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Original Research |

Urinary Incontinence in Young Nulligravid Women: A Cross-sectional Analysis

Tessa O'Halloran; Robin J. Bell, MBBS, PhD; Penelope J. Robinson, MBiostat; and Susan R. Davis, MBBS, PhD
[+] Article, Author, and Disclosure Information

From the Women's Health Research Program, School of Public Health, Monash University, Melbourne, Victoria, Australia.

Grant Support: By grant 490939 from the Australian National Health and Medical Research Council (Dr. Davis) and a Victorian Cancer Agency Public Health Research Fellowship (Dr. Bell).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-2540.

Reproducible Research Statement:Study protocol, statistical code, and data set: Available from Dr. Davis (e-mail, susan.davis@monash.edu).

Requests for Single Reprints: Susan R. Davis, MBBS, PhD, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, Victoria 3004, Australia; e-mail, susan.davis@monash.edu.

Current Author Addresses: Ms. O'Halloran, Drs. Bell and Davis, and Ms. Robinson: Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, Victoria 3004, Australia.

Author Contributions: Conception and design: T. O'Halloran, R.J. Bell, S.R. Davis.

Analysis and interpretation of the data: T. O'Halloran, R.J. Bell, P.J. Robinson, S.R. Davis.

Drafting of the article: T. O'Halloran, R.J. Bell, S.R. Davis.

Critical revision of the article for important intellectual content: T. O'Halloran, R.J. Bell, S.R. Davis.

Final approval of the article: T. O'Halloran, R.J. Bell, P.J. Robinson, S.R. Davis.

Provision of study materials or patients: S.R. Davis.

Statistical expertise: R.J. Bell, P.J. Robinson.

Administrative, technical, or logistic support: T. O'Halloran, S.R. Davis.

Collection and assembly of data: T. O'Halloran.

Ann Intern Med. 2012;157(2):87-93. doi:10.7326/0003-4819-157-2-201207170-00005
Text Size: A A A

Background: Although pregnancy is a risk factor for urinary incontinence (UI), the extent of UI in nulligravid women has not been reported.

Objective: To investigate the rate of UI in a sample of young nulligravid women and its potential risk factors and effect on quality of life.

Design: Cross-sectional, self-administered questionnaire–based study.

Setting: University campuses and medical and allied health clinics.

Participants: Nulligravid Australian women aged 16 to 30 years.

Measurements: The Questionnaire for Urinary Incontinence Diagnosis, the Psychological General Well-Being Index (PGWBI), the King's Health Questionnaire, and the International Physical Activity Questionnaire-Short Form. Demographic variables and potential risk factors were also documented.

Results: 1018 of 1620 questionnaires (63%) were returned, and 1002 provided analyzable data. The mean age of participants was 22.5 years (SD, 3.2). The rate of any UI was 12.6% (95% CI, 10.5% to 14.7%). Incontinence was slightly more common in students than in nonstudents (13.2% [CI, 11.0% to 15.8%] vs. 10.6% [CI, 6.7% to 14.6%]). Rates of UI varied according to sexual activity and use of combined oral contraceptives (COCs), with highest rates reported by students who were ever sexually active and not using COCs (21.5% [CI, 16.7% to 27.3%]). Women with UI reported significantly lower overall well-being than women without UI and had worse PGWBI scores related to anxiety, depression, positive well-being, and self-control.

Limitation: A convenience sample of healthy, well-educated women was recruited, and response rates and participant characteristics varied by setting.

Conclusion: In a sample of young nulligravid women, UI was associated with ever being sexually active and no COC use, as well as lower psychological well-being. Further research is needed to assess the prevalence and risk factors for UI in nulligravid women.

Primary Funding Source: None.


Grahic Jump Location

Study flow diagram.

QUID = Questionnaire for Urinary Incontinence Diagnosis.

Grahic Jump Location




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Error of Comparing Groups in the Absence of Sufficient Statistical Power
Posted on July 17, 2012
Michael Falola, MD,MPH
University of Alabama at Birmingham
Conflict of Interest: None Declared

In the abstract of the paper “Urinary Incontinence in Young Nulligravid Women: A Cross-sectional Analysis” by O’Halloran T et al (1), it was stated that “Incontinence was slightly more common in students than in nonstudents…” and that highest rates of urinary incontinence (UI) were reported by those ever sexually active and not using combined oral contraceptive (COC). While I can think of how increased sexual activity and and lack of use of oral contraceptive can be indirectly linked to increased rate of urinary incontinence, I can not figure out how being a student can be linked to UI. And unfortunately, the authors did not provide explanation in their discussion for this finding. Could the “student status” represent unmeasured factors? If yes, what are they? From the logistic analysis, if higher rates of UI were truly more in the people that were ever sexually active and not using COCs and UI is “slightly more common” in students, then one would expect the presence of these factors to be higher among students when compared to nonstudents. However, the data in table showed the exact opposite.In my opinion, I think UI was slightly more common in students as a result of insufficient sample, particularly of the nonstudents. Less than 24% of the analysed participants were nonstudents. Obviously, more students were recruited probably because of easy access. The study was not well-powered to compare the rates of UI between students and nonstudents. Besides, if authors deemed it necessary to restrict the remaining part to students due to smaller number of nonstudents with UI (n=25), then they should reframe the statement that UI is more common in students or provide scientific explanation for the finding.


