The Role of Serotonin in Pelvic Floor Adaptation Induced by Physical Activity During Gestational Diabetes Mellitus

Background: Gestational diabetes mellitus (GDM) is one of the most common metabolic disorders during pregnancy and is associated with pregnancy-specific urinary incontinence (PSUI) and long-term pelvic floor dysfunction. Hyperglycemia-induced inflammation, oxidative stress, and diabetic myopathy may impair pelvic floor adaptation, increasing the risk of pelvic floor muscle injury (PFMI) and pelvic organ prolapse (POP). Physical activity is a key non-pharmacological strategy to attenuate diabetic myopathy and promote pelvic floor adaptation. Serotonin has emerged as a potential mediator linking metabolic dysregulation, neuroimmunoendocrine signaling, and pelvic floor adaptation because of its neurological, metabolic, immunomodulatory, and tissue-homeostatic functions. Thus, this narrative review synthesizes and integrates current evidence on the relationships among GDM, diabetic myopathy, pelvic floor dysfunction, serotonin signaling, and physical activity. Methods: We examined the available literature to identify potential mechanistic interactions, current knowledge gaps, and emerging therapeutic perspectives. Results: Current evidence indicates that GDM-induced metabolic and inflammatory alterations may contribute to impaired pelvic floor adaptation and increase the risk of PSUI and POP. Although physical activity and serotonin independently influence metabolic regulation and pelvic floor function, their interaction remains poorly understood. Unlike previous reviews that address these mechanisms separately, we propose a conceptual model connecting metabolic, neuromuscular, and immunological pathways to explain pelvic floor dysfunction in women with GDM. Conclusions: This integrative framework can support the development of targeted preventive and therapeutic strategies while guiding future mechanistic and clinical research.