Hypothesis / aims of study
Adverse childhood events (ACEs), including direct abuse and household dysfunction, are highly prevalent and linked to long-term health consequences. Globally, nearly half of all children experience violence or neglect each year. The widespread impact of ACEs, along with their economic burden—estimated at 2–6% of GDP in European countries—highlights the need for multisectoral intervention (1).
Emerging evidence suggests that ACEs may contribute to pelvic floor symptoms, such as pelvic pain and pelvic organ prolapse (POP), possibly through stress-related physiological changes (2). While the link between ACEs and pelvic pain has been documented, the association with POP and the mediating role of depression remain underexplored.
This study examines whether depression mediates the relationship between ACEs and pelvic pain/POP. We hypothesize that ACEs increase depression risk, which in turn exacerbates pelvic floor symptoms. Findings may inform trauma-informed, targeted interventions.
Study design, materials and methods
This cross-sectional study used data from a larger prospective, population-based cohort in Coevorden, the Netherlands, conducted in collaboration with general practitioners. Community-dwelling individuals aged ≥16 years were invited to complete online or paper questionnaires. Analyses included only participants with complete data on ACEs, depression, pelvic pain, and pelvic organ prolapse (POP).
ACEs were measured using four NEMESIS items on abuse before age 16 (score range 0–12; Cronbach’s α = 0.783). Depression was assessed via the Patient Health Questionnaire-9 (PHQ-9). POP symptoms were measured with the POPDI-6, and pelvic pain with a binary study-specific item.
We conducted Structural Equation Modeling (SEM) and Path Analysis to assess whether depression mediated the relationship between ACEs and pelvic symptoms. Three models were tested: ACEs and pelvic pain (females and males), and ACEs and POP (females). Mediation was evaluated using bootstrapped confidence intervals (2,000 resamples). Model fit was assessed using standard indices, and explained variance (R²) was reported per Cohen’s guidelines. Ethical approval was obtained from the University Medical Center Groningen (METc2018/601).
Results
The study included 780 females and 552 males. Females reported higher depressive symptoms and greater exposure to childhood adversity.
In females, ACEs were significantly associated with pelvic pain (β = 0.163, p = 0.020), with depression partially mediating the relationship (indirect effect: β = 0.081, p < 0.001). R² was 0.116 for pelvic pain and 0.107 for depression, indicating moderate effects.
In males, the direct effect of ACEs on pelvic pain was not significant (β = 0.056, p = 0.196), but a significant indirect effect through depression was found (β = 0.049, p = 0.023), supporting full mediation. R² values were 0.042 (pelvic pain) and 0.070 (depression), suggesting small effects.
For POP in females, ACEs had no direct effect (β = -0.012, p = 0.722), but depression fully mediated the relationship (indirect effect: β = 0.121, p < 0.001). R² was 0.161 for POP and 0.107 for depression. Model fit indices confirmed acceptable to good fit.
Interpretation of results
Depression mediated the relationship between ACEs and pelvic pain/POP, with sex-specific patterns. In females, both direct and indirect effects were found, suggesting additional factors beyond depression may influence symptoms. In males, depression fully mediated the ACEs–pelvic pain link, indicating a more direct psychological pathway. POP symptoms in females were also fully mediated by depression. These findings support a biopsychosocial understanding of pelvic floor symptoms and highlight the value of trauma-informed, psychologically integrated care for individuals with a history of childhood adversity.