Characterization of pelvic floor symptoms in community-dwelling women of northeastern Liberia.

Urinary incontinence (UI), fecal incontinence (FI), and pelvic organ prolapse (POP) are common conditions among women in the United States. Prevalence rates have been characterized by large diverse population-based studies [1], [2]; however, there is little robust data characterizing the prevalence and quality of life (QoL) impact of pelvic floor disorders in women of West Africa, where parity is, on average, higher than in the United States [3]. Some studies have reported that pelvic floor symptoms such as UI and POP may not be as prevalent in African American women compared with white women [1], [4]. This has been attributed to factors such as physiologic or anatomic differences [4] or simple lack of reporting of these symptoms. The aim of the present study was to survey a large number of community-dwelling West African women without vesicovaginal fistulae to provide some insight regarding these reports. A questionnaire (Fig. 1) addressing symptoms of UI, FI, and POP as well as the impact on QoL was administered to reproductive-age, community-dwelling women in Ganta, Liberia, during two, 2-week surgical service trips in May, 2008 and January, 2009. Institutional Review Board approval was obtained prior to collecting data and verbal consent was obtained prior to questioning the participants. Questionnaire utilized to determine prevalence of pelvic floor disorders in northeastern Liberia. The questionnaire was designed by combining components of the Sandvik Severity questionnaire [5], the PISQ-12 [6], the PFIQ-7 and PFDI-20 [7], and the Modified Manchester [8] questionnaires. Data were analyzed, using SAS version 9.2 (SAS, Cary, NC, USA), to determine if a relationship existed between prior hysterectomy, cesarean delivery, number of vaginal births, and body mass index on the prevalence of UI, FI, and POP symptoms using the Fisher exact test for hysterectomy and cesarean delivery history, and logistic regression for vaginal births and BMI. The Bonferroni correction was used to adjust an overall 0.05 level of significance for multiple comparisons, and P ≤ 0.004 was considered significant. The relationships between UI, FI, and POP were also examined using the Fisher exact test. A total of 424 patients were surveyed; select characteristics of the participants are given in Table 1. Seven respondents (1.7%) reported urinary incontinence with less than half of these (n = 3) reporting daily leakage. QoL responses revealed that of these 7 individuals suffering from UI, more than 85% (n = 6) reported a major impact on their QoL. Five respondents (71.4%) suffering from UI reported that incontinent episodes were affecting their relationship with their partner. Four participants (< 1%) reported flatus incontinence, with one respondent also reporting both incontinence of solid and liquid stool at least once a week. A total of 14 respondents (3.3%) reported some symptom of pelvic organ prolapse. QoL responses revealed that 42.8% (n = 6) of these 14 respondents quoted moderate to severe QoL impact. Despite the low prevalence rates, we wished to explore potential factors associated with the presence of UI, FI, and POP symptoms. Logistic regression determined that of the 7 women with UI, 2 also reported FI, indicating a strong relationship between these outcomes (P = 0.002). This association should be interpreted cautiously because of the low prevalence of these outcomes. Urinary and fecal incontinence are reasonably prevalent conditions in women in the industrialized world and have been well characterized by well-designed, large, population-based studies of diverse patient populations [1], [2]. However, these studies have not determined the impact of these symptoms on QoL. The prevalence rates for UI, FI, and POP in this parous population in Liberia were quite low. Factors such as previous hysterectomy, previous cesarean delivery, number of prior vaginal deliveries, and body mass index did not appear to affect the risk of developing pelvic floor symptoms in this population. However, because of the low prevalence of UI, FI, and POP reported, this study is underpowered to detect these relationships if they truly exist. Multiple studies have demonstrated lower prevalence rates for POP, UI, and FI in African American women compared with white women [1], [2], [4]. As noted in these reports, factors such as physiologic or anatomic differences or lack of reporting of these symptoms may be the cause for this finding. A weakness of the present study includes a potential communication barrier. Although English is the official language of the country, there are many participants that spoke local languages, the most popular being Mano. Although native Liberian citizens administered the questionnaires, some of the terms and ideas may have been foreign to the participants. Furthermore, it is not ideal to lift single questions or modify them from a validated questionnaire, but in the interest of time constraints with the participants, this was performed. A strength of the study is its use of a modified questionnaire based on validated questionnaires to investigate QoL impact in this population in addition to reporting the overall prevalence. Additional strength is found in the study's moderately large numbers, being drawn from a group of local, community-dwelling women. It serves as a novel report on an understudied subject and population. Further larger studies with questionnaires validated specifically for this population could potentially yield different findings. The authors have no conflict of interest to disclose.