{"paper_id":"6cf4f3f0-53ea-481a-81c4-f7b9e0e1f1dd","body_text":"The World Health Organization (WHO) defines physical activity as bodily movement produced by skeletal muscles requiring energy expenditure, thus referring to any activity, including leisure time, itinerary transport to work, or even intense physical activity improving health  [1] ,  [2] . Physical activity is a protective factor against different pathologies and health problems, and people who do not participate in physical activity are up to 30% more likely to die  [1] .\nPhysical activity has numerous benefits on both physical and mental levels  [2] ,  [3] ,  [4] ,  [5] ,  [6] . On a physical level, it improves bone mass and resistance  [3] , and helps prevent cardiovascular diseases such as hypertension, weight loss  [4] , cancer  [7] , and diabetes  [8] . On a mental level, it reduces the symptoms of depression and anxiety  [5] ,  [6] , and improves thinking, learning, critical judgment, quality of life, and general well-being  [5] ,  [6] . These benefits occur in women at all stages of their lives  [9] .\nThe new WHO guidelines recommend at least 150–300 min of moderate or vigorous aerobic physical activity per week for all adults, including people living with chronic conditions or disability  [10] . The consequences of physical inactivity at the health level and the cost that this entails, globally it would be approximately $5.2 billion in physical inactivity over a period of 11 yr (2020–30) if global levels of physical activity do not increase  [11] . In this sense, it is necessary to know the physical activity patterns of women  [12] , as well as the factors associated with them  [13] ,  [14] . Thus, factors such as age  [15] , sex  [16] , socioeconomic level  [17] , or interest in the activity to be carried out, especially in women, are associated with the pattern of physical activity  [18] .\nOther more specific factors can also influence the level of physical activity, such as urinary incontinence (UI). Among US women, nearly two out of three view this problem as a barrier to physical activity, meaning that they do not exercise, exercise less, or even have to change their activity routines to accommodate this pelvic floor dysfunction  [19] ,  [20] ,  [21] . This is due, among other reasons, to urine loss during physical activity, which determines not to carry it out  [22] ,  [23] . Additionally, physical activity is considered a social activity; therefore, being affected by UI would negatively impact women's relationships and social life  [24] .\nThe pelvic floor is made up of muscles, ligaments, and fascia. This composition gives it stability to fulfill, among others, its urinary continence function; disturbance of this anatomical structure can cause UI  [25] . Other pelvic floor dysfunctions include pelvic organ prolapse, pelvic pain  [26] , or fecal incontinence  [27] ,  [28] ,  [29] . It is a prevalent problem worldwide and is underdiagnosed  [27] ,  [28] , with global figures that, in some cases, reach 46.5%  [25] ,  [30] ,  [31] . There are different studies with contrasting results, and very few deal with physical activity and its association with UI  [32] .\nOwing to the high prevalence of incontinence and the consequences that it could have on the pattern of physical activity, it becomes a problem with a significant impact on the health of women on physical, mental, and social levels. For this reason and due to the scarcity of recent studies, the objective was to determine whether UI influences the pattern of physical activity and whether a greater impact of urinary symptoms could influence level physical activity.\n\nThis observational study was conducted with women in 2021 and 2022 in Spain. Women under 18 yr of age were excluded, as well as those who had difficulty understanding Spanish, those who had given birth within the previous 12 mo, and those with mental health or cognitive disorders that could affect data collection.