualitative methodology appropriate? 3. Was the research design appropriate to address the aims of the research? 4. Was the recruitment strategy appropriate to the aims of the research? 5. Was the data collected in a way that addressed the research issue? 6. Has the relationship between researcher and participants been adequately considered? 7. Have ethical issues been taken into consideration? 8. Was the data analysis sufficiently rigorous? 9. Is there a clear statement of findings? 10. How valuable is the research?\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003e(\u003cem\u003eY\u003c/em\u003e\u0026thinsp;=\u0026thinsp;Yes, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;No, \u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;Unclear)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Thematic synthesis of findings\u003c/h2\u003e \u003cp\u003eThree overarching themes were identified: changes in sexual functioning, changes in relational activity due to pain and changes to the embodied self. The three themes intersected with each other, creating three subthemes: changes in relationship satisfaction, changes in sexuality and changes in relational roles, with a central theme of disrupted embodied sexual-relational self. The overlapping relationship between the themes is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSexual functioning\u003c/b\u003e: \u003cb\u003echanges in sexual behaviour due to chronic pain\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePain disrupting sexual activity featured in each of the data sets. Women described the painful implications of having penetrative sex and experienced an array of physical symptoms during sex, including vaginal dryness, sharp burning pain and spasms, bleeding, infections and offensive odour, and prolonged pain after sex (C, F, G, H). The pain was felt locally and in other areas of the body, including the abdomen, back, and bladder (H). As a result of the painful and unpleasant symptoms, women reported changes in libido and felt unable to want or enjoy sex (C).\u003c/p\u003e \u003cp\u003eIn study D participants were identified as being mildly, moderately, or severely injured by mesh. Regardless of the severity of their injury, women in each category experienced disruption to sexual intimacy. Study D reported pain interfering with the women\u0026rsquo;s ability to engage in sexual activity was similar regardless of the severity of mesh complications and injury. Women who were identified as having mild injury appeared to be more psychologically flexible and able to engage with other ways of bonding with their partner:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Instead, they reduced the disruption caused by their lack of, or reduced, sex lives by reevaluating and shifting the meanings they attached to their romantic relationships.\u0026rdquo;\u003c/em\u003e (D).\u003c/p\u003e \u003cp\u003eSome women reported refraining from sexual relations completely (D) with no plans to have sex again (F). The loss of sexual intercourse ranged from months (D) to upwards of 10 years (F). The loss of sexual activity was associated with feelings of grief (G). However, some women reported feeling a sense of duty to continue to have sexual intercourse and regain their ability to function as a sexual partner despite the pain (A, B, D, E, H); this was sometimes related to factors such as maintaining financial security (D).\u003c/p\u003e \u003cp\u003eAdditionally, mesh erosion was also associated with physical injury to partners (A, D, F, G, H) which resulted in women avoiding sexual intercourse, and contributed to psychological distress including anxiety, guilt, grief, and depression (H).\u003c/p\u003e \u003cp\u003e \u003cb\u003eChanges in sexuality\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe embodied disruption meant women no longer felt able to physically want or enjoy sex, negatively impacting on their sexual identity (B, C, D, E, G, H). Women were left feeling as though they were not sexy (D) or attractive as a result of their mesh injury (B).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think, the inability to \u0026hellip; to have a sexual relationship you know, sort of is another sort of very, difficult journey you know, to deal with I think, because you feel unattractive you know, you feel \u0026hellip; that there is a strain on the relationship because of it\u0026rdquo;\u003c/em\u003e (B).\u003c/p\u003e \u003cp\u003eThe physical harms caused by mesh implants and subsequent surgeries resulted in anatomical changes which felt incompatible with women perceiving themselves as a sexual being. One participant reported that they no longer had enough tissue to form a vagina (C) and another reported a comment made by their partner that they were a \u0026lsquo;cheese grater\u0026rsquo; (G), leading to feelings of embarrassment. As a result of the ongoing complications and disruption to their sex lives, women reported reconciling with the idea that they would never function as a sexual partner again (D, G, H) and thus questioned if they would ever be able to maintain a relationship. This marked end to sexual intercourse represents the most severe sexual outcome for mesh-injured women.