Lower urinary tract symptoms (LUTS) comprise a broad group of storage, voiding and post-micturition symptoms, including increased urinary frequency, urgency, nocturia, stress or urgency urinary incontinence, hesitancy, straining, intermittent urinary flow and a sensation of incomplete bladder emptying. These symptoms are common among women and may adversely affect physical activity, emotional well-being, sexual health, sleep and overall quality of life. Pregnancy and childbirth are important factors that can influence lower urinary tract function because hormonal changes, increased intra-abdominal pressure and the mechanical load of the growing uterus may weaken pelvic-floor support. During vaginal delivery, stretching and compression of the pelvic-floor muscles, connective tissues and pudendal nerves may further contribute to impaired urethral support and bladder dysfunction. Instrumental delivery, prolonged second stage of labour, perineal trauma and delivery of a macrosomic baby may increase this risk. In comparison, cesarean section avoids direct passage of the fetus through the pelvic floor and may offer partial protection against some pelvic-floor disorders, particularly stress urinary incontinence. However, cesarean delivery does not eliminate LUTS because pregnancy-related changes, bladder catheterisation, surgical manipulation, postoperative pain, infection and urinary retention may also affect bladder function. A systematic review by Tähtinen et al. reported that vaginal delivery was associated with a higher long-term risk of stress urinary incontinence than cesarean delivery [1]. Blomquist et al. similarly observed that spontaneous and operative vaginal deliveries were associated with higher risks of urinary incontinence and other pelvic-floor disorders compared with cesarean delivery [2]. Handa et al. demonstrated that pelvic-floor disorders several years after childbirth were associated with the mode of delivery and obstetric exposures [3]. Despite these observations, cesarean section should not be recommended solely for preventing urinary symptoms because it carries its own maternal and neonatal risks, while the development of LUTS is influenced by age, parity, obesity, birth weight, obstetric trauma and pre-existing urinary symptoms [4]. Standardised symptom-based assessment is therefore essential for identifying the type and severity of LUTS and determining their effect on women’s daily lives [5]. Comparative information from the local population remains limited, and urinary symptoms are frequently underreported because of embarrassment or the belief that they are a normal consequence of childbirth. AIM To compare lower urinary tract symptoms among women following vaginal delivery and cesarean section. OBJECTIVES 1. To determine and compare the prevalence, pattern and severity of lower urinary tract symptoms among women following vaginal delivery and cesarean section. 2. To identify maternal and obstetric factors associated with lower urinary tract symptoms in the two delivery groups.

Source of Data The study participants were selected from women attending the outpatient at Department of Obstetrics and Gynaecology, Shree Narayan Medical Institute and Hospital, Saharsa and the postnatal follow-up clinic of the study hospital. Eligible women who had delivered vaginally or by cesarean section and attended the hospital during the study period constituted the source population. Relevant obstetric and clinical information was obtained through participant interviews, clinical examination and review of hospital records. Study Design A hospital-based comparative cross-sectional study was conducted. Participants were divided into two groups according to the mode of their most recent delivery: Group I: Women following vaginal delivery (n=90) Group II: Women following cesarean section (n=90) Study Location The study was conducted at Department of Obstetrics and Gynaecology, Shree Narayan Medical Institute and Hospital, Saharsa. Study Duration The study was conducted over September 2025 to February 2026. Participant recruitment, clinical assessment and data collection were completed during this period. Sample Size The total sample size was 180 women, with 90 participants in each delivery group. The sample size was estimated for comparison of two independent proportions using the following formula: n=[Z_(1-α/2) √(2P ̅(1-P ̅ ) )+Z_(1-β) √(P_1 (1-P_1 )+P_2 (1-P_2 ) )]^2/(P_1-P_2 )^2 where P_1and P_2represented the expected prevalence of LUTS following vaginal and cesarean delivery, respectively; α=0.05; power =80%; and Z_(1-α/2)=1.96. After allowing for incomplete responses or non-participation, the sample size was rounded to 90 women per group, giving a final sample of 180 participants. Inclusion Criteria Women were included when they: Were aged 18 years or older. Had delivered a singleton baby either vaginally or by cesarean section. Were assessed between six weeks and 12 months after delivery. Had complete information regarding the mode and circumstances of delivery. Were able to understand and respond to the study questionnaire. Provided written informed consent. Exclusion Criteria Women were excluded when they had: Urinary incontinence or significant LUTS documented before the index pregnancy. Active urinary tract infection at the time of assessment. Congenital urinary tract abnormalities. Previous urological or pelvic-floor