\nTo estimate the sample size, we used a prevalence of 11.6%  [20] ,  [21]  for women who do not partake in physical activity within the group of women with UI, a confidence level of 95%, an absolute error of 3%, and an increase due to losses/dropouts of 10%. Thus, a minimum of 487 women with UI would be needed. Taking into account that UI can reach 46.5%  [25] ,  [30] ,  [31]  a total of 1047 women would be needed.\nFirst, women were recruited for the study, and informed consent was obtained. Next, trained observers interviewed the women included in the study to obtain sociodemographic and employment data, previous medical history, health status, lifestyle and habits, obstetric history, and health problem using a previously piloted self-made questionnaire. Data were collected consecutively.\nTo assess the impact of urinary symptoms, the Urogenital Distress Inventory (UDI-6) subscale of the Pelvic Floor Distress Inventory (PFDI-20) was used  [33] ,  [34] . Each question uses the following 0–4 response format, categorized into four levels of dysfunction: none, a little, moderate, or a lot. The minimum score for each subscale is 0, and the maximum is 100 points. The UDI-6 measures the presence, severity, associated urogenital symptoms, and type of UI. Presence and severity are measured on a Likert scale: 0, the symptom does not appear; 1, there is a symptom without discomfort; 2, a symptom with little discomfort; 3, a symptom with moderate discomfort; and 4, a symptom with a lot of discomfort. The presence of incontinence corresponds to values 1–4. This scale is converted into another from 0 to 100; the average value is found (quotient between the sum of values obtained and the number of items answered) and multiplied by 25, obtaining a result of 0, indicating null severity, to 100, indicating maximum severity of urogenital symptoms. Some of the items from the questionnaire are used to classify the type of incontinence. For example, item 2 identifies urge UI, item 3 identifies stress incontinence, and both identify mixed incontinence.\nThe International Physical Activity Questionnaire (IPAQ) was used in its short version to study physical activity  [35] ,  [36] . This classifies adult populations based on activity levels (low, moderate, and high). This questionnaire has adequate validity  [35] . A low level of physical or inactive activity was considered when 600 METs (physical activity unit of the test) were not reached.\nFirst, descriptive statistics were carried out using absolute and relative frequencies, and means with standard deviation (SD) for continuous variables. Next, a bivariate analysis was performed to determine the differentiating characteristics in the sociodemographic and clinical profile of the participating women in relation to the presence of UI.\nBivariate and multivariate analyses were then performed to determine the relationship between UI types and low physical activity or inactivity levels. Finally, this same analysis was carried out, but only on the population of women with incontinence and introducing the impact of urinary symptoms as an independent variable (UDI-6 scale). In both analyses, the Pearson chi-square test was used, and the odds ratio (OR) and adjusted odds ratio (aOR) were estimated with their respective 95% CIs, using binary logistic regression in the latter. When the multivariate analysis was carried out, it was decided to include all the variables with statistical association and/or considered potential confounding factors to adjust the relationship between the types of UI and the impact (UDI-6) on low-level physical activity or inactivity. The statistical program used to analyze the information was SPSS 28.0.\nThe study was approved by the Research Ethics Committee of the province of Jaen (SPCV-0220/0302-N-20). Before starting the questionnaire, the women had to read an information sheet about the study and its objectives, and confirm their consent to participate.