Urinary incontinence symptoms and knowledge across activity levels in young women (UI-SKY Project): a mixed-methods comparative study

Abstract

Background

Urinary incontinence (UI) in young women is increasingly recognized but remains under-reported and insufficiently addressed. While physical activity has been implicated in pelvic floor dysfunction, evidence regarding its relationship with urinary incontinence remains heterogeneous and context-dependent. This study aimed to evaluate UI prevalence, symptom burden, and knowledge, and to explore perceptions and care-seeking behaviors among young women.

Methods

A nationwide mixed-methods comparative study was conducted among 461 women aged 18–40 years in Thailand. Participants were categorized into three groups based on physical activity levels: athletes (n = 141), recreationally active (n = 152), and sedentary (n = 168). Quantitative data were collected using validated questionnaires including ICIQ-UI SF, IIQ-7, and PIKQ-UI which assessed UI severity, impact on quality of life, and knowledge of urinary incontinence, respectively. Multivariable regression analyses were performed to assess associations between activity level and outcomes. In-depth interviews were conducted with 30 participants and analyzed using reflexive thematic analysis. Findings were integrated using an explanatory sequential approach.

Results

Overall, 30.8% of participants reported UI, with prevalence decreasing across activity levels (39% sedentary, 30% recreationally active, 22% athletes; p = 0.004). Athletes had significantly lower odds of UI compared with sedentary women (adjusted OR 0.45, 95% CI 0.25–0.80; p = 0.007). Physical activity was not associated with symptom severity among symptomatic individuals. Both athletes and recreationally active women reported lower quality-of-life impact compared with sedentary participants (adjusted OR 0.55 and 0.52, respectively). Despite these favorable outcomes, athletes demonstrated significantly lower pelvic floor knowledge (adjusted OR 0.17, 95% CI 0.08–0.34; p < 0.001), indicating a knowledge–behavior gap. Qualitative findings revealed consistent themes of age-related misperception, symptom normalization, stigma, and delayed care-seeking. Participants commonly relied on self-management and informal information sources, and a substantial gap between PFMT awareness and practice was identified.

Conclusion

UI in young women in this study population represents an under-recognized public health issue, with prevalence highest among sedentary individuals. While physical activity is associated with lower UI prevalence and better quality-of-life outcomes, significant gaps in pelvic floor knowledge and health-seeking behavior persist, particularly among athletes. Integrated, behaviorally informed interventions are needed to improve awareness, promote preventive practices, and address system-level barriers in this population.

Introduction

Female urinary incontinence (UI), defined as the involuntary leakage of urine, is commonly classified into stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). UI affects women across all age groups, with an estimated prevalence of 30% to 60%, and represents a significant public health concern due to its impact on quality of life [1, 2]. Well-established risk factors for UI include pregnancy and childbirth, chronic conditions associated with increased intra-abdominal pressure, aging, and menopause [3]. However, growing evidence indicates that UI is not limited to older or parous women. In recent years, UI has been increasingly reported among young women, including those engaging in high-impact or vigorous physical activity; however, findings across studies remain inconsistent [4, 5]. Repetitive loading of the pelvic floor has been proposed as a potential mechanism contributing to stress urinary incontinence in certain high-impact athletic populations; however, its role in overall urinary incontinence risk among young women remains uncertain [6].

The underlying mechanisms of SUI are largely attributed to repeated increases in intra-abdominal pressure, which impose excessive strain on the pelvic floor muscles and urethral support structures [7]. Over time, this mechanical stress may lead to muscle fatigue, impaired urethral support, and delayed reflex contraction, resulting in urinary leakage. These mechanisms may be relevant in specific contexts, particularly among women exposed to high-impact or high-volume physical activity, although their overall contribution remains unclear [8]. However, the extent to which these mechanisms translate into clinically significant UI in broader populations remains uncertain.

In contrast, UUI, or overactive bladder (OAB), is generally associated with dysregulation of bladder control mediated by the autonomic nervous system [9]. Although more commonly linked to aging, UUI has also been observed in younger women, and it has been hypothesized that physiological stress related to intensive training may contribute to autonomic imbalance and abnormal bladder function [10], although evidence in younger populations remains limited.

Beyond symptom occurrence, urinary incontinence in young women is often under-recognized and underreported, particularly among physically active individuals in whom symptoms may be perceived as a normal consequence of exercise [11]. Misconceptions that UI primarily affects older or parous women may further limit awareness, leading to normalization of symptoms, delayed care-seeking, and unmet health needs [12]. Importantly, while previous studies have largely focused on prevalence and risk factors, limited attention has been given to the level of knowledge and awareness of UI in young women, and how this may vary across different activity levels [11, 13]. Understanding both symptom burden and knowledge is essential, as insufficient awareness may hinder early recognition and appropriate health-seeking behavior [14, 15]. Furthermore, quantitative approaches alone may not adequately capture the underlying perceptions, attitudes, and barriers related to UI in this population. A mixed-methods approach is therefore warranted to provide a more comprehensive understanding by integrating quantitative assessment with qualitative insights into individual experiences and perceptions.

Participation in physical activity among women has increased substantially in recent years. However, comparative evidence examining UI across different levels of physical activity remains limited, particularly studies that concurrently evaluate both symptoms and knowledge. Understanding these aspects across athletes, recreational exercisers, and non-exercisers may help identify high-risk groups, reveal knowledge gaps, and inform targeted screening, education, and preventive strategies at the population level.

Therefore, this study aimed to compare the prevalence and types of urinary incontinence, symptom burden, and pelvic floor knowledge across different physical activity levels in young women, and to explore perceptions and care-seeking behaviors related to urinary incontinence using a mixed-methods approach.

Methods

Study design and setting

This study employed a mixed-methods comparative design using an explanatory sequential approach. The quantitative component consisted of a cross-sectional survey conducted among young women in Thailand using an online, self-administered questionnaire. The qualitative component comprised in-depth interviews to further explore perceptions, experiences, and barriers related to urinary incontinence. Participants were categorized into three groups based on physical activity levels: sedentary, recreationally active, and athletes, according to predefined criteria adapted from prior literature.