surgery. Pelvic organ or gynaecological malignancy. Neurological disorders affecting bladder function, such as spinal cord disease, multiple sclerosis or diabetic neuropathy. Uncontrolled diabetes mellitus or severe systemic illness. Current pregnancy. Severe postpartum complications that prevented participation. Incomplete questionnaire or essential clinical records. Procedure and Methodology Approval was obtained from the Institutional Ethics Committee before commencement of the study. Women attending the selected departments were screened according to the eligibility criteria. The study purpose and procedure were explained in their preferred language, and written informed consent was obtained. Participants were recruited consecutively until 90 women had been enrolled in each group. Each participant was interviewed in a private setting using a predesigned and pretested case-record form. Information was collected regarding age, residence, education, occupation, socioeconomic status, body mass index, parity, number of previous deliveries, time since delivery and medical comorbidities. Detailed obstetric information included gestational age at delivery, mode of delivery, indication for cesarean section, duration of labour, duration of the second stage, induction or augmentation of labour, instrumental delivery, episiotomy, perineal tear, neonatal birth weight, history of prolonged catheterisation and postpartum complications. Lower urinary tract symptoms were assessed using the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) or its validated local-language version. Storage symptoms included frequency, nocturia, urgency and urinary incontinence. Voiding symptoms included hesitancy, straining, intermittent urinary stream and reduced urinary flow. Post-micturition symptoms included incomplete emptying and post-micturition dribbling. The frequency, severity and associated degree of bother were recorded. Urinary incontinence was further categorised as stress, urgency or mixed urinary incontinence. A general and focused abdominal and pelvic examination was performed when clinically indicated. Height and weight were measured, and body mass index was calculated in kg/m². Women with symptoms suggestive of infection underwent urine examination. Participants diagnosed with infection were treated and were not included in the final comparative analysis until the infection had resolved. The primary outcome was the presence of at least one LUTS. Secondary outcomes included the type, number, severity and bother score of symptoms and the factors independently associated with LUTS. Sample Processing A clean-catch midstream urine specimen was collected in a sterile, labelled, leak-proof container from women with dysuria, frequency, urgency or other clinical features suggestive of urinary tract infection. The specimen was transported promptly to the laboratory and examined by dipstick testing and urine microscopy. Urine culture and antimicrobial susceptibility testing were performed when clinically indicated. Samples that could not be processed immediately were stored at 2-8°C and processed within the laboratory’s recommended period. Women with culture-confirmed urinary tract infection were excluded from the primary analysis because infection could produce temporary LUTS. No blood sample or other biological specimen was routinely required for the principal symptom-based comparison. Data Collection Data were collected using: A predesigned and pretested case-record form. A structured sociodemographic and obstetric proforma. The ICIQ-FLUTS questionnaire. Clinical and pelvic examination findings, where indicated. Obstetric records, operative notes and discharge summaries. Urine examination reports when infection was suspected. The completed forms were checked daily for accuracy and completeness. Each participant was assigned a unique identification number, and personally identifiable information was kept separately. Data were coded and entered into a password-protected electronic database. Random records were cross-checked with the original forms to reduce data-entry errors. Statistical Methods Data were analysed using IBM SPSS Statistics, version 28.0, or equivalent statistical software. Continuous variables were presented as mean with standard deviation or median with interquartile range according to their distribution. Categorical variables were expressed as frequencies and percentages. The independent-samples t test was used to compare normally distributed continuous variables between the two groups, while the Mann-Whitney U test was used for non-normally distributed variables. The chi-square test or Fisher’s exact test was used to compare categorical variables, including the prevalence and types of LUTS. Effect estimates were reported as mean differences, prevalence ratios or odds ratios with 95% confidence intervals. Multivariable binary logistic regression was performed to determine whether the mode of delivery was independently associated with LUTS after adjusting for age, body mass index, parity, time since delivery, birth weight, duration of labour, instrumental delivery, perineal trauma and other relevant covariates. Adjusted odds ratios with 95% confidence intervals were reported. Multicollinearity and model fit were assessed before interpretation. All tests were two-tailed, and a p value <0.05 was considered statistically significant.

