The World Health Organization estimates that approximately 30% of women worldwide have experienced sexual violence (SV) at least once in their lifetime, with higher prevalence in conflict settings. In the Kivu region of the eastern Democratic Republic of the Congo (DRC), nearly 40% of women have experienced Conflict-Related SV [1]. Such violence leads to long-term pelvic and psychological consequences. However, no study to date has used validated questionnaires to investigate the impact of SV-related post-traumatic stress disorder (PTSD) on anal function, particularly constipation. This gap limits the development of appropriate rehabilitation interventions. This study aimed to assess the impact of PTSD related to SV on constipation among Congolese women living in the Kivu region.

A cross-sectional study was conducted among 328 women living in Goma and Bukavu, recruited through hospitals, medical centers, and community networks. Participants were divided into three groups: SV survivors with PTSD (SV-PTSD), SV survivors without PTSD (SV-NoPTSD), and a control group (CG). Inclusion criteria were age ≥18 years, residence in the DRC, and ability to communicate in French or via translation. Exclusion criteria included pregnancy, early postpartum, and obstetric fistula.
Data were collected using a questionnaire on socio-demographic characteristics and SV-related variables. Constipation and PTSD were assessed using the KESS and PCL-5 questionnaires respectively in their French version. PTSD was defined according to DSM-5 criteria, and a KESS score ≥11 indicated constipation. Group comparisons were performed using the Kruskal–Wallis test with Bonferroni correction and Pearson’s Chi-squared test, with significance levels set at 1.7% and 5%, respectively.

Between autumn 2022 and summer 2024, 152 women were included in the control group, and 174 SV survivors were allocated to the SV-PTSD (n=102) and SV-NoPTSD (n=74) groups. Groups were comparable in terms of demographic characteristics.
Most assaults were perpetrated by armed groups (51.1%) and involved penetrative rape. SV-PTSD participants more frequently reported multiple assaults (39.4%), multiple perpetrators (56.4%), and prolonged abuse such as sexual slavery (35.3%) (Table 1).
Constipation prevalence differed significantly across groups (25.0% CG, 29.7% SV-NoPTSD, 45.1% SV-PTSD). After Bonferroni correction, only the difference between CG and SV-PTSD remained significant (p=0.001). Among participants with constipation (GC: 38; SV-NoPTSD: 22; SV-PTSD: 46), no significant differences in severity were observed between groups (Table 2).

This study is the first to compare constipation prevalence and severity among Congolese SV survivors with and without PTSD using validated measures. The higher prevalence of constipation in SV survivors with PTSD aligns with evidence linking PTSD to gastrointestinal symptoms.
Interestingly, the prevalence of constipation in the control group was also higher than the national estimate of 16.1% (95% CI: 13.1–19.6%) reported by Nzinga et al. (2025) [2]. This suggests that living in a conflict-affected environment may independently contribute to constipation, potentially through chronic stress and limited access to adequate nutrition and hydration.
The absence of differences in constipation severity contrasts with previous findings [3] and may reflect limited cultural adaptation of the KESS questionnaire, particularly for items related to treatment use in contexts with restricted healthcare access.

SV survivors with PTSD in the Kivu region exhibit a higher prevalence of constipation. These findings highlight the need to integrate trauma-informed care and mental health considerations into the management of anorectal disorders in this population.

[1] Johnson K, Scott J, Rughita B, Kisielewski M, Asher J, Ong R, et al. Association of sexual violence and human rights violations with physical and mental health in territories of the Eastern Democratic Republic of the Congo. JAMA. 2010;304:553–62. https://doi.org/10.1001/JAMA.2010.1086.
[2] Nzinga, AM.L., Reman, T., Mukwege, D. et al. Prevalence and Determinants of Constipation in Community-Dwelling Adult Women in the Democratic Republic of Congo: A Cross-Sectional Study. Int Urogynecol J (2025). https://doi.org/10.1007/s00192-025-06455-w
[3] Imhoff LR, Liwanag L, Varma M. Exacerbation of symptom severity of pelvic floor disorders in women who report a history of sexual abuse. Arch Surg. 2012 Dec;147(12):1123-9. doi: 10.1001/archsurg.2012.1144. PMID: 23248015.