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  • Research article
  • Open Access
  • Open Peer Review

Prevalence and antimicrobial susceptibility of asymptomatic bacteriuria among women with pelvic organ prolapse in Abakaliki, South-East Nigeria

  • 1,
  • 1,
  • 1,
  • 1Email author,
  • 1,
  • 2,
  • 1 and
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BMC Women's HealthBMC series – open, inclusive and trusted201818:53

https://doi.org/10.1186/s12905-018-0545-9

  • Received: 16 February 2017
  • Accepted: 16 March 2018
  • Published:
Open Peer Review reports

Abstract

Background

Pelvic organ prolapse (POP) is the herniation of pelvic organs from its anatomical confines, and it is of considerable importance to the practicing gynaecologist in middle and low income countries. It is commonly associated with, urinary tract infection (UTI), both symptomatic and asymptomatic due to anatomical and physiological changes. The aim of this study was to determine the prevalence of asymptomatic bacteriuria among women with pelvic organ prolapse, to know the organisms commonly implicated and the sensitivity pattern.

Methods

This study was conducted among 96 women with POP at the National Obstetric Fistula Centre Abakaliki. A cross sectional descriptive study was done. Standard microbial technique was used to analyze the urine. Data was analysed using the Statistical Package for Social Sciences version 17.

Results

Out of the 96 patients, 76 were found to have asymptomatic bacteriuria giving a prevalence of 79.2%. Nine different bacteria species isolated include E. Coli (34.2%), Streptococcus pneumonia (23.7%), Staphylococcus aureus (7.9%), Proteus Spp (7.9%) others (5.3%). The highest level of microbial sensitivity to the antimicrobials was with Ciprofloxacin.

Conclusions

This study suggests that prevalence of asymptomatic bacteriuria is very high among women with POP. More than 50% of the bacterial isolates were mainly E.coli and Streptococcus pneumonia. The highest level of microbial sensitivity was with ciprofloxacin while the least was with cotrimoxazole.

Keywords

  • Pelvic organ prolapse
  • Asymptomatic bacteriuria
  • Abakaliki
  • Nigeria

Background

Pelvic organ prolapse (POP) is the herniation of the pelvic organs from its anatomical confines [1]. It is a common gynaecological problem particularly in the grandmultipara [18]. It is of considerable importance to the practicing gynaecologist in the developing countries because of its strong association with repeated child bearing [24, 810]. Poor conduct of labour can predispose to uterine prolapse [3, 11, 12].

Pelvic organ prolapse is also common in conditions of chronically raised intra-abdominal pressure [24, 11]. Very rarely, it could be due to congenital weakness of the pelvic floor muscles and altered collagen metabolism [3, 12].

The prevalence of asymptomatic bacteriuria is 1.0%–5.0% in healthy population [13]. Pelvic organ prolapse (POP) is a very common problem with a prevalence of 41–50% in women over the age of 40 years. It was reported as present in 50% of parous women, with the aggregated rates of prolapse surgery which were estimated at between 15 and 49 per 10,000 per women year [14, 15].

It is commonly associated with, urinary tract infection, UTI (both symptomatic and asymptomatic) due to anatomical and physiological changes [1]. Asymptomatic bacteriuria is the presence of live bacteria in the urine of an individual without symptoms of UTI [10]. Significant bacteriuria is the finding of 100,000 pure colonies in 1 ml of uncentrifuged urine sample [11]. Further, with the abuse of antibiotics, resistant bacterial strains are likely to emerge as major microbial isolates in urine, thus further complicating the management [12].

Escherichia coli remains the single most common organism isolated from bacteriuric women [13, 16, 17] Other Enterbacteriaceae (such as Klebsiella pneumonia) and other organisms (including coagulase negative staphylococci, Enterococcus species, group B streptococci, and Gardnerella vaginalis) are common as well [13].