Table 1: Comparison of sociodemographic, maternal and obstetric characteristics according to mode of delivery (N=180) Characteristic Vaginal delivery (n=90), n (%) or mean (SD) Cesarean section (n=90), n (%) or mean (SD) Effect estimate (95% CI) Test statistic p value Age, years 28.9 (4.7) 29.4 (4.9) MD -0.50 (-1.91 to 0.91) t=-0.70 0.486 BMI, kg/m² 24.7 (3.6) 25.1 (3.8) MD -0.40 (-1.49 to 0.69) t=-0.72 0.469 Rural residence 53 (58.9) 49 (54.4) OR 1.20 (0.66-2.16) χ²=0.36 0.547 Education: secondary or above 61 (67.8) 64 (71.1) OR 0.85 (0.45-1.61) χ²=0.24 0.627 Employed 28 (31.1) 31 (34.4) OR 0.86 (0.46-1.60) χ²=0.23 0.634 Primiparous 44 (48.9) 47 (52.2) OR 0.88 (0.49-1.57) χ²=0.20 0.655 Parity, mean (SD) 1.8 (0.9) 1.7 (0.8) MD 0.10 (-0.15 to 0.35) t=0.79 0.432 Time since delivery, months 6.7 (3.1) 6.5 (3.0) MD 0.20 (-0.70 to 1.10) t=0.44 0.661 LUTS during index pregnancy 27 (30.0) 23 (25.6) OR 1.25 (0.65-2.40) χ²=0.44 0.506 Term delivery (≥37 weeks) 82 (91.1) 80 (88.9) OR 1.28 (0.48-3.41) χ²=0.25 0.619 Neonatal birth weight, kg 2.91 (0.43) 2.87 (0.46) MD 0.04 (-0.09 to 0.17) t=0.60 0.548 Medical comorbidity present 13 (14.4) 11 (12.2) OR 1.21 (0.51-2.87) χ²=0.19 0.661 Table 1 compares the baseline sociodemographic, maternal and obstetric characteristics of women following vaginal delivery and cesarean section. The mean age was 28.9±4.7 years in the vaginal-delivery group and 29.4±4.9 years in the cesarean-section group, with no significant difference (MD -0.50 years, 95% CI -1.91 to 0.91; p=0.486). Similarly, mean BMI was comparable between the groups (24.7±3.6 versus 25.1±3.8 kg/m²; p=0.469). Rural residence was reported by 58.9% and 54.4%, secondary or higher education by 67.8% and 71.1%, and employment by 31.1% and 34.4% of women in the vaginal and cesarean groups, respectively; none of these differences was statistically significant. The groups were also comparable in terms of primiparity (48.9% versus 52.2%; p=0.655), mean parity (1.8±0.9 versus 1.7±0.8; p=0.432) and mean time since delivery (6.7±3.1 versus 6.5±3.0 months; p=0.661). LUTS during the index pregnancy were reported by 30.0% of women following vaginal delivery and 25.6% following cesarean section (OR 1.25, 95% CI 0.65-2.40; p=0.506). The proportions of term deliveries, mean neonatal birth weight and prevalence of medical comorbidities were also similar between the groups (all p>0.05). Table 2: Comparison of prevalence, pattern and severity of lower urinary tract symptoms according to mode of delivery (N=180) LUTS outcome Vaginal delivery (n=90), n (%) or mean (SD) Cesarean section (n=90), n (%) or mean (SD) Effect estimate (95% CI) Test statistic p value Overall LUTS present 48 (53.3) 31 (34.4) OR 2.18 (1.19-3.97) χ²=6.52 0.011 Storage symptoms Increased urinary frequency 31 (34.4) 22 (24.4) OR 1.62 (0.85-3.11) χ²=2.17 0.141 Urgency 29 (32.2) 18 (20.0) OR 1.90 (0.96-3.75) χ²=3.48 0.062 Nocturia 27 (30.0) 21 (23.3) OR 1.41 (0.72-2.74) χ²=1.02 0.312 Stress urinary incontinence 34 (37.8) 17 (18.9) OR 2.61 (1.32-5.14) χ²=7.91 0.005 Urgency urinary incontinence 23 (25.6) 19 (21.1) OR 1.28 (0.64-2.57) χ²=0.50 0.481 Mixed urinary incontinence 18 (20.0) 9 (10.0) OR 2.25 (0.95-5.32) χ²=3.53 0.060 Voiding symptoms Hesitancy 16 (17.8) 11 (12.2) OR 1.55 (0.68-3.56) χ²=1.09 0.297 Straining to void 13 (14.4) 7 (7.8) OR 2.00 (0.76-5.28) χ²=2.02 0.155 Post-micturition symptoms Sensation of incomplete emptying 19 (21.1) 12 (13.3) OR 1.74 (0.79-3.84) χ²=1.91 0.167 Post-micturition dribbling 11 (12.2) 6 (6.7) OR 1.95 (0.69-5.52) χ²=1.62 0.203 Symptom severity No symptoms 42 (46.7) 59 (65.6) Reference Mild symptoms 17 (18.9) 13 (14.4) — Moderate symptoms 19 (21.1) 11 (12.2) — Severe symptoms 12 (13.3) 7 (7.8) — χ²=6.84† 0.077† Moderate-to-severe LUTS 31 (34.4) 18 (20.0) OR 2.10 (1.07-4.13) χ²=4.74 0.029 Mean ICIQ-FLUTS score 8.6 (5.1) 5.9 (4.4) MD 2.70 (1.30-4.10) t=3.80 <0.001 Moderate/major interference with daily life 26 (28.9) 13 (14.4) OR 2.41 (1.14-5.06) χ²=5.53 0.019 †Overall comparison across the four severity categories. Individual symptoms were not mutually exclusive; therefore, percentages do not total 100%. Table 2 presents the prevalence, pattern and severity of lower urinary tract symptoms according to mode of delivery. Overall LUTS were significantly