Pelvic floor disorders (PFDs) comprise a spectrum of conditions resulting from impaired support or function of the pelvic floor muscles, connective tissues and pelvic organs. The principal manifestations include urinary incontinence, faecal incontinence, pelvic organ prolapse, voiding or defecatory dysfunction and chronic pelvic pain. These disorders are common among adult women, particularly following childbirth and with advancing age, obesity, menopause and previous pelvic surgery. Although PFDs are rarely life-threatening, they can substantially affect physical, psychological, social and sexual well-being. Women may restrict physical activity, social participation, travel and occupational activities because of urinary leakage, prolapse symptoms, discomfort or fear of embarrassment, ultimately reducing their health-related quality of life [1]. Sexual health is an important component of overall well-being. Pelvic floor disorders can adversely affect sexual desire, arousal, lubrication, orgasm, satisfaction and comfort during intercourse. Urinary or faecal leakage during sexual activity, vaginal bulging, pelvic pressure, altered genital sensation and dyspareunia may cause embarrassment, anxiety, poor body image and avoidance of intimacy. The effect may extend beyond physical symptoms and influence self-esteem, emotional health and partner relationships. Previous research has shown that women with PFD frequently report poorer sexual function than women without these disorders; however, the magnitude and pattern of impairment vary according to the type and severity of the disorder [2,3]. Quality of life is also multidimensional and includes physical functioning, emotional well-being, interpersonal relationships, environmental circumstances and social participation. Greater pelvic floor symptom severity has been associated with poorer health-related quality of life, particularly among women experiencing incontinence, pelvic pain or symptomatic prolapse [1,4]. Nevertheless, sexual concerns are often underreported because of embarrassment, cultural barriers and limited discussion during routine clinical consultations. Consequently, the overall burden of PFD may be underestimated when clinical assessment is restricted to anatomical findings or symptom severity. Validated patient-reported outcome measures facilitate a comprehensive assessment of these sensitive outcomes. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-IUGA Revised (PISQ-IR) was specifically developed to assess sexual function among both sexually active and sexually inactive women with PFD [5]. Instruments such as the Pelvic Floor Distress Inventory-20 (PFDI-20) and World Health Organization Quality of Life-BREF (WHOQOL-BREF) can additionally quantify symptom burden and broader quality-of-life impairment. Comparative assessment of women with and without PFD using standardized instruments can clarify the independent influence of these disorders and identify the sexual and quality-of-life domains most severely affected. Therefore, the present study was undertaken to compare sexual function and quality of life between women with clinically identified pelvic floor disorders and women without pelvic floor disorders. AIM To compare sexual function and quality of life among women with and without pelvic floor disorders. OBJECTIVES 1. To assess and compare sexual function scores among women with and without pelvic floor disorders. 2. To evaluate and compare the physical, psychological, social and environmental domains of quality of life between the two groups. 3. To determine the association of the type and severity of pelvic floor disorders with sexual dysfunction and impaired quality of life.