\n\nA total of 1446 women participated. Their mean age was 44.3 yr (SD = 14.68) and the mean body mass index (BMI) was 25.0 (SD = 4.75). The majority, 85.7% (1239) of women, did not smoke, and 54.4% (786) drank occasionally. Regarding personal and obstetric history, 28.9% (418) were in menopause, 33.0% (477) had some type of illness, and 78.6% (1131) had been pregnant. Regarding the type of birth, 67.2% (917) had a previous vaginal birth and 26.2% (379) an instrumental one. Regarding the existence of UI and its types, we found that 55.8% (807) of the women reported having some type of UI, the most frequent being mixed in 26.3% (380). The rest of the characteristics can be found in  Table 1 . Table 1 Sociodemographic and clinical characteristics of the study sample Variable n  (%)  N  = 1446 Mean (SD) Age (yr) 44.3 (14.68)  <30 220 (15.2)  30–49.9 799 (55.3)  ≥50 427 (29.5) BMI 25.0 (4.75)  Normal weight <25 830 (57.4)  Overweight 25–29.9 405 (28.0)  Obesity ≥30 211 (14.6) Income level (€)  <1000 196 (13.6)  1000–1999 512 (35.4)  2000–2999 425 (29.4)  >3000 313 (21.6) Alcohol consumption  Never 351 (24.3)  Occasionally 786 (54.4)  Only weekends 144 (10.0)  Frequently 142 (9.8)  Daily 23 (1.6) Smoking habit  No 1239 (85.7)  Yes 207 (14.3) Pregnancy  None 315 (21.8)  One 194 (13.4)  Two or more 937 (64.8) Vaginal birth  None 475 (32.8)  One 289 (20.0)  Two or more 682 (47.2) Instrumental birth  No 1067 (73.8)  Yes 379 (26.2) Tear  No 904 (62.5)  Yes 542 (37.5) Macrosomia  No 1250 (86.4)  Yes 194 (13.4) Menopause  No 1028 (71.1)  Yes 418 (28.9) Illness  No 969 (67.0)  Yes 477 (33.0) Cardiovascular disorder  No 1323 (91.5)  Yes 123 (8.5) Respiratory disorder  No 1408 (97.4)  Yes 38 (2.6) Endocrine disorder  No 1298 (89.8)  Yes 148 (10.2) Gynecological disorder  No 1404 (97.1)  Yes 42 (2.9) Musculoskeletal disorder  No 1353 (93.6)  Yes 93 (6.4) Neurological disorder  No 1412 (97.6)  Yes 34 (2.4) Neoplastic disease  No 1434 (99.2)  Yes 12 (0.8) Gastrointestinal disorder  No 1404 (97.1)  Yes 42 (2.9) Dermatological disorder  No 1424 (98.5)  Yes 22 (1.5) Neoplastic disorder  No 1421 (98.3)  Yes 25 (1.7) Nephrourological disorder  No 1436 (99.3)  Yes 10 (0.7) Immunological disorder  No 1435 (99.2)  Yes 11 (0.8) Ophthalmological ENT disorder  No 1421 (98.3)  Yes 25 (1.7) Type of incontinence  No incontinence 639 (44.2)  Exclusively stress incontinence 86 (5.9)  Exclusively urge incontinence 341 (23.6)  Mixed incontinence 380 (26.3) BMI = body mass index; ENT = ear, nose, and throat; SD = standard deviation.\nSociodemographic and clinical characteristics of the study sample\nBMI = body mass index; ENT = ear, nose, and throat; SD = standard deviation.\nNext, the differentiating characteristics between the women who reported having UI and those who did not present this problem were studied. In this analysis, it was observed that women with UI had a statistically significant ( p  ≤ 0.05) older age, higher BMI, greater number of pregnancies, vaginal births, instrumental birth, perineal trauma, higher frequency of menopausal status, higher percentage of previous illness, and greater probability of low physical activity ( Table 2 ). Table 2 Characteristics of the women based on the presence of urinary incontinence (bivariate analysis) Variable Urinary incontinence p  value No  n  (%)  ( N  = 639) Yes  n  (%)  ( N  = 807) Age (yr) <0.001  <30 145 (22.7) 75 (15.2)  30–49.9 348 (54.5) 451 (55.9)  ≥50 146 (22.8) 281 (34.8) BMI <0.001  Normal weight <25 430 (67.3) 400 (49.6)  Overweight 25–29.9 157 (24.6) 248 (30.7)  Obesity ≥30 52 (8.1) 159 (19.7) Income level (€) 0.618  <1000 78 (12.2) 118 (14.6)  1000–1999 229 (35.8) 283 (35.1)  2000–2999 191 (29.9) 234 (29.0)  >3000 141 (22.1) 172 (21.3) Alcohol consumption 0.372  Never 139 (21.8) 212 (26.3)  Occasionally 355 (55.6) 431 (53.4)  Only weekends 68 (10.6) 76 (9.4)  Frequently 66 (10.3) 76 (9.4)  Daily 11 (1.7) 12 (1.5) Smoking habit 0.255  No 540 (84.5) 699 (86.6)  Yes 99 (15.5) 108 (13.4) Pregnancy <0.001  None 208 (32.6) 107 (13.3)  One 95 (14.9) 99 (12.3)  Two or more 336 (52.6) 601 (74.5) Vaginal birth <0.001  None 301 (47.1) 174 (21.6)  One 104 (16.3) 185 (22.9)  Two or more 234 (36.6) 448 (55.5) Previous cesarean 0.127  None 523 (81.8) 660 (81.8)  One 76 (11.9) 113 (14.0)  Two or more 40 (6.3) 34 (4.2) Instrumental birth <0.001  No 517 (80.9) 550 (68.2)  Yes 122 (19.1) 257 (31.8) Perineal trauma (episiotomy or tear) <0.001  No 534 (86.5) 565 (72.5)  Yes 83 (13.5) 214 (27.5) Menopause <0.001  No 492 (47.9) 536 (52.1)  Yes 147 (35.2) 271 (64.8) Illness <0.001  No 969 (67.0)  Yes 477 (33.0) Cardiovascular disorder <0.001  No 610 (95.5) 713 (88.4)  Yes 29 (4.5) 94 (11.6) Respiratory disorder 0.113  No 627 (98.1) 781 (96.8)  Yes 12 (1.9) 26 (3.2) Endocrine disorder 0.030  No 586 (91.7) 712 (88.2)  Yes 53 (8.3) 95 (11.8) Gynecological disorder 0.623  No 622 (97.3) 782 (96.9)  Yes 17 (2.7) 25 (3.1) Musculoskeletal disorder <0.001  No 616 (96.4) 737 (91.3)  Yes 23 (3.6) 70 (8.7) Neurological disorder 0.014  No 631 (98.7) 781 (96.8)  Yes 8 (1.3) 26 (3.2) Neoplastic disease 0.447  No 635 (94.2) 799 (99.0)  Yes 4 (0.6) 8 (1.0) Gastrointestinal disorder 0.003  No 630 (98.6) 774 (95.9)  Yes 9 (1.4) 33 (4.1) Dermatological disorder 0.239  No 632 (98.9) 792 (98.1)  Yes 7 (1.1) 15 (1.9) Neoplastic disorder 0.014  No 634 (99.2) 787 (97.5)  Yes 5 (0.8) 20 (2.5) Nephrourological disorder 0.122  No 637 (99.7) 799 (99.0)  Yes 2 (0.3) 8 (1.0) Immunological disorder 0.600  No 635 (99.4) 800 (99.1)  Yes 4 (0.6) 7 (0.9) Ophthalmological ENT disorder 0.004  No 635 (99.4) 786 (97.4)  Yes 4 (0.6) 21 (2.6) Prolapse <0.001  No 588 (92.0) 655 (81.2)  Yes 51 (8.0) 152 (18.8) Pelvic pain <0.001  No 563 (88.1) 612 (75.8)  Yes 76 (11.9) 195 (24.2) Low levels of physical activity 0.022  No 494 (77.3) 581 (72.0)  Yes 145 (639) 226 (28.0) BMI = body mass index; ENT = ear, nose, and throat. The values in bold are statistically significant values.\nCharacteristics of the women based on the presence of urinary incontinence (bivariate analysis)\nBMI = body mass index; ENT = ear, nose, and throat.\nThe values in bold are statistically significant values.\nThe next step was to determine the relationship between UI and low level of physical activity using bivariate and multivariate analyses. In this last analysis, it was observed that only the highest level of economic income was associated with a lower probability of low physical activity ( p  < 0.001), while pelvic pain (aOR: 1.48; 95% CI: 1.08–2.02) and the type of mixed incontinence (aOR: 1.53; 95% CI: 1.09–2.15) were statistically associated with a higher frequency of low physical activity ( Table 3 ). Table 3 Type of incontinence and relationship with low levels of physical activity (bivariate and multivariate analyses) Variable Low levels of physical activity Bivariate analysis Multivariate analysis No  n  (%)  ( N  = 1075) Yes  n  (%)  ( N  = 371) OR (95% CI) p  value aOR (95% CI) p  value Age (yr) 0.038 0.177  <30 163 (74.1) 57 (25.9) 1 (ref.) 1 (ref.)  30–49.9 613 (76.7) 186 (23.3) 0.87 (0.62–1.22) 0.418 0.73 (0.43–1.23) 0.230  ≥50 299 (79.0) 128 (30.0) 1.22 (0.85–1.77) 0.278 1.12 (0.53–2.36) 0.774 BMI <0.001 0.480  Normal weight <25 645 (77.7) 185 (22.3) 1 (ref.) 1 (ref.)  Overweight 25–29.9 291 (71.9) 114 (28.1) 1.37 (1.04–1.79) 0.024 0.88 (0.55–1.43) 0.623  Obesity ≥30 139 (65.9) 72 (34.1) 1.81 (1.30–2.51) <0.001 1.37 (0.61–3.10) 0.448 Income level (€) <0.001 <0.001  <1000 116 (59.2) 80 (40.8) 1 (ref.) 1 (ref.)  1000–1999 370 (72.3) 142 (27.7) 0.56 (0.39–0.79) <0.001 0.64 (0.44–0.92) 0.017  2000–2999 334 (78.6) 91 (21.4) 0.40 (0.27–0.57) <0.001 0.46 (0.31–0.69) <0.001  >3000 255 (81.5) 58 (18.5) 0.33 (0.22–0.49) <0.001 0.39 (0.25–0.61) <0.001 Alcohol consumption 0.164 0.684  Never 244 (69.5) 107 (30.5) 1 (ref.) 1 (ref.)  