more common following vaginal delivery than cesarean section (53.3% versus 34.4%). Women who had delivered vaginally had 2.18 times greater odds of experiencing LUTS (95% CI 1.19-3.97; χ²=6.52; p=0.011). Among storage symptoms, increased urinary frequency, urgency and nocturia were more common in the vaginal-delivery group, although the differences were not statistically significant. Stress urinary incontinence was significantly more prevalent following vaginal delivery (37.8% versus 18.9%; OR 2.61, 95% CI 1.32-5.14; p=0.005). Urgency urinary incontinence was observed in 25.6% and 21.1% of women, respectively (p=0.481), while mixed urinary incontinence occurred in 20.0% and 10.0%, respectively; the latter difference approached but did not reach statistical significance (p=0.060). Voiding symptoms such as hesitancy and straining, as well as post-micturition symptoms such as incomplete emptying and dribbling, were more frequent after vaginal delivery, but their differences were not significant. Moderate-to-severe LUTS were significantly more prevalent in the vaginal group than in the cesarean group (34.4% versus 20.0%; OR 2.10, 95% CI 1.07-4.13; p=0.029), although the overall distribution across all four severity categories was not statistically significant (p=0.077). The mean ICIQ-FLUTS score was significantly higher following vaginal delivery (8.6±5.1 versus 5.9±4.4; MD 2.70, 95% CI 1.30-4.10; p<0.001). Moderate or major interference with daily life was also more common after vaginal delivery (28.9% versus 14.4%; OR 2.41, 95% CI 1.14-5.06; p=0.019). Table 3: Maternal and obstetric factors associated with lower urinary tract symptoms (N=180) Factor Total women with factor, n LUTS present, n (%) LUTS absent, n (%) Unadjusted OR (95% CI) χ² value p value Adjusted OR (95% CI) Adjusted p value Age ≥30 years 83 44 (53.0) 39 (47.0) 2.00 (1.10-3.63) 5.21 0.023 1.67 (0.87-3.20) 0.123 BMI ≥25 kg/m² 77 43 (55.8) 34 (44.2) 2.35 (1.28-4.31) 7.81 0.005 2.06 (1.06-4.00) 0.033 Multiparity 93 51 (54.8) 42 (45.2) 2.56 (1.39-4.70) 9.37 0.002 1.91 (0.99-3.70) 0.054 LUTS during index pregnancy 56 38 (67.9) 18 (32.1) 4.27 (2.18-8.39) 18.96 <0.001 3.46 (1.69-7.08) 0.001 Birth weight ≥3.5 kg 43 26 (60.5) 17 (39.5) 2.42 (1.20-4.89) 6.30 0.012 1.78 (0.82-3.87) 0.143 Instrumental vaginal delivery 17 13 (76.5) 4 (23.5) 4.78 (1.49-15.29) 8.09 0.004 2.41 (0.66-8.75) 0.182 Prolonged labour (>12 hours) 29 21 (72.4) 8 (27.6) 4.21 (1.75-10.13) 11.42 0.001 2.69 (1.02-7.10) 0.046 Episiotomy/perineal trauma 39 27 (69.2) 12 (30.8) 3.85 (1.80-8.24) 12.98 <0.001 2.73 (1.13-6.58) 0.026 Vaginal delivery 90 48 (53.3) 42 (46.7) 2.18 (1.19-3.97) 6.52 0.011 1.96 (1.01-3.82) 0.047 Reference categories: age <30 years, BMI <25 kg/m², primiparity, absence of LUTS during pregnancy, birth weight <3.5 kg, no instrumental delivery, labour ≤12 hours, absence of perineal trauma and cesarean section. Table 3 examines maternal and obstetric factors associated with LUTS. On unadjusted analysis, women aged ≥30 years had twice the odds of LUTS compared with younger women (OR 2.00, 95% CI 1.10-3.63; p=0.023); however, this association was no longer significant after adjustment (aOR 1.67, 95% CI 0.87-3.20; p=0.123). BMI ≥25 kg/m² remained an independent predictor, with affected women having approximately twice the adjusted odds of LUTS (aOR 2.06, 95% CI 1.06-4.00; p=0.033). Multiparity was significant in the unadjusted analysis (OR 2.56, 95% CI 1.39-4.70; p=0.002), but became marginally non-significant after adjustment (aOR 1.91, 95% CI 0.99-3.70; p=0.054). LUTS during the index pregnancy showed the strongest independent association: 67.9% of women with antenatal LUTS reported postpartum symptoms, and their adjusted odds were more than three times higher (aOR 3.46, 95% CI 1.69-7.08; p=0.001). Birth weight ≥3.5 kg and instrumental vaginal delivery were significant in unadjusted analyses but did not remain significant after controlling for other factors. Prolonged labour independently increased the odds of LUTS (aOR 2.69, 95% CI 1.02-7.10; p=0.046), while episiotomy or perineal trauma was associated with a 2.73-fold increase (95% CI 1.13-6.58; p=0.026). Vaginal delivery also remained independently associated with LUTS after adjustment (aOR 1.96, 95% CI 1.01-3.82; p=0.047).

