Female sexual dysfunction is independently associated with depressive symptom burden in premenopausal pelvic floor clinic patients: a cross-sectional analysis

Female sexual dysfunction (FSD) is common among women attending pelvic floor clinics, yet its independent association with depressive symptom burden has not been systematically examined within a multidomain pelvic floor cohort. To determine whether FSD is independently associated with Self-Rating Depression Scale (SDS) scores in premenopausal women undergoing structured pelvic floor evaluation, and whether cumulative pelvic floor phenotype load (urinary, pain, and FSD domains) relates to SDS in an overall positive ordinal pattern. Retrospective cross-sectional study of 876 premenopausal women at one pelvic floor center (2020); multivariable regression used a complete-case sample of 764 women with all covariates. FSD was defined by FSFI total ≤ 26.55; domains included POP-Q stage ≥ I prolapse, urinary SUI/OAB, pelvic pain (chronic pain or VAS ≥ 1), and FSD. Primary phenotype burden counted three non-prolapse domains (urinary, pelvic pain, FSD; range 0–3); sensitivity analyses used four-domain scores including prolapse. HC3-robust linear regression evaluated FSD in clinical and extended (PFDI-20 and I-QOL) models. SDS (continuous); phenotype burden gradient; adjusted regression coefficients. FSD was present in 530 women (60.5%). Mean SDS was higher with than without FSD (33.04 ± 8.36 vs. 30.15 ± 7.96; P < 0.001). Mean SDS increased across higher three-domain burden strata (0 domains: 29.0, n = 164; 1: 32.4, n = 353; 2: 32.1, n = 267; 3: 34.5, n = 92; Spearman r = 0.158, P < 0.001), with similar means in the one- and two-domain groups. In the clinical model ( n = 764; R² = 0.115), FSD had the largest coefficient (β = 3.14; 95% CI 1.97–4.31), with smaller independent effects for urinary phenotype and defecation dysfunction; lactation was inversely associated (β = −4.02; 95% CI − 5.40 to − 2.64). In the extended model ( R ² = 0.164), FSD remained significant (β = 2.52; 95% CI 1.36–3.67) while urinary effects attenuated; PFDI-20 and I-QOL were independently associated with SDS. FSD showed the largest adjusted association with depressive symptoms among evaluated phenotypes in this cross-sectional cohort. These findings support considering sexual function assessment alongside brief mood screening in pelvic floor clinics, particularly among women with higher multidomain burden, while recognizing that only associations—not causality—can be inferred. Strengths include a large premenopausal cohort, standardized multidomain phenotyping, self-administered FSFI with physician-recorded total scores, a continuous SDS endpoint, and HC3 regression. Limitations include cross-sectional single-center data, near-universal POP stage I+ (limiting POP subgroup contrasts), and systematic differences between regression-eligible and excluded participants. FSD was the strongest independent correlate of depressive symptom burden and remained significant after adjustment for global symptom distress and incontinence-specific quality of life. An overall positive ordinal association between three-domain phenotype burden and SDS supports phenotype-aware screening considerations and integrated psychosocial care pathways.