Reviewer's report 
 Prevalence of Urinary Incontinence in Andorra: Impact on Womens Health. Title: 
Authors: 
avellanet m.a merce PhD ( saas.rhb@andorra.ad )
Dr fiter m.f meritxell MD ( mfv@andorra.ad )
coll m.c margarida MD ( alaycoll@myp.ad )
 2  3 Dec 2002 Version: Date: 
 Dr Chris Shaw Reviewer: 
 A paper of limited interest Level of interest: 
 Unable to decide on acceptance or rejection until the authors have Advice on publication: 
responded to the compulsory revisions 
Compulsory revisions 
1. More detail is required on the methodology, specifically addressing the 
following points. 
Did all health care professionals agree to take part in the study. If not, what 
proportion did? Were all female patients approached to fill out a questionnaire during the study period, or a random sample, or did health care professionals choose who to 
give it to? 
Why was a validated questionnaire not used? 2. Sample bias. One cannot assess sample bias in an epidemiological study 
without more detail concerning the sample. Response rates should be detailed. 
How many women refused to answer the questionnaire? Is there any information 
available on non-responders? What are the characteristics of responders in terms of the variables of interest i.e. age, social class, ethnicity etc? There is some mention of how representative the sample is in the discussion, with a 
mention of census data. The characteristics of the sample could be compared to 
that of the population in the census. It is necessary to determine how representative the sample is of the population that it purports to represents. 3. Unconscious Incontinence is not a useful category to use. This is most 
probably a response anomaly. One needs to ask questions concerning incontinence 
in a number of different ways. Indeed, we found in our own research that women 
will respond negatively to a general question about leakage but positively to 
specific questions about stress or urge leakage. Unconscious incontinence is 
more strictly defined as leakage that the individual does not feel happening. 
Categories of incontinence should be based either on severity or type. The categorisation used here tries to mix the two by having two categories based on severity and one on type of incontinence. 
4. The researchers note the decrease in prevalence in the older age group. 
They suggest that this is due to small sample size in this group. This may well be, but we have no indication of the sample size in this group (see point above). It could, however, be due to a preponderance of stress incontinence in 
the sample. Women tend to have a peak at around 50 years of age of stress 
incontinence, which decreases in older age. The overall prevalence increases in 
older age because of a greater preponderance of urge incontinence in older age 
groups. It would be informative to see some categorisation of stress and urge 
symptoms if this were possible from the data. 5. It is also reported that university graduates report less unconscious incontinence. This would support the view that unconscious incontinence is a 
response issue as the more educated people are more likely to complete the 
questionnaire correctly. 6. It is difficult to assess whether any associations with the social factors are real without a clear description of the sample and an indication of 
any response bias. But assuming that there is no response bias, the analysis 
should aim to assess associations statistically, firstly focusing on univariate analysis and then entering those variables that demonstrate some association 
with the dependent variable into a multivariate model. In this way one can then 
assess associations whilst controlling for all other confounding factors. 
7. The discussion does point out that the sample consists of women attending for health care but fails to point out that this might result in an overestimate of the prevalence if applied to the general population. The paper 
needs to be clear in the title, the abstract, aims and conclusions that the 
study estimates the prevalence of urinary incontinence in a primary and secondary care population. 
Competing interests: 
None declared.