Ethics

This study was approved by the Human Research Ethics Committee of the Faculty of Medicine Ramathibodi Hospital, Mahidol University (MURA2025/892), and conducted in accordance with the Declaration of Helsinki.

For the quantitative component, participants provided electronic informed consent via the first page of the online questionnaire before accessing the study questions. Data were collected anonymously, and no personally identifiable information was recorded.

For the qualitative component, participants provided written informed consent prior to participation in in-depth interviews. Interviews were audio-recorded, transcribed verbatim, and pseudonymised to ensure confidentiality. All data were securely stored and accessible only to the research team. Participation was voluntary.

Clinical trial number: not applicable.

Participants

Eligible participants were Thai women aged 18–40 years who were able to communicate in Thai and willing to complete the study questionnaires. Exclusion criteria included a history of diagnosed pelvic floor disorders (e.g., urinary incontinence, anal incontinence, pelvic organ prolapse), chronic medical conditions affecting pelvic floor function (e.g., connective tissue diseases, neurological disorders), and self-reported neurological conditions affecting lower urinary tract function (e.g., spinal cord injury, multiple sclerosis, Parkinson’s disease, post-stroke lower urinary tract symptoms). Participants were stratified into three groups according to physical activity levels [16]:

1. Sedentary: <150 moderate-equivalent minutes/week; no structured training or competition in the past 6 months.

2. Recreationally active: 150–300 moderate-equivalent minutes/week; no elite/professional training or formal competition.

3. Athletes: ≥300 moderate-equivalent minutes/week and participation in structured training or competition within the past 6 months.

Sample size

The sample size was calculated to detect differences in the prevalence of stress urinary incontinence (SUI) across three activity groups. Based on prior studies reporting SUI prevalence of approximately 30% in athletes, 22% in recreationally active women, and 14% in non-exercisers [17], a total sample size of 388 participants (129 per group) was required to achieve 80% power at a two-sided α of 0.05, and equal allocation across the three groups using the Cochran–Armitage trend test. SUI was used as the reference condition for sample size calculation because it is the most consistently reported subtype in the literature and represents a substantial proportion of overall urinary incontinence in this population.

Quantitative component

The quantitative component aimed to assess prevalence, symptom burden, and knowledge across activity groups.

Measurements

Urinary incontinence was assessed using the validated Thai version of the International Consultation on Incontinence Questionnaire–Urinary Incontinence Short Form (ICIQ-UI SF) [18]. UI was defined as any score greater than zero. Types of UI (SUI, UUI, and mixed UI) were classified based on responses to the non-scored item on leakage circumstances. Severity of UI was measured using the total ICIQ-UI SF score (range 0–21), with higher scores indicating greater severity and impact. Quality of life was assessed using the Incontinence Impact Questionnaire–Short Form (IIQ-7) [19]. Scores were calculated as the sum of item responses (range 0–21), with higher scores indicating greater impact.

Knowledge of UI was evaluated using the validated Thai version of the Prolapse and Incontinence Knowledge Questionnaire–Urinary Incontinence domain (PIKQ-UI) [20]. Scores were calculated as the number of correct responses, and knowledge proficiency was defined as ≥ 80% correct [21, 22].

Pelvic floor muscle training (PFMT) awareness and practice were assessed using self-reported items on prior experience and frequency of practice. PFMT awareness and practice were assessed using brief, study-specific items. Participants were asked the following questions:

1. “Have you ever heard of pelvic floor muscle training (e.g., Kegel exercises)?” (yes/no).

2. “Do you currently perform pelvic floor muscle training?” (yes/no).

3. “If yes, how often do you perform pelvic floor muscle training?” with response options including “rarely,” “occasionally,” and “regularly.” These items were designed to capture basic awareness and behavior and were used for descriptive and exploratory purposes rather than as validated measures of PFMT knowledge or adherence.

Statistical analysis

Descriptive statistics were used to summarize participant characteristics. Continuous variables were presented as mean ± standard deviation or median (interquartile range), as appropriate, and categorical variables as frequencies and percentages.

The primary outcome was the prevalence of UI across activity groups. Differences were assessed using the Chi-square test, followed by multivariable logistic regression adjusting for potential confounders, including age, body mass index (BMI), parity, PFMT awareness, and lifestyle factors. For analysis, PFMT awareness was defined as a “yes” response to the first question, and regular practice was defined based on self-reported frequency. Results were reported as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Pairwise comparisons were conducted with Bonferroni correction (α = 0.0167). A Cochran–Armitage trend test was used to assess trends across ordered activity levels. Continuous outcomes (ICIQ-UI SF, IIQ-7, and PIKQ-UI scores) were compared using ANOVA or Kruskal–Wallis tests, with appropriate post hoc analyses. Multivariable linear regression models were used to estimate adjusted differences. Missing data were handled using complete-case analysis if < 5% missingness; otherwise, multiple imputation using chained equations was applied under a missing-at-random assumption. All statistical analyses were performed using R software (R Foundation for Statistical Computing, Vienna, Austria).

Qualitative component

The qualitative component aimed to explore perceptions, experiences, and barriers related to urinary incontinence.

Data collection

In-depth interviews were conducted with a purposive sample of participants. Topics included experiences and perceptions of UI, its emotional and social impact, knowledge and understanding of PFMT, barriers and facilitators to care-seeking, and sociocultural influences. Interviews were conducted either in person or via secure online platforms and lasted approximately 10–15 min. An interview approach was used, guided by open-ended topics rather than a fixed questionnaire.

Data analysis

Interview transcripts were analyzed using reflexive thematic analysis following Braun and Clarke’s framework [23]. Coding was primarily inductive, with consideration of key quantitative findings. Trustworthiness was ensured through analyst triangulation, reflexivity, and maintenance of an audit trail. Coding and theme development were discussed among members of the research team to enhance credibility. Member checking was not performed due to the anonymized design and exploratory nature of the study.

Mixed-methods integration

Findings from quantitative and qualitative components were integrated using an explanatory sequential approach. Joint displays were developed to align quantitative results with qualitative themes, enabling comprehensive interpretation.

