Zhao CY, Peng XC, Liu ZH, Yin J, Zhao L. Psychological distress and pelvic floor dysfunction in postpartum women: Associations with anxiety, perceived stress, and sexual health. World J Psychiatry 2026; 16(10): 119636 [DOI: 10.5498/wjp.119636]
Corresponding Author of This Article
Cong-Ying Zhao, MD, Department of Ultrasound Obstetrics and Gynecology, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Xinhua District, Shijiazhuang 050005, Hebei Province, China. congyingzcy@163.com
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Zhao CY, Peng XC, Liu ZH, Yin J, Zhao L. Psychological distress and pelvic floor dysfunction in postpartum women: Associations with anxiety, perceived stress, and sexual health. World J Psychiatry 2026; 16(10): 119636 [DOI: 10.5498/wjp.119636]
Cong-Ying Zhao, Jing Yin, Li Zhao, Department of Ultrasound Obstetrics and Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang 050005, Hebei Province, China
Xian-Chai Peng, Department of Obstetrics, The Second Hospital of Hebei Medical University, Shijiazhuang 050005, Hebei Province, China
Zhen-Hong Liu, Department of Psychiatry, The Second Hospital of Hebei Medical University, Shijiazhuang 050005, Hebei Province, China
Co-corresponding authors: Cong-Ying Zhao and Li Zhao.
Author contributions: Zhao CY and Zhao L conceived and designed the study, they contributed equally as co-corresponding authors of this study; Zhao CY, Peng XC, and Yin J were responsible for participant recruitment, data collection, and clinical assessment; Liu ZH provided psychiatric expertise, contributed to the psychological assessment framework, and participated in the interpretation of mental health–related data; Peng XC and Yin J performed the statistical analysis; Zhao CY drafted the initial manuscript; Zhao L critically revised the manuscript for important intellectual content; all authors reviewed and approved the final version of the manuscript and agreed to be accountable for all aspects of the work.
Supported by 2023 Hebei Province Medical Research Project Plan, No. 20230070.
Institutional review board statement: The study protocol was approved by the Ethics Committee of the Second Hospital of Hebei Medical University.
Informed consent statement: Written informed consent was obtained from all participants.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement- checklist of items.
Data sharing statement: No available data.
Corresponding author: Cong-Ying Zhao, MD, Department of Ultrasound Obstetrics and Gynecology, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Xinhua District, Shijiazhuang 050005, Hebei Province, China. congyingzcy@163.com
Received: March 27, 2026 Revised: April 27, 2026 Accepted: May 22, 2026 Published online: October 19, 2026 Processing time: 196 Days and 23.6 Hours
Abstract
BACKGROUND
In postpartum women, pelvic floor dysfunction (PFD) may be closely related to anxiety, perceived stress, and sexual health, providing insights for enhancing their psychological well-being.
AIM
To explore associations between PFD and anxiety, perceived stress, and sexual health in postpartum women and factors influencing psychological distress.
METHODS
This cross-sectional study included 140 consecutive postpartum women attending postpartum follow-up or pelvic floor outpatient services. PFD, anxiety, perceived stress, and sexual function were assessed using the Pelvic Floor Distress Inventory-20 (PFDI-20), Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A), 10-item Perceived Stress Scale (PSS-10), and Female Sexual Function Index (FSFI), respectively, and compared between the PFD and non-PFD groups. Spearman correlation analysis assessed between-scale correlations. Multivariable logistic regression identified independent factors associated with anxiety, high perceived stress, and sexual dysfunction.
RESULTS
Among the 140 postpartum women, 98 (70.0%) were in the PFD group, and 42 (30.0%) were in the non-PFD group. In the PFD group, the HADS-A and PSS-10 scores were significantly higher (7.6 ± 3.8 vs 5.2 ± 3.1 and 19.8 ± 6.1 vs 15.7 ± 5.4, respectively; both P < 0.001), and the total FSFI score was significantly lower (23.7 ± 5.4 vs 27.8 ± 4.6, P < 0.001). The PFDI-20 total score was positively correlated with HADS-A (r = 0.46) and PSS-10 (r = 0.52) and negatively correlated with the FSFI total score (r = -0.49; all P < 0.001). Multivariable analysis indicated that each 10-point increase in the PFDI-20 score was associated with increased risks of anxiety, high perceived stress, and sexual dysfunction. Poor sleep quality and lower social support were also independently associated with adverse psychological and sexual outcomes.
