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Systematic review article https://doi.org/10.47460/minerva.v7i20.338

Pelvic Floor Dysfunction and Gut-Brain Axis: Implications for

Multidisciplinary Diagnosis and Treatment in Gynecology,

Gastroenterology, an d General Surger y

Cindy Michelle Cede

no Calero*

https://orcid.org/0009-0005-7505-4200

dracindycedeno.gastro@outlo ok.com

Hospital de Especialidades Portoviejo

Portoviejo, Ecuador

enesis Guadalupe Cede

no Bazurto

https://orcid.org/0009-0004-9870-8070

cedenogenesisg@gmail.com

Independent researcher

Toronto, Canad

Carla Emilia Parra Mor

https://orcid.org/0009-0005-0485-6206

carla.parra1008@gmail.com

Independent researcher

Quito, Ecuador

Juan Geancarlo Tapia Olarte

https://orcid.org/0009-0009-5011-0789

juangeancarlonieblesolarte@gmail.com

Independent researcher

Cusco, Per

*Corresponding author:

dracindycedeno.gastro@outlook.com

Received: (08/06/2026), Accepted: (30/07/2026)

Abstract. Pelvic Ćoor dysfunction is a prevalent multifactorial condition that signiĄcantly impairs qua-

lity of life. Traditionally managed from a compartmentalized perspective, recent evidence highlights the

connection between the pelvic Ćoor and the gut-brain axis. This review analyzes the pathophysiological

association between both and proposes an integrated diagnostic and therapeutic approach involving

gynecology, gastroenterology, and general surgery. A narrative review of the literature was conducted.

Bidirectional communication between the central nervous system, enteric nervous system, and gut

microbiota inĆuences pelvic tone, visceral sensitivity, and symptom perception. Chronic constipation,

intestinal dysbiosis, and psychological stress can exacerbate or trigger pelvic Ćoor dysfunction, which in

turn alters bowel habits and contributes to anxiety and depression. An interdisciplinary model enables

comprehensive management including dietary interventions, pelvic Ćoor physical therapy, psychological

support, and coordinated surgery, thereby improving diagnostic accuracy and expanding therapeutic

options.

Keywords: pelvic Ćoor dysfunction, gut-brain axis, interdisciplinary collaboration, microbiota.

Disfunci´on del suelo p´elvico y eje cerebro-intestino: implicaciones

para el diag n ´ostico y tratamiento multidisciplinario en ginecolog´ıa,

gastroenterolog´ıa y cirug´ıa general

Resumen. La disfunci

on del suelo p

elvico es una afecci

on multifactorial prevalente que deteriora la cali-

dad de vida de quienes la padecen. Tradicionalmente abordada desde una visi

on compartimentalizada,

la evidencia reciente destaca la conexi

on entre el suelo p

elvico y el eje cerebro-intestino. Esta revisi

analiza la asociaci

on Ąsiopatol

ogica entre ambos y prop one un enfoque diagn

ostico y terap

eutico inte-

grado que involucra a la ginecolog

ıa, la gastroenterolog

ıa y la cirug

ıa general. Se realiz

o una revisi

narrativa de la literatura. La comunicaci

on bidireccional entre el sistema nervioso central, el sistema

nervioso ent

erico y el microbiota intestinal inĆuye en el tono p

elvico, la sensibilidad visceral y la per-

cepci

on sintom

atica. El estre

nimiento cr

onico, la disbiosis intestinal y el estr

es psicol

ogico pueden

exacerbar o desencadenar la disfunci

on p

elvica, y esta, a su vez, altera el h

abito intestinal y contribuye

a la ansiedad y la depresi

on. Un modelo interdisciplinario permite un manejo integral con interven-

ciones diet

eticas, Ąsioterapia p

elvica, apoyo psicol

ogico y cirug

ıa coordinada, mejorando la precisi

diagn

ostica y ampliando las opciones terap

euticas.

Palabras clave: disfunci

on del suelo p

elvico, eje cerebro-intestino, colaboraci

on interdisciplinaria, mi-

crobiota.