Results

Participant characteristics

Participant characteristics are summarized in Table 1. A total of 461 women were included in the final analysis: 141 (30.6%) athletes, 152 (33.0%) recreationally active, and 168 (36.4%) sedentary participants. Differences were also observed in healthcare-related occupations and pelvic floor muscle training practice. All findings should be interpreted within the context of this study population, which excluded individuals with a prior diagnosis of pelvic floor disorders.

Table 1.

Baseline characteristics of study participants by physical activity group

Characteristic	Overall (N = 461)	Athlete (N = 141)	Recreationally active (N = 152)	Sedentary (N = 168)	p-value
Age, years (mean ± SD)	26.7 (6.8)	23.4 (4.9)	28.4 (7.2)	28.1 (7.0)	< 0.001
BMI, kg/m² (mean ± SD)	22.0 (4.4)	20.6 (2.9)	21.8 (3.6)	23.3 (5.6)	< 0.001
Education ≥ university, n (%)	391 (85%)	105 (74%)	135 (89%)	151 (90%)	< 0.001
Healthcare occupation, n (%)	101 (22%)	12 (8.5%)	43 (28%)	46 (27%)	< 0.001
Married/cohabiting, n (%)	65 (14%)	7 (5.0%)	24 (16%)	34 (20%)	< 0.001
Parity ≥ 1, n (%)	53 (11%)	12 (8.5%)	17 (11%)	24 (14%)	0.30
Vaginal delivery, n (%)	16 (3.5%)	8 (5.7%)	3 (2.0%)	5 (3.0%)	0.20
Current smoker, n (%)	1 (0.2%)	0 (0%)	0 (0%)	1 (0.6%)	0.40
Regular caffeine intake, n (%)	314 (68%)	95 (67%)	104 (68%)	115 (68%)	> 0.90
Hormonal contraception, n (%)	91 (20%)	19 (13%)	38 (25%)	34 (20%)	0.046
PFMT awareness, n (%)	206 (45%)	57 (40%)	80 (53%)	69 (41%)	0.055
Regular PFMT practice, n (%)	75 (16%)	40 (28%)	25 (16%)	10 (6.0%)	< 0.001
Regular core exercise, n (%)	102 (22%)	32 (23%)	60 (39%)	10 (6.0%)	< 0.001

Values are presented as mean (standard deviation) or number (percentage). Between-group differences were assessed using one-way ANOVA or Kruskal–Wallis tests for continuous variables, and Pearson’s chi-squared test for categorical variables

BMI body mass index, PFMT pelvic floor muscle training

Prevalence and subtypes of urinary incontinence

Overall, 142 participants (30.8%) reported urinary incontinence within this previously undiagnosed population. A significant gradient in prevalence was observed across activity groups, with the highest prevalence among sedentary women (39%), followed by recreationally active (30%) and athletes (22%) (p = 0.004).

Because Table 2 includes both continent and incontinent participants, distributions of symptom scores are influenced by a high proportion of zero values; therefore, additional analyses were performed among participants with urinary incontinence. Unadjusted comparisons of urinary symptoms and related outcomes across activity groups are shown in Table 2. Among women with UI (n = 142), subtype distribution differed significantly across groups (Fisher’s exact test with Monte Carlo simulation, p = 0.035). Stress urinary incontinence (SUI) predominated among athletes (76%), whereas urgency urinary incontinence (UUI) was proportionally more common among sedentary participants (30%). Mixed and other subtypes accounted for smaller proportions across all groups (Figs. 1 and 2).

Table 2.

Urinary incontinence outcomes by physical activity group

Outcome	Overall (N = 461)	Athlete (N = 141)	Recreationally active (N = 152)	Sedentary (N = 168)	p-value
Urinary incontinence, n (%)					0.004
No UI	319 (69%)	110 (78%)	107 (70%)	102 (61%)
UI	142 (31%)	31 (22%)	45 (30%)	66 (39%)
ICIQ-UI SF score, median (Q1, Q3)	0.0 (0.0, 4.0)	0.0 (0.0, 0.0)	0.0 (0.0, 3.0)	0.0 (0.0, 4.0)	0.006
IIQ-7 score, median (Q1, Q3)	0.0 (0.0, 4.8)	0.0 (0.0, 0.0)	0.0 (0.0, 0.0)	0.0 (0.0, 4.8)	0.023
Knowledge proficiency, n (%)					< 0.001
Not proficient	313 (68%)	129 (91%)	86 (57%)	98 (58%)
Proficient	148 (32%)	12 (8.5%)	66 (43%)	70 (42%)

Values are presented as number (percentage) or median (Q1, Q3). Between-group differences were assessed using Pearson’s chi-squared test for categorical variables and Kruskal–Wallis tests for continuous variables

UI urinary incontinence, ICIQ-UI SF International Consultation on Incontinence Questionnaire–Urinary Incontinence Short Form, IIQ-7 Incontinence Impact Questionnaire–7

Fig. 1.

Distribution of urinary incontinence subtypes among participants with UI, by physical activity group. Stacked bar chart showing the distribution of urinary incontinence subtypes among participants with urinary incontinence across activity groups. Colors represent urgency UI, stress UI, mixed UI, and other types

Fig. 2.

Adjusted odds ratios for the association between physical activity group and urinary incontinence. Forest plot showing adjusted odds ratios and 95% confidence intervals for urinary incontinence across physical activity groups

Association between physical activity and urinary incontinence

In multivariable logistic regression adjusting for age, BMI, educational attainment, marital status, parity, PFMT practice, core exercise engagement, and hormonal contraceptive use, athletes had significantly lower odds of reporting UI compared with sedentary women (adjusted OR 0.45, 95% CI 0.25–0.80; p = 0.007). The recreationally active group showed a non-significant reduction in UI odds (adjusted OR 0.69, 95% CI 0.40–1.16; p = 0.16). A significant dose–response relationship was observed, with each decrement in activity level associated with increased odds of UI (OR 1.48, 95% CI 1.12–1.98; p for trend = 0.007) (Figure 2). Higher BMI was independently associated with increased odds of UI (adjusted OR 1.09 per unit increase, p < 0.001) (Table 3). This association is visually represented in Fig. 3.