CONCLUSION
PFD in postpartum women increases with the severity of anxiety, perceived stress, and sexual dysfunction. Management should include psychological screening, sexual health assessments, and attention to sleep and social support.
Core Tip: Postpartum pelvic floor dysfunction mainly presents with a mixture of physiological changes and severe psychological problems; anxious reactions arising from mothers’ overly intense self-assessment have also appeared. The burden of pelvic floor symptoms is positively correlated with the degree of psychological problems; therefore, patients presenting with more severe pelvic floor symptoms will have higher levels of anxiety or depression. Poor quality of sleep and a lack thereof also contribute to this problem; thus, they are essential moderators. The above data show that integrating regular psychological screening content in the postpartum period of pelvic-facility-follow-up programme for women will not only help them recover health comprehensively but also improve their overall quality of life.
Citation: Zhao CY, Peng XC, Liu ZH, Yin J, Zhao L. Psychological distress and pelvic floor dysfunction in postpartum women: Associations with anxiety, perceived stress, and sexual health. World J Psychiatry 2026; 16(10): 119636
Postpartum pelvic floor structure and functions have a tendency to be affected by pregnancy and delivery stress. Some women may develop stress urinary incontinence, pelvic organ prolapse, defecatory disorders, prolonged chronic lower abdominal pain syndrome, etc. Although the above circumstances are usually not life-threatening; In terms of affecting infant care and socialisation activities more persistently, it becomes an important reason for post-partum burden[1,2].
In addition to the above, postnatal hormones causing mood swings, fatigue due to new responsibilities at home; The need for more care has become urgent. Due to this reason, systemic pelvic floor symptoms may occur along with localized pain. Due to the interference of these symptoms on urination, defecation and sexual life, many women feel ashamed, lack a desire for treatment due to their sensitivity towards others’ perceptions, thus worsening anxiety and perceived stress[3,4].
The sexual health issues of new mothers have received insufficient attention so far. Postpartum exhaustion due to childbirth and breastfeeding; Lactation hormone changes affect sexual arousal and response directly. In addition to fear of incontinence, vaginal laxity and discomfort during sex due to psychological changes such as loss of self-esteem after childbirth[5,6]. Therefore, the combination of pelvic floor symptoms, emotional distress and sexual dysfunction needs to be evaluated simultaneously; no separate monitoring system exists for individual Subjects.
Several earlier studies have revealed a relationship among pelvic floor dysfunction (PFD), emotional distress, including anxiety and depression[7]. Evidence is insufficient to explore the interrelations among pelvic floor symptom burden, anxiety, perceived stress, and sexual function at one time point among new mothers with these symptoms. Also, possibly modifiable elements like sleep quality and socialisation might affect the relationship with loneliness in some ways[8]. Therefore, in this study, we systematically evaluated and compared the burden of pelvic floor symptoms, anxiety, perceived stress, and sexual function in postpartum women who had or did not have PFD to analyse the relevant correlation coefficients and independent influencing factors; With this as a basis, integrated psychological and sexual health assessment should be included in postpartum pelvic floor follow-up guidance.
MATERIALS AND METHODS
Study subjects
This cross-sectional study recruited a total of 140 post-partum women who had undergone post-partum observation or pelvic floor disease examination in the second hospital affiliated to Hebei medical university from January 2021 to June 2025. Patients meet any of the following conditions: (1) Age between 18 and 45 years old; (2) Postpartum for 6- to 12-weeks; (3) Able to cooperate with completing questionnaires alone; and (4) Consent after being informed in writing. The postpartum interval of six weeks to one year is selected to cover the normal recovery period, re-examination and pelvic floor rehabilitation course in clinical work. The postpartum month was registered, and then added to the data for mitigation of the impact of time-window heterogeneity. The exclusion items included a history of pelvic floor reconstruction or urinary incontinence surgery; severe cardiovascular, hepatic, renal and nervous system diseases; diagnosed with mental disorders or currently taking anxiolytics or antidepressants; had serious postpartum complications (severe postpartum hemorrhage, infection), etc.; incomplete data was not collected. The study’s approval was granted by the Ethical Review Board of the Second Hospital of Hebei Medical University; all subjects provided written informed consent.
