Body image (BI) is defined as an individual’s perception and emotions related to their physical appearance.Negative body image has been shown to have associations with urogynaecological conditions which may have a profound effect on patients’ mental health and associated quality of life. 
Pelvic floor dysfunction is prevalent within the general population.  It is estimated that 1 in 3 parous women will experience urinary incontinence (UI), and 1 in 2 women will develop pelvic organ prolapse (POP) during their lifetime. These conditions can have negative effects on a woman’s perception of her body, particularly on genital self-image. Despite acknowledging the potential effects on quality of life, little is known about the relationship between the impact of these conditions on body image. Feelings of embarrassment, shame and low self-esteem can lead to anxiety, depression and social isolation, and have a negative impact on a person’s intimacy and perceived sexual function. More research into the impact of incontinence and prolapse on body image, and subsequent effect on quality of life is required.
In this study, our aim was to assess whether urinary incontinence and pelvic organ prolapse have a negative impact on body image, and which age groups are more likely to be affected with a negative body image in relation to their pelvic floor disorder.

Data was obtained from a pre-existing database of 2,321 women who had completed the electronic Personal Assessment Questionnaire - Pelvic Floor (ePAQ-PF) between March 2018 and January 2022. The questionnaire is a validated electronic personal health questionnaire widely used in gynaecology clinics across the UK providing a measure of self-reported symptoms and impact on quality of life measures from women with pelvic floor disorders. It is a tool recognised by the National Institute of healthCare and Excellence (NICE) and the British Society of Urogynaecology (BSUG) as a useful clinical assessment tool and patient reported outcome measure (PROM). 
The study protocol was approved by the research ethics committee and the local research department. All participants completed this questionnaire as part of their routine care, and provided informed consent for their responses to be used in research studies. Analysis was carried out using SPSS (version 28.0. Armonk, NY: IBM Corp.).
The One-Way ANOVA test was used to determine whether different age groups (age <50, 50-70, >70 years) experienced a different impact on body image. The independent t-test was used to analyse whether people who were not sexually active, but considered sexual activity as important, had higher BI impact scores. Body image impact scores were then filtered, including only participants who had a body image impact score of 50 or above. 13% (n=297) of the participants within the database had reported BI scores >50. For this cohort, the Pearson correlation coefficient test was used to establish whether there was a correlation between body image impact scores and urinary incontinence and pelvic organ prolapse. Further correlation was then sought when stratifying the groups according to age, symptoms and body image impact scores.

A one-way repeated measure analysis of variance (ANOVA) revealed a significant difference between age groups (<50, 50-70 and >70 years) and impact on body image (p <.001). 52% (n=1,198) were sexually active at the time of completing the questionnaire vs 20% (n=460) who were not sexually active but considered sexual activity as important. The mean BI impact scores for each group were 16 vs 25 respectively, with women with a higher BI impact score regarding sexual activity as being important in their life, but they were not sexually active (p= <.001). 
The mean age of women who had a BI impact score >50 was 54 years (n=297). 57% (n=170) had both UI and POP as primary symptoms. There was a positive correlation between UI impact scores and BI impact scores for women with urinary incontinence (Pearson correlation 0.128, p= 0.049). For POP, there was a positive correlation (Pearson correlation 0.111) however this was not statistically significant (p= 0.11). When stratifying the groups for age, symptoms and BI impact scores, the correlation between these factors was not statistically significant (UI p=0.54, POP p=0.09). 38% (n=114) of participants with a BI impact score >50, recorded sexual activity as important, however, they were not sexually active. The mean BI scores for women who were sexually active and those that were not, did not differ in this group (mean scores = 74).

The impact of body image is inversely proportional to a patient’s age, with negative body image having  a higher impact on younger women. Additionally, women with a higher BI impact score experienced lower rates of sexual activity despite regarding sexual activity as being meaningful in their life. Urinary incontinence had a negative effect on patients’ body image, despite their age or level of sexual activity. POP had a negative effect on body image, however the level of correlation for this patient group was not statistically significant. Confounding factors such as body mass index (BMI), severity of symptoms, and severity of the POP may affect the statistical significance of this. For the purposes of this analysis, clinical examination was not taken into consideration, hence we cannot conclude the precise reason for this.

The impact of body image can be influenced by a patient’s age, with younger patients showing the highest impact of negative body image. Hence, the importance of body image and the patient’s perception should be taken into account when counselling patients on management of pelvic floor dysfunction in gynaecology clinics. It is also important to recognise that a negative body image can significantly affect the woman’s sexual function. As a result, consideration of patients’ sexual activity and degree of importance of sexual function in their life is essential. Furthermore, as women with pelvic floor dysfunction experience a negative impact on their body image, this highlights the importance of optimising care and treatment for UI and POP for all age groups.

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