Table 3.

Multivariable regression analyses of physical activity group and urinary incontinence outcomes

Outcome	Model	Variable	Adjusted estimate (95% CI)	p-value
Urinary incontinence (UI) (ref: sedentary)	Logistic	Athlete	0.45 (0.25–0.80)	0.007
		Recreationally active	0.69 (0.40–1.16)	0.160
		Dose–response (ordinal)	1.48 (1.12–1.98)	0.007
ICIQ-UI SF score (ref: sedentary)	Linear	Athlete	−0.82 (− 1.50 to − 0.13)	0.017
		Recreationally active	−0.45 (− 1.05 to 0.15)	0.140
IIQ-7 score (ref: sedentary)	Linear	Athlete	−1.45 (− 3.10 to 0.20)	0.084
		Recreationally active	−1.93 (− 3.65 to − 0.21)	0.027
Knowledge proficiency (ref: sedentary)	Logistic	Athlete	0.17 (0.08–0.34)	< 0.001
		Recreationally active	1.08 (0.66–1.78)	0.750

The ordinal model was specified such that higher values represent lower levels of physical activity; therefore, the reported odds ratio reflects the increase in odds of urinary incontinence per one-level decrease in physical activity

Fig. 3.

Conceptual model of urinary incontinence perceptions and care pathways in young women

Symptom severity

Across all participants, athletes had significantly lower ICIQ-UI SF scores compared with sedentary women (adjusted β = −0.82, 95% CI − 1.50 to − 0.13; p = 0.017), indicating a lower overall symptom burden. However, among symptomatic participants (ICIQ-UI SF > 0), physical activity group was not significantly associated with symptom severity (p > 0.05 for all comparisons), suggesting that physical activity is associated with the occurrence of UI rather than its severity once present among this population.

Quality of life impact

Recreationally active women had significantly lower IIQ-7 scores compared with sedentary women (adjusted β = −1.93; p = 0.027). In logistic regression analyses, both athletes (adjusted OR 0.55, 95% CI 0.31–0.96; p = 0.038) and recreationally active women (adjusted OR 0.52, 95% CI 0.30–0.91; p = 0.022) had lower odds of reporting any quality-of-life impairment (IIQ-7 > 0) compared with sedentary participants. Regular PFMT practice was also associated with reduced odds of quality-of-life impact (adjusted OR 0.46, 95% CI 0.22–0.89; p = 0.027).

Pelvic floor knowledge proficiency

Overall, 148 participants (32%) were classified as having proficient knowledge of pelvic floor health. Knowledge proficiency among participants in this study differed significantly across groups, with markedly lower rates among athletes (8.5%) compared with recreationally active (43%) and sedentary women (42%). In adjusted analyses, athletes had significantly lower odds of knowledge proficiency (adjusted OR 0.17, 95% CI 0.08–0.34; p < 0.001). Healthcare-related occupation was the strongest independent predictor of knowledge proficiency (adjusted OR 7.7, 95% CI 4.6–13.3; p < 0.001).

PFMT awareness and practice

Overall, 206 participants (44.7%) reported awareness of PFMT, whereas only 75 (15.2%) reported regular practice. A clear awareness–practice gap was observed: 15.2% were both aware and practicing PFMT, 29.5% were aware but not practicing, and 55.3% had no awareness.

PFMT practice, based on self-reported non-validated items, differed significantly across activity groups (28% in athletes, 16% in recreationally active, and 6% in sedentary participants; p < 0.001), whereas PFMT awareness did not differ significantly (p = 0.055).

Qualitative findings

A total of 30 participants were interviewed. The analysis revealed a consistent pattern of misperception, normalization, stigma, and delayed care-seeking, providing explanatory context for the quantitative findings. A conceptual model integrating these findings is presented in Fig. 3.

Theme 1: “UI Is an old person’s problem”

Participants overwhelmingly framed urinary incontinence (UI) as a condition affecting older or parous women. This deeply embedded perception led to low perceived susceptibility, even among symptomatic individuals.

“I used to think it only happens when you’re much older. I didn’t pay much attention because no one close to me had it. It felt far removed from my life.” — (Recreationally active 10).

This age-centric model also shaped how participants interpreted risk factors. Although factors such as heavy exercise, urine holding, or childbirth were recognized, they were consistently attributed to “others” rather than oneself.

“From what I know, it tends to happen to people who are quite elderly.” — (Recreationally active 08, runner)

I’m Young - This Shouldn’t Be Happening to Me.

Among symptomatic participants, this perception created a mismatch between expectation and experience, leading to confusion, self-doubt, and delayed interpretation of symptoms as clinically relevant.

“Patients who seek medical care for urinary incontinence tend to be older; younger individuals are rarely seen.” — (Sedentary 06, Science student).

“I don’t think it would happen to someone young. — (Recreationally active 04, a trained healthcare professional).

Participants recognized several contributing factors, but consistently framed them as risks for ‘people like that’ rather than for themselves.

“Heavy exercise causes bladder problems because it puts pressure downward.” — (Athlete 04).

“It might occur after childbirth because the pelvic area has to bear a lot of weight from the baby.” — (Sedentary 07).

“I think the muscles that help control urination aren’t working properly, like they’re not working together.” — (Recreationally active 06).

“It might be related to having had a hysterectomy.” — (Athlete 08).

Theme 2: minimizing & normalizing symptoms

Participants commonly downplayed symptoms as minor or normal, particularly when leakage was infrequent or small in volume. This internal minimization was reinforced by peer and family normalization.

“It doesn’t affect me that much because it doesn’t happen often.” — (Sedentary 09).

“I just thought the symptoms were minor, so I didn’t consult anyone.” — (Sedentary 10).

“It seems normal because my friends at university have similar symptoms (peer normalisation).” — (Sedentary 03).

“My mum didn’t really say anything. She said it’s kind of normal, sometimes if you laugh too hard, you just can’t hold it.” — (Recreationally active 02).