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I. INTRODUCTION

Pelvic Ćoor dysfunction (PFD) is a highly prevalent clinical syndrome that extends b e yond anatomi-

cal impairment, profoundly aﬀecting the quality of life of millions of people worldwide, particularly

women [

1]. It encompasses pelvic organ prolapse, urinary and fecal incontinence, voiding and defecatory

disorders, and chronic pelvic pain syndromes. In Latin America, and particularly in Ecuador, its true

prevalence is likely underestimated because of healthcare limitations and cultural stigmas that discourage

timely consultation [

2]. Traditionally, PFD has b ee n managed through a compartmentalized approach

in which gynecologists, gastroenterologists, and general surgeons address isolated manifestations with

limited interdisciplinary coordination, often overlooking the functional integration of the pelvic Ćoor [3].

Recent advances have highlighted the gut-brain axis (GBA) as a key framework for understanding the

multifactorial nature of PFD. The GBA is a bidirectional communication network linking the central

and enteric nervous systems, autonomic pathways, and the intestinal microbiota, thereby regulating

gastrointestinal motility, permeability, immune responses, and visceral sensitivity [

4]. This integrated

perspective suggests that PFD should be interpreted not only as a structural disorder but also as the

consequence of complex neurophysiological, microbial, and endocrine interactions.

Accumulating evidence indicates that psychological stress, anxiety, and depression can alter gas-

trointestinal motility through activation of the hypothalamic-pituitary-adrenal axis, promoting chronic

constipation and repetitive straining, both re cognized risk factors for prolapse and incontinence [

5]. Like-

wise, intestinal dysbiosis and low-grade inĆammation increase visceral hypersensitivity and contribute to

chronic pelvic pain, while persistent PFD symptoms may further exacerbate psychological distress and

gut dysfunction, creating a self-perpetuating cycle [

6], [7], [8], [9], [10]. These Ąndings have encouraged

interdisciplinary management strategies integrating pelvic Ćoor rehabilitation, microbiota-oriented nu-

tritional interventions, psychological support, and coordinated surgical care, which have demonstrated

better clinical outcomes than isolated treatments [

3], [5], [8], [11], [12].

Despite these advances, evidence on the mechanisms linking the gut-brain axis and pelvic Ćoor

dysfunction remains dispersed across diﬀerent medical specialties, limiting its translation into com-

prehensive clinical practice. Therefore, this study aims to analyze the pathophysiological mechanisms

connecting the GBA with PFD and to examine the evidence supporting an interdisciplinary management

model that integrates gynecology, gastro e nterology, and general surgery.

II. THEORETICAL FRAMEWORK

A. Pelvic Floor Dysfunction: Multifactorial Condition

PFD encompasses a heterogeneous group of disorders aﬀecting the structural and functional in-

tegrity of the pelvic Ćoor. This complex anatomical structure, composed of muscles, ligaments, fasciae,

and neural elements, provides support to pelvic organs, maintains continence, and facilitates normal

voiding and defecation [

1]. PFD may manifest as pelvic organ prolapse, urinary and fecal incontinence,

voiding dysfunction, defecatory disorders, and chronic pelvic pain syndromes. Its etiology is multi-

factorial, involving genetic predisposition, obstetric trauma, aging, hormonal changes, obesity, chronic

straining, heavy lifting, and neurological disorders [

2], [3]. Prevalence increases with age, and parity is

one of the most signiĄcant risk factors. In Latin America, cultural stigmas surrounding these disorders

discourage care-seeking, leading to underdiagnosis and delayed treatment [

2]. A full understanding of

PFD requires acknowledging the role of central and peripheral neural regulation, which brings us to the

concept of the gut-brain axis.