Occasionally 594 (75.6) 192 (24.4) 0.74 (0.56–0.98) 0.032 0.86 (0.64–1.16) 0.317  Only weekends 112 (77.8) 32 (22.2) 0.65 (0.41–1.03) 0.064 0.79 (0.48–1.26) 0.306  Frequently 109 (76.8) 33 (23.2) 0.69 (0.44–1.08) 0.107 0.83 (0.52–1.34) 0.451  Daily 16 (69.6) 7 (30.4) 1.00 (0.40–2.50) 0.996 1.34 (0.52–3.48) 0.549 Smoker 0.878 0.619  No 922 (74.4) 317 (25.6) 1 (ref.) 1 (ref.)  Yes 153 (73.9) 54 (26.1) 1.03 (0.73–1.44) 1.09 (0.77–1.55) Menopause 0.119 0.087  No 776 (75.5) 252 (24.5) 1 (ref.) 1 (ref.)  Yes 299 (71.5) 119 (28.5) 1.23 (0.94–1.58) 0.61 (0.34–1.08) Number of pregnancies 0.323 0.403  Zero 244 (77.5) 71 (22.5) 1 (ref.) 1 (ref.)  One 140 (72.2) 54 (27.8) 1.33 (0.88–2.00) 0.178 1.36 (0.68–2.73) 0.391  Two or more 691 (73.7) 246 (26.3) 1.22 (0.91–1.65) 0.190 1.01 (0.45–2.27) 0.972 Number of vaginal births 0.157 0.649  Zero 369 (77.7) 106 (22.3) 1 (ref.) 1 (ref.)  One 210 (72.7) 79 (27.3) 1.31 (0.94–1.83) 0.117 1.32 (0.72–2.42) 0.366  Two or more 496 (72.7) 186 (27.3) 1.31 (0.99–1.72) 0.057 1.01 (0.45–2.27) 0.395 Previous cesarean 0.508 0.482  None 873 (73.8) 310 (26.2) 1 (ref.) 1 (ref.)  One 147 (77.8) 42 (22.2) 0.81 (0.56–1.16) 0.245 0.89 (0.55–1.43) 0.623  Two or more 55 (74.3) 19 (25.7) 0.97 (0.57–1.67) 0.920 1.37 (0.61–3.10) 0.448 Previous instrumental birth 0.230 0.554  No 802 (75.2) 265 (24.8) 1 (ref.) 1 (ref.)  Yes 273 (72.0) 106 (28.0) 1175 (0.90–1.53) 0.91 (0.67–1.24) Perineal trauma 0.030 0.964  No 863 (75.6) 278 (24.4) 1 (ref.) 1 (ref.)  Yes 212 (69.5) 93 (30.5) 1.36 (1.03–1.80) 1.01 (0.73–1.40) Menopause 0.118 0.087  No 776 (75.5) 252 (24.5) 1 (ref.) 1 (ref.)  Yes 299 (71.5) 119 (28.5) 1.22 (0.95–1.58) 0.61 (0.34–1.08) Pelvic pain <0.001 0.01 5  No 901 (76.7) 274 (23.3) 1 (ref.) 1 (ref.)  Yes 174 (64.2) 97 (35.8) 1.83 (1.38–2.43) 1.48 (1.08–2.02) Prolapse 0.002 0.135  No 942 (75.8) 301 (24.2) 1 (ref.) 1 (ref.)  Yes 133 (65.5) 70 (34.5) 1.65 (1.20–2.26) 1.30 (0.92–1.85) Previous illness 0.024 0.870  No 738 (76.2) 231 (23.8) 1 (ref.) 1 (ref.)  Yes 337 (79.6) 140 (29.4) 1.33 (1.04–1.70) 1.02 (0.77–1.35) Type of incontinence <0.001 0.038  No incontinence 494 (77.3) 145 (22.7) 1 (ref.) 1 (ref.)  Exclusively stress incontinence 70 (81.4) 16 (18.6) 0.78 (0.44–1.38) 0.505 0.75 (0.42–1.35) 0.335  Exclusively urge incontinence 253 (74.2) 88 (25.8) 1.19 (0.87–1.61) 0.141 1.22 (0.89–1.67) 0.223  Mixed incontinence 258 (67.9) 122 (32.1) 1.61 (1.21–2.14) <0.001 1.53 (1.09–2.15) 0.014 aOR = adjusted odds ratio; BMI = body mass index; CI = confidence interval; OR = odds ratio; ref. = reference. The values in bold are statistically significant values.\nType of incontinence and relationship with low levels of physical activity (bivariate and multivariate analyses)\naOR = adjusted odds ratio; BMI = body mass index; CI = confidence interval; OR = odds ratio; ref. = reference.\nThe values in bold are statistically significant values.\nFinally, it was analyzed how the impact of urinary symptoms influences low-level physical activity; for this analysis, only the group of incontinent women were included. In this way, after adjusting for all the variables, it was identified that a greater intensity of urinary symptoms (UDI-6 score) was associated with a greater probability of low physical activity (aOR: 1.014; 95% CI: 1.01–1.02;  Table 4  and  Fig. 1 ). Furthermore, in this analysis, older age and BMI were also associated with a higher probability of low physical activity, while a higher income level was associated with a lower probability of low physical activity ( p  < 0.001;  Table 4 ). Table 4 Factors associated with low levels of physical activity in women with urinary incontinence and its relationship with the impact of urinary symptoms (bivariate and multivariate analyses) Variable Low levels of physical activity Bivariate analysis Multivariate analysis No  n  (%)  ( N  = 581) Yes  n  (%)  ( N  = 226) OR (95% CI) p  value aOR (95% CI) p  value Age (yr) 0.001 0.045  <30 58 (77.3) 17 (22.7) 1 (ref.) 1 (ref.)  30–49.9 343 (76.1) 108 (23.9) 1.07 (0.60–1.92) 0.809 1.22 (0.55–2.71) 0.629  ≥50 180 (64.1) 101 (35.9) 1.91 (1.06–3.46) 0.032 2.99 (1.05–8.56) 0.041 BMI 0.001 0.120  Normal weight <25 309 (77.3) 91 (22.8) 1 (ref.) 1 (ref.)  