Urinary incontinence (UI) is often approached as a condition primarily driven by physical factors, such as pelvic floor strength and coordination, and behavioral factors, such as toileting routines and fluid intake. However, psychological and trauma-related factors, such as stress, anxiety, post-traumatic stress disorder (PTSD), and sexual trauma, may induce physiological responses that contribute to UI. Such factors can cause changes in brain regions critical for urinary control or activate the sympathetic nervous system or hypothalamic-pituitary adrenal axis to release cortisol, which may disrupt the urinary microbiome and impair bladder function. First-line behavioral UI treatment strategies employ pelvic floor muscle training to target pelvic floor strength and coordination, as well as bladder control strategies and fluid modification to improve UI. Although these approaches are evidence-based and effective for many women, they do not address psychological and trauma-related factors, which may attenuate response to first-line behavioral UI treatments.
We conducted a secondary analysis of data from 200 women Veterans who participated in a randomized controlled trial of two remote behavioral UI treatment modalities. Higher levels of perceived stress, diagnosed anxiety, PTSD, and reported sexual trauma were associated with greater UI severity. Notably, higher levels of perceived stress were also associated with lower odds of response to behavioral UI treatment. Although the effect size was modest, this finding provides preliminary evidence suggesting that stress may be an important, actionable intervention target that should be considered in UI care.
An important aspect of our findings is that perceived stress emerged as the only psychological or trauma-related factor associated with treatment response. One potential explanation for this is methodological. Perceived stress was assessed using the validated continuous Perceived Stress Scale-10, which enabled evaluation of stress severity and potential dose-response relationships. In contrast, anxiety, PTSD, and sexual trauma were assessed using binary self-report items, limiting the ability to capture current symptom burden or variability. Notably, unlike PTSD diagnoses or historical trauma exposure, stress and anxiety may reflect more proximal and modifiable factors that directly influence response to behavioral UI treatments. Thus, it is plausible that the use of validated continuous measures of anxiety, such as the Generalized Anxiety Disorder-7, may have identified an association with treatment response.
Women who experience stress, anxiety, or trauma may have reduced engagement in the self-management behaviors required for successful behavioral UI treatment, including adherence to pelvic floor muscle training, bladder control strategies, and fluid modification. Such factors may interfere with the cognitive, emotional, and regulatory resources needed to consistently engage in these interventions over time. For example, elevated stress or anxiety may impair motivation, self-efficacy, and coping capacity, all of which are central to sustained treatment engagement. Women experiencing trauma-related symptoms may also avoid body-focused exercises or healthcare interactions due to discomfort, hypervigilance, shame, or emotional distress. Thus, psychological resilience, defined as the capacity to adaptively regulate emotional responses and maintain goal-directed behavior, may be another key modifiable factor influencing UI severity and treatment response.
Importantly, our findings are unlikely to be unique to women Veterans. Although women Veterans experience disproportionately high rates of stress, anxiety, PTSD, and sexual trauma, such factors are also highly prevalent among non-Veteran women. Therefore, our findings may have broader implications for women with UI, particularly those who have experienced psychological and trauma-related factors.
Our findings are clinically important because women with UI are not typically screened for stress, anxiety, trauma exposure, or mental health conditions. Conversely, UI is not usually assessed in mental health settings. Thus, there is a need for more integrated and interdisciplinary approaches to UI care. Incorporating trauma-informed care principles, including fostering emotional safety, minimizing stigma, promoting empowerment, and recognizing the long-term effects of trauma and current effects of stress and anxiety may improve UI outcomes for women.
As behavioral interventions for UI continue to evolve, including those that are technology-based, there is an opportunity to reconsider how UI care is conceptualized and delivered. Integrating strategies that address psychological and trauma-related factors alongside pelvic floor strength, coordination, and behavioral factors may enhance treatment effectiveness and improve outcomes for women with UI.
Written by: Danielle Scharp, PhD, APRN, FNP-BC,1,2 Karen M. Goldstein, MD, MSPH,3,4 Ursula A. Kelly, PhD, MSN,5,6 Kathryn L. Burgio, PhD,7,8 Camille P. Vaughan, MD, MS,9,10 Orna Intrator, PhD,2,11 Alayne D. Markland, DO, MSc12,13
- Icahn School of Medicine at Mount Sinai, Division of General Internal Medicine, New York, NY
- James J. Peters VA Medical Center, Geriatric Research Education and Clinical Center, Bronx, NY
- Durham VA Health Care System, Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC
- Duke University School of Medicine, Department of Medicine, Durham, NC
- Atlanta VA Health Care System, Nursing and Patient Care Services, Atlanta, GA
- Emory University, Nell Hodgson Woodruff School of Nursing, Atlanta, GA
- University of Alabama at Birmingham, Department of Medicine, Birmingham, AL
- Birmingham VA Healthcare System, Geriatric Research, Education, and Clinical Center, Birmingham, AL
- Emory University, Department of Medicine, Atlanta, GA
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham/Atlanta, GA
- Brookdale Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, UT
- Salt Lake City VA Healthcare System, Geriatric Research, Education, and Clinical Center, Salt Lake City, UT