B. The Gut-Brain Axis: Anatomy and Function

The GBA is a bidirectional communication system between the gastrointestinal tract and the central

nervous system [

4]. This network integrates neural, endocrine, and immune signaling pathways. Its

main components are: (1) the enteric nervous system, often called the Şsecond brain,Ť which regulates

gastrointestinal motility, secretion, and blood Ćow [

4]; (2) the vagus nerve, the primary neural pathway

transmitting aﬀerent signals from the gut to the brainstem and eﬀerent signals from the brain to the

gut, modulating motility, secretion, and inĆammation [

4], [7]; (3) the gut microbiota, whose trillions

of microorganisms produce metabolites, neurotransmitters, and signaling molecules that inĆuence gut

function and systemic physiology, including behavior and emotions; dysbiosis has been implicated in

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various gastrointestinal and neurological disorders [4], [6], [8]; (4) the HPA axis, the neuro endocrine

arm that mediates stress responses through cortisol release, aﬀecting motility and visceral sensitivity

[7], [10]; and (5) the immune system, whose gut-associated lymphoid tissue and cytokine production

can sensitize aﬀerent pathways, leading to visceral hyperalgesia [

8]. The bidirectional nature of the

GBA implies that gut alterations aﬀect brain function and vice versa, with profound implications for

PFD [

4], [8].

C. Pathophysiological Mechanisms Linking the GBA and PFD

The association between the GBA and PFD is mediated by three interconnected pathways (Table

1). The neurological vagal-spinal pathway involves the vagus nerve, which modulates pelvic pain

perception, and spinal reĆexes, which coordinate defecation and micturition; stress can dysregulate

these reĆexes, leading to pelvic Ćoor dyssynergia [

5], [7]. The microbiological pathway is related to

gut dysbiosis, increased intestinal permeability, and low-grade systemic inĆammation; the microbiota

produces neurotransmitters, such as GABA and serotonin, that aﬀect neural excitability, sensitizing

the pelvic region and contributing to chronic pain [

4], [8]. The neuroendocrine pathway is associated

with psychological stress, which activates the HPA axis, releases cortisol, alters motility, and promotes

constipation [

7], [10]; chronic straining constitutes direct mechanical injury to pelvic supports, creating

a vicious cycle between mental state and physical damage [

10], [12].

Tabla 1. Pathophysiological pathways linking the gut-brain axis and pelvic ﬂoor dysfunction.

Pathway Key ﬁndings from the literature Clinical interpretation

Neurological (vagal-

spinal)

The vagus nerve modulates pelvic pain per-

ception; spinal reﬂexes coordinate defeca-

tion and micturition; stress can dysregulate

these reﬂexes [

5], [7].

PFD is not solely peripheral; central

nervous system processing plays a

critical role, potentially leading to

pelvic ﬂoor dyssynergia.

Microbiological (gut mi-

crobiota)

Gut dysbiosis is associated with increased

intestinal permeability and low-grade sys-

temic inﬂammation; microbiota produce

neurotransmitters, such as GABA and sero-

tonin, affecting central and enteric neural

excitability [

4], [8].

Provides a mechanistic link be-

tween gut health and pelvic

symptoms; microbiota modulation

emerges as a potential therapeutic

target.

Neuroendocrine (HPA

axis)

Psychological stress activates the HPA axis,

releasing cortisol; chronic stress can alter

gut motility and promote constipation [

7],

[

10].

Explains the high comorbidity with

anxiety and depression; stress-

induced constipation causes me-

chanical pelvic ﬂoor injury.

D. Clinical Evidence of Comorbidity

The reviewed literature shows a signiĄcant clinical overlap between PFD and functional gastroin-

testinal disorders, particularly irritable bowel syndrome (IBS) and chronic constipation (Table

2). A

systematic review by Till et al. [

8] found that women with IBS had a 50Ű80 % higher prevalence of

PFD compared to controls, with shared symptom s including chronic pelvic pain and bloating. This high

comorbidity suggests shared mechanisms through the GBAŠs role in visceral sensitivity and central pain

processing. In practice, a patient presenting with IBS should be screened for PFD, and vice versa, since

treating one condition in isolation may not resolve the global symptom burden. Studies indicate that

up to 50 % of women with signiĄcant pelvic organ prolapse report obstructive defecation symptoms [

1],

[

13], [14], [15], [16], [17], [18], [19], [20]. Conversely, chronic functional constipation is a recognized

risk factor for prolapse development and progression [

16]. This bidirectional relationship highlights the

need for dual assessment: gynecological evaluation for anatomy and gastroenterological evaluation for

bowel function and anorectal physiology [

3]. Anxiety and depression are disproportionately prevalent in

PFD patients compared to the general population [

10], [12]. This is not merely a reaction to a chronic

condition but is embedded in the neurobiology of the GBA, mediated by the HPA axis and its eﬀects

on gut and pelvic Ćoor function [7], [10].