\u003c/p\u003e \u003cp\u003eIn contrast, women who were identified as mildly and moderately injured remained hopeful that they would be able to resume sexual intercourse and saw their injury as a temporary disruption to their sexual selves (D). Whilst the women in both these categories experienced severe symptoms in relation to sexual functioning, they either considered their symptoms to be manageable (mild) or expected that with treatment, they would be able to recover from the complications (moderate) (D).\u003c/p\u003e \u003cp\u003e \u003cb\u003eChanges in relational roles\u003c/b\u003e \u003c/p\u003e \u003cp\u003eChanges in relation roles were reported across five studies (B, C, D, E, H). Women described feeling unable to be the partner they envisioned themselves being (H) and being reliant on partners who had transitioned into caring roles (C, D, H). Women also described their partners as friends, roommates, and platonic (B, D, E):\u003c/p\u003e \u003cp\u003eA key contributor to the change in roles was the loss of relational and sexual activity, resulting in relational roles shifting. Activities of shared interest, which may have previously facilitated bonding and maintenance of a romantic relationship, were lost due to the continued experience of pain (B, D, G, H)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Me and my husband, we\u0026rsquo;re not a couple ...It\u0026rsquo;s more platonic than anything else... He\u0026rsquo;s in his room, and I just lay in here and listen to music because I can\u0026rsquo;t even concentrate on a TV programme because of pain...\u0026rdquo;\u003c/em\u003e (D).\u003c/p\u003e \u003cp\u003e \u003cb\u003eRelational activity\u003c/b\u003e: \u003cb\u003echanges in relational activity due to chronic pain\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe pain experienced by women resulted in disruptions to other areas of their relationships, with women reporting they felt unable to participate in activities which they had previously enjoyed with their partners (D, G). There were, however, variations to this. Women who identified as having mild injury felt that with adjustments, they were able to maintain some level of their pre-injury functioning, limiting the embodied impact (D), again demonstrating psychological flexibility.\u003c/p\u003e \u003cp\u003eHowever, women who were identified as moderately or severely injured in study D, were faced with a significant loss of relational activity or felt forced to forfeit activities with their wider social network to focus their efforts on maintaining activity with their partners.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We used to go walking in the Lake District [...] we used to go to football matches, gigs [...] I just can't stand for any length of time I get so much pain... even sitting here now I\u0026rsquo;m in pain [...] We still love each other but our relationship has changed. He\u0026rsquo;s one of those people who hates staying in, so we spend more time apart now.\u0026rdquo;\u003c/em\u003e (D)\u003c/p\u003e \u003cp\u003e \u003cb\u003eChanges in relationship satisfaction\u003c/b\u003e \u003c/p\u003e \u003cp\u003eRelationship satisfaction appeared to change for many couples due to the sexual and relational impacts caused by mesh injury (B, D, E, G). Women reported feeling heartbroken and isolated by the changes in their relationship (E). Women who had been experiencing mesh injury complications for protracted periods of time appeared to be more likely to be negatively impacted in this domain (D, G), signalling the long-term effects of the pressure felt within the couple.\u003c/p\u003e \u003cp\u003eIn contrast, some relationships were able to withstand the effects of mesh injury. This appeared to occur when a timely diagnosis had been received (D). Timely diagnosis meant couples were able to attribute the difficulties to mesh injury and remained hopeful that treatment would mean they could resume their pre-injury relational activities, both sexually and leisurely. Thus, timely diagnosis acted as a protective mechanism.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I\u0026rsquo;m blessed to be in an incredibly strong marriage...I've got a lovely husband who understands that there's no pressure. We just love each other... There\u0026rsquo;s other ways of showing your affection and showing your love and kindness...\u0026rdquo;\u003c/em\u003e (D)\u003c/p\u003e \u003cp\u003eIn some couples, relationship satisfaction was closely related to sexual activity (A, D). Women felt that even though sexual activity was painful and presented physical harm to both them and their partners, they were obligated to engage in sexual activity to protect the satisfaction in the relationship (A, D). This carried an emotional and physical cost for the women.