Overweight 25–29.9 173 (69.8) 75 (30.2) 1.47 (1.03–2.11) 0.034 1.22 (0.83–1.79) 0.313  Obesity ≥30 99 (62.3) 60 (37.7) 2.06 (1.38–3.06) <0.001 1.59 (1.02–2.48) 0.040 Income level (€) <0.001 0.003  <1000 60 (50.8) 58 (49.2) 1 (ref.) 1 (ref.)  1000–1999 205 (72.4) 78 (27.6) 0.39 (0.25–0.61) <0.001 0.51 (0.32–0.30) 0.007  2000–2999 181 (77.4) 53 (22.6) 0.30 (0.19–0.49) <0.001 0.39 (0.23–0.24) <0.001  >3000 135 (78.5) 37 (21.5) 0.28 (0.17–0.47) <0.001 0.41 (0.23–0.73) 0.002 Alcohol consumption 0.079 0.737  Never 137 (64.6) 75 (35.4) 1 (ref.) 1 (ref.)  Occasionally 323 (74.9) 108 (25.1) 0.61 (0.43–0.87) 0.007 0.81 (0.55–1.19) 0.287  Only weekends 58 (76.3) 18 (23.7) 0.57 (0.31–1.03) 0.063 0.89 (0.46–1.69) 0.711  Frequently 55 (72.4) 21 (27.6) 0.70 (0.39–1.24) 0.220 0.93 (0.50–1.74) 0.824  Daily 8 (66.7) 4 (33.3) 0.91 (0.27–3.13) 0.885 1.57 (0.43–5.79) 0.500 Smoker 0.455 0.973  No 500 (71.5) 199 (28.5) 1 (ref.) 1 (ref.)  Yes 81 (75.0) 27 (25.0) 0.84 (0.53–1.33) 0.99 (0.61–1.63) Menopause 0.054 0.054  No 401 (74.8) 135 (25.2) 1 (ref.) 1 (ref.)  Yes 180 (66.4) 91 (33.6) 0.48 (0.23–1.01) 0.48 (0.23–1.01) Number of pregnancies 0.483 0.733  Zero 82 (76.6) 25 (23.4) 1 (ref.) 1 (ref.)  One 69 (69.7) 30 (30.3) 1.43 (0.77–2.65) 0.262 1.05 (0.39–2.86) 0.915  Two or more 430 (71.5) 171 (28.5) 1.30 (0.81–2.11) 0.279 0.81 (0.28–2.37) 0.704 Number of vaginal births 0.159 0.605  Zero 135 (77.6) 39 (22.4) 1 (ref.) 1 (ref.)  One 133 (71.9) 52 (28.1) 1.35 (0.84–2.19) 0.216 1.50 (0.68–3.33) 0.317  Two or more 313 (69.9) 135 (30.1) 1.49 (0.99–2.25) 0.055 1.46 (0.58–3.68) 0.427 Previous cesarean 0.097 0.218  None 466 (70.6) 194 (29.4) 1 (ref.) 1 (ref.)  One 91 (80.5) 22 (19.5) 0.58 (0.35–0.95) 0.031 0.65 (0.35–1.19) 0.163  Two or more 24 (70.6) 10 (29.5) 1.00 (0.47–2.13) 0.998 1.33 (0.46–3.84) 0.604 Instrumental birth 0.398 0.226  No 401 (72.9) 149 (27.1) 1 (ref.) 1 (ref.)  Yes 180 (70.0) 77 (30.0) 1.15 (0.83–1.60) 0.79 (0.53–1.16) Perineal trauma 0.127 0.739  No 432 (73.5) 156 (26.5) 1 (ref.) 1 (ref.)  Yes 149 (68.0) 70 (32.0) 1.30 (0.93–1.83) 0.93 (0.63–1.40) Menopause 0.012 0.063  No 401 (74.8) 135 (25.2) 1 (ref.) 1 (ref.)  Yes 180 (66.4) 91 (33.6) 1.50 (1.09–2.07) 0.49 (0.23–1.04) Pelvic pain <0.001 0.205  No 464 (75.8) 148 (24.2) 1 (ref.) 1 (ref.)  Yes 117 (60.0) 78 (40.0) 2.09 (1.49–2.94) 1.32 (0.86–2.04) Prolapse 0.037 0.764  No 482 (73.6) 173 (26.4) 1 (ref.) 1 (ref.)  Yes 99 (65.1) 53 (34.9) 1.49 (1.02–2.17) 1.07 (0.70–1.64) Previous illness 0.014 0.750  No 371 (75.1) 123 (24.9) 1 (ref.) 1 (ref.)  Yes 210 (67.1) 103 (32.9) 1.48 (1.08–2.02) 0.94 (0.65–1.37) Impact of urinary symptoms (UDI-6), mean (SD) 31.00 (20.42) 42.64 (27.38) 1.02 (1.01–1.03) 0.001 1014 (1.01–1.02) 0.001 aOR = adjusted odds ratio; BMI = body mass index; CI = confidence interval; OR = odds ratio; ref. = reference; SD = standard deviation; UDI-6 = Urogenital Distress Inventory. The values in bold are statistically significant values. Fig. 1 Urogenital Distress Inventory (UDI-6) scale scores according to low level of physical activity VS normal level physical activity.\nFactors associated with low levels of physical activity in women with urinary incontinence and its relationship with the impact of urinary symptoms (bivariate and multivariate analyses)\naOR = adjusted odds ratio; BMI = body mass index; CI = confidence interval; OR = odds ratio; ref. = reference; SD = standard deviation; UDI-6 = Urogenital Distress Inventory.\nThe values in bold are statistically significant values.\nUrogenital Distress Inventory (UDI-6) scale scores according to low level of physical activity VS normal level physical activity.\n\nMore than half of the women in the present study had UI, with mixed UI being the most frequent type and present in one out of four women. Among the factors associated with low physical activity in the group of women, low income, pelvic pain, and the type of UI were found. In addition, within the group of incontinent women, we found age, income, BMI, and the impact of urinary symptoms to have a relationship with a greater probability of low physical activity.