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Tabla 2. Clinical evidence of comorbidity between pelvic ﬂoor dysfunction and gut-brain

axis-related disorders.

Association Key ﬁndings from the literature Clinical interpretation

PFD and IBS Women with IBS have 50±80 % higher

PFD prevalence; shared symptoms include

chronic pelvic pain and bloating [

8].

High comorbidity suggests shared

mechanisms through the GBA’s role

in visceral sensitivity; screening for

both conditions is recommended.

PFD and functional con-

stipation

Up to 50 % of women with pelvic organ

prolapse report obstructive defecation [

1];

chronic functional constipation is a risk fac-

tor for prolapse development and progres-

sion [

16].

Bidirectional relationship: prolapse

can cause mechanical obstruction,

while straining damages pelvic

support; dual assessment is re-

quired.

PFD and psychological

comorbidities

Anxiety and depression are disproportion-

ately prevalent in patients with PFD and

chronic pelvic pain compared to the general

population [

10], [12].

Psychological distress is embedded

in GBA neurobiology; it can be both

a cause and a consequence of PFD,

mediated by the HPA axis.

E. Interdisciplinary Management Models

Although robust randomized trials on fully integrated models are still emerging, evidence on indi-

vidual comp onents and small-scale programs points to their superiority over siloed approaches (Table

3). Biofeedback therapy for fecal incontinence and dyssynergic defecation, which retrains pelvic Ćoor

muscles using visual or auditory feedback, shows success rates of 70Ű80 % [

5]. This is a prime exam-

ple of eﬀective treatment requiring collaboration: the gastroenterologist diagnoses the dyssynergia via

manometry, and the physical therapist delivers the treatment. Case series report improved functional

outcomes and patient satisfaction when complex pelvic surgery, for example, for rectocele and entero-

cele, is planned and performed by a combined team of gynecological and colorectal surgeons [

3], [19].

This approach enables a single comprehensive procedure addressing all pelvic compartments, potentially

reducing the need for repeated surgeries and minimizing functional trade-oﬀs. Evidence supports Ąber

supplementation for constipation-related PFD and, in selected cases, a low-FODMAP diet guided by a

dietitian or gastroenterologist for overlapping IBS and PFD symptoms [

8], [11]. This extends mana-

gement beyond traditional pelvic Ćoor treatments to address the gut component of the axis, reducing

straining and bloating and indirectly alleviating mechanical stress on the pelvic Ćoor.

Tabla 3. Components and outcomes of interdisciplinary management models for pelvic ﬂoor

dysfunction.

Component of care Key ﬁndings from the literature Clinical interpretation

Integrated physical

therapy (biofeedback)

Biofeedback for fecal incontinence and

dyssynergic defecation shows 70±80 % suc-

cess rates [

5].

Effective treatment requiring col-

laboration: gastroenterologist diag-

noses via manometry, physical ther-

apist delivers therapy.

Combined surgical

planning

Case series report improved functional

outcomes and satisfaction when complex

pelvic surgery is performed by combined

gynecological and colorectal teams [

3], [19].

Enables a single comprehensive

procedure addressing all compart-

ments, reducing repeated surgeries

and functional trade-offs.

Dietary and microbiota

management

Evidence supports ﬁber supplementation

and, in selected cases, a low-FODMAP diet

for overlapping IBS and PFD symptoms [

8],

[

11].

Addresses the gut component,

reducing straining and bloating,

thereby alleviating mechanical

stress on the pelvic ﬂoor.

III. METHODOLOGY

A systematic review was conducted following the PRISMA 2020 guidelines [18], with the aim

of synthesizing available evidence on the association between the GBA and PFD, and to evaluate

interdisciplinary management models integrating gynecology, gastro enterology, and general surgery.

The review protocol was registered on the Open Science Framework platform. A systematic search was

performed in PubMed/MEDLINE, Scopus, Web of Science, and SciELO, last updated on 31 May 2026.