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It\u0026rsquo;s keeping our relationship alive in a way so that after the surgery there\u0026rsquo;s still a relationship to return to\u0026rdquo;.\u003c/em\u003e (D)\u003c/p\u003e \u003cp\u003eFor some the relational impacts of mesh injury were so severe that the relationship had not been able to withstand the stress. This resulted in a complete breakdown of the relationship leading to separation and divorce (A, C, D, G).\u003c/p\u003e \u003cp\u003e \u003cb\u003eEmbodied self\u003c/b\u003e: \u003cb\u003echanging sense of self, navigating life with mesh complications/injury and chronic pain\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWomen have been faced with navigating a changing sense of identity as a result of mesh injury (C, G, H). Being unable to engage in activities that they were previously able to, such as social activities, household activities, and maintain the role they had previously held in their relationship led to changes in their sense of self (H). Women describe a loss of feeling whole, with mesh injury causing disruption to the unity between their body and their sense of self (C).\u003c/p\u003e \u003cp\u003eAlthough only explicitly stated in one study, study G pointed to the impacts in communities of women where cultural practices and beliefs are impacted by mesh injury. This indicates that changing identity was not only felt by the participants but may be imposed on them by others in the community.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The impact of isolation on Indigenous women, you will find that if they have this mesh, they will be totally ostracised. When our women talk about sex, sex is not just sex; it encompasses a whole community and involves love, intimacy, touch deprivation\u0026mdash;everything\u0026rdquo;\u003c/em\u003e (G)\u003c/p\u003e \u003cp\u003e \u003cb\u003eDisrupted embodied sexual-relational self\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe accounts provided by women in each of the studies demonstrate that each area was not impacted in silo (A, B, C, D, E, F, H). The women\u0026rsquo;s experiences of change to their sexual activity and sexual identity created changes in their relationships, as did the changes in the activities they could participate in with their partner. The women were left navigating changes in their role within their relationship, which impacted on their sense of self. This is captured in the final theme of disrupted embodied sexual-relational self which brings together the complex and multifaceted nature of mesh injury.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe purpose of the review was to locate and synthesise the accounts of women injured by surgical mesh implants, specifically in relation to their sexual and relational functioning. The available reports were critically appraised. The literature drawn upon in the discussion reflects different aetiological causes of chronic pain, which, although a limitation, increase understanding how chronic pain influences sexual and relational outcomes for women.\u003c/p\u003e \u003cp\u003eWhilst the aims of each report examined the overall experience of mesh-injured women, painful intercourse as a result of mesh injury was a common theme across the studies, evidencing the significant disruption to women\u0026rsquo;s sexual functioning. The existing literature demonstrates that for women chronic pain and sexual dysfunction are often co-occurring difficulties (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). This review suggests that chronic pain as a result of mesh injury results in sexual dysfunction as identified in research other chronic pain conditions. Existing research demonstrates that sexual dysfunction as a result of chronic pain conditions results in lower levels of sexual satisfaction for women (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e), which was reflected in the accounts of women included in the review.\u003c/p\u003e \u003cp\u003eSexual dysfunction has been described as a multifactorial problem, with multiple detrimental impacts creating psychological, interpersonal, intrapersonal, and economic difficulties (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). The findings of this review demonstrate the multifactorial nature and wider impacts of sexual dysfunction for mesh-injured women such as their perceived sexuality, relationship satisfaction and changing identity.\u003c/p\u003e \u003cp\u003eMotivators for sexual relations change throughout the course of relationships (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e), therefore changing the nature and frequency of sexual intimacy. For women with mesh injury, pain has severely disrupted their sexual activity in new (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) and established relationships (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In line with Meston and Buss\u0026rsquo; (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) findings, women\u0026rsquo;s motivators for intercourse varied, with women seeking emotional intimacy, role fulfilment and relational security.