\nAmong the strengths of the study, we can highlight the large sample size and the study of the impact of urinary symptoms, and not only the presence or absence of incontinence as a factor. In addition, to determine the physical activity level and presence of pelvic floor dysfunction, we used validated instruments that have already been used in a population similar to that of the study  [33] ,  [34] ,  [35] ,  [36] . In the case of a survey, memory and selection biases cannot be ruled out completely; however, if present in this study, there would be little influence on the results as the questionnaire had been piloted and the questions were formulated in colloquial language accessible to all educational levels. We do not believe that a confounding bias has influenced the results. We aimed to control for biases as much as possible with the selection criteria of the participants, for example, by excluding women who had given birth in the last 12 mo to avoid the influence that the process of pregnancy and childbirth can have on their pattern of physical activity, as well as by using a multivariable analysis and including in the model all those variables that could influence the results.\nAn older age was associated with a higher probability of low physical activity, in line with other authors  [15] ,  [37] . This may be due to physical deterioration with increasing age, which in turn is combined with a decrease in physical activity, affecting a woman's physical condition  [37] .\nA low-income level was associated with a higher probability of having low physical activity, which coincides with the findings of other studies  [17] . In this sense, Martins et al.  [15]  found that having few financial resources decreases physical activity rather than increasing it, in line with our results.\nPelvic pain, in our results, was identified to be associated with a greater possibility of having low physical activity, in line with other studies, although most collect results from the stage of pregnancy, childbirth, and postpartum  [38] . Other authors indicate physical activity as an intervention that favors the reduction of the intensity of pain caused by endometriosis, although more research is needed  [39] .\nIn our study, the intensity of urinary symptoms was associated with the probability of low physical activity, such that a higher intensity increases the probability of low physical activity, as already identified by other researchers  [19] ,  [20] ,  [21] . Although this seems to be due to the fact that urine losses force women to adapt their physical activity  [22] ,  [23] , in some cases, it conditions them so significantly that they abandon physical activity entirely, becoming completely inactive  [19] ,  [40] . A priori, the bidirectionality of these variables, UI and physical activity, can be considered. However, not all women who have little physical activity have UI. We carried out a literature search and did not find any study that has studied these variables and considered this association: associating low physical activity with a greater probability of incontinence. In addition, UI has been identified in women who practice professional sports  [41] . On the contrary, it is very reasonable to consider that women who have UI can stop doing physical activity. In the literature, it is stated that individuals who suffer from UI are more predisposed to suffer emotional problems and social isolation, and many feel ashamed and worried. Some even go so far as to drastically modify their habitual customs, especially in the case of women, avoiding leaving their homes, not using public transport, or rejecting sexual activity, among others  [42] . Women with UI are afraid of urine leaking in social situations due to this lack of control and loss of self-esteem, and there is a social stigma regarding the subject. Women report feeling ashamed that urine leakage occurs, for example, when doing physical activity, and that it can be perceived by other people (the smell, the mark it can leave on clothes, etc.)  [24] . All of this suggests that these reasons may lead women with UI to reduce and even stop doing physical activity, as has already been discussed and identified by other authors  [32] ,  [43] .\nWith an adequate assessment and individualized interventions, the quality of life of these women could be improved, allowing them to exercise, thereby providing them with the benefits of physical activity. UI is associated with a lower level of physical activity, and these women are deprived of the benefits physical activity provides in preventing and dealing with multiple pathologies  [2] ,  [3] ,  [4] ,  [5] ,  [6] ,  [7] ,  [8] ,  [9] .\nIn the approach to pelvic floor problems, and more specifically to UI, it is necessary to take into account the inclusion of the decrease in physical activity that this entails, in order to be able to implement the necessary measures to address it and encourage the initiation or maintenance of physical activity, so that these women can benefit from all that physical activity provides on physical, mental, and social levels. For this reason, it is also necessary to provide greater visibility to this problem experienced by many women, implementing controls and monitoring at all levels to detect these conditions and provide early care with adequate and effective treatment  [44] .\n\nMixed-type UI is associated with low-level physical activity or inactivity in women, while among women with UI, a greater impact of the symptoms increases the probability of low physical activity or inactivity.\nAuthor contributions:  All authors had full access to all the data in the study and take responsability for the integrity of the data and the accuracy of the data analysis.\nStudy concept and design : Juan Miguel Martínez-Galiano.\nAcquisition of data : Juan Miguel Martínez-Galiano, Rocio Adriana Peinado-Molina, Sergio Martínez-Vázquez.\nAnalysis and interpretation of data : Juan Miguel Martínez-Galiano, Antonio Hernández-Martínez, Rocio Adriana Peinado-Molina.\nDrafting of the manuscript : Juan Miguel Martínez-Galiano, Rocio Adriana Peinado-Molina, Sergio Martínez-Vázquez, Antonio Hernández-Martínez.\nCritical revision of the manuscript for important intellectual content : Juan Miguel Martínez-Galiano, Rocio Adriana Peinado-Molina, Antonio Hernández-Martínez, Sergio Martínez-Vázquez.\nStatistical analysis : Antonio Hernández-Martínez.\nObtaining funding : Juan Miguel Martínez-Galiano, Rocio Adriana Peinado-Molina.\nAdministrative, technical, or material support : Juan Miguel Martínez-Galiano, Antonio Hernánedez-Martínez, Sergio Martínez-Vázquez, Rocio Adriana Peinado-Molina.\nSupervision : Juan Miguel Martínez-Galiano.\nOther : None.\nFinancial disclosures:  All authors certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.\nFunding/Support and role of the sponsor:  This project was cofunded by the Operative Program FEDER 2014–2020, and the Ministry of Economics and Knowledge of the Government of Andalucía ( 1380358). The third author received a Grant from the Program University Teacher Training, financed by the Ministry of Universities Government of Spain (FPU20/01567).\nEthics statement:  The study received a favorable opinion from the Research Ethics Committee of the province of Jaen (SPCV-0220/0302-N-20). Before starting the questionnaire, the women had to read an information sheet about the study and its objectives, and confirm their consent to participate. The consent form notified all participants of our intent to publish.\nData sharing:  Data are available upon reasonable request.\nAcknowledgments:  The authors thanks all the participants of this study.","source_license":"CC-BY-4.0","license_restricted":false}