Hypothesis / aims of study
Pelvic floor symptoms (PFS) commonly present as overlapping conditions rather than isolated complaints (1). Although adverse childhood events (ACE) have been associated with individual PFS domains (2), it remains unclear whether they contribute to multi-domain symptom burden. This study aimed to examine the association between ACE and co-occurring PFS in community-dwelling adults. We hypothesized that individuals with higher ACE exposure are more likely to report symptoms across multiple pelvic floor domains.
Study design, materials and methods
This study was conducted as a secondary analysis of baseline data from the Coevorden observational population-based cohort. Data were derived from community-dwelling men and women aged ≥16 years in the municipality of Coevorden, the Netherlands (3), who completed self-administered questionnaires.
PFS domains were assessed using validated questionnaires. Lower urinary tract symptoms were measured using the ICIQ-MLUTS and ICIQ-FLUTS; defecation problems using combined Wexner incontinence and constipation scores; sexual dysfunction using the PISQ-IR, items from the Sexual Health in the Netherlands questionnaire, and male-specific LUTSsex items; pelvic organ prolapse using the POPDI-6; and pelvic pain using a study-specific questionnaire. Co-occurring PFS were defined as the presence of symptoms in two or more domains.
ACEs were assessed using four NEMESIS items on emotional, psychological, physical, and sexual abuse before the age of 16. Items were scored from 0 (“never”) to 3 (“regularly”) and summed into a cumulative score ranging from 0 to 12.
Logistic regression analyses were conducted separately for men and women to examine the association between ACE and co-occurring PFS, adjusting for age and body mass index. Analyses were performed using complete-case data.
Results
A total of 569 men and 806 women with complete data were included in the analyses. Co-occurring PFS were common in both sexes.
Emotional abuse was the most commonly reported ACEs in both women (20.2%) and men (14.4%). In women, this was followed by sexual (16.0%), psychological (15.0%), and physical abuse (12.5%), whereas in men psychological (12.7%) and physical abuse (12.5%) were next most common, and sexual abuse was least frequently reported (5.3%).
In sex-stratified analyses, higher ACE exposure was significantly associated with co-occurring PFS in both women and men. In women, each one-point increase in ACE score was associated with a 13% higher odds of co-occurring symptoms (adjusted OR 1.13, 95% CI 1.07–1.19, p<0.001). In men, the association was slightly stronger, with a 17% increase in odds per ACE point (adjusted OR 1.17, 95% CI 1.07–1.27, p<0.001).
Interpretation of results
These findings demonstrate that ACEs are consistently associated with multi-domain PFS burden across both men and women. The observed pattern suggests that ACEs may contribute to shared vulnerability pathways underlying symptom co-occurrence, rather than isolated organ-specific dysfunction.
This association can be understood within a biopsychosocial framework. Early-life adversity may lead to long-term alterations in stress regulation and central pain processing, increasing susceptibility to symptoms across multiple pelvic floor domains. In addition, psychological processes such as symptom appraisal, emotional responses, and coping mechanisms may further influence the persistence and clustering of symptoms.
Importantly, these results provide empirical support for the hypothesis that ACE may identify a more complex patient profile, characterized by co-occurring PFS. Such complexity is clinically relevant, as patients with multi-domain symptoms may require broader assessment and more individualized, trauma-informed management.
The consistency of the association across sexes highlights the cross-sex relevance of psychosocial determinants in PFS clustering and supports a more integrated, biopsychosocial approach to understanding and managing these conditions.