Prolapse classically produces a sensation of fullness in the vagina or a visible or palpable lump at the introitus. While women who have prolapse may have stress incontinence, particularly if the urethra is not well supported, they may also have voiding dysfunction secondary to kinking for the urethra [1]. Voiding dysfunction may result in frequency (due to incomplete bladder emptying), hesitancy and a poor urinary stream. This results in stasis of urine in the urinary tract, which is culture medium for bacteria growth [1]. Incomplete bladder emptying may in turn result in recurrent urinary tract infection with accompanying frequency, urgency and urge incontinence. Most cases of asymptomatic bacteriuria are subclinical UTI. This can be exacerbated by surgery and other stressors [1, 4, 5].

This aspect of knowledge is so sparsely studied and there is paucity of literature bank in this area. Our aim was to determine the prevalence and antimicrobial susceptibility of asymptomatic bacteriuria among women with pelvic organ prolapse.

Methods

The study was conducted at the National Obstetric Fistula Centre, Abakaliki which offers free surgical services to patients with urogenital fistula and pelvic organ prolapse. A cross sectional descriptive study was done. Study population was women with pelvic organ prolapse presenting at the centre for surgery. Patients with pelvic organ prolapse without symptoms of urinary tract infection were included in this study. Women with symptoms of UTI and those who refused to give consent were excluded. The study was carried over a 12-month period (Ist July 2013 – 30th June 2014).

The sample size was calculated by a statistical formula based on the proportion of 3.91% [18] for women with POP from a study by Ojiyi et al. in Imo State, South East Nigeria, and a confidence level set at 95% with an error margin of 0.05.

Following informed consent, a questionnaire was used to obtain relevant information from the study participants. Midstream urine was collected from each of the subjects using a urethral catheter into sterile containers (universal bottles). Urine samples were cultured on cystine lactose electrolyte deficiency (CLED) and blood agar (BA) medium [19, 20]. The culture plates were incubated at 37 °C for a duration of 24 h. Several biochemical tests were conducted for bacterial isolation and identification. Bacteria isolates made were subjected to antibiotic sensitivity analysis using the disc diffusion methods [20, 21]. The sensitive drugs were gentamycin, ciprofloxacin, ceftriaxone, ofloxacin, perfloxacin, cotrimoxazole, cefuroxime Tetracycline, Chloramphenicol, Cloxacillin, Streptomycin, Nalidixic acid, Augmentin, Erythromycin, Amoxicillin and Nitrofurantoin. Study participants with significant bacteriuria were treated accordingly.

Collected data was analyzed using the Statistical Package for Social Sciences (SPSS) version 17.

Ethical approval was obtained from the Ethics and Research committee of the National Obstetric Fistula Centre, Abakaliki. Individual informed consent form was attached to each questionnaire and the respondent gave her consent before the questionnaires were filled.

Results

The findings of this study are presented as follows:

The age groups 40–49 years and 50–59 years constituted the greatest percentage with 25.0% and 33.3% respectively. This is as shown in Table 1.
Table 1

Social demographic variables

Variables

Frequency (%)

Age

 20–29

2 (2.1)

 30–39

13(13.5)

 40–49

24(25.0)

 50–59

32(33.3)

 60–69

20(20.8)

 70–79

3(3.1)

  > 79

2(2.1)

Median age = 51

 

Parity

 2–4

16(6.6)

 5–7

51(53)

 8–10

25(26)

  > 10

4(4.2)

Median parity = 6

 

Marital Status

 Married

75(78.1)

 Divorced

6(6.3)

 Widow

15(15.6)

Level of Education

No formal education

81(84.4)

Part Prim. Education

9(9.4)

Primary education

6(6.2)

Occupation

 Unemployed

23(24.0)

 Unskilled

65(67.7)

 Middle level

8(8.3)

Husband Occupation

 Unemployed

20(20.8)

 Unskilled

51(53.1)

 Middle level

11(11.5)

 Professional

14(14.6)

Out of the 96 women with pelvic organ prolapse recruited, 76 of them were positive for asymptomatic bacteriuria. This makes the prevalence of asymptomatic bacteriuria to be 79.2%.

