Medical personnel are expected to be familiar with SUI, particularly since it is a common and rarely discussed condition. Research sheds light on the serious and significant problems of stress urinary incontinence and draws the attention of medical personnel to this issue. It was assumed that medical staff would be interested in spreading health awareness among their future patients regarding the ways to prevent this disorder. It is advisable to put more emphasis on educating medical students regarding SUI due to their frequent and direct contact with patients suffering from this condition. Medical staff are required to have knowledge about civilization-related diseases, including SUI. Without well-educated specialist medical personnel able to see the need to act for a specific case, it is difficult to undertake long-term preventive or therapeutic initiatives. Meanwhile, knowledge of risk factors for SUI was declared by approx. 75% among the medical students surveyed (physiotherapy students) to approx. 82% medical students, which is insufficient, especially among medical staff who have direct contact with women suffering from this condition in their work.
Risk factors of SUI were divided into four groups: predisposing, causative, promoting and decompensation . Predisposing factors included: genetic (women with genetic disorders such as Ehlers–Danlos syndrome, Parkinson’s disease, or diabetes have three times more increased frequency of urinary incontinence among first-degree relatives) [14,15,16]. Neurological changes in nerve impulse flow to the lower urinary system, e.g. [17,18,19]. During multiple sclerosis may be reasons of urinary incontinence, in particular of urgent and stress types . Anatomical sagging and lowering of pelvic floor structures and weak urethra contraction mechanisms may also contribute to problems with urinary continence. Collagen-related pathology —studies have revealed that an inborn defect of collagen structure can cause urinary incontinence as the connective tissue plays an important role in stabilizing the urethra and in maintaining proper statics of genital organs. Cultural—it was shown that the number of incidences of urinary incontinence in Western Europe and the USA (30%) is similar, but it differs from the number of people who experience urinary incontinence in Asia, where the number is lower and amounts to 20% on average. The reason of such variation has not been clearly demonstrated, but it might result from e.g. differences in child-bearing, hygiene, socioeconomic status or the use of different definitions of urinary incontinence . In the conducted research, the highest index of indications regarding genetic factor of stress urinary incontinence in women was 0.16 in medical group of students. None of the student group had indicated in the vast majority neurological diseases as a SUI risk factor. These only appeared as single indications, but there were so few of them that they were classified in the group “other”. Apparently, most students were unaware of this risk factor. Students also failed to mention anatomical sagging, lowering of pelvic floor structures and defect of collagen structure. They did point out, however, “weakness of pelvic floor muscles”, and physiotherapy students indicated the such most answers, index 0.23. This is a risk factor that has already been described in 1949 by gynecologist Kegel , who published the results of his 15-year study using pelvic floor muscle exercises, which were used in patients with urinary incontinence, and their goal was to strengthen the weakened pelvic floor muscles. To this day, these exercises are extremely popular and are recommended by gynecologists and midwives. Currently, other methods have been introduced for strengthening this muscle group, including the especially effective electrostimulation of the pelvic floor muscles using an intravaginal electrode and impulse current with specified parameters .
Another group of risk factors of urinary incontinence are causative factors, which include childbirth and impairment in the pelvic muscle nerves during birth, and the development of atrophy in related pelvic floor muscles —the results of most epidemiological studies suggest that pregnancy and childbirth burden the pelvic floor and thus, are an integral risk factor of urinary incontinence later in a woman’s [24,25,26,27,28,29,30]. Among the answers of the students graduating from medical faculties to the question regarding risk factors of stress urinary incontinence in women, the combined phrase, ‘pregnancy and childbirth, and the consequences thereof’ took the lead and was subsequently merged into a category by that name. These causative factors were definitely most often mentioned by the surveyed students, and the index of indications was the highest among nurses and midwives who most often mentioned pregnancy and childbirth, which was according to their field of study.