\u003c/p\u003e \u003cp\u003eThe impact of chronic pain extends beyond the sexual act, with pain interfering with women\u0026rsquo;s feelings of sexual desire (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Sexuality is posited to be central to the human psychological experience (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The impact of chronic pain extends beyond the sexual act, with pain interfering with women\u0026rsquo;s feelings of sexual desire (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Painful sexual experiences significantly disrupted women\u0026rsquo;s experiences of sexuality. Sexuality encompasses perceptions of self as a sexual being, thereby influencing sexual activities and behaviours (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). This is consistent with the findings of the review, that women not only felt physically unable to engage in sexual activity due to pain but also reported a loss of libido and no longer viewed themselves as a sexual being.\u003c/p\u003e \u003cp\u003eSexual dysfunction was reported by women regardless of the severity of their mesh injury, indicating that sexual outcomes should be considered for all women experiencing mesh complications. Findings from the Cumberlege (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) review indicate that reporting on adverse outcomes of mesh devices was not representative of the risks and complications women have faced. Painful intercourse as a complication of the medical device was not reported as a risk. This may reflect a discrepancy in the importance women place on their ability to maintain a healthy sex life, compared to the manufacturers who did not perceive this as an important outcome. Sexual pleasure is a key aspect of women\u0026rsquo;s overall sexual health (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) and the Women\u0026rsquo;s Health Strategy for England (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e) acknowledges current gender biases in healthcare, calling for the discrepancies to be addressed by healthcare providers.\u003c/p\u003e \u003cp\u003eThe development of individual identity, bonds, and intimate relationships are closely related to sexual functioning (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Women\u0026rsquo;s sexual motivations encompass the desire for emotional intimacy (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Thus, sexual dysfunction as a result of mesh injury cannot be understood solely as a physical complaint or in silo. This is reflected in the overlap of changes in sexual functioning and women\u0026rsquo;s reports of changing sexuality, identity and relationship satisfaction.\u003c/p\u003e \u003cp\u003eThe findings of the review indicate that relationships were damaged, sometimes irreparably by chronic pain. Whilst the review indicates changes in relationship satisfaction may relate to changes in sexual and relational activity, there may be other variables which are not accounted for which influence this domain. Spousal responses to their partners experience of pain directly impact relationship satisfaction (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e), which has been replicated in more recent studies (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Therefore, future research may incorporate partner responses in mesh-injured women\u0026rsquo;s experiences.\u003c/p\u003e \u003cp\u003eWomen who spoke positively about their relationship satisfaction appeared to demonstrate psychological flexibility in their approach to values-based relational activities. These women had identified new ways of bonding with their partner which may have acted as a protective mechanism for the relationship.\u003c/p\u003e \u003cp\u003eThe significant loss of valued activities in the relationship including both sexual and recreational activities that served as bonding experiences appeared to be related to not only relationship satisfaction, but higher levels of psychological distress. Pain as a barrier to quality time in couples has been found to have a detrimental impact on relationship satisfaction (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e), which the findings of this review support. Couples engaging with interventions that promote relational flexibility and relationship rebuilding activities have been found to improve pain related distress within couples (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eACT approaches to chronic pain acknowledge that the avoidance of activities provides short-term relief, however, have long-term detrimental impacts due to the loss of meaningful life activities (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). A recent meta-analysis (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e) and systematic review (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) found that ACT reduced how much pain affects daily life with medium effect. Ye et al. (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) also found that ACT improved participants ability to function with moderate to large effect sizes. Therefore, supporting women to continue to engage with meaningful activities with their partners may positively impact on the experience of chronic pain and relational distress.