1. O’Halloran T, Bell RJ, Robinson PJ, Davis SR. Urinary Incontinence in Young Nulligravid Women: A Cross-sectional Analysis.Ann Intern Med. 17 July 2012;157(2):87-93

Sub-analysis of the Effect of OCPs on Different Types of Urinary Incontinence Missing
Posted on July 24, 2012
Ashish K Tiwari
Michigan State University
Conflict of Interest: None Declared

I read with interest the recent article by O'Halloran and colleagues that describes the prevalence of Urinary incontinence (UI) in nulliparous young women (1). Menopause and parity are the two most commonly associated physiological variables with UI that have received considerable attention in the past. The uniqueness of the study lies in its target population: relatively healthy young females with no significant predisposition to develop UI. However, although authors presented their data on the type of UI in students plus non-students together, they didn't provide the sub analysis of UI type when they excluded non-students from their calculation. This is of significance because: 1) observations made in the study (regarding the protective effect of OCPs) are contrary to previous studies which have been meticulous with regards to the type of UI; 2) urge- and stress- UI have different mechanisms and a sub analysis could help explain the reasons behind these contrary observations in young nulliparous females. For example, in NHS study (2), OCPs were found to increase the risk of urge-UI but no change in stress/mixed-UI. On the other hand, WHI study observed that HRT increased the incidence of stress- and mixed-UI in post-menopausal women but had no effect on urge-UI (3). Although a closer look at the study population reveals some clues towards possible explanations for such contradictory results [nulliparous (1), premenopausal but likely parous (2), and postmenopausal (3)], the underlying mechanism is still unclear. A sub analysis of the effect of OCPs on the incidence of different types of UI in nulliparous young females could probably help in developing a better understanding of the underlying mechanism.


(1) O’Halloran T, Bell RJ, Robinson PJ, Davis SR. Urinary Incontinence in Young Nulligravid Women: A Cross-sectional Analysis.Ann Intern Med. 17 July 2012;157(2):87-93

(2) Townsend MK, Curhan GC, Resnick NM, Grodstein F. Oral contraceptive use and incident urinary incontinence in premenopausal women.. J Urol. 2009;1812170-5

(3) Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML. et al., Writing Group for the Women's Health Initiative Investigators, Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial.. JAMA. 2002;288321-33

Author's Response
Posted on September 19, 2012
Susan R. Davis, MBBS, Ph.D., Penelope J Robinson MBiostat, Robin J Bell MBBS, Ph.D.
Women’s Health Research Program, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Commercial Road, Melbourne VIC 3004, Australia
Conflict of Interest: None Declared

We appreciate the opportunity to respond to the letters of Michael Falola and Ashish Tawari about our report on the rate of urinary incontinence (UI) in young nulligravid women[1].

Due to our recruiting methods, our sample consisted of 2 sub-groups, students and non-students. An initial examination of the data showed that the students had a slightly higher rate of UI. Although Falola questions the validity of this comparison on the basis of study power, this was not the only difference found between these groups: students were younger, more likely to be single and never sexually active and were less likely to be using the combined oral contraceptive (COC) and report urinary tract infections. From the logistic regression analysis (which was restricted to students), we found that the likelihood of UI was associated with being ever sexually active and not using the COC. Falola suggests that if these factors were responsible for the higher rate of UI in students, then non-students would be less likely to be sexually active and more likely to be using the COC- and Falola claims our results show the “exact opposite”. However this is not correct- although we showed non-students to be more likely to be sexually active, we also showed that they were more likely to be using the COC. So the lower rate of UI in the non-students could be explained by their use of the COC or it may be that there are other differences between students and non-students of which we are unaware. Ultimately we had to make a decision about how to proceed with the analysis with two subgroups of participants which were different from each on a number of parameters. We had the choice of analyzing the total, knowing the group was heterogeneous, or restricting our analysis to the larger of the subgroups, which we did at the request of journal reviewers.

Tiwari has commented on our lack of evidence in relation to different types of UI (stress, urge and mixed) and that our finding in relation to use of COC and likelihood of UI in young women is inconsistent with evidence from the Nurses Health Study[2] that COC use is associated with a greater likelihood of urge UI. However the evidence in this area is not consistent with Iliadou et al [3] reporting that the use of the COC in young women was associated with a reduced risk of all types of UI. Our study was not powered to examine sub-types of UI.


1. O'Halloran T, Bell RJ, Robinson PJ, Davis SR (2012) Urinary Incontinence in Young Nulligravid Women: A Cross-sectional Analysis Ann Intern Med 157: 87-93

2. Townsend MK, Curhan GC, Resnick NM, Grodstein F (2009) Oral contraceptive use and incident urinary incontinence in premenopausal women J Urol 181: 2170-2175

3. Iliadou A, Milsom I, Pedersen NL, Altman D (2009) Risk of urinary incontinence symptoms in oral contraceptive users: a national cohort study from the Swedish Twin Register Fertil Steril 92: 428-433

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Urinary Incontinence in Women Who Have Never Been Pregnant

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