Pelvic floor symptoms (PFS), including bowel dysfunction, urinary problems, sexual dysfunction, and pelvic pain, are prevalent in both males and females and are frequently linked to underlying pelvic floor muscle (PFM) dysfunction. Our previous research found that adverse childhood events (ACEs) were associated with lower urinary tract symptoms (1), potentially due to alterations in pelvic muscle tone. Depression has also been consistently associated with PFS, though the underlying mechanism, whether psychological, or neurobiological, remains unclear. In contrast, higher body mass index (BMI) may influence PFM function through more direct biomechanical mechanisms. This study aimed to examine whether ACEs, depressive symptoms, and BMI  are associated with PFM dysfunction, focusing on the puborectalis muscle (PRM) and external anal sphincter (EAS), across multiple functional domains.

This exploratory study was nested within a population-based cohort in the Netherlands, described in detail elsewhere (2,3). Adults aged ≥21 years were purposively sampled. PFM function was assessed via standardized internal digital palpation (per rectum) by an experienced pelvic physiotherapist. Assessments targeted key functional domains of the PRM and EAS, which were each dichotomized as normal or abnormal according to predefined criteria. Muscle tone was considered normal when resting tension was within physiological range; both increased and decreased tone were classified as abnormal. Voluntary contraction was normal when there was an adequate lift or contraction; straining or absent movement indicated abnormality. Voluntary relaxation was deemed normal when complete; partial or absent relaxation was abnormal. Frequency of contraction was categorized as normal for 7–10 repetitions and abnormal for fewer than 7. Endurance was normal if a contraction could be held for 7–10 seconds, and abnormal if it lasted less than 7 seconds. Maximum voluntary contraction was classified as normal when strong or moderate, and abnormal when weak or absent. Lastly, anorectal angle increase during contraction was expected in normal function; failure of the angle to increase was defined as abnormal.
ACEs were measured using adapted items from the NEMESIS questionnaire, covering emotional, physical, sexual, and psychological abuse before age 16. Each item was scored from 0 (never) to 3 (frequently), yielding a total score (0–12; Cronbach’s α = 0.783). Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9; range: 0–27), and BMI was calculated from self-reported height and weight. Associations were tested using logistic regression, adjusting for age and sex.

A total of 358 participants were included in the analysis, comprising 189 males and 169 females. Higher BMI was significantly associated with abnormal PRM tone (OR = 1.07, 95% CI: 1.01–1.14, p = .028) and impaired anorectal angle increase during contraction (OR = 1.08, 95% CI: 1.02–1.14, p = .008), and reduced endurance of EAS (OR = 1.07, 95% CI: 1.00–1.15, p = .039). No significant associations were found between ACEs or depressive symptoms and dysfunction across any domain of the PRM or EAS.

These findings challenge the assumption that psychological factors such as ACEs and depressive symptoms are associated with measurable PFM dysfunction. Instead, other mechanisms—perhaps central, neurophysiological, or functional in nature—may underlie this relationship. The consistent association between BMI and specific muscular impairments supports a more direct biomechanical explanation. Given that previous research has linked depressive symptoms with higher BMI, it is conceivable that physical factors may partly mediate the impact of psychological distress on pelvic floor function—an avenue worth exploring in future research.

While ACEs and depressive symptoms were not associated with PFM dysfunction, higher BMI showed consistent links to specific muscular impairments—highlighting the importance of addressing physical factors, such as weight, in pelvic floor assessment and care.

Mahjoob DM, Teunissen DAM, van Koeveringe GA, Leusink P, Blanker MH, Knol-de Vries GE. Depressive feelings as mediator in the relation between adverse childhood events and lower urinary tract symptoms in males and females. Neurourol Urodyn. 2024 Feb;43(2):479–85.
Knol-de Vries GE, Malmberg GGA, Notenboom-Nas FJM, Voortman DBH, de Groot A, Dekker JH, et al. Exploring concomitant pelvic floor symptoms in community-dwelling females and males. Neurourol Urodyn. 2022 Aug 21;
Notenboom-Nas FJM, Knol-de Vries GE, Beijer L, Tolsma Y, Slieker-Ten Hove MCP, Dekker JH, van Koeveringe GA, Blanker MH. Exploring pelvic floor muscle function in men with and without pelvic floor symptoms: A population-based study. Neurourol Urodyn. 2022 Nov;41(8):1739-1748. doi: 10.1002/nau.24996. Epub 2022 Jul 25. PMID: 35876473; PMCID: PMC9795878.

Continence 15S (2025) 102100
DOI: 10.1016/j.cont.2025.102100