\u003c/p\u003e \u003cp\u003eThe implications of each overarching theme resulted in a central disruption to the embodied sexual-relational self. The concept of embodiment is rooted in philosophy but has been garnering increased attention within the realm of psychology (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e). The self is a sum of traits that collectively inform an individual\u0026rsquo;s sense of being (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e), with embodiment considering the combined experience of having a body and being a body, the synthesis of which is central to the development of self-identity (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e). Disharmonious synthesis is associated with psychological distress (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e). Mesh injury can be conceptualised as a significant event which creates disharmonious synthesis, inhabiting a body which no longer aligns with the ideal sense of self. Furthermore, social conditions and relationships are features of the embodied self (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e). Feminist theories of embodiment consider the embodied experience within the discursive structures with shape women\u0026rsquo;s experiences (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). This was demonstrated in one study where women were at higher risk of being ostracised within their community as a result of their mesh-injury, highlighting the impact of the discursive structures that influence the embodied experience.\u003c/p\u003e \u003cp\u003eIntrinsic to the embodied self is sexuality (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Women who experience chronic pain are at increased risk of experiencing a cognitive dissonance, where their reality does not align with their desired sexual self (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), thereby disrupting the embodied self. The inability to have sexual intercourse is a threat to a sense of belonging and value, as women face pressures to comply with the heterosexual norms of intercourse (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The development of sexual subjectivity without the end goal of achieving sexual intercourse allows for sexual intimacy and unexpected pleasure (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). This appears to fit with the ACT approach, as the development of psychological flexibility may promote the exploration of new approaches to achieving intimacy and relational activity, with the aim of increasing relationship satisfaction.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Strengths and limitations\u003c/h2\u003e \u003cp\u003eThis is the first systematic review seeking to understand the sexual and relational impacts women experience as a result of surgical mesh injury. The inclusion of a reflexive statement allows the reader to position the research in the context of the author\u0026rsquo;s approach and positionality, increasing transparency. Whilst this does not eliminate any potential bias in the development and construction of the coding and themes, readers are able to assess the strengths and limitations of the author's interpretation of the findings.\u003c/p\u003e \u003cp\u003e The review was conducted in accordance with the PRISMA guidelines, providing consistency and confidence in the reporting of the findings. Searching four databases allowed for broad inclusion of literature across a range of disciplines. The inclusion of grey literature supported minimisation of publication bias. The limited number of studies which report of sexual and relational outcomes for mesh-injured women creates a limitation in the conclusions that can be drawn, notwithstanding that the reports included in the review were not inherently focusing on sexual and relational outcomes after mesh injury.\u003c/p\u003e \u003cp\u003e The methodological quality of the studies included in the review was generally high. However, none of the studies focused on sex and relationships, meaning important nuances may not have been captured and therefore not included in the discussion. The study samples were largely homogenous (age, gender, ethnicity), which limits the applicability to women living in countries not captured in the current research.