No strict temporal restrictions were applied, but studies published from 2010 onwards were prioritized.

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The search strategy used a combination of MeSH terms and free-text keywords combined with Boolean

operators. The search was limited to English and Spanish articles. Reference lists of included studies

and previous systematic reviews were manually screened to identify additional records using the snowball

method.

Fig. 1. PRISMA ﬂow diagram of study selection.

Eligibility criteria were deĄned according to the PICOS framework. Inclusion criteria were adult

patients, aged ≥ 18 years, with a diagnosis of PFD; studies evaluating the association with the GBA

or reporting outcomes of interdisciplinary management involving at least two sp ecialties; studies with

comparison groups or cohort data; outcomes including measures of association or clinical results; and

study designs including randomized controlled trials, prospective and retrospective cohorts, case-control

studies, systematic reviews, meta-analyses, and clinical practice guidelines. Exclusion criteria were case

reports with n < 10 and case series without comparison groups; conference abstracts, editorials, letters,

and opinion articles; inaccessible full texts; and studies focused exclusively on a single specialty without

an integrative perspective, unless they provided key pathophysiological insights.

Study selection was conducted in two phases. Phase 1 consisted of independent screening of titles

and abstracts by two reviewers; discrepancies were resolved through consensus or, when necessary, by

consultation with a third reviewer. Phase 2 involved full-text assessment of all potentially eligible arti-

cles. Data were extracted using a standardized form capturing author(s), year, country, study design,

population characteristics, interventions or exposures, comparators, main outcomes, and reported limi-

tations. Methodological quality was assessed using AMSTAR 2 for systematic reviews [

14], AGREE II for

clinical guidelines [

17], the Newcastle-Ottawa Scale for observational studies, and the Cochrane RoB 2

tool for randomized trials. Due to the expected heterogeneity of study designs and outcome measures, a

narrative synthesis was conducted, organizing the Ąndings into three thematic axes: pathophysiological

mechanisms, clinical evidence of comorbidity, and interdisciplinary management models.

IV. RESULTS AND DISCUSSION

The systematic search yielded 250 records from the consulted databases. After removing duplicates

(n = 65), 185 titles and abstracts were screened, of which 85 were excluded for not meeting the

eligibility criteria. One hundred full-text articles were assessed, and 22 were excluded: 12 for not

meeting the inclusion criteria, 6 for insuﬃcient results, and 4 due to inaccessible full texts. Finally,

78 publications were included in the qualitative synthesis. The evidence was organized into three

thematic axes: (1) pathophysiological mechanisms linking the GBA and PFD, (2) clinical evidence

on the comorbidity between both conditions, and (3) interdisciplinary management models integrating

gynecological, gastroenterological, surgical, nutritional, physical, and behavioral interventions.

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A. Pathophysiological Pathways Linking the GBA and PFD

Of the 78 included studies, 45 (57.7 %) directly or indirectly addressed the pathophysiological

mechanisms of the association. Among these, 23 (51.1 %) focused on the neurological pathway, 12

(26.7 %) on the microbiological pathway, and 10 (22.2 %) on the neuroendocrine pathway (Table

4).

Studies on the neurological pathway concur that dysregulation of spinal reĆexes, mediated by stress

and anxiety, contributes to pelvic Ćoor dyssynergia. Rao and Patcharatrakul [

5] showed that 70Ű80 %

of patients with dyssynergic defecation present paradoxical anal sphincter contraction during straining,

suggesting altered central neural control. Vagal stimulation has also b een shown to reduce pelvic pain

perception in IBS patients, supporting the vagus nerveŠs role in visceral sensitivity modulation [

4],

[

6]. In the microbiological pathway, gut dysbiosis was associated with increased intestinal permeability

and activation of innate immunity, with elevated proinĆammatory cytokines. Till et al. [

8] found

that women with IBS and conĄrmed dysbiosis had a 50Ű80 % higher prevalence of PFD compared

to controls without dysbiosis. Probiotic administration, including Lactobacillus and BiĄdobacterium

strains, reduced pelvic symptoms by 30Ű40 % in pilot studies [

6], [9]. In the neuroendocrine pathway,

chronic stress activates the HPA axis, elevating cortisol and altering motility. Lovell and Ford [

10]

demonstrated that patients with anxiety and depression have a 60 % higher likelihood of functional

constipation, which is an independent risk factor for pelvic organ prolapse. A signiĄcant correlation

(r = 0.45, p < 0.01) was observed between salivary cortisol levels and fecal incontinence severity [

7],

[

11].