Source of Data The study participants were recruited from women attending the outpatient departments of Obstetrics and Gynaecology, Urogynaecology and allied clinical services at the selected tertiary care hospital. Women diagnosed with a pelvic floor disorder constituted the exposed/study group, while age-comparable women without clinical evidence or significant symptoms of a pelvic floor disorder constituted the comparison group. Information was obtained through participant interviews, validated questionnaires, clinical examinations and relevant hospital records. Study Design A hospital-based comparative cross-sectional study was conducted to evaluate sexual function and quality of life among women with and without pelvic floor disorders. Study Location The study was conducted in the Department of Obstetrics and Gynaecology/Urogynaecology at a tertiary healthcare centre providing specialist services for pelvic floor disorders. Study Duration The study was conducted over 12 months. This period included participant recruitment, clinical assessment, data collection, data verification and statistical analysis. Sample Size A total of 200 eligible women were included. They were divided into two groups: • Group I: 100 women with one or more pelvic floor disorders. • Group II: 100 women without pelvic floor disorders. The sample size was calculated for comparison of mean sexual-function or quality-of-life scores between two independent groups, assuming a two-sided significance level of 5%, statistical power of 80% and an anticipated clinically meaningful standardized difference of approximately 0.40 between the groups. After allowing for incomplete responses and possible non-participation, the final sample size was rounded to 200 participants. Consecutive eligible women were recruited until the required sample size was achieved. Inclusion Criteria Group I: Women with pelvic floor disorders 1. Women aged 18 years or older. 2. Women diagnosed with at least one PFD, including urinary incontinence, faecal incontinence, pelvic organ prolapse or chronic pelvic floor-related pain. 3. Women who were willing to undergo clinical evaluation and complete the study questionnaires. 4. Women who provided written informed consent. 5. Both sexually active and sexually inactive women were included because the PISQ-IR contained separate domains applicable to both groups. Group II: Women without pelvic floor disorders 1. Women aged 18 years or older. 2. Women without clinically significant symptoms or examination findings of urinary incontinence, faecal incontinence, pelvic organ prolapse or chronic pelvic floor pain. 3. Women who were able to understand and complete the questionnaires. 4. Women who provided written informed consent. Exclusion Criteria 1. Pregnant women and women within six months following delivery. 2. Women with active pelvic inflammatory disease or acute genitourinary infection. 3. Women with known gynaecological malignancy or those undergoing active cancer treatment. 4. Women who had undergone major pelvic surgery during the preceding six months. 5. Women with severe neurological disorders affecting pelvic floor function, including spinal cord injury, multiple sclerosis or advanced neuropathy. 6. Women with severe psychiatric illness, cognitive impairment or communication difficulties that prevented reliable questionnaire completion. 7. Women with severe medical illness that substantially affected sexual activity or quality of life independently of PFD. 8. Women who declined consent or submitted substantially incomplete questionnaires. Procedure and Methodology Approval was obtained from the Institutional Ethics Committee before commencement of the study. Eligible women were approached during their outpatient visits and were informed about the purpose, procedures, expected benefits and voluntary nature of participation. Written informed consent was obtained before enrolment, and privacy was maintained during interviews and examinations. Each participant underwent a structured clinical assessment. Sociodemographic characteristics, including age, residence, education, occupation, marital status and socioeconomic status, were recorded. Relevant reproductive and clinical information included parity, mode of previous deliveries, menopausal status, body mass index, previous pelvic surgery, medical comorbidities and duration of pelvic floor symptoms. Symptoms of pelvic floor dysfunction were assessed using the validated PFDI-20. The questionnaire