Groupings and indicator definitions
PFD: The Pelvic Floor Distress Inventory-20 (PFDI-20)[9] was used to assess it, consisting of three sub-items: Pelvic organ prolapse distress inventory, colorectal-anal distress inventory and urogenital distress inventory. All responders rated all aspects based on their respective criteria; among these, those with high ratings were relatively few across most items. Considering the prevalence of pelvic floor symptoms among mothers after childbirth and established threshold values from previous research; In this study, PFD was diagnosed as a PFDI-20 score ≥ 60 to define the PFD and non-PFD groups. To observe the gradient effect of severity on psychological and sexual health; The PFD group was then divided into mild (60-89 points), moderate (90-119 points) and severe (≥ 120 points) subgroups based on the score in the PFDI-20.
Quality of life: A five-item Pelvic Floor Impact Questionnaire-7 (PFIQ-7)[10], assessing the extent to which women affected by gynecological conditions experience changes in their quality of life score from 0 (“none”) to 100 (“extremely severe”). A higher number indicated that the patients’ lives, work, interpersonal relationships, emotions and other aspects were more influenced by pelvic floor symptoms.
Prolapse: Pelvic Organ Prolapse Quantification (POP-Q) staging was recorded during patient visits, with clinically significant prolapse defined as a stage ≥ II.
Anxiety: The Hospital Anxiety and Depression Scale-anxiety subscale (HADS-A)[11] was used to evaluate anxiety. The subscale contains seven items, each scored from 0 to 3, yielding a total score ranging 0-21 points. In this study, anxiety symptoms were defined as a HADS-A score ≥ 8. Since the primary objective of this study was to assess anxiety-related psychological distress directly associated with symptom vigilance, embarrassment, and help-seeking behavior in postpartum PFD, the HADS-Depression subscale (HADS-D) was not concurrently used to minimize questionnaire burden in the outpatient setting; this limitation is acknowledged in the discussion.
Perceived stress: The Perceived Stress Scale (PSS-10)[12] was used to assess perceived stress, with the total score ranging 0-40 points. High perceived stress state was defined as a score ≥ 20 points.
Sexual function: The Female Sexual Function Index (FSFI)[13] was used to assess sexual function, with total scores ranging 2-36 points across six domains: Desire, arousal, lubrication, orgasm, satisfaction, and pain. Sexual dysfunction was defined as a FSFI score < 26.55.
Control indicators of confounders: Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI)[14], with poor sleep defined as a PSQI score > 7 points. Social support was assessed using the Social Support Rating Scale (SSRS)[15] reflecting the overall level of support, with lower scores indicating inadequate support.
Data collection and scale evaluation
Data collection was conducted by uniformly trained researchers. The training encompassed the study protocol, eligibility assessment, standardized explanations of each questionnaire, neutral communication skills, privacy protection requirements, on-site completeness checking, double data entry rules, and procedures for consistency verification. Participants completed the questionnaire in an independent and relatively private setting. Researchers provided only standardized instructions regarding item comprehension and completion requirements, avoiding any inductive prompts. When sexual health items were included, anonymity and confidentiality were emphasized to mitigate social desirability bias.
General data were obtained through structured forms that included age, body mass index (BMI), educational level, marital status, number of deliveries, mode of delivery (vaginal delivery or cesarean section), presence of lateral perineal incision or laceration of degree II or higher, postnatal age in months, lactation status, history of chronic fecal and secret conditions, and previous history of pelvic floor-related symptoms.