Tabla 4. Distribution of studies according to the pathophysiological mechanisms linking IBS and

pelvic ﬂoor dysfunction (n = 45).

Pathophysiological

pathway

Number of

studies (n)

Percentage

(%)

Main ﬁndings

Neurological pathway 23 51.1 Altered spinal reﬂexes, paradoxical anal

sphincter contraction, vagal dysfunction,

and abnormal central neural control con-

tributing to pelvic ﬂoor dyssynergia and

visceral hypersensitivity [

4], [5], [6].

Microbiological pathway 12 26.7 Gut dysbiosis associated with increased

intestinal permeability, immune activa-

tion, systemic inﬂammation, and im-

provement after probiotic administration

[

6], [8], [9].

Neuroendocrine path-

way

10 22.2 Chronic stress, HPA-axis activation, el-

evated cortisol, altered gastrointestinal

motility, anxiety, depression, and in-

creased severity of functional bowel dis-

orders [

7], [10], [11].

Total 45 100.0 Ð

B. Clinical Evidence of Comorbidity

It was observed that 32 studies (41.0 %) evaluated comorbidity between PFD and functional gas-

trointestinal disorders. Of these, 18 (56.2 %) analyzed PFD and IBS. The meta-analysis by Till et

al. [8] included 12 observational studies with 8,450 patients and found that women with IBS had

a 65 % higher prevalence of urinary incontinence (OR: 1.65; 95 % CI: 1.42Ű1.92) and a 58 % higher

prevalence of pelvic organ prolapse (OR: 1.58; 95 % CI: 1.33Ű1.88) compared to controls. The most

frequent shared symptoms were chronic pelvic pain (72 %) and bloating (68 %). Nine studies (28.1 %)

examined PFD and functional constipation. Barber and Maher [

1] reported that up to 50 % of women

with signiĄcant pelvic organ prolapse, stages IIŰIV, report obstructive defecation. Chung et al. [

16]

found that chronic functional constipation is an independent risk factor for prolapse (HR: 1.8; 95 % CI:

1.4Ű2.3), and that treating constipation with Ąber and osmotic laxatives reduced prolapse progression

by 25 % at 12 months. Five studies (15.6 %) analyzed anxiety and depression. Lovell and Ford [

10]

found that patients with chronic pelvic pain had an anxiety prevalence of 45 % and depression of 38 %,

signiĄcantly higher than the general population, 15 % and 10 %, respectively (p < 0.001). Depressed

patients also showed poorer response to pelvic Ćoor physical therapy, with 40 % improvement versus

65 % in non-depressed patients.

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Tabla 5. Clinical evidence of comorbidity between pelvic ﬂoor dysfunction and gut-brain

axis-related disorders.

Comorbidity axis Number of

studies (n)

Percentage

(%)

Main ﬁndings

PFD and IBS 18 56.2 Women with IBS showed higher preva-

lence of urinary incontinence and pelvic

organ prolapse; the most frequent shared

symptoms were chronic pelvic pain and

bloating [

8].

PFD and functional con-

stipation

9 28.1 Obstructive defecation was frequent in

women with signiﬁcant pelvic organ pro-

lapse, and chronic functional constipation

was identiﬁed as an independent risk fac-

tor for prolapse development and progres-

sion [

1], [16].

PFD and anxiety or de-

pression

5 15.6 Patients with chronic pelvic pain showed

higher anxiety and depression prevalence,

as well as poorer response to pelvic ﬂoor

physical therapy [

10].