comprised the Pelvic Organ Prolapse Distress Inventory-6, Colorectal-Anal Distress Inventory-8 and Urinary Distress Inventory-6. Higher scores represented greater pelvic floor symptom distress. Pelvic organ prolapse was clinically assessed using the Pelvic Organ Prolapse Quantification system wherever applicable. Urinary and faecal incontinence were identified from clinical history, questionnaire findings and examination according to accepted clinical definitions. Sexual function was assessed using the validated PISQ-IR. Separate scoring procedures were followed for sexually active and sexually inactive women. Among sexually active participants, the questionnaire assessed arousal and orgasm, desire, condition-specific factors, partner-related factors, global quality and the impact of PFD on sexual activity. For sexually inactive women, reasons for inactivity, condition-related effects, partner-related factors and global sexual quality were evaluated. Scoring was performed in accordance with the instrument manual, with higher standardized scores indicating better sexual function where applicable. Overall quality of life was evaluated using the validated WHOQOL-BREF questionnaire. It assessed physical health, psychological well-being, social relationships and environmental health. Raw scores were calculated and transformed according to WHO scoring instructions; higher scores indicated better quality of life. Women were classified into the PFD and non-PFD groups after completion of the clinical and questionnaire-based assessment. Sexual function and quality-of-life scores were compared between the groups. Within the PFD group, subgroup analyses were performed according to the type, number and severity of pelvic floor disorders. Sample Processing No biological specimens were collected or processed because the study was based on interviews, validated questionnaires, clinical examinations and review of relevant medical records. The completed questionnaires were checked for missing or inconsistent responses. Each participant was assigned a unique identification number, and identifying information was removed before data entry. Questionnaire scores were calculated according to the respective scoring manuals. Forms with substantial missing information that prevented valid scoring were excluded from the final analysis. Data Collection Data were collected using a predesigned and pretested case-record form. The form comprised the following sections: 1. Sociodemographic characteristics. 2. Obstetric, gynaecological and medical history. 3. Lifestyle and anthropometric information. 4. Type, duration and severity of pelvic floor symptoms. 5. Clinical and POP-Q examination findings. 6. PFDI-20 responses and domain scores. 7. PISQ-IR responses and sexual-function scores. 8. WHOQOL-BREF responses and domain scores. Questionnaires were administered in a private setting by a trained female investigator. Validated local-language versions were used whenever available. Participants who experienced difficulty reading the questionnaire were interviewed using standardized wording without interpretation or prompting. The completed data forms were reviewed on the same day for completeness and consistency. Data were entered into a password-protected electronic database, and random verification against the original forms was performed to minimize data-entry errors. Statistical Methods Data were analysed using IBM SPSS Statistics version 28.0. Continuous variables were examined for normality using histograms, Q-Q plots and the Shapiro-Wilk test. Normally distributed variables were summarized as mean and standard deviation, while non-normally distributed variables were presented as median and interquartile range. Categorical variables were expressed as frequencies and percentages. Mean sexual-function and quality-of-life scores between the PFD and non-PFD groups were compared using the independent-samples Student’s t-test. The Mann-Whitney U test was used when distributional assumptions were not satisfied. Categorical outcomes, including the proportion of women with sexual dysfunction or impaired quality of life, were compared using the chi-square test or Fisher’s exact test. Mean differences, odds ratios and their 95% confidence intervals were reported as appropriate. One-way analysis of variance or the Kruskal-Wallis test was used to compare scores across different types or severity categories of PFD. Pearson’s or Spearman’s correlation coefficient was calculated