Hysterectomy—due to static disorder of genital organs . Radiation—atrophic changes in vascularization of the lower part of the urinary system have been demonstrated which might lead to urinary incontinence and which result from pelvic radiotherapy due to e.g. cervical cancer or endometrial cancer . These factors were not mentioned by the surveyed students. Obesity is a promoting factor—a close correlation between urinary incontinence and obesity was demonstrated, and it was shown that obese women with a body mass index greater than 30 kg/m2 experience urinary incontinence two times more frequently than women of normal weight [33,34,35,36]. A number of scientific studies highlighted that obesity is an inherent risk factor of SUI in women, but it is only one of many factors that influence the development of this condition. Therefore, it cannot be said that obese women is the sole group of women who are exposed to stress urinary incontinence. The risk of SUI in women with high BMI results mainly from an increased amount of adipose tissue, which causes pressure on the pelvic tissues and speeds their chronic tension. As a consequence, intra-abdominal pressure increases, which results in an increase of intra-bladder pressure and a reduction of the pressure difference between the urinary bladder (intra-bladder pressure) and the urethra (intraurethral pressure). This finally results in urinary incontinence. Moreover, the urethra closing mechanisms among obese women is ineffective, which may be due to chronic tension of the urogenital diaphragm [33,34,35,36]. The students surveyed were aware that obesity may contribute to urinary continence problems; the highest index of indications was noted in the group of medical students and was at 0.42.
Diet—it has been proven that certain food products such as alcohol or caffeine can increase the incidence of urinary incontinence. It is unclear whether this is related to lifestyle or the diuretic effect of these products which cause increased urinary urgency [37, 38]. Menopause—hypoestrogenism initiates atrophic changes which are manifested with mass and size reduction of genital organs and the thickness of their mucous membranes. Urogenital atrophy is also related to myofascial structures of the pelvic floor and lower part of the urinary system. As a consequence, a low level of estrogen and atrophic changes may lead to prolapse of genital organs and the appearance of urinary incontinence symptoms [39,40,41,42,43]. This risk factor was indicated by many students, most in the group of future doctors, indication index at 0.56 and in the group of physiotherapists, at 0.45. At this point, however, attention should be paid to literature reports , since a multicentre, randomized trial demonstrated that administering estrogen during menopause as hormone replacement therapy has no clinical confirmation in the treatment of stress urinary incontinence. Hendrix et al.  suggest re-examining the biological effect of estrogen on the lower urinary tract. The conclusion of these studies clearly shows that there is no role for estrogen in the prevention or treatment of urinary incontinence and the estrogen is no longer a treatment option for this symptom.
Occupation—a profession involving hard physical work and lifting heavy loads may lead to urinary incontinence. Physical activity level—it has been proven that both too low and too high a level of physical activity are risk factors of urinary incontinence [44,45,46]. The students of physiotherapy identified two completely opposite factors, namely lack of physical activity and excessive physical effort. Other groups paid almost no attention to lack of physical activity. Although many authors have shown that moderate physical exercise is associated with strengthening pelvic floor muscles and has a positive effect on reducing the risk of stress urinary incontinence, some types of physical activity may in fact contribute to these symptoms. Physical activity—such as jumping or running—often leads to urinary incontinence. Professional sport and excessive exercise may cause urinary incontinence in young women [44,45,46].
The surveyed students did not indicate urinary incontinence as a risk factor, as well as urinary system infections—urinary incontinence is associated with frequent infections of the urinary system. It has been demonstrated that past cystitis predisposes a mixed form of urinary incontinence. Mixed urinary incontinence is a form in which symptoms typical for stress urinary incontinence are combined with urge urinary incontinence, i.e., involuntary leakage of urine occurs, e.g., during exercise or sudden stress, combined with a feeling of sudden irrepressible urge to void. When a predominance of one group of symptoms can be established, stress urinary incontinence with detrusor instability or urge urinary incontinence with a stress component on the background is diagnosed. Risk factors for mixed urinary incontinence will include both those causing stress and urge forms of urinary incontinence, e.g., a menopausal age, pregnancies, childbirths, surgeries within the lesser pelvis, infections affecting the urinary system, or stress [1, 5, 7].