“We just chatted about it over a meal; nobody really thought of it as a serious problem.” — (Recreationally active 01).

However, further exploration revealed hidden impacts, including embarrassment, reduced confidence, and behavioral adaptation, suggesting that perceived triviality masked meaningful burden.

“It’s mostly about cleanliness, that’s what stresses me the most. Sometimes I feel uncomfortable.“— (Athlete 06).

“If I have to wear a pad for it… I’m not sure whether it would show through. If it did, that would really knock my confidence.” — (Recreationally active 03, Runner).

“If it happens while I’m doing important work, it can affect my performance.” — (Athlete 03, Badminton player).

Theme 3: a body to be ashamed of stigma, shame & secrecy around UI in young women

UI was experienced as a stigmatized and concealable condition. Participants carefully controlled disclosure, typically confiding only in close, trusted individuals.

At the same time, clinicians were perceived as unlikely to initiate discussions about UI in young women, resulting in a mutual silence between patients and healthcare providers.

“She was afraid people at the market would notice she couldn’t hold it (Describing mother’s anxiety about public exposure).” — (Recreationally active 09).

Disclosure followed a consistent hierarchy (same-sex close friends, partner or spouse, mother, known healthcare contact).

“I told my husband. He’s the closest person to me. I’d feel comfortable talking to him about it. I wouldn’t want to worry my mum.” — (Recreationally active 04).

Both patients and clinicians described the same dynamic from opposite sides: patients withheld information due to embarrassment; clinicians did not proactively screen for UI in young women.

“There’s probably shame involved, they don’t feel confident coming in to discuss it. Most who do come are elderly women. Some doctors may not even realize that women who exercise are at risk.” — (Recreationally active 01, Physician/researcher).

“When I went about the uterine polyp, the doctor focused on the reproductive organs — UI was never mentioned.” —(Recreationally active 03).

“I consulted an obstetrician–gynaecologist directly, but not about leakage.” — (Sedentary 08).

Theme 4: self-navigation before seeking help information-seeking & self-management pathways

No symptomatic participant went directly to a healthcare provider as their first response. Every individual followed a staged process: search online, consult a trusted peer, self-manage, and seek professional help only if self-management failed. This pattern indicates that care-seeking was reactive rather than proactive, often triggered only by persistent or worsening symptoms.

“The very first thing I’d do is Google it, search YouTube, look for other people with the same symptoms and how they dealt with it.” — (Recreationally active 09).

“I came across it on social media platforms like TikTok.” — (Sedentary 04).

“I imagine having to wait to see the doctor from early morning, it would take a long time before getting treatment, which feels like a waste of time. (Describing perceived access barriers)”. — (Recreationally active 05).

Friends who were medical students or healthcare professionals were particularly valued; they provided clinically credible information in an informal, non-judgmental setting, bypassing the embarrassment of a formal consultation.

“I learned about pelvic floor exercise from a friend studying medicine (peer education as primary knowledge source).” — (Recreationally active 05, Engineering student).

“I’d probably ask my younger sister first, she works at a hospital, whether she thinks I need to see a specialist.” — (Recreationally active 03).

Theme 5: coping strategies & adaptation managing ui through behavioral and lifestyle adjustments

Participants commonly adopted coping strategies such as frequent voiding, use of protective pads, and pre-emptive planning. While these strategies reduced immediate discomfort, they also lowered perceived urgency for seeking care.

“I try not to hold my urine; if I feel the urge, I go to the restroom immediately.” — (Athlete 01).

“ I noticed I couldn’t hold it as long, so whenever I start to feel the urge, I look for the nearest bathroom straightaway.” — (Recreationally active 09).

Several participants adopted sanitary or incontinence pads as a precautionary measure, or developed routines (e.g., pre-exercise bathroom visits) that allowed them to exercise with reduced anxiety.

“It feels like, to be completely safe, I would wear a sanitary pad as protection.” — (Athlete 09).

“What I found suggested that controlling weight and losing weight could help.” — (Athlete 03).

“I wondered whether taking supplements, like herbal remedies for internal health, might help.” — (Athlete 02).

Theme 6: kegel: heard of it, never done it the awareness–practice gap in pelvic floor exercise

Although awareness of pelvic floor muscle training (PFMT) was common, consistent and correct practice was rare.

“I believe it refers to Kegel exercises, but I’ve never tried doing them myself.” — (Athlete 01).

“I’ve heard of it, but I’ve never actually tried it.” — (Recreationally active 08,10).

This gap reflected not only a lack of knowledge but also uncertainty about technique and the absence of structured guidance, explaining the discrepancy observed in quantitative findings.

“I just do it when I come across an article, maybe once a year.” — (Recreationally active 03 ).

“I’m not sure whether I’m doing it right. I just squeeze.” — (Recreationally active 04, Physiotherapist).

“I’d seen it on TikTok, someone talking about what they had to do after giving birth. But they weren’t really explaining the method. I tried it once after watching, but didn’t keep going because I wasn’t sure it was actually doing anything.” — (Sedentary 09).

Theme 7: healthcare system blind spots structural gaps leaving young women unscreened and unsupported

Participants reported limited exposure to UI-related public health information and the absence of routine screening in clinical encounters. Healthcare providers rarely initiated discussions, and PFMT advice, when given, lacked follow-up. No one had encountered a poster, leaflet, or campaign about UI specifically targeting young or working-age women. Only a few participants reported learning about UI through any formal educational channel at all.

“The information I’ve come across is always in the older-age section.” — (Recreationally active 05).

“I’ve never seen anything like that at all. (On UI public health materials for young women)” — (Recreationally active 10).

Integration with quantitative findings

These qualitative findings provide a coherent explanation for the quantitative results. Despite a substantial prevalence of UI, particularly among less active women, low perceived susceptibility, normalization of symptoms, stigma, and reliance on self-management contributed to under-recognition and delayed care-seeking. The observed gap between PFMT awareness and practice was similarly explained by inadequate instruction, low confidence, and lack of behavioral reinforcement. Summary of qualitative themes, sub-themes, and integration with quantitative findings were shown in Table 4.