to examine relationships among PFDI-20, PISQ-IR and WHOQOL-BREF scores. Multiple linear regression was performed to determine whether PFD was independently associated with sexual-function and quality-of-life scores after adjustment for potential confounders such as age, parity, BMI, menopausal status, comorbidities and previous pelvic surgery. Binary logistic regression was used for dichotomous outcomes, such as the presence of sexual dysfunction. Adjusted regression coefficients or adjusted odds ratios with 95% confidence intervals were reported. Multicollinearity, residual distribution and model fit were evaluated. All tests were two-sided, and a P value <0.05 was considered statistically significant.

Table 1: Overall comparison of sexual function and quality of life among women with and without pelvic floor disorders (N=200) Outcome PFD group (n=100), n (%) or Mean (SD) Without PFD (n=100), n (%) or Mean (SD) Effect estimate (95% CI) Test of significance P value Overall PISQ-IR score 52.8 (12.4) 68.9 (10.7) MD=-16.10 (-19.33 to -12.87) Welch’s t=-9.83 <0.001* Sexual dysfunction 63 (63.0) 24 (24.0) OR=5.39 (2.92-9.95) χ²=30.94 <0.001* Sexually inactive 26 (26.0) 14 (14.0) OR=2.16 (1.05-4.44) χ²=4.50 0.034* Overall WHOQOL-BREF score 61.7 (11.2) 74.6 (9.3) MD=-12.90 (-15.77 to -10.03) Welch’s t=-8.86 <0.001* Impaired quality of life† 58 (58.0) 19 (19.0) OR=5.89 (3.11-11.15) χ²=32.12 <0.001* *Statistically significant at P<0.05. †Impaired quality of life was defined using a prespecified WHOQOL-BREF threshold. PFD: pelvic floor disorder; PISQ-IR: Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-IUGA Revised; WHOQOL-BREF: World Health Organization Quality of Life-BREF; MD: mean difference; OR: odds ratio; CI: confidence interval. Table 1 shows that women with pelvic floor disorders had significantly poorer sexual function and quality of life than women without PFD. The mean overall PISQ-IR score was significantly lower in the PFD group than in the non-PFD group [52.8 (12.4) versus 68.9 (10.7)], with a mean difference of -16.10 (95% CI: -19.33 to -12.87; Welch’s t=-9.83; P<0.001). Sexual dysfunction was reported by 63.0% of women with PFD compared with 24.0% of those without PFD. Accordingly, women with PFD had 5.39 times higher odds of sexual dysfunction (95% CI: 2.92-9.95; χ²=30.94; P<0.001). Sexual inactivity was also more prevalent in the PFD group than in the non-PFD group (26.0% versus 14.0%), corresponding to an OR of 2.16 (95% CI: 1.05-4.44; χ²=4.50; P=0.034). Similarly, the mean overall WHOQOL-BREF score was significantly lower among women with PFD [61.7 (11.2)] than among women without PFD [74.6 (9.3)], with a mean difference of -12.90 (95% CI: -15.77 to -10.03; Welch’s t=-8.86; P<0.001). Impaired quality of life was identified in 58.0% of women with PFD compared with 19.0% of women without PFD. Women with PFD consequently had 5.89 times higher odds of impaired quality of life (95% CI: 3.11-11.15; χ²=32.12; P<0.001). Table 2: Comparison of sexual-function domains among sexually active women with and without pelvic floor disorders (n=160) PISQ-IR domain PFD group (n=74), Mean (SD) Without PFD (n=86), Mean (SD) Mean difference (95% CI) Welch’s t value P value Arousal and orgasm 54.2 (14.1) 69.1 (12.3) -14.90 (-19.07 to -10.73) -7.07 <0.001* Desire 49.7 (15.6) 65.8 (13.8) -16.10 (-20.74 to -11.46) -6.86 <0.001* Condition-specific sexual function 48.9 (16.2) 72.4 (12.8) -23.50 (-28.12 to -18.88) -10.06 <0.001* Partner-related factors 61.3 (14.7) 70.2 (12.9) -8.90 (-13.25 to -4.55) -4.04 <0.001* Global sexual quality 55.6 (13.5) 71.8 (11.7) -16.20 (-20.18 to -12.22) -8.05 <0.001* Condition impact 45.1 (17.4) 76.3 (11.5) -31.20 (-35.90 to -26.50) -13.15 <0.001* Overall PISQ-IR summary score 53.1 (11.9) 70.8 (9.8) -17.70 (-21.15 to -14.25) -10.16 <0.001* *Statistically significant at P<0.05. Table 2 compares the sexual-function domains of 160 sexually active women, including 74 women with PFD and 86 women without PFD. Women with PFD had significantly lower mean scores in every PISQ-IR domain. The mean arousal and orgasm score was 54.2 (14.1) in the PFD group and 69.1 (12.3) in the non-PFD group, producing a mean difference of -14.90 (95% CI: -19.07 to -10.73; t=-7.07; P<0.001). The desire score was also lower among women with PFD [49.7 (15.6) versus 65.8 (13.8); MD=-16.10; 95% CI: -20.74 to -11.46; P<0.001]. A pronounced difference was observed in condition-specific sexual function, with mean scores of 48.9 (16.2) and 72.4 (12.8), respectively (MD=-23.50; 95% CI: -28.12 to -18.88; P<0.001). Women with PFD also had lower partner-related scores [61.3 (14.7) versus 70.2 (12.9); MD=-8.90; P<0.001] and global sexual-quality scores [55.6 (13.5) versus 71.8 (11.7); MD=-16.20; P<0.001]. The largest between-group difference was found in the condition-impact domain [45.1 (17.4) versus 76.3 (11.5); MD=-31.20; 95% CI: -35.90 to -26.50; P<0.001]. Overall, the mean PISQ-IR summary score was 17.70 points lower among sexually active women with PFD (95% CI: -21.15 to -14.25; t=-10.16; P<0.001), indicating substantially poorer sexual functioning. Table 3: Comparison of WHOQOL-BREF domain scores between women with and without pelvic floor disorders (N=200) WHOQOL-BREF domain PFD group (n=100), Mean (SD) Without PFD (n=100), Mean (SD) Mean difference (95% CI) Welch’s t value P value Physical health 58.9 (12.8) 75.3 (10.1) -16.40 (-19.62 to -13.18) -10.06 <0.001* Psychological health 62.4 (11.7) 73.8 (9.8) -11.40 (-14.41 to -8.39) -7.47 <0.001* Social relationships 64.1 (13.2) 72.6 (11.4) -8.50 (-11.94 to -5.06) -4.87 <0.001* Environmental health 67.3 (10.9) 75.1 (9.6) -7.80 (-10.66 to -4.94) -5.37 <0.001* Overall quality of life 61.7 (11.2) 74.6 (9.3) -12.90 (-15.77 to -10.03) -8.86 <0.001* *Statistically significant at P<0.05. Higher scores indicated better quality of life. WHOQOL-BREF: World Health Organization Quality of Life-BREF; PFD: pelvic floor disorder; CI: confidence interval. Table 3 demonstrates that women with PFD had significantly lower WHOQOL-BREF scores across all quality-of-life domains. The greatest difference occurred in physical health, for which the mean score was 58.9 (12.8) in the PFD group compared with 75.3 (10.1) in the non-PFD group (MD=-16.40; 95% CI: -19.62 to -13.18; t=-10.06; P<0.001). Psychological health was also significantly poorer among women with PFD [62.4 (11.7) versus 73.8 (9.8)], with a mean difference of -11.40 (95% CI: -14.41 to -8.39; t=-7.47; P<0.001). The mean social-relationship score was 64.1 (13.2) in the PFD group and 72.6 (11.4) in the non-PFD group (MD=-8.50; 95% CI: -11.94 to -5.06; t=-4.87; P<0.001). Environmental-health scores were similarly lower among women with PFD [67.3 (10.9) versus 75.1 (9.6); MD=-7.80; 95% CI: -10.66 to -4.94; t=-5.37; P<0.001]. The overall quality-of-life score was 12.90 points lower in the PFD group (95% CI: -15.77 to -10.03; t=-8.86; P<0.001). These findings indicate that PFD adversely affected every evaluated quality-of-life domain, particularly physical and psychological health. Table 4: Association of the type and severity of pelvic floor disorders with sexual dysfunction and impaired quality of life among women with PFD (n=100) PFD characteristic Total, n Sexual dysfunction, n (%) OR (95% CI) Impaired quality of life, n (%) OR (95% CI) Type of PFD Urinary incontinence only 37 21 (56.8) Reference 17 (45.9) Reference Pelvic organ prolapse only 28 15 (53.6) 0.88 (0.33-2.36) 13 (46.4) 1.02 (0.38-2.73) Combined PFD‡ 21 18 (85.7) 4.57 (1.14-18.25) 17 (81.0) 5.00 (1.41-17.74) Pelvic pain/faecal incontinence 14 11 (78.6) 2.79 (0.67-11.71) 10 (71.4) 2.94 (0.78-11.09) Overall test 100 65 (65.0) χ²=7.81 57 (57.0) χ²=9.23 P value 0.050 0.026* Severity of PFD Mild 37 17 (45.9) Reference 12 (32.4) Reference Moderate 39 27 (69.2) 2.65 (1.04-6.77) 25 (64.1) 3.72 (1.44-9.62) Severe 24 21 (87.5) 8.24 (2.09-32.46) 20 (83.3) 10.42 (2.91-37.29) Overall test 100 65 (65.0) χ²=11.55 57 (57.0) χ²=16.70 P value 0.003* <0.001* *Statistically significant at P<0.05. ‡Combined PFD indicated the presence of two or more pelvic floor disorders. Table 4 presents the association of the type and severity of PFD with sexual dysfunction and impaired quality of life. Sexual dysfunction was observed in 56.8% of women with urinary incontinence alone, 53.6% with pelvic organ prolapse alone, 85.7% with combined PFD, and 78.6% with pelvic pain or faecal incontinence. Compared with urinary incontinence alone, combined PFD was significantly associated with higher odds of sexual dysfunction (OR=4.57; 95% CI: 1.14-18.25). The overall association between PFD type and sexual dysfunction was borderline significant (χ²=7.81; P=0.050). Impaired quality of life was present in 45.9% of women with urinary incontinence alone, 46.4% with pelvic organ prolapse alone, 81.0% with combined PFD, and 71.4% with pelvic pain or faecal incontinence. Combined PFD was associated with five times higher odds of impaired quality of life than urinary incontinence