For clients without asymptomatic bacteriuria, mean parity was 6.75 ± 2.83.

Nine (9) different bacteria species were isolated (Table 2) More than half of the bacteria isolated from the urine of the patients were E. coli (34.2%) and Streptococcus pneumonia (23.7%).
Table 2

Bacteria isolated from urine of Participants (n = 76)

Common Organism implicated

Frequency (%)

Strept faecalis

4 (5.3)

Staph aureus

6(7.9)

Strept pneumonia

18(23.7)

Proteus spp

6(7.9)

E. coli

26(34.2)

Klepsiella spp

4(5.3)

Strept pyogenes

4(5.3)

Pseudomonas aeruginosa

4(5.3)

Enterobacter

4(5.3)

Total

76(100)

The highest level of microbial sensitivity to the antimicrobials was with ciprofloxacin while the least was with cotrimoxazole (Table 3).
Table 3

Sensitivity/Resistance pattern of various organisms isolated from urine of Patients

Organism

Sensitivity

Resistance

Strept faecalis

Tetracycline, Chloramphenicol, Cloxacillin, Streptomycin, Augmentin, Gentamycin, Ciprofloxacin

Erythromycin, Cotrimoxazole

Staph aerueus

Gentamycin, Streptomycin, Augmentin, Chloramphenicol, Cloxacillin

Erythromycin, Cotrimoxazole, Ciprofloxacin, Tetracycline

Strept pneumonia

Augmentin, Cloxacillin, Chloramphenicol, Ciprofloxacin

Gentamycin, Erythromycin, Cotrimoxazole, Tetracycline, Streptomycin

Proteus spp

Nitrofurantoin, Ciprofloxacin

Cotrimoxazole, Tetracycline, Augmentin, Gentamycin, Nalidixic acid, Amoxicillin, Ofloxacin

Escherichia coli

Nitrofurantoin, Ofloxacin, Gentamycin, Nalidixic acid, Ciprofloxacin

Cotrimoxazole, Amoxicillin, Tetracycline, Augmentin

Klebsiella spp

Streptomycin, Cotrimoxazole, Gentamycin, Augmentin, Chloramphenicol, Ciprofloxacin

Tetracycline, Cloxacillin, Erythromycin

Strept pyogenes

Chloramphenicol, Augmentin, Ciprofloxacin, Cloxacillin

Gentamycin, Streptomycin, Tetracycline, Cotrimoxazole

Pseudomonas aeruginosa

Gentamycin

Nalidixic acid, Cotrimoxazole, Amoxicillin, Tetracycline, Augmentin, Ofloxacin, Nitrofurantoin

Enterobacter

Ofloxacin, Gentamycin, Nalidixic acid, Nitrofurantoin

Cotrimoxazole, Amoxicillin, Tetracycline, Augmentin

Discussion

The age group 40–49 years and 50–59 years constituted the greatest percentage of the patients (25%) and (33.3%) respectively with POP and the mean age was 52.79 years with standard deviation of 10.84 years. These sociodemographic variables are similar to studies done in Lagos [2], Enugu [3], India [4], Ibadan [9], Nnewi [12]. This could be due to reduction in the production of female hormones especially estrogen during the perimenopausal and menopausal age range and the subsequent effect of these reduced hormones in the pelvic supporting structures [22] .Secondly, most women in this age range are multipara with its attendant effect on the ligaments and other pelvic supporting organs [2, 18, 21]. Majority of the women were grandmultiparous (that is 5 or more deliveries) with highest value being Para 6(18.8%).The mean Parity was 6.74 with standard deviation of 2.27 and the median parity was 6. This is also similar to studies done in Lagos [2], Enugu [3], India [4], Ibadan [9], Nnewi [12], Benin [23], where the majority of the women were grandmultiparous