Table 4.

Summary of qualitative themes, sub-themes, and integration with quantitative findings

Theme	Sub-theme	Description	Representative Quote	Quantitative Link
Theme 1 “UI Is an Old Person’s Problem"	Age-centric illness model	UI was perceived as a condition exclusive to older or parous women, resulting in low perceived personal susceptibility.	“I used to think it only happens when you’re much older. It felt far removed from my life.” (Recreationally active 10)	Despite 30.8% overall UI prevalence, only 32% demonstrated knowledge proficiency; low perceived risk may limit self-identification.
	“This shouldn’t be happening to me"	Symptomatic young women experienced confusion and self-doubt when leakage occurred, delaying recognition of symptoms as clinically significant.	“I don’t think it would happen to someone young.” (Recreationally active 04, healthcare professional)	Athletes, the group with lowest UI prevalence (22%), also had the lowest knowledge proficiency (8.5%), suggesting misperception persists regardless of activity level.
Theme 2 Minimizing & Normalizing Symptoms	Internal minimization	Participants dismissed symptoms as trivial, particularly when leakage was infrequent or minor in volume.	“It doesn’t affect me that much because it doesn’t happen often.” (Sedentary 09)	Sedentary women had the highest UI prevalence (39%) yet lowest PFMT practice rate (6%), consistent with low urgency to act.
	Social normalization	Peer and family members reinforced symptom normalization, framing leakage as a shared, unremarkable experience.	“It seems normal because my friends at university have similar symptoms.” (Sedentary 03)	55.3% of participants reported no PFMT awareness, suggesting normalization may suppress health information-seeking.
	Hidden burden	Despite minimization, participants revealed embarrassment, reduced confidence, and behavioral adaptation, indicating meaningful concealed impact.	“If I have to wear a pad for it… I’m not sure whether it would show through. If it did, that would really knock my confidence.” (Recreationally active 03)	IIQ-7 scores confirmed quality-of-life impairment, particularly among sedentary women (higher IIQ-7 vs. active groups, p = 0.023).
Theme 3 A Body to be Ashamed Of	Stigma and concealment	UI was treated as a shameful, private condition. Disclosure was carefully controlled and limited to trusted individuals following a consistent hierarchy.	“There’s probably shame involved; they don’t feel confident coming in to discuss it.” (Recreationally active 01, Physician/researcher)	Only 30.8% of women reported UI; under-reporting due to stigma likely inflates this gap between true and detected prevalence.
	Clinical double silence	Patients withheld symptoms due to embarrassment; clinicians did not proactively screen for UI in young women, creating mutual silence.	“When I went about the uterine polyp, the doctor focused on the reproductive organs. UI was never mentioned.” (Recreationally active 03)”	No quantitative measure directly captured disclosure; this theme contextualizes the gap between UI prevalence and care-seeking rates.
Theme 4 Self-Navigation Before Seeking Help	Staged care-seeking pathway	No participant sought professional care as a first response. All followed a predictable sequence: online search → peer consultation → self-management → formal care only if symptoms persisted.	“The very first thing I’d do is Google it, search YouTube, look for other people with the same symptoms.” (Recreationally active 09)	Formal healthcare utilization data were not collected; this theme explains delayed presentation and potential under-diagnosis.
	Peer-mediated health information	Friends with medical or healthcare backgrounds were prioritized as information sources, offering clinically credible advice without the stigma of a formal clinical encounter.	“I learned about pelvic floor exercise from a friend studying medicine.” (Recreationally active 05, Engineering student)	Healthcare occupation was the strongest predictor of knowledge proficiency (aOR 7.7, 95% CI 4.6–13.3), underscoring peer knowledge as a proxy access pathway.
Theme 5 Coping Strategies & Adaptation	Behavioral coping strategies	Participants adopted frequent voiding, protective pads, dietary adjustments, and pre-exercise bathroom visits to manage symptoms independently.	“It feels like, to be completely safe, I would wear a sanitary pad as protection.” (Athlete 09)	Coping strategies reduced perceived urgency for care, contributing to the care-seeking gap despite high symptom burden.
	Coping as barrier to care	Effective coping lowered the perceived threshold for professional help-seeking, reinforcing delayed and reactive care patterns.	“I try not to hold my urine; if I feel the urge, I go to the restroom immediately.” (Athlete 01)	Consistent with qualitative findings, only 15.2% of participants reported regular PFMT practice despite 44.7% having PFMT awareness.
Theme 6 “Kegel: Heard of It, Never Done It"	Awareness–practice gap	PFMT awareness was common, but consistent and correct practice was rare. Barriers included technique uncertainty, lack of structured guidance, and absence of behavioral reinforcement.	“I believe it refers to Kegel exercises, but I’ve never tried doing them myself.” (Athlete 01)	44.7% aware of PFMT; only 15.2% practiced regularly, a 29.5%-point awareness–practice gap across all participants.
	Fragmented practice without understanding	Some participants performed PFMT based on informal exposure (TikTok, peers) without conceptual knowledge, explaining athletes’ higher practice rates despite lower knowledge scores.	“I’m not sure whether I’m doing it right. I just squeeze.” (Recreationally active 04, Physiotherapist)	Athletes had highest PFMT practice (28%) yet lowest knowledge proficiency (8.5%), a knowledge–behavior paradox confirmed quantitatively (aOR 0.17, p < 0.001).
Theme 7 Healthcare System Blind Spots	Absence of targeted public health information	Participants had no recall of UI-related public health materials directed at young or physically active women; available information was consistently framed around older populations.	“The information I’ve come across is always in the older-age section.” (Recreationally active 05)	Low knowledge proficiency overall (32%) reflects a structural gap in UI education, not merely individual knowledge deficits.
	Lack of routine clinical screening	Healthcare providers rarely initiated UI discussions in young patients, leaving symptoms undetected during clinical encounters for unrelated conditions.	“I’ve never seen anything like that at all. [On UI public health materials for young women]” (Recreationally active 10)	Healthcare occupation was the sole strong predictor of knowledge proficiency, highlighting system-level disparities in UI health education access.