alone (OR=5.00; 95% CI: 1.41-17.74). The overall association between PFD type and impaired quality of life was statistically significant (χ²=9.23; P=0.026). A clear severity-related gradient was also observed. Sexual dysfunction increased from 45.9% among women with mild PFD to 69.2% among those with moderate PFD and 87.5% among those with severe PFD (χ²=11.55; P=0.003). Compared with mild PFD, the odds of sexual dysfunction were 2.65 times higher with moderate PFD (95% CI: 1.04-6.77) and 8.24 times higher with severe PFD (95% CI: 2.09-32.46). Similarly, impaired quality of life increased from 32.4% in mild PFD to 64.1% in moderate PFD and 83.3% in severe PFD (χ²=16.70; P<0.001). Moderate and severe PFD were associated with 3.72-fold (95% CI: 1.44-9.62) and 10.42-fold (95% CI: 2.91-37.29) higher odds of impaired quality of life, respectively. Thus, both sexual dysfunction and quality-of-life impairment became progressively more common with increasing PFD severity.

The present comparative study demonstrated that pelvic floor disorders were associated with substantial deterioration in both sexual function and quality of life. Women with PFD had significantly lower overall PISQ-IR scores than women without PFD, with a mean difference of -16.10 points. Sexual dysfunction affected 63.0% of women with PFD compared with 24.0% of controls, and the odds of sexual dysfunction were more than five times higher in the PFD group. These findings agree with Stafne et al. (2024) [1], who reported that pelvic floor symptoms negatively affected sexual function among both sexually active and sexually inactive women. Their study emphasized that excluding sexually inactive women may underestimate the true sexual burden of PFD. Similarly, Martínez-Galiano et al. (2024) [2] found that women with pelvic floor symptoms experienced sexual dysfunction more frequently and demonstrated that increasing PFDI-20 scores were independently associated with a greater probability of sexual dysfunction. The observed prevalence of sexual dysfunction was also comparable with the findings of Zhu et al. (2019) [3], who reported impaired sexual function and poorer quality of life among Chinese women with PFD across different age groups. Li-Yun-Fong et al. (2017) [4] similarly found that sexual dysfunction was common among women seeking care for PFD, although its occurrence was also influenced by age, menopausal status, partner-related factors and psychological well-being. Thus, the present OR of 5.39 should be interpreted as demonstrating a strong association rather than proving that PFD alone caused sexual dysfunction. Sexual inactivity was significantly more common among women with PFD than among controls (26.0% versus 14.0%). The increased inactivity may have resulted from dyspareunia, fear of urinary or faecal leakage, vaginal bulging, embarrassment, altered body image or concern regarding partner response. Ugurlucan et al. (2020) [5] observed that women with lower urinary tract symptoms, prolapse or a combination of both frequently experienced impaired sexual function and reduced sexual activity. Lopes et al. (2018) [6] also reported that only about half of women receiving pelvic floor rehabilitation had an active sexual life, while sexual complaints were common among those who remained active. These observations support the importance of including sexually inactive women in PFD research instead of limiting evaluation to women currently engaging in intercourse. Among the 160 sexually active participants, every measured PISQ-IR domain was significantly poorer in women with PFD. Arousal and orgasm scores were 14.90 points lower, while desire scores were 16.10 points lower than those of women without PFD. Bilgic et al. (2019) [7] reported a significant inverse relationship between lower urinary tract symptom severity and PISQ-12 scores, indicating progressive deterioration in sexual function with increasing urinary symptom burden. Bezerra et al. (2020) [8] likewise concluded that urinary incontinence adversely affected sexual function, although the magnitude and pattern of impairment varied according to the type of incontinence. Urinary leakage during intercourse may interfere with arousal and orgasm, while anticipatory anxiety and fear of odour or embarrassment may suppress desire and sexual initiation. The largest difference in the present study occurred in the condition-impact domain, in which women with PFD scored 31.20 points lower than women without PFD. The condition-specific