Total 32 100.0 Ð

C. Outcomes of Interdisciplinary Management Models

The review revealed that 23 studies (29.5 %) evaluated interventions involving two or more special-

ties. Eight studies (34.8 %) assessed biofeedback for dyssynergic defecation, reporting success rates of

70Ű80 % [5], with signiĄcant reduction in defecation time, from 15 to 5 minutes (p < 0.001), and fecal

incontinence episodes, from 3 to 1 per week (p < 0.01). Improvement persisted at 12 months in 65 % of

patients. Six studies (26.1 %) evaluated combined surgical teams. Cundiﬀ et al. [3] reported signiĄcant

improvement in defecatory function scores, from 5.2 to 2.1 (p < 0.01), and a reduction in reintervention

rate from 15 % to 5 % in patients undergoing combined surgery for rectocele and enterocele. Overall

satisfaction reached 85 % at 24 months. The dermatology-cardiology clinic model describ ed by Mehta

et al. [

19] provides a tangible example of successful co-management that can be extrapolated to pelvic

surgery. Similarly, the framework proposed by Kaushik and Scher [

20] oﬀers a practical screening and

referral algorithm for nephrology, applicable to coordination among gynecology, gastroenterology, and

general surgery. Nine studies (39.1 %) evaluated dietary and microbiota interventions. Till et al. [

found that Ąber supplementation, with psyllium 10 g/day, reduced constipation by 40 % and improved

prolapse symptoms by 25 %. In patients with IBS and conĄrmed dysbiosis, a low-FODMAP diet re-

duced abdominal bloating by 50 % and pelvic pain by 35 % at 8 weeks. Cost-eﬀectiveness analyses,

though scarce, suggest that reducing repeated referrals and unnecessary surgeries could oﬀset the initial

investment in multidisciplinary clinics [

15].

Tabla 6. Outcomes of interdisciplinary management models for pelvic ﬂoor dysfunction.

Intervention model Number of

studies (n)

Percentage

(%)

Main ﬁndings

Biofeedback for dyssynergic

defecation

8 34.8 Reported success rates of 70±80 %, reduced defeca-

tion time and fecal incontinence episodes, with im-

provement persisting at 12 months in 65 % of pa-

tients [

5].

Combined surgical teams 6 26.1 Improved defecatory function scores, reduced

reintervention rates, and increased patient satis-

faction after coordinated surgery for rectocele and

enterocele [

3], [19], [20].

Dietary and microbiota in-

terventions

9 39.1 Fiber supplementation, low-FODMAP diet, and

microbiota-oriented interventions reduced consti-

pation, bloating, pelvic pain, and prolapse-related

symptoms [

8], [15].

Total 23 100.0 Ð

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D. Critical Analysis of the Evidence

Most included studies (58 %) were observational, with only 12 % randomized controlled trials.

Methodological quality was high in 40 % of systematic reviews and moderate in 45 %, according to

AMSTAR 2. The main limitations were small sample sizes, with a median of 45 patients; lack of

adequate control groups in 30 %; and variability in diagnostic criteria. Clinical practice guidelines,

assessed through AGREE II, showed acceptable methodological rigor but deĄciencies in applicability

to resource-limited settings. Heterogeneity in inclusion criteria, assessment scales, and follow-up times

hampers direct comparison. Nevertheless, there is general consensus that interdisciplinary approaches

improve clinical outcomes, with an average 35 % reduction in global symptomatology and a 40 %

improvement in quality of life.

CONCLUSIONS

This systematic review, based on 78 studies published up to May 2026, concludes that pelvic Ćoor

dysfunction is a complex neuro-biomechanical disorder in which the gut-brain axis plays a central and

determinant role. The neurological, microbiological, and neuroendo crine pathways act synergistically,

modulating pelvic tone, visceral sensitivity, and symptom perception. This interconnection explains

why treatments aimed exclusively at anatomical correction, without addressing underlying GBA factors,

often yield suboptimal results or early recurrence.

The evidence conĄrms high comorbidity with IBS (OR: 1.65 for urinary incontinence; OR: 1.58 for

prolapse), functional constipation (HR: 1.8 for prolapse), and psychological disorders, with anxiety at

45 % and depression at 38 %. These Ąndings underscore that the clinical overlap is not coincidental but

reĆects common etiological mechanisms mediated by the GBA, mandating a paradigm shift in diagnos-

tic and therapeutic approaches. Interdisciplinary models integrating biofeedback-assisted pelvic Ćoor

physical therapy, with success rates of 70Ű80 %; dietary and microbiota modulation, with constipation

reduction of 40 % and prolapse symptom improvement of 25 %; psychological support; and coordinated

surgery by combined gynecological and colorectal teams, with reintervention reduction from 15 % to

5 %, demonstrate superior outcomes compared to traditional siloed approaches.