\u003c/p\u003e \u003cp\u003eThe samples were however heterogeneous in terms of research field and discipline (theology, nursing, psychology, sociology, political). Drawing from multiple types of knowledge production supported in depth exploration of the lived experience of women. The common themes identified across disciplines indicate the significance of the findings, supporting the application of findings in a range of contexts, thereby enhancing the utility of the findings. The adoption of thematic synthesis accommodates for the disciplinary variation and tension in the interpretation of findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Implications for practice and future research\u003c/h2\u003e \u003cp\u003eFuture research specifically aimed at understanding the impact of mesh injury on sexual functioning, sexuality and relational outcomes would be beneficial to further understand the needs of women in this group and capture nuances that may have been missed in this review.\u003c/p\u003e \u003cp\u003eOutcomes that relate to women\u0026rsquo;s overall health are an important consideration and should be addressed by healthcare providers (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). The findings are an important consideration for complex mesh centres in the UK providing care for mesh-injured women. For women presenting with mesh complications, timely care that places importance on sexual and relational outcomes may mitigate some of the sexual and relational harms experienced by women.\u003c/p\u003e \u003cp\u003eACT has a developed evidence base for treatment of chronic pain. However, there is currently a general assumption that an ACT approach is applicable across pain types (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e). Psychological flexibility was identified as a potential protective mechanism for mesh-injured women in relation to continued engagement with values-based actions such as sexual and relational activities. Therefore, further research in relation to ACT as an approach for mesh-injured women requires interventional studies to understand the effectiveness of the approach for this client group. Furthermore, research that seeks to understand adjustment to pain and the adaptive and maladaptive coping mechanisms within couples may inform couples-based ACT approaches to pain management where mesh injury is present.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACT Acceptance and Commitment Therapy\u003c/p\u003e\n\u003cp\u003eCASP Critical Appraisal Skills Programme\u003c/p\u003e\n\u003cp\u003eFDA Food and Drug Administration\u003c/p\u003e\n\u003cp\u003en Sample size / number of participants\u003c/p\u003e\n\u003cp\u003eNP Not provided\u003c/p\u003e\n\u003cp\u003ePEO Population, Exposure, Outcome\u003c/p\u003e\n\u003cp\u003ePRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses\u003c/p\u003e\n\u003cp\u003eQoL Quality of Life\u003c/p\u003e\n\u003cp\u003eUK United Kingdom\u003c/p\u003e\n\u003cp\u003eUSA United States of America\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData generated and analysed during the study is included in the article and is supplementary information file.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review did not receive funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNB acted as the primary author and developed the review, conducted the literature searches, screened studies, extracted and synthesised data and drafted the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDDB provided primary supervision of the review, including guidance on the analysis and interpretation of the results and revision of the manuscript.\u003c/p\u003e\n\u003cp\u003eMG provided secondary supervision of the review, contributing to the development of the review and manuscript revision. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDucey A, Donoso C, Ross S, Robert M. From anatomy to patient experience in pelvic floor surgery: Mindlines, evidence, responsibility, and transvaginal mesh. Soc Sci Med. 2020 Sep;260:113151. doi:10.1016/j.socscimed.2020.113151\u003c/li\u003e\n\u003cli\u003eCumberlege J. First do no harm: report of the Independent Medicines and Medical Devices Safety Review. London: Independent Medicines and Medical Devices Safety Review; 2020. Report No.\u003c/li\u003e\n\u003cli\u003eAustralian Parliament Senate Community Affairs References Committee. Number of women in Australia who have had transvaginal mesh implants and related matters. [Internet]. 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The Role of Partner-Related Fascination in the Association Between Sexual Functioning and Relationship Satisfaction. J Sex Marital Ther. 2015 Nov 2;41(6):672\u0026ndash;9. doi:10.1080/0092623X.2014.966398\u003c/li\u003e\n\u003cli\u003eBurri A, Spector T. Recent and Lifelong Sexual Dysfunction in a Female UK Population Sample: Prevalence and Risk Factors. J Sex Med. 2011 Sep 1;8(9):2420\u0026ndash;30. doi:10.1111/j.1743-6109.2011.02341.x\u003c/li\u003e\n\u003cli\u003eLeonard MT, Chatkoff DK, Maier KJ. Couples\u0026rsquo; Relationship Satisfaction and Its Association with Depression and Spouse Responses Within the Context of Chronic Pain Adjustment. Pain Manag Nurs. 2018 Aug;19(4):400\u0026ndash;7. doi:10.1016/j.pmn.2017.10.008\u003c/li\u003e\n\u003cli\u003eCano A, Weisberg JN, Gallagher RM. Marital Satisfaction and Pain Severity Mediate the Association between Negative Spouse Responses to Pain and Depressive Symptoms in a Chronic Pain Patient Sample. 