Potential causes of nocturia in a low resource population

McDougald M1, Ahmed M1, van Hennik M2

Research Type


Abstract Category

Female Lower Urinary Tract Symptoms (LUTS) / Voiding Dysfunction

Abstract 597
E-Poster 3
Scientific Open Discussion Session 31
Friday 6th September 2019
13:10 - 13:15 (ePoster Station 5)
Exhibition Hall
Nocturia Urgency/Frequency Mixed Urinary Incontinence Stress Urinary Incontinence
1.Barbara May Maternity Hospital, 2.Barabra May Maternity Hospital

Margaret McDougald




Hypothesis / aims of study
We reported recently on the prevalence of unreported  urinary incontinence in a low resource setting(1).  For this study we validated the UDI 6 (Urinary Distress Inventory) in Afar and Amharic. Out of 195 respondents, 8% of respondents had experienced severe episodes of incontinence in the preceding month. The predominant symptom was urge incontinence whereas other studies have shown stress incontinence to be more prevalent.  There was a high prevalence of nocturia which is surprising in this hot dry climate. This study examines  possible causes of reported nocturia. We identified these as: 
•	FGM, which makes voiding difficult and could potentially lead to incomplete emptying and more frequent small urination, There is also one reported study of an association between urge urinary incontinence and FGM(2) 
•	Coffee intake since coffee is the national drink and the coffee ceremony is practised by all ethnic groups and has great cultural significance 
•	Drop in temperature at night – at the time of the original study we were experiencing the coldest “winter” for a decade  
•	The possibility that in the bush where open defaecation is the norm, women might prefer to get up at night to defaecate and would urinate at the same time.  
•	We considered ethnicity since the overwhelming majority of our Afar patients have FGM whereas few of the Amharic ones do.
Study design, materials and methods
138 patients attending our gynae clinic and who did not complain of any urinary symptoms were asked at the end of the consultation if they would be happy to complete the questionnaire.  Patients in whom a significant problem was identified were offered further investigation, advice and treatment. The previously validated UDI 6 questionnaire was used with addition of questions about number of voids per day and per night to replace question on frequency which was found to have no meaning. In this second survey, patients were asked about their Ethnic group. Place of residence, FGM, parity and coffee intake. They were also asked about dysuria, specifically about a burning sensation on urination which is a common complaint in this population. Owing to  the breakdown of our solar water system necessitating several weeks concentration on maintenance, which was then followed by Ramadan, we were unable to repeat the study in warmer weather despite having the hottest summer for a decade. As over 98% of our patients are illiterate, the questions were posed orally by the same person.  The study met the criteria of the declaration of Helsinki.
The average age of the respondents was 28.6 years (range 15 – 50).  57% of the respondents were Afar, of whom 52% were from town or market town and 47% were from the bush. 29% were Amarhic.  This does not reflect the demographic of the region where 87% of the population live in the bush and 90% are Afar. It is however representative of our gynae clinic population.  24% had been troubled by incontinence in the preceding month and for 8% of them, this was moderate or severe. As in the previous study, the  predominant symptom was urge incontinence. (Figure 1). Significantly more patients with FGM has urge incontinence (p< 0.05), whereas significantly fewer patient with stress incontinence had FGM (p < 0.05).  

 16 % of the population had not got up at night and 44% had had  two or more episodes of nocturia.  There was no significant correlation between nocturia and ethnicity, coffee intake, residence in the bush. However there was a significant correlation between nocturia and FGM and also between nocturia and  dysuria - (p< 0.05).  There was no significant difference in nocturia between women living in the bush and women living in the town
Interpretation of results
Reviewing our potential causes of nocturia,of those we were able to assess,  only FGM showed a correlation.  Dysuria was significantly more frequent in women with FGM, as was urge urinary incontinece.  Obviously the numbers sampled so far are relatively few but both our surveys have shown a preponderance of urge urinary incontinence which contrasts with other population studies. This study suggests that  the presence of FGM in our population could account for some of the observed differences.  We are continuing to use the validated UDI 6 as part of a larger study of lower urinary tract sympotms in women with and without FGM The literature suggests a great many bad outcomes from FGM but it is clear from a study of the serious literature that much of this is pure conjecture because it is difficult to carry out research on women with FGM.  Few studies have looked at urinary dysfunction, but all agree on the paucity of hard data on either the symptoms or the benefits of de-infibulation. A recent paper by Effa et al (2)  highlights the absence of any randomised controlled studies or appropriate observational studies in countries where FGM is routinely carried out.
Concluding message
Conclusion: This study confirms our previous findings of substantial unreported urinary incontinence and nocturia in our population. It has  shown a correlation between nocturia and FGM.  FGM could also account for the preponderance of urge urge urinary incontinence as the dominant unreported symptom.  We are now repeating  the study in the hottest season
Figure 1 Prevalence of different types of incontinence
Figure 2 Possible factors affecting nocturia
  1. McDougald M, Hamed M, Mayram M. Mohammed M, Omer H: 2018 eposter International Continence Society Annual Meeting, Philadelphia Assessing the prevalence of urinary incontinence in a low resource setting
  2. Effa E, Olumuyiwa O, Ihesie A, Meremikwu MM 2017 Inj J Gynecol Obstet 136 (Suppl) 11 30 -33 Defibulation for treating urologic complications of Type III female genital mutilation: A Systemic Review
Funding NONE Clinical Trial No Subjects Human Ethics not Req'd This was not an interventional study, but one to ascertain the potential causes of the prevalence of an unreported condition. Subjects voluntarily participated and were not limited to patients. In the case of patients, the questions were asked after the consultation had ended and had no bearing on the treatment of their unrelated presenting condition. Their answers were anonymous. All respondents gave consent for participation. Helsinki Yes Informed Consent Yes
19/06/2024 18:21:39