Relevant clinical information pertaining to the pelvic floor (such as POP-Q staging) was extracted from outpatient evaluation records. The scale section comprised PFDI-20, PFIQ-7, HADS-A, PSS-10, FSFI, PSQI, and SSRS. All scales were in their validated Chinese versions, and total scores and sub-domain scores were calculated according to the scoring methods of the original scale. Missing items were addressed according to the scale descriptions. If the number of missing items exceeded the specified proportion, the questionnaire was deemed invalid and excluded. Data were entered into the database by two individuals through dual entry. Following data entry, consistency checks and logic checks (such as assessing scale score ranges and the relationship between score fields and total scores) were performed. Supplementary confirmation of questionable or contradictory information was conducted via telephone or through outpatient reviews. To minimize information deviation resulting from discussions or filling processes, the electronic questionnaire was configured to allow submission from a single device, while paper questionnaires were collected on-site and checked for completeness.
Statistical analysis
Using SPSS 26.0 for statistical analysis, etc. The measured data are presented in the form of means ± SD following a normality test; respectively, the t-test or ANOVA is used to compare results among groups. Non-normally distributed data are presented as medians with interquartile ranges, and comparisons among groups use the rank-sum test. Categorical data are presented as n (%) to indicate that there was a relationship among different categories; between-groups comparison used χ2 test/Fisher’s exact probability method. Select Spearman rank-order correlation for determining associations. Anxiety (yes/no), high-perceived-stress (yes/no), and sexual-dysfunction (yes/no) were regarded as the dependent variables; those with P < 0.05 in univariate analysis would be added to the multiple-logistic-regression model. Reported odds ratios (ORs) and their corresponding 95%CI. Both tests had statistical differences at P < 0.05 level.
RESULTS
General data
A total of 140 postpartum women were included in the study, comprising 98 cases (70.0%) in the PFD group and 42 cases (30.0%) in the non-PFD group. Compared to the non-PFD group, the PFD group had significantly higher age (31.2 ± 4.1 years vs 29.6 ± 4.3 years, P = 0.031), a higher proportion of lateral episiotomy or laceration above degree II (38.8% vs 21.4%, P = 0.043), a higher proportion of PSQI > 7 indicating poor sleep quality (46.9% vs 23.8%, P = 0.009), and a lower total SSRS score (40.6 ± 6.7 vs 44.1 ± 6.2, P = 0.004). No statistically significant differences in BMI, postpartum duration, parity, mode of delivery, breastfeeding status, or history of constipation were observed (all P > 0.05, Table 1).
Table 1 Comparison of general characteristics of postpartum women between the two groups, n (%)/mean ± SD/median (interquartile range).
The PFD group had a significantly higher PFDI-20 total score (108.4 ± 32.7 vs 38.6 ± 12.4, P < 0.001) and PFIQ-7 total score [57 (36-84) vs 14 (7-26), P < 0.001] than the non-PFD group. In addition, the incidences of stress urinary incontinence (53.1% vs 21.4%, P < 0.001), pelvic organ prolapse-related symptoms (9.6% vs 4.8%, P = 0.001), defecation disorder and anal incontinence symptoms (21.4% vs 7.1%, P = 0.033), chronic pelvic floor pain-associated discomfort (27.6% vs 11.9%, P = 0.039), and a POP-Q stage ≥ II (24.5% vs 2.4%, P = 0.001) were significantly higher in the PFD group (Figures 1 and 2, Table 2).
Figure 1 Comparison of the Pelvic Floor Distress Inventory-20 total score between the pelvic floor dysfunction and non-pelvic floor dysfunction groups.
PFDI-20: Pelvic Floor Distress Inventory-20; PFD: Pelvic floor dysfunction.
Figure 2 Violin plot showing the distribution of the Pelvic Floor Impact Questionnaire-7 total score between the pelvic floor dysfunction and non-pelvic floor dysfunction groups.
PFIQ-7: Pelvic Floor Impact Questionnaire-7; PFD: Pelvic floor dysfunction.