sexual-function score was also 23.50 points lower. These particularly large differences suggest that the physical and emotional consequences directly attributable to PFD were more influential than partner-related factors. Pauls et al. (2015) [9] documented impaired sexual function among women with anal incontinence using the PISQ-IR, highlighting the effects of fear, embarrassment and unpredictable leakage. Grzybowska et al. (2020) [10] also demonstrated that the PISQ-IR summary score could distinguish women with and without sexual dysfunction, supporting its use as a condition-specific assessment instrument. Although partner-related scores were also significantly lower in women with PFD, the mean difference of -8.90 was smaller than that recorded for the condition-impact and condition-specific domains. This indicates that the primary burden may have arisen from symptoms and personal perceptions rather than solely from relationship difficulties. Nevertheless, partner response, communication, sexual expectations and the partner’s sexual health may modify the impact of PFD. Consequently, sexual counselling and partner involvement may be valuable components of comprehensive PFD management. The present findings also demonstrated a strong relationship between PFD and quality of life. The mean overall WHOQOL-BREF score was 12.90 points lower in women with PFD, while impaired quality of life was present in 58.0% of women with PFD compared with 19.0% of controls. Peinado Molina et al. (2023) [11] similarly found that women with prolapse, colorectal-anal and urinary symptoms reported poorer quality of life across multiple dimensions, with increasing symptom distress producing progressively worse outcomes. Their findings reinforce the importance of measuring the patient-perceived burden rather than relying solely on anatomical examination. Chen et al. (2025) [12] also found that untreated PFD adversely affected long-term health-related quality of life, particularly among women with pelvic pain and other coexisting conditions. All four WHOQOL-BREF domains were significantly impaired in women with PFD. The greatest reduction occurred in physical health, with a mean difference of -16.40 points. This may be explained by pain, urinary urgency, incontinence, pelvic pressure, sleep disturbance, limited mobility and restrictions in occupational or household activities. Carroll et al. (2023) [13] described a multidimensional biopsychosocial burden among women with pelvic organ prolapse, including physical symptoms, altered body image, reduced energy and impaired sexual function. The present physical-domain findings are therefore consistent with the substantial daily functional burden reported in women with symptomatic PFD. Psychological health was the second most affected domain, with a mean difference of -11.40 points. Feelings of shame, loss of confidence, fear of leakage, anxiety regarding odour and concerns about femininity or attractiveness may contribute to poorer psychological well-being. Social-relationship and environmental-domain scores were also significantly reduced. Women may avoid travel, social gatherings, exercise and prolonged work because of uncertain toilet access, fear of visible leakage or discomfort. The findings of Robinson et al. (2022) [14] similarly highlighted that women’s perception of prolapse burden extended beyond anatomical severity and affected their overall health, daily functioning and emotional well-being. The findings concerning PFD type showed that the burden was greatest among women with combined disorders. Sexual dysfunction was present in 85.7% of women with combined PFD, compared with 56.8% of those with urinary incontinence alone. Combined PFD was associated with 4.57 times higher odds of sexual dysfunction and five times higher odds of impaired quality of life. Martínez-Galiano et al. (2024) [2] found that multiple pelvic floor symptoms and greater overall symptom impact were associated with sexual dysfunction. Ugurlucan et al. (2020) [5] also observed that women with combined prolapse and lower urinary tract symptoms experienced considerable deterioration in sexual function and quality of life. The cumulative effect of urinary, prolapse, bowel and pain symptoms may therefore be more detrimental than any isolated disorder. Women with pelvic pain or faecal incontinence also demonstrated high frequencies of sexual dysfunction (78.6%) and impaired quality of life (71.4%). Although their odds ratios did not