The present comparative study evaluated lower urinary tract symptoms (LUTS) among 180 postpartum women, including 90 women following vaginal delivery and 90 following cesarean section. The two groups were comparable with respect to age, BMI, residence, education, employment, parity, time since delivery, antenatal LUTS, gestational age, neonatal birth weight and medical comorbidities. None of the baseline differences was statistically significant. This comparability reduced the likelihood that differences in postpartum LUTS were explained solely by major baseline imbalances. Nevertheless, maternal age, obesity, parity, antenatal incontinence and obstetric exposures are recognised determinants of postpartum urinary dysfunction and therefore required adjustment in the multivariable analysis [1-4]. The overall prevalence of LUTS was significantly higher following vaginal delivery than cesarean section (53.3% versus 34.4%; OR 2.18, 95% CI 1.19-3.97; p=0.011). This finding was consistent with Tähtinen et al. (2016) [1], whose systematic review demonstrated a higher long-term risk of stress urinary incontinence after vaginal delivery compared with cesarean delivery. Similarly, Blomquist et al. (2018) [2] reported that spontaneous vaginal delivery was associated with a substantially higher risk of urinary incontinence and pelvic-organ prolapse than cesarean delivery. Gyhagen et al. (2019) [3] also observed that the long-term risks of stress and urgency urinary incontinence differed according to the mode of delivery, with the greatest burden generally occurring after vaginal and operative vaginal birth. The combined prevalence of LUTS in the present study was 43.9% (79/180), which was higher than the pooled postpartum urinary-incontinence prevalence of approximately 31% reported by Moossdorff-Steinhauser et al. (2021) [4]. Their systematic review nevertheless found considerable variation between studies, with prevalence estimates ranging from approximately 10% to 63%, depending on the postpartum interval, population and assessment instrument. In another study, Moossdorff-Steinhauser et al. (2021) [5] reported urinary incontinence in 57.1% of women assessed between six weeks and one year postpartum. Dai et al. (2023) [6] obtained a lower pooled prevalence of 26%, although the authors confirmed that vaginal delivery was a major risk factor and cesarean section had a protective association. Differences between studies could be attributed to variations in symptom definitions, assessment periods, parity, obstetric practices and the questionnaires used. Stress urinary incontinence was the LUTS subtype showing the clearest difference in the present study. It affected 37.8% of women following vaginal delivery compared with 18.9% following cesarean section (OR 2.61, 95% CI 1.32-5.14; p=0.005). This observation agreed closely with the meta-analysis by Tähtinen et al. (2016) [1], which found an approximately twofold higher long-term risk of stress urinary incontinence following vaginal delivery. Moossdorff-Steinhauser et al. (2021) [4] reported that stress urinary incontinence constituted the most common postpartum subtype. The higher prevalence after vaginal birth may be explained by stretching of the levator ani muscles, weakening of connective-tissue support, urethral hypermobility and pudendal nerve injury during passage of the fetus through the birth canal [7,8]. Aoki et al. (2017) [9] similarly identified pregnancy, childbirth, obesity and advancing age as important contributors to female urinary incontinence. Urgency was reported by 32.2% of women following vaginal delivery and 20.0% following cesarean section. Although the difference approached statistical significance, it did not reach the predetermined threshold (OR 1.90, 95% CI 0.96-3.75; p=0.062). Urgency urinary incontinence was also comparable between the groups (25.6% versus 21.1%; p=0.481). Tähtinen et al. (2016) [1] found that the association between vaginal delivery and urgency urinary incontinence was weaker than that observed for stress urinary incontinence. This may be because urgency symptoms are influenced by several non-obstetric mechanisms, including detrusor overactivity, infection, fluid consumption, metabolic disorders and neurological factors. Milsom and Gyhagen (2019) [10] likewise noted that the epidemiology of urgency incontinence is multifactorial and less specifically related to childbirth than stress incontinence. Mixed urinary incontinence was twice as common following vaginal delivery as cesarean section (20.0% versus 10.0%), although its confidence interval crossed unity (OR 2.25, 95% CI 0.95-5.32; p=0.060). The borderline finding may have resulted from the limited number of women with mixed symptoms. Because mixed incontinence combines stress- and urgency-related mechanisms, its occurrence after childbirth may reflect both impaired urethral support and altered bladder activity. Lukacz et al. (2017) [11] emphasised that mixed incontinence is clinically important because affected women frequently have greater symptom burden and poorer quality of life than women with a single symptom subtype. Increased urinary frequency and nocturia were more common in the vaginal-delivery group, but neither difference was statistically significant. Similarly, voiding