Table 2 Symptoms and effects of pelvic floor dysfunction in the two groups, n (%)/mean ± SD/median (interquartile range).
Compared to the non-PFD group, the PFD group had a significantly higher HADS-A score (7.6 ± 3.8 vs 5.2 ± 3.1, P < 0.001), anxiety detection rate (41.8% vs 21.4%, P = 0.020), PSS-10 score (19.8 ± 6.1 vs 15.7 ± 5.4, P < 0.001), proportion of high perceived stress (45.9% vs 21.4%, P = 0.007), and incidence of sexual dysfunction (63.3% vs 33.3%, P = 0.001) and a significantly lower total FSFI score (23.7 ± 5.4 vs 27.8 ± 4.6, P < 0.001) FSFI sub-domain scores (all P < 0.05, Table 3).
Table 3 Anxiety, perceived stress, and sexual health status in the two groups, n (%)/mean ± SD.
Relationship among pelvic floor function, anxiety, and sexual function
Spearman correlation analysis revealed that the pelvic floor symptom burden, as measured by the PFDI-20, was positively correlated with the HADS-A (r = 0.46, P < 0.001) and the PSS-10 (r = 0.52, P < 0.001) and negatively correlated with the FSFI total score (r = -0.49, P < 0.001). The PFIQ-7 also demonstrated similar correlations with the HADS-A (r = 0.41), PSS-10 (r = 0.44), and FSFI total score (r = -0.42; all P < 0.001). The HADS-A was positively correlated with the PSS-10 (r = 0.58, P < 0.001), whereas the PSS-10 was negatively correlated with the FSFI total score (r = -0.35, P < 0.001, Table 4).
Table 4 Correlations among pelvic floor function, psychological status, and sexual function.
Multi-factor logistic regression analysis of anxiety, high perceived stress, and sexual dysfunction
After incorporating potential related variables in the multivariable model based on the univariate analysis, the total PFDI-20 score remained an independent factor affecting anxiety, high perceived stress, and sexual dysfunction. Specifically, for each 10-point increase in the PFDI-20 score, the odds of anxiety, high perceived stress, and sexual dysfunction increased by 29% (OR = 1.29, 95%CI: 1.10-1.52), 35% (OR = 1.35, 95%CI: 1.15-1.59), and 31% (OR = 1.31, 95%CI: 1.12-1.54), respectively. Poor sleep quality and lower social support were also independently associated with these outcomes (Table 5).
Table 5 Multivariable logistic regression analysis of anxiety, high perceived stress, and sexual dysfunction in postpartum women.
Comparison by gradient of severity of pelvic floor symptoms
According to the PFDI-20 stratification, a clear gradient pattern was observed. Mean HADS-A scores increased from 5.2 ± 3.1 in the non-PFD group to 6.3 ± 3.3, 7.6 ± 3.6, and 9.0 ± 4.1 in the mild, moderate, and severe PFD groups, respectively. Similarly, PSS-10 scores increased from 15.7 ± 5.4 to 16.9 ± 5.3, 19.9 ± 5.7, and 23.1 ± 6.0, respectively. In contrast, the FSFI total score decreased from 27.8 ± 4.6 to 25.4 ± 4.8, 23.6 ± 5.3, and 21.7 ± 5.6, respectively. The detection rates of anxiety, high perceived stress, and sexual dysfunction also rose progressively across the four groups (Table 6).
Table 6 Comparison of psychological and sexual health outcomes across severity levels of pelvic floor symptoms, n (%)/mean ± SD.
By collecting the data of post-partum follow-ups and samples from pelvic floor specialists in January 2021 to June 2025, it has been found that postpartum PFD is significantly related to anxiety, high-perceived stress, and sexual dysfunction, as well as exhibits a progressive pattern among individuals ranked by their scores for symptoms. PFD due to childbirth is not limited to problems related only with its functions anymore; Instead of impacting self-perception, role adjustment, intimacy in life, etc., during the puerperium after childbirth extensively, it can lead to more significant psychological repercussions[16,17].