PFMT pelvic floor muscle training, UI urinary incontinence, aOR adjusted odds ratio, CI confidence interval. Participant identifiers reflect group membership (Athlete, Recreationally active, Sedentary) and interview sequence number

Discussion

This mixed-methods study provides a comprehensive evaluation of urinary incontinence (UI), its impact, awareness, and UI knowledge among young women across different physical activity levels. Three key findings emerged. First, overall UI prevalence was highest among sedentary women and decreased with increasing levels of physical activity. Second, despite lower UI prevalence and better quality-of-life outcomes, athletes demonstrated the lowest level of UI proficiency knowledge. Third, qualitative findings revealed a consistent pattern of misperception, normalization, stigma, and delayed care-seeking, offering important explanatory context for the quantitative results. These findings should be interpreted within the context of existing heterogeneous evidence. While some studies have reported increased stress urinary incontinence among athletes, our results suggest that, at a population level, physical activity may also be associated with lower overall UI prevalence. This underscores the complexity of the relationship and suggests that different mechanisms may operate across UI subtypes and populations.

Previous studies have largely focused on stress urinary incontinence (SUI) among athletes and have often reported higher SUI prevalence in physically active populations [17, 24]. In contrast, the present study demonstrated that sedentary women had the highest overall burden. However, this finding should be interpreted in light of the study design, as participants with a prior diagnosis of pelvic floor disorders, including UI, were excluded; therefore, the results should be interpreted as reflecting urinary incontinence among women without prior diagnosis. This broader outcome definition may explain the apparent discrepancy with prior literature and highlights the importance of considering the full spectrum of UI subtypes when evaluating population-level burden. Importantly, a dose–response pattern was observed, although this finding should be interpreted with caution, with UI prevalence decreasing progressively across sedentary, recreationally active, and athlete groups. This pattern may suggest a potential association between higher physical activity levels and lower overall UI prevalence, although causality cannot be inferred from this cross-sectional design [25, 26]. This pattern reframes UI in young women not as a sport-related condition alone, but as a broader lifestyle-related health issue. At the same time, the higher proportion of SUI among athletes supports the concept that high-impact activity may still impose localized mechanical stress on the pelvic floor, even in otherwise healthier individuals. The apparent contradiction with prior hypotheses, that athletes would have a higher burden of UI, may be explained by differences in study populations and design. The present study focused on young women, in whom UUI and lifestyle-related factors may play a greater role than parity-related pelvic floor damage. In addition, athletes in this cohort were younger, had lower BMI, and may represent a healthier subgroup, potentially reflecting selection or participation effects. These factors may shift the overall UI profile away from SUI-dominant patterns observed in elite athletic cohorts toward a broader and more heterogeneous presentation.

A notable and clinically important finding was the paradoxical pattern observed among athletes: despite having the lowest prevalence of UI and the least impact on quality of life, they demonstrated the lowest level of PFMT knowledge. This paradox challenges the assumption that higher physical performance equates to better health literacy. This suggests a gap between physical performance and pelvic floor health awareness. One possible explanation is that pelvic floor activation may be incorporated implicitly within structured training programs without explicit education, resulting in practice without conceptual understanding [27]. This disconnect may limit the sustainability and effectiveness of preventive strategies.

This apparent “knowledge–behavior paradox” is further explained by the qualitative findings. While athletes demonstrated lower knowledge scores, they were more likely to report engaging in PFMT, suggesting that behavior may be shaped by informal exposure rather than structured understanding. Several participants described having heard of pelvic floor exercises through peers, social media, or training environments, but without clear or comprehensive instruction.

For example, one athlete noted, “I believe it refers to Kegel exercises, but I’ve never tried doing them myself,” while another participant expressed uncertainty about proper technique despite awareness of it. These findings suggest that PFMT-related behaviors may be adopted in a fragmented or experiential manner, without corresponding conceptual knowledge. This disconnect may explain the observed quantitative pattern and highlights the importance of distinguishing between exposure, awareness, and true understanding in pelvic floor health. Together, these findings demonstrate the added value of a mixed-methods approach in uncovering underlying behavioral mechanisms that are not captured by quantitative measures alone.

The qualitative findings provide critical insight into behavioral and sociocultural mechanisms underlying these quantitative patterns. Participants consistently perceived UI as a condition affecting older women, leading to low perceived susceptibility among young individuals [28]. Even when symptoms were present, they were frequently minimized or normalized, particularly when mild or intermittent. Despite this normalization, participants described meaningful psychosocial impacts, including embarrassment, reduced confidence, and behavioral adaptation [29]. Stigma emerged as a central theme influencing help-seeking behavior. UI was treated as a private and potentially shameful condition, resulting in selective disclosure and reluctance to seek care. This was further reinforced by a “double silence” within the healthcare system [30], where patients did not volunteer symptoms and clinicians did not routinely screen for UI in younger populations.

The gap between PFMT awareness and actual practice represents another key finding. Although many participants had heard of PFMT, consistent and correct practice was rare. This suggests that barriers extend beyond knowledge alone and may include lack of confidence, insufficient instruction, and absence of behavioral reinforcement. These findings highlight the need for interventions that move beyond awareness toward sustained behavioral change.

Public health framing

Urinary incontinence (UI) in young women represents a substantial but under-recognized public health burden. Despite a relatively high prevalence, particularly among less physically active individuals, symptoms are frequently normalized, underreported, and not perceived as a condition requiring medical attention. The qualitative findings highlight how misperceptions, stigma, and low perceived susceptibility contribute to delayed recognition and unmet health needs in this population. Beyond individual factors, the findings also suggest a mismatch between symptom burden and health literacy, particularly among physically active women. The observed gap between awareness and effective practice of pelvic floor muscle training (PFMT), as well as the paradoxically low knowledge among athletes, indicates that current health education strategies are insufficient. This gap may limit the effectiveness of early prevention and contribute to persistent under-recognition of UI. This reflects a structural gap in current public health approaches, where UI is framed primarily as a condition of older women, leaving younger populations systematically overlooked.