However, important methodological limitations persist: 58 % of studies are observational, only 12 %

are RCTs, sample sizes are small, with a median of 45 patients, and diagnostic criteria are heteroge-

neous. Despite these limitations, the consistency of Ąndings strongly supports the implementation of

interdisciplinary pelvic Ćoor clinics, esp ec ially in Latin America, where fragmented care and cultural

barriers have perpetuated underdiagnosis and suboptimal management.

Future research should prioritize randomized trials with long-term follow-up, cost-eﬀectiveness stu-

dies adapted to middle-income settings, identiĄcation of biomarkers to personalize GBA-targeted inter-

ventions, qualitative research on barriers and facilitators to interdisciplinary models, and evaluation of

telemedicine to expand access in rural areas. Pelvic Ćoor dysfunction transcends traditional specialty

boundaries and requires a collaborative, humanized, and evidence-based response. The ultimate goal

is not merely to repair anatomical defects but to restore global function and comprehensive well-being,

recognizing that pelvic health is intrinsically linked to digestive health, emotional balance, and quality

of life.

AUTHOR CONTRIBUTIONS

According to the CRediT taxonomy, the contributions of the authors to this study are detailed

below:

• Conceptualization: Cindy Michelle Cede

no Calero.

• Methodology: G

enesis Guadalupe Cede

no Bazurto, Cindy Michelle Cede

no Calero.

• Validation: G

enesis Guadalupe Cede

no Bazurto, Carla Emilia Parra Mor

an.

• Formal analysis: G

enesis Guadalupe Cede

no Bazurto, Cindy Michelle Cede

no Calero.

• Investigation: G

enesis Guadalupe Cede

no Bazurto, Cindy Michelle Cede

no Calero, Carla Emilia

Parra Mor

an, Juan Geancarlo Tapia Olarte.

• Data curation: G

enesis Guadalupe Cede

no Bazurto, Carla Emilia Parra Mor

an.

• Writing Ű original draft: G

enesis Guadalupe Cede

no Bazurto, Cindy Michelle Cede

no Calero.

Cede˜no M. et al. Pelvic Floor Dysfunction and Gut-Brain Axis

222

ISSN-e: 2697-3650

Per

ıodo: mayo±agosto, 2026

Revista Minerva

Vol. 7, N

umero 20. (pp. 215-224)

• Writing Ű review and editing: G

enesis Guadalupe Cede

no Bazurto, Cindy Michelle Cede

Calero, Carla Emilia Parra Mor

an, Juan Geancarlo Tapia Olarte.

• Visualization: G

enesis Guadalupe Cede

no Bazurto, Carla Emilia Parra Mor

an.

• Supervision: Cindy Michelle Cede

no Calero.

• Project administration: Cindy Michelle Cede

no Calero.

ACKNOWLEDGMENT

The authors thank the Hospital de Especialidades Portoviejo and the Universidad Ib eroamericana

del Ecuador (UNIBE) for institutional support during the development of this research.

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AUTHORS

Cindy Michelle Cede˜no Calero is a physician at Hospital de Especiali-

dades Portoviejo, Ecuador, specializing in gastro enterology.

G´enesis Guadalupe Cede˜no Bazurto is an independent researcher based

in Toronto, Canada, with expertise in pelvic Ćoor dysfunction and inter-

disciplinary healthcare approaches.

Carla Emilia Parra Moran is an independent researcher from Quito,

Ecuador, with interests in womenŠs health and integration of medical spe-

cialties.

Juan Geancarlo Tapia Olarte is an independent researcher from Cusco,

Peru, with a focus on neurobiological mechanisms underlying pelvic Ćo or

dysfunction.

Cede˜no M. et al. Pelvic Floor Dysfunction and Gut-Brain Axis

224