The PFDI-20 showed a mild positive correlation with the HADS-A and PSS-10 scores, and remained independently related to anxiety and high-perceived stress after controlling for covariates. From this, we know that it is also one of the factors among the main reasons for psychological stress. A possible reason could be that urinary leakage, feeling of prolapse, difficulty defecating persistently increase one’s sensitivity to body signals and lead to anticipation of embarrassment in work, life, etc.[18,19]. Following childbirth, women have heavy care burdens and changing positions of role adjustment. When patients regard their pelvic floor symptoms as a lack of bodily control, it leads to self-embarrassment and shyness; this reduced sense of openness will further increase anxiety and perceived pressure[20,21]. Therefore, under this regulatory mechanism, as symptoms progress and worsen accordingly, an individual’s emotional state should also become progressively more intense with time.
Additionally, the total FSFI score and scores for all main domains of the FSFI have decreased in the PFD group; sexual dysfunction has become more common as the severity of PFD increases. Specific paths will definitely be different. In view of physical factors, various impacts exist on the quality of life for seniors in their 80s who have had menopause. psychologically, the fear of urinary incontinence, sense of smell, proliferation symptoms, and discomfort during sexual life can all lead to anticipatory withdrawal before any objective signs have appeared in individuals[22-24]. Following childbirth, the aforementioned negative emotions may exacerbate their existing anxiety among women of childbearing age in China[25]. Therefore, the sexual health consequences of PFD are not solely caused by one’s own structure, but rather involve emotions and how to communicate with others in a relationship.
Based on the results of multi-variable analysis, poor sleep quality and inadequate socialization are associated with anxiety; high perceived stress is linked to erectile dysfunction; Sleep disturbance commonly occurs in pregnancy; however, for women with PFD, it may present clinically more frequently due to their higher frequency of nocturia, uncomfortable conditions, symptom-oriented repetition, and frequent awakenings that disrupt the continuity of sleep[26-28]. Sleep deprivation can impair emotion regulation and stress resistance to make people bear more mental pressure of pelvic-floor problems. On the contrary, it is believed that there is a protection against social isolation; sufficient emotional and material care from family members or friends helps people feel less ashamed, improve their sense of commitment to rehabilitation work and confidence for recovery, thereby alleviating symptoms and reducing isolation behaviour[29-32].
Therefore, according to the above-mentioned conclusions, clinical treatment currently fails to transcend focusing solely on pelvic-facial muscles training. During routine postpartum check-ups and pelvic floor therapy, women with high PFDI-20 scores may be screened at the same time for anxiety, perception of stress, sleeping conditions, sexual problems. Through this way, some people who are relatively uncomfortable will be recognised earlier to help them receive psychotherapy, sleep intervention measures, or sexual health guidance in time[33-35]. If it is necessary to provide sufficient explanation, then there will be an increase in the accuracy of identifying sensitive data; therefore, adjusted based on different circumstances.
There are some deficiencies. Firstly, it was a single-centre, cross-sectional study with insufficient numbers to make causal claims; thus, there are no such determinations here either as regards causality or generalisability to other settings. Recruiting participants from the following up after treatment or specialist outpatients might introduce selection bias. Thirdly, although an inclusion window of 6-12 weeks post-partum enabled coverage of regular clinical follow-up, due to the relatively wide range of posts-birth time, there would still be some heterogeneity after controlling statistically. Fourthly, due to self-reporting in psychology and sex-health education programmes, they are also prone to recall bias and social desirability bias. Fifth, The HADS-D, partner-related factors, and Objective Pelvic Floor Function Tests were all excluded simultaneously. In future multicond-centrally-longitudinal studies, we must pay attention to expanding sample size and collecting a more extensive range of psychosocial-functional data at different stages.
CONCLUSION
Postpartum PFD is significantly associated with anxiety, increased perceived stress, and sexual dysfunction, with these outcomes displaying a graded relationship with symptom severity. Sleep quality and social support appear to play crucial modifying roles. Integrating psychological and sexual health screening into postpartum pelvic floor follow-up and rehabilitation may contribute to more comprehensive and patient-centered care.
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