Policy implications

These findings support the need for targeted public health interventions focusing on early education and prevention of UI in young women. Integrating pelvic floor health education into school curricula, university health programs, and sports training environments may improve awareness and promote preventive behaviors before symptom onset.

At the healthcare system level, routine screening for UI should be considered in primary care and gynecological settings, even among younger and physically active populations. In addition, interventions should extend beyond awareness campaigns to include structured, accessible, and behaviorally informed PFMT programs that emphasize correct technique, adherence, and long-term engagement. Together, these strategies may help bridge the gap between knowledge, behavior, and clinical care.

This study has several strengths. The mixed-methods design enabled integration of quantitative and qualitative data, providing both epidemiological estimates and contextual understanding. The inclusion of participants across a spectrum of physical activity levels allowed for comparative analysis and exploration of potential dose–response relationships. In-depth interviews provided rich insights into behavioral and systemic factors that are not captured by quantitative measures alone. Several limitations should be acknowledged. First, the cross-sectional design precludes causal inference. Second, data were based on self-reported questionnaires and may be subject to recall and social desirability bias. Third, qualitative findings may be influenced by the researcher interpretation, although this was mitigated through triangulation and independent review. Fourth, detailed sport-specific characteristics such as type of sport, training frequency, training volume, and competition exposure were not assessed, which may influence pelvic floor loading and UI risk and introduce residual confounding. Fifth, member checking was not conducted in this study, which may limit the credibility and confirmability of the qualitative findings. Additionally, PFMT awareness and practice were assessed using non-validated, self-reported items. These measures may be subject to recall bias and limited measurement precision, and may not fully capture the complexity or accuracy of PFMT behavior. Therefore, findings related to PFMT should be interpreted with caution. Finally, the use of an online survey may limit generalizability due to potential selection bias. A key limitation of this study is the exclusion of participants with previously diagnosed pelvic floor disorders. Therefore, the findings should be interpreted as reflecting urinary incontinence among women without prior diagnosis, rather than the overall population prevalence. Despite this limitation, the qualitative findings provide valuable insights into perceptions and experiences of urinary incontinence among young women.

The use of an online, self-administered survey may have introduced selection bias, as participants were more likely to be younger, digitally literate, and highly educated. In this study, a high proportion of participants had university-level education, which may not be representative of the general population. This may have influenced both knowledge and reporting patterns. Higher educational attainment may be associated with greater health awareness and access to information, potentially leading to higher measured knowledge levels. At the same time, increased awareness may influence symptom recognition and reporting behavior, which could affect prevalence estimates. Therefore, the findings should be interpreted with caution and may not be fully generalizable to populations with different sociodemographic characteristics, particularly those with lower educational attainment or limited access to digital platforms.

Future directions

Building on the present findings, future research should focus on developing and evaluating targeted interventions to improve pelvic floor health awareness and behaviors among young women. In particular, an “UI-SKY Action Phase” is proposed to translate the identified gaps in knowledge, perception, and care-seeking into practical, evidence-based strategies.

One potential approach is the development of tailored educational content designed specifically for young women, including short-form videos and digital health communication delivered through commonly used platforms. Given the observed gap between awareness and behavior, these interventions should be designed using behavioral science principles to enhance engagement, understanding, and sustained practice of pelvic floor muscle training (PFMT). A randomized controlled trial is warranted to compare the effectiveness of different content formats (e.g., expert-led educational videos, peer-based storytelling, or interactive digital modules) in improving knowledge, PFMT adherence, and symptom outcomes. Such an approach would provide robust evidence to inform scalable, population-level interventions aimed at early prevention and improved management of urinary incontinence in young women.

Conclusions

This study demonstrates a stepwise association between higher levels of physical activity and a lower prevalence of urinary incontinence (UI) among young women. However, physical activity was not associated with symptom severity among those already affected, indicating distinct mechanisms in the development and persistence of UI. A notable finding is the “knowledge paradox,” whereby athletes, despite having the lowest prevalence of UI, exhibited the lowest level of UI knowledge. Together with the observed gap between PFMT awareness and consistent practice, these findings highlight a disconnect between behavior, knowledge, and preventive health strategies.

Overall, UI in young women emerges as an under-recognized and systemically overlooked public health issue. Targeted, behaviorally informed, and scalable interventions are needed to improve awareness, promote preventive practices, and bridge the gap between knowledge and action in this population.

Abbreviations

UI

Urinary incontinence

SUI

Stress urinary incontinence

UUI

Urgency urinary incontinence

MUI

Mixed urinary incontinence

PFMT

Pelvic floor muscle training

ICIQ-UI SF

International Consultation on Incontinence Questionnaire–Urinary Incontinence Short Form

IIQ-7

Incontinence Impact Questionnaire–Short Form

PIKQ-UI

Prolapse and Incontinence Knowledge Questionnaire – Urinary Incontinence domain

HRQoL

Health-related quality of life

BMI

Body mass index

aOR

Adjusted odds ratio

CI

Confidence interval

Authors’ contributions

VR: Project development, Data collection, Funding, Manuscript writing. KA: Data collection JM: Data collection, Validation, Data analysis, Supervision. RW: Data collection, Data analysisOC: Data collection. AS: Project development, Supervision, Data analysis, Manuscript editing, Essentially Intellectual Contributor. All authors edited and approved the final version to be published.

Funding

This research was conducted in the absence of any commercial or financial relationships. This research received funding support from the Faculty of Medicine Ramathibodi Hospital, Mahidol University.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Human Research Ethics Committee of the Faculty of Medicine Ramathibodi Hospital, Mahidol University (MURA2025/892), and conducted in accordance with the Declaration of Helsinki. For the quantitative component, participants provided electronic informed consent via the online questionnaire. Data were collected anonymously, and no personally identifiable information was recorded. For the qualitative component, participants provided written informed consent prior to participation. Interviews were audio-recorded, transcribed verbatim, and pseudonymised to ensure confidentiality. All data were securely stored and accessible only to the research team. Participation was voluntary.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.