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Pain and Functioning of Rheumatoid Arthritis Patients Based on Marital Status: Is a Distressed Marriage Preferable to No Marriage? J Pain. 2010 Oct;11(10):958\u0026ndash;64. doi:10.1016/j.jpain.2010.01.003\u003c/li\u003e\n\u003cli\u003eSuso‐Ribera C, Yakobov E, Carriere JS, Garc\u0026iacute;a‐Palacios A. The impact of chronic pain on patients and spouses: Consequences on occupational status, distribution of household chores and care‐giving burden. Eur J Pain. 2020 Oct;24(9):1730\u0026ndash;40. doi:10.1002/ejp.1616\u003c/li\u003e\n\u003cli\u003eGroven KS, R\u0026aring;heim M, H\u0026aring;konsen E, Haugstad GK. \u0026ldquo;Will I ever be a true woman?\u0026rdquo; An exploration of the experiences of women with vestibulodynia. Health Care Women Int. 2016 Aug 2;37(8):818\u0026ndash;35. doi:10.1080/07399332.2015.1103739\u003c/li\u003e\n\u003cli\u003eNational Institute for Health and Care Excellence. 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Clin J Pain. 2017 Jun;33(6):552\u0026ndash;68. doi:10.1097/AJP.0000000000000425\u003c/li\u003e\n\u003cli\u003eYe L, Li Y, Deng Q, Zhao X, Zhong L, Yang L. Acceptance and commitment therapy for patients with chronic pain: A systematic review and meta-analysis on psychological outcomes and quality of life. Shrestha S, editor. PLOS ONE. 2024 Jun 14;19(6):e0301226. doi:10.1371/journal.pone.0301226\u003c/li\u003e\n\u003cli\u003eDindo L, Van Liew JR, Arch JJ. Acceptance and Commitment Therapy: A Transdiagnostic Behavioral Intervention for Mental Health and Medical Conditions. Neurotherapeutics. 2017 Jul;14(3):546\u0026ndash;53. doi:10.1007/s13311-017-0521-3\u003c/li\u003e\n\u003cli\u003eHayes SC, Strosahl KD, Bunting K, Twohig M, Wilson KG. What Is Acceptance and Commitment Therapy? In: Hayes SC, Strosahl KD, editors. A Practical Guide to Acceptance and Commitment Therapy [Internet]. Boston, MA: Springer US; 2004 [cited 2026 Feb 18]. p. 3\u0026ndash;29. Available from: http://link.springer.com/10.1007/978-0-387-23369-7_1 doi:10.1007/978-0-387-23369-7_1\u003c/li\u003e\n\u003cli\u003eMaathz P, Flink IK, Engman L, Ekdahl J. Psychological Inflexibility as a Predictor of Sexual Functioning Among Women with Vulvovaginal Pain: A Prospective Investigation. Pain Med. 2020 Dec 25;21(12):3596\u0026ndash;602. doi:10.1093/pm/pnaa042\u003c/li\u003e\n\u003cli\u003eRutschmann R, Romanczuk-Seiferth N, Gloster A, Richter C. Increasing psychological flexibility is associated with positive therapy outcomes following a transdiagnostic ACT treatment. Front Psychiatry. 2024 Jul 15;15:1403718. doi:10.3389/fpsyt.2024.1403718\u003c/li\u003e\n\u003cli\u003eHeidari A, Heidari H, Davoudi H. Effectiveness of acceptance and commitment-based therapy on the physical and psychological marital intimacy of women. Int J Educ Psychol Res. 2017;3(3):163. doi:10.4103/jepr.jepr_62_16\u003c/li\u003e\n\u003cli\u003eBarraca J, Polanski T, Duarte-D\u0026iacute;az A, Perestelo-P\u0026eacute;rez L. Acceptance and commitment therapy for couples: A systematic review and meta-analysis. J Context Behav Sci. 2025 Jan;35:100867. doi:10.1016/j.jcbs.2024.100867\u003c/li\u003e\n\u003cli\u003eFlaherty KR, Demirjian CC, Nelson CJ. The role of acceptance and mindfulness based therapies in sexual health. J Sex Med. 2023 Dec 22;21(1):4\u0026ndash;8. doi:10.1093/jsxmed/qdad142\u003c/li\u003e\n\u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29;n71. doi:10.1136/bmj.n71\u003c/li\u003e\n\u003cli\u003eDolezal L. Feminism, embodiment and emotions. In: The Routledge handbook of phenomenology of emotion. London: Routledge; 2020.\u003c/li\u003e\n\u003cli\u003eHesse-Biber S, Leavy P. Feminist Research Practice [Internet]. 2455 Teller Road, Thousand Oaks California 91320 United States of America: SAGE Publications, Inc.; 2007 [cited 2026 Feb 18]. Available from: https://methods.sagepub.com/book/feminist-research-practice doi:10.4135/9781412984270\u003c/li\u003e\n\u003cli\u003eThomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008 Dec;8(1):45. doi:10.1186/1471-2288-8-45\u003c/li\u003e\n\u003cli\u003eCritical Appraisal Skills Programme. CASP qualitative studies checklist [Internet]. 2023 [cited 2025 Jul 1]. Available from: https://casp-uk.net/casp-tools-checklists/\u003c/li\u003e\n\u003cli\u003eFlegge LG, Barr A, Craner JR. Sexual Functioning Among Adults with Chronic Pain: Prevalence and Association with Pain-Related Outcomes. Pain Med. 2023 Feb 1;24(2):197\u0026ndash;206. doi:10.1093/pm/pnac117\u003c/li\u003e\n\u003cli\u003eBerman JR, Berman L, Goldstein I. 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Fam Syst Health. 