Drug-induced—drugs that cause increased urine production (diuretics) can cause urinary bladder instability, leading to urinary urgency and incontinence. Antiestrogens can cause stress urinary incontinence by reducing vascularization of the urethra and impairing the so-called ‘mucosal sealing mechanism’ [1, 2, 4, 5, 7,8,9,10]. It should be noted that among other factors mentioned by the examined students were drugs and medicine. Literature confirms that drugs, e.g. diuretics, can lead to urinary urgency, and antiestrogens to stress urinary incontinence. Smoking negatively affects synthesis of collagen by weakening pelvic floor muscles. It also induces chronic cough leading to an increase in pressure inside the abdomen, which can cause episodes of SUI. Pulmonary diseases associated with chronic cough—a connection between urinary incontinence and pulmonary diseases such as chronic obstructive pulmonary disease that causes hypoxia, night-time apnea or chronic cough resulting from, e.g. smoking. These disorders affect collagen production, which weakens the pelvic floor structure. As a consequence, when coughing, the pressure inside the abdomen suddenly increases and urinary incontinence occurs . In only few individual responses, classified as “other diseases”, the surveyed students mentioned “bronchial asthma” as a risk factor for SUI. Mental illness—it has been stated that depression as a result of decreased serotonin level and decreased inhibition in the central nervous system causes urinary incontinence due to sudden urinary urgency among 60% of patients . Each surveyed group of students showed a very small index of indications for mental factors that could affect the proper urinary continence; it was the highest in the other medical group and was at 0.19.
Studies have shown that the general place to gain knowledge about the studied problem were higher studies and textbooks. The subjects in which this study topic was mentioned were mostly among the groups of future doctors, nurses and midwives, and the physiotherapists mentioned clinical surgical subjects such as surgery, gynecology and obstetrics, emergency medicine and urology. In the group of students covering other medical faculties and in the group of physiotherapists, the high index of indications concerned subjects in the physiotherapy category, such as: physical therapy, kinesitherapy, clinical basics of physiotherapy or basics of physical movement education. On the other hand, considering the index of items for the category of the theory of medicine, it was found that the highest was in the group covering other medical faculties. The most frequently mentioned subjects of this group were anatomy, medical biology, physiology, genetics and pathophysiology. Approximately 10% of students of general medicine and physiotherapy, about 17% of nursing and obstetrics students and nearly 70% of students of other medical faculties said that the subject of stress urinary incontinence was not implemented in any subject during their studies. This seems likely only for the latter group. The third place among sources of knowledge was the Internet. It is certainly a quick way to find the information you are looking for and later expand upon it, and often verify it from professional sources of knowledge.
It was expected that all surveyed students would have sufficient knowledge to be able to have a professional conversation and even conduct an interview with a woman suffering from SUI. The authors of this study expected students who are studying to become physicians and physiotherapists to have more knowledge of the subject, since both of these groups belong to medical personnel who have daily and direct contact with women suffering from SUI and are obliged to know more about diseases of affluence, including SUI. It seems that the subject of SUI was well presented in medical studies but some of the students apparently did not master this issue enough to help women suffering or at risk of SUI.
The main limitation of this study was that it only included students from two universities in Poland. However, these universities are two of the largest institutions in the Silesian region educating future medical personnel. What is more, the Medical University of Silesia is one of the largest universities in Poland. At the same time, the advantage of this study is the fact that 402 graduates of physiotherapy from two different universities were examined.
Innovation of this study is its originality, because available medical databases do not include any research on knowledge of future medical personnel about stress urinary incontinence in women, which is one of the most hidden civilizational diseases that has been passed over in silence. Millions of women do not seek treatment because they are ashamed to talk about it, and medical personnel do not ask about it in their standard procedures. The article touches upon the issue of educating future medical personnel who will have direct professional contact with women who are at risk of developing urinary incontinence or are already suffering from this disorder. In addition, the article might provide inspiration for considering the importance of the disciplinary focus of a studies and the educational effects which it achieves, as well as providing inspiration for future and present medical personnel to undertake greater action for the benefit of women suffering from stress urinary incontinence. Another advantage of this article is that the questionnaire encompassed both general and very specialist knowledge, i.e. preventive measures, diagnostics and methods of conservative and surgical treatment.