This study is the first to investigate which factors are most influential to female patients when selecting from all available treatment and/or management options for urinary incontinence, and then delve into the relative priority of these factors for different segments.
Urinary incontinence (UI) is a profoundly distressing and stigmatizing ailment, impacting over 20% women in India, and the low urologist to patient ratio makes the situation worse. UI can typically be managed at the primary care level initially, with referral to specialists if conservative measures fail. Treatment options range from lifestyle modifications, pelvic floor muscle training, drugs and injectable agents to surgical interventions [1]. 
Patient preference and individual circumstances often guide treatment choices, however, very few studies [2-3] have evaluated these for different forms of UI treatment. While the work of Johnson et al. is limited to perspectives of nursing staff, frail older adults at a long-term care facility and their family members [2], that of Diokno et al. is limited to only three treatment methods: behavioral modification, pharmacotherapy, or surgery for UI [3].

A total of 47 female participants experiencing UI were interviewed as part of the study, following obtaining their consent. Audio recordings were made for subsequent analysis.
Study Questions: The study used a set of guided, qualitative questions to understand the participants’ perception of their own condition and the pathway they took in identifying a solution and integrating it into their lives. First, the following two hypotheses were tested: (i) Women having UI consider it to be a problem for which a solution should be sought; (ii) Women having UI are actively seeking a remedy for their condition. With a clear evidence-based confirmation or falsification of the hypotheses, the team delved into asking questions about participants' awareness of available treatment options, their personal experiences with these treatments, the decision-making process behind their choices, and their satisfaction levels.
Validation of Hypotheses: The team arrived at a conclusion regarding the validity of the hypotheses through evidence collection. For example, in case of the first hypothesis, “Women having UI consider it to be a problem for which a solution should be sought”: when a participant described how UI impacted their daily life, detailed adjustments they made to cope with it, or actively sought solutions, such actions were considered as compelling evidence supporting that UI was indeed perceived as a substantial problem. On the other hand, if a participant merely acknowledged UI as a problem without displaying any active efforts being made currently or in the past to address; this was interpreted as evidence suggesting that it may not be as severe or pressing for them.
Interim Analysis: An interim analysis was performed after every 8-10 interviews. Identified patterns about their treatment preferences and factors influencing the decision were converted into additional hypotheses to be tested in the subsequent interviews. For example, after it was identified that a subset of women preferred allopathy medications despite the side effects due to convenience, a new hypothesis was formed: “Incontinent women who are currently on medication, are actively trying to stop consuming them.” This was followed by questions about the number and variety of medicinal solutions they have tried, reasons for selection, efforts to discontinue medication, and alternative strategies for managing incontinence, such as exploring “risk-free” solution like exercise. This iterative approach allowed the team to not only identify factors affecting the treatment choices, but also provided insights into the relative priority of these factors.

Patients from a diverse background participated in the study: mean age – 51.37±15.05 years, mean time since first symptoms – 6.01±5.40 years, mean number of solutions tried – 1.90±1.34, with a wide variety in their work backgrounds (homemakers to executive roles), socioeconomic backgrounds, lifestyles (sedentary to athletes), and different geographic locations within the country. 
Through various interactions and observations, valuable insights were gained regarding the challenges faced by individuals adhering to pelvic floor exercise routines, frequent clinic visits, reliance on absorbent pads, persistent anxiety about leakage, and limitations such as avoiding bus travel. The strong association of UI with societal stigma was found to lead to various fears in the mind of a patient. Essentially, the patients had the wish to feel free. 
Analysis revealed that women working from home or new mothers often manage UI with voiding schedules, while those with private transportation opt for convenient stops, perceiving UI as a problem but not actively seeking solutions. Conversely, women reliant on public transport, office-going new mothers, and those with busy, inflexible schedules – all whose regular lifestyle was severely affected by UI (henceforth referred to as ‘affected women’), were actively trying to solve it. Key factors that affect their choices: uninterrupted routine, ease of use, risk-free nature, cost-effectiveness, and efficacy of the solution. 
It was found that 86% of all participants followed solutions recommended by their clinicians. 53% of all affected women were actively looking for an alternative to their current solution despite multiple failed attempts in the past. Others affected had the tendency to lose hope after a point, and to eventually learn to live with UI. Of all participants interviewed, 85% of those who were within 3 years of being diagnosed, were actively looking for a new solution, as compared to 54% of those who were not in the same timeframe.
About 80% of affected women who were under the age of 60 and leading a busy lifestyle (typically pursuing/settled in their career/work and financially independent), were using medication, despite severe side effects, because it was convenient, and gave them an uninterrupted work routine. 93% were not fully satisfied with the choice, but only 67% were actively supplementing it with other methods, like exercising whenever possible, in the hope that they could stop medication sooner.
Affected women within six months of having given birth prioritized their newborn and their post-partum recovery over UI and primarily relied on pads, with few expressing interests in alternative solutions if their condition persisted. About 58% of affected women interviewed above the age of 60 were leading a moderate to active lifestyle and were making attempts at treating their condition. 57% of these were relying on alternative medicine to manage their day-to-day incontinence. Treatment cost was identified as a consideration of more importance for both these groups of women as compared to the young ones having financial independence.

The study findings show that women’s attitudes towards UI and their treatment preferences are closely related with its impact on their lifestyle. When UI begins to impede their daily activities and routines, women become motivated to seek solutions actively. Women tend to gravitate towards interventions that impose minimal disruptions or constraints on their daily activities. This is clear from the identified factors that affect their choices and their prioritization of these factors. 
The authors identify a small number of participants as a limitation of the study. Future work with a focus on more specific demographics, cultural influences and access to healthcare services is planned.

Healthcare providers must consider not only the efficacy of interventions but also their practicality and suitability for patients' lifestyles. By offering options that align with women's daily routines and responsibilities, healthcare professionals can empower them to actively engage in managing and treating their UI and improve their overall well-being.

Wood, L.N. and Anger, J.T., 2014. Urinary incontinence in women. Bmj, 349.
Johnson, T.M., Ouslander, J.G., Uman, G.C. and Schnelle, J.F., 2001. Urinary incontinence treatment preferences in long-term care. Journal of the American Geriatrics Society, 49(6), pp.710-718.
Diokno, A. and Yuhico, M., 1995. Preference, compliance, and initial outcome of therapeutic options chosen by female patients with urinary incontinence. The Journal of urology, 154(5), pp.1727-1731.