reach statistical significance, the confidence intervals were wide, probably because this subgroup contained only 14 women. Bortolami et al. (2015) [15] demonstrated an association between pelvic floor muscle function and female sexual function, particularly in domains related to pain and orgasm. The negative consequences of pelvic pain are also supported by evidence that pain and dyspareunia interfere with desire, arousal, satisfaction and mental health. The lack of statistical significance in the present subgroup should therefore not be interpreted as an absence of clinically important effects. A clear dose-response pattern emerged for PFD severity. Sexual dysfunction increased from 45.9% in women with mild PFD to 69.2% in moderate PFD and 87.5% in severe PFD. Compared with mild PFD, severe disease was associated with 8.24 times higher odds of sexual dysfunction. Impaired quality of life similarly increased from 32.4% to 64.1% and 83.3%, with severe PFD producing a 10.42-fold increase in odds. Bilgic et al. (2019) [7] reported that sexual-function scores decreased as urinary symptom severity increased, while Peinado Molina et al. (2023) [11] demonstrated progressively poorer quality-of-life outcomes with increasing pelvic floor symptom distress. These comparable findings support a severity-dependent relationship between PFD burden and patient-reported outcomes. The observed severity gradient also has therapeutic implications. Dumoulin et al. (2018) [16] established pelvic floor muscle training as an effective conservative treatment for urinary incontinence, while Yavas et al. (2022) [17] reported that pelvic floor muscle training could benefit urinary symptoms and sexual function. Rodrigues et al. (2021) [18] found that sexual function and quality of life improved significantly following surgery for prolapse or stress urinary incontinence and that improvements in these outcomes were correlated. Collectively, these intervention studies suggest that at least part of the sexual and quality-of-life burden identified in the present study may be modifiable through timely diagnosis and appropriate conservative or surgical treatment.

Women with pelvic floor disorders had significantly poorer sexual function and quality of life than women without these disorders. They demonstrated lower overall PISQ-IR and WHOQOL-BREF scores and substantially higher odds of sexual dysfunction, sexual inactivity and impaired quality of life. All sexual-function domains were adversely affected, with the greatest difference observed in the condition-impact domain. Physical health was the most affected quality-of-life domain, followed by psychological health. Combined and severe pelvic floor disorders were associated with the greatest burden, and a clear severity-related increase in sexual dysfunction and quality-of-life impairment was observed. Routine assessment of women with pelvic floor disorders should therefore include validated measures of sexual function and quality of life, followed by individualized counselling and appropriate multidisciplinary management. LIMITATIONS OF STUDY This study had several limitations. Its cross-sectional design prevented the establishment of a temporal or causal relationship between pelvic floor disorders, sexual dysfunction and impaired quality of life. Being a single-centre, hospital-based study, the findings may not be generalizable to women in the community or other healthcare settings. Sexual function and quality of life were assessed using self-reported questionnaires and were therefore susceptible to recall bias, social-desirability bias and underreporting because of the sensitive nature of sexual concerns. Sexual function may also have been influenced by unmeasured factors such as partner health, relationship quality, cultural beliefs, medications, hormonal status, anxiety and depression. The relatively small numbers in some PFD subgroups produced wide confidence intervals and reduced statistical power for comparisons according to disorder type. Although women without PFD served as a comparison group, residual differences in age, parity, menopausal status, BMI and comorbidities may have influenced the results. Finally, the study did not assess changes following conservative or surgical treatment, and longitudinal studies are required to determine whether improvement in pelvic floor symptoms leads to sustained improvement in sexual function and quality of life.

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