2020 Mar;38(1):51\u0026ndash;6. doi:10.1037/fsh0000472\u003c/li\u003e\n\u003cli\u003eTrindade IA, Guiomar R, Carvalho SA, Duarte J, Lapa T, Menezes P, et al. Efficacy of Online-Based Acceptance and Commitment Therapy for Chronic Pain: A Systematic Review and Meta-Analysis. J Pain. 2021 Nov;22(11):1328\u0026ndash;42. doi:10.1016/j.jpain.2021.04.003\u003c/li\u003e\n\u003cli\u003eLundh LG, Foster L. Embodiment as a synthesis of having a body and being a body, and its role in self-identity and mental health. New Ideas Psychol. 2024 Aug;74:101083. doi:10.1016/j.newideapsych.2024.101083\u003c/li\u003e\n\u003cli\u003eGough J. The embodied, relational self: extending or rejecting the mind? Inquiry. 2025 Feb 7;68(2):663\u0026ndash;95. doi:10.1080/0020174X.2022.2075921\u003c/li\u003e\n\u003cli\u003eSchneider M, Tallaksen DW, Haukland M, Haugstad GK. If I stop, then what am I supposed to do? The experiences of sexual intimacy of women who live with provoked vestibulodynia. 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J Pain Res. 2018 Oct;Volume 11:2145\u0026ndash;59. doi:10.2147/JPR.S144631\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Women’s health, chronic pain, vaginal mesh injury, complications, sexual functioning, relationships, embodiment","lastPublishedDoi":"10.21203/rs.3.rs-8918556/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8918556/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSurgical mesh used to treat Pelvic Organ Prolapse and Stress Urinary Incontinence has caused substantial injury to a growing number of women. The impact of mesh injury is far-reaching, significantly disrupting women\u0026rsquo;s lives. Whilst there is a growing body of literature examining the impacts, there is little research that specifically aims to understand the sexual and relational implications of mesh injury. This study aimed to systematically review evidence regarding the impacts of mesh injury reported by women in relation to sexual and relational functioning.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA systematic search of four databases (MEDLINE, CINAHL, PubMed, and ProQuest Dissertations and Theses) and a grey literature search was conducted in July 2025. Studies reporting qualitative data about women\u0026rsquo;s experiences of mesh injury where sexual and relational impacts were reported were included. The quality of each study was assessed using the qualitative CASP checklist. The data was thematically synthesised. (PROSPERO registration: CRD420251077730).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of eight studies were included, with upwards of 639 participants identified; however, two of the reports included did not specify the number of participants. Of the eight studies included, five were rated high quality with three rated as moderate. Seven overlapping themes were developed from the data: 1) Sexual functioning: changes due to pain, 2) Changes to sexuality, 3) Relational activity: changes due to pain, 4) Changes to relationship satisfaction, 5) Identity: changing sense of self navigating life with mesh injury, 6) Changes in relational roles and a seventh central theme of disrupted embodied sexual-relational self.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWomen with mesh injury experience significant sexual and relational disruption as a result of chronic pain, contributing to psychological distress. Psychological flexibility appears to be a protective mechanism for relational distress. Further research that seeks to understand these impacts is needed, which may inform the development of appropriate psychological interventions.\u003c/p\u003e","manuscriptTitle":"An Exploration of Sexual and Relational Impacts of Vaginal Mesh Injury: A Systematic Review using Thematic Synthesis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-25 06:01:33","doi":"10.21203/rs.3.rs-8918556/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-25T12:58:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-24T11:17:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-16T07:07:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"234728556777101867156664754940431436923","date":"2026-03-16T04:06:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"223910166484991782749235036689532265301","date":"2026-03-13T10:29:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124951726463711739810525814183022915064","date":"2026-03-11T20:12:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-06T22:29:37+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-26T11:18:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-23T01:17:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-23T01:16:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2026-02-19T13:40:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b72fe3f1-408e-4be0-928c-1d10f1c44eef","owner":[],"postedDate":"March 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-19T07:09:04+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-25 06:01:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8918556","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8918556","identity":"rs-8918556","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}