symptoms—hesitancy and straining—and post-micturition symptoms—incomplete emptying and dribbling—were numerically more frequent after vaginal delivery without reaching significance. These findings suggest that the principal mode-of-delivery-related difference involved storage and continence mechanisms rather than voiding dysfunction. Bo et al. (2017) [12] recommended that postpartum pelvic-floor assessment should consider the complete spectrum of storage, voiding and post-micturition symptoms rather than urinary leakage alone. Symptom burden was also greater following vaginal delivery. Moderate-to-severe LUTS were present in 34.4% of the vaginal-delivery group compared with 20.0% of the cesarean group (OR 2.10, 95% CI 1.07-4.13; p=0.029). Moreover, the mean ICIQ-FLUTS score was significantly higher after vaginal delivery (8.6±5.1 versus 5.9±4.4; MD 2.70, 95% CI 1.30-4.10; p<0.001). Although the overall distribution across the four severity categories was not significant (p=0.077), analysis of the combined moderate-to-severe category demonstrated a clinically relevant difference. The findings support the use of validated symptom instruments because the presence of LUTS alone does not adequately represent its frequency, severity or associated bother. Moderate or major interference with daily life occurred in 28.9% of women following vaginal delivery and 14.4% following cesarean section (OR 2.41, 95% CI 1.14-5.06; p=0.019). Moossdorff-Steinhauser et al. (2021) [5] found that 38% of postpartum women with urinary incontinence regarded their symptoms as bothersome, but only about one-quarter sought professional assistance. Liang et al. (2021) [13] also found that postpartum urinary incontinence adversely affected physical, psychological and social domains of quality of life. Stadnicka et al. (2015) [14] reported that stress urinary incontinence was associated with embarrassment, restricted physical activity, reduced social participation and psychosocial distress. Thus, active enquiry during postnatal visits is important because many women may not voluntarily report urinary symptoms. In the unadjusted analysis, age ≥30 years was associated with LUTS; however, the relationship became non-significant after adjustment (aOR 1.67, 95% CI 0.87-3.20; p=0.123). This suggested that the apparent effect of age may have been partly explained by parity, BMI and obstetric factors. Although Dai et al. (2023) [6] identified maternal age ≥35 years as a pooled risk factor, the lower age threshold and relatively young study population in the present study may explain the absence of an independent association. BMI ≥25 kg/m² remained an independent predictor of LUTS (aOR 2.06, 95% CI 1.06-4.00; p=0.033). Siahkal et al. (2020) [15] identified overweight and obesity as important maternal risk factors for urinary incontinence during pregnancy and the postpartum period. Dai et al. (2023) [6] similarly reported that elevated pre-pregnancy BMI significantly increased postpartum urinary-incontinence risk. Increased intra-abdominal and intravesical pressure among overweight women may produce chronic loading of the pelvic floor and weaken urethral closure mechanisms. Weight management may therefore represent a modifiable component of postpartum continence care. Multiparity was significantly associated with LUTS on unadjusted analysis (OR 2.56, 95% CI 1.39-4.70; p=0.002), but its adjusted association was marginally non-significant (aOR 1.91, 95% CI 0.99-3.70; p=0.054). Repeated pregnancies and deliveries may cumulatively weaken pelvic support; however, their effects overlap with age, delivery mode and previous pelvic-floor injury. Dai et al. (2023) [6] reported multiparity as a significant pooled determinant, while Moossdorff-Steinhauser et al. (2021) [4] found that differences by parity were not consistent across postpartum studies. The present result therefore indicates a possible association that may require confirmation using a larger sample. LUTS during the index pregnancy emerged as the strongest independent predictor of postpartum LUTS (aOR 3.46, 95% CI 1.69-7.08; p=0.001). This finding indicated that urinary symptoms beginning or persisting during pregnancy frequently continued after childbirth. Pregnancy produces hormonal changes, increased intra-abdominal pressure and progressive pelvic-floor loading even before delivery occurs. Daly et al. (2018) [16] similarly demonstrated that urinary leakage during pregnancy was a strong predictor of persistent postpartum incontinence. Moossdorff-Steinhauser et al. (2021) [17] also documented a high prevalence of urinary incontinence during pregnancy, reinforcing the importance of antenatal screening. Neonatal birth weight ≥3.5 kg was associated with LUTS in unadjusted analysis but did not remain significant after adjustment (aOR 1.78, 95% CI 0.82-3.87; p=0.143). Larger infants may increase stretching and compression of the pelvic floor during delivery, but the effect may be mediated through prolonged labour, instrumental delivery and perineal trauma. Dai et al. (2023) [6] found that birth weight exceeding 4 kg was a significant pooled risk factor. The lower cut-off used in the present study and the relatively small number of high-birth-weight infants could have reduced the strength of the adjusted association. Instrumental vaginal delivery was associated with LUTS on unadjusted analysis (OR 4.78, 95% CI 1.49-15.29; p=0.004), but it was not independently significant (aOR 2.41, 95% CI 0.66-8.75; p=0.182). The wide confidence interval reflected the small number of instrumental births. Blomquist et al. (2018) [2] found that operative vaginal delivery, particularly forceps delivery, carried the greatest risk of pelvic-floor disorders. Gyhagen et al. (2019) [3] also reported that long-term urinary-incontinence risk varied between spontaneous and operative vaginal deliveries. The absence of independent significance in the present study should therefore be interpreted cautiously rather than as evidence of no association. Prolonged labour remained independently associated with LUTS (aOR 2.69, 95% CI 1.02-7.10; p=0.046). A prolonged second stage may expose the levator ani muscles, fascial supports and pudendal nerves to sustained pressure and stretching. The meta-analysis by Dai et al. (2023) [6] identified a prolonged second stage as a significant determinant of postpartum incontinence. Mulder et al. (2019) [18] also described relationships between obstetric exposures, pelvic-floor muscle injury and postpartum pelvic-floor symptoms. These observations support careful labour monitoring and avoidance of unnecessarily prolonged obstructed labour. Episiotomy or perineal trauma was another independent predictor (aOR 2.73, 95% CI 1.13-6.58; p=0.026). Perineal trauma may coexist with deeper muscular and connective-tissue injury and can consequently impair urethral and pelvic-floor support. Siahkal et al. (2020) [15] and Dai et al. (2023) [6] identified perineal laceration as an important risk factor. However, episiotomy alone may sometimes be a marker of a difficult delivery rather than a direct cause of LUTS. Jiang et al. (2017) [19] found that routine episiotomy did not provide clear protection against urinary incontinence and supported restrictive rather than routine use. After adjustment for maternal and obstetric variables, vaginal delivery remained independently associated with LUTS (aOR 1.96, 95% CI 1.01-3.82; p=0.047). This supported an independent contribution of the birth route to postpartum urinary dysfunction. Nevertheless, the lower prevalence following cesarean section should not be interpreted as justification for cesarean delivery solely to prevent LUTS. Cesarean section carries important short- and long-term maternal and neonatal risks, and it does not completely prevent urinary symptoms. Preventive strategies should instead include antenatal identification of high-risk women, avoidance of unnecessary obstetric trauma, postpartum symptom screening and appropriately supervised pelvic-floor muscle training. Woodley et al. (2020) [20] concluded that pelvic-floor muscle training may help prevent urinary incontinence during late pregnancy and the postpartum period, particularly when introduced through structured antenatal or postnatal programmes.

Lower urinary tract symptoms were significantly more common among women following vaginal delivery than among those following cesarean section. Women who delivered vaginally had a higher prevalence of overall LUTS, stress urinary incontinence, moderate-to-severe symptoms, higher ICIQ-FLUTS scores and greater interference with daily activities. Elevated BMI, LUTS during pregnancy, prolonged labour, episiotomy or perineal trauma and vaginal delivery were identified as independent predictors of postpartum LUTS. These findings support routine antenatal and postnatal screening for urinary symptoms, particularly among high-risk women. Appropriate counselling, weight management, prevention of avoidable obstetric trauma and early pelvic-floor rehabilitation may reduce the burden of postpartum urinary dysfunction. However, cesarean section should not be recommended solely to prevent LUTS because it does not provide complete protection and carries other maternal and neonatal risks. LIMITATIONS The study had several limitations. First, its cross-sectional design did not allow temporal or causal relationships between the mode of delivery and LUTS to be established. Second, it was conducted at a single tertiary-care hospital, which may limit the generalisability of the findings. Third, urinary symptoms were assessed primarily using a self-reported questionnaire and may have been affected by recall bias, reporting bias or embarrassment. Fourth, objective investigations such as urodynamic testing, uroflowmetry, post-void residual measurement and pelvic-floor ultrasonography were not routinely performed. Fifth, pre-pregnancy pelvic-floor strength and objectively documented urinary symptoms were unavailable, making it difficult to identify newly developed symptoms with certainty. Sixth, the interval between delivery and assessment varied among participants, and some symptoms may have improved naturally over time. Seventh, the relatively small number of women with instrumental delivery, high neonatal birth weight and severe LUTS resulted in wide confidence intervals for certain associations. Finally, residual confounding from factors such as pelvic-floor exercises, breastfeeding, constipation, physical activity, indication for cesarean section and number of previous deliveries could not be completely excluded.

1. Tähtinen RM, Cartwright R, Tsui JF, Aaltonen RL, Aoki Y, Cárdenas JL, et al. Long-term impact of mode of delivery on stress urinary incontinence and urgency urinary incontinence: a systematic review and meta-analysis. Eur Urol. 2016;70(1):148-58. 2. Blomquist JL, Muñoz A, Carroll M, Handa VL. Association of delivery mode with pelvic floor disorders after childbirth. JAMA. 2018;320(23):2438-47. 3. Tähtinen RM, Cartwright R, Vernooij RWM, Rortveit G, Hunskaar S, Guyatt GH, et al. Long-term risks of stress and urgency urinary incontinence after different vaginal delivery modes. Am J Obstet Gynecol. 2019;220(2):181.e1-181.e8. 4. Moossdorff-Steinhauser HFA, Berghmans BCM, Spaanderman MEA, Bols EMJ. Prevalence, incidence and bothersomeness of urinary incontinence between 6 weeks and 1 year postpartum: a systematic review and meta-analysis. Int Urogynecol J. 2021;32(7):1675-93. 5. Moossdorff-Steinhauser HFA, Berghmans BCM, Spaanderman MEA, Bols EMJ. Urinary incontinence 6 weeks to 1 year postpartum: prevalence, experience of bother, beliefs, and help-seeking behavior. Int Urogynecol J. 2021;32(7):1817-24. 6. Dai S, Chen H, Luo T. Prevalence and factors of urinary incontinence among postpartum women: systematic review and meta-analysis. BMC Pregnancy Childbirth. 2023;23(1):761. 7. Dietz HP. Pelvic floor trauma in childbirth. Aust N Z J Obstet Gynaecol. 2017;57(3):220-30. 8. Eickmeyer SM. Anatomy and physiology of the pelvic floor. Phys Med Rehabil Clin N Am. 2017;28(3):455-60. 9. Aoki Y, Brown HW, Brubaker L, Cornu JN, Daly JO, Cartwright R. Urinary incontinence in women. Nat Rev Dis Primers. 2017;3:17042. 10. Milsom I, Gyhagen M. The prevalence of urinary incontinence. Climacteric. 2019;22(3):217-22. 11. Lukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L. Urinary incontinence in women: a review. JAMA. 2017;318(16):1592-604. 12. Bø K, Frawley HC, Haylen BT, Abramov Y, Almeida FGA, Berghmans B, et al. An International Urogynecological Association/International Continence Society joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction. Neurourol Urodyn. 2017;36(2):221-44. 13. Liang Y, Chen Y, Li J, Wang X, Jiang C, Wu J, et al. Quality of life among women with postpartum urinary incontinence: a cross-sectional study. Gynecol Obstet Clin Med. 2021;1(2):69-74. 14. Stadnicka G, Łepecka-Klusek C, Pilewska-Kozak AB, Jakiel G. Psychosocial problems of women with stress urinary incontinence. Ann Agric Environ Med. 2015;22(3):499-503. 15. Siahkal SF, Iravani M, Mohaghegh Z, Sharifipour F, Zahedian M. Maternal, obstetrical and neonatal risk factors' impact on female urinary incontinence: a systematic review. Int Urogynecol J. 2020;31(11):2205-24. 16. Daly D, Clarke M, Begley C. Urinary incontinence in nulliparous women before and during pregnancy: prevalence, incidence, type and risk factors. Int Urogynecol J. 2018;29(3):353-62. 17. Moossdorff-Steinhauser HFA, Berghmans BCM, Spaanderman MEA, Bols EMJ. Urinary incontinence during pregnancy: prevalence, experience of bother, beliefs, and help-seeking behavior. Int Urogynecol J. 2021;32(3):695-701. 18. Mulder FEM, Hakvoort RA, Schoffelmeer MA, Limpens J, Van der Post JAM, Roovers JPWR. Postpartum urinary retention: a systematic review of adverse effects and management. Int Urogynecol J. 2019;30(12):1981-90. 19. Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017;2(2):CD000081. 20. Woodley SJ, Lawrenson P, Boyle R, Cody JD, Mørkved S, Kernohan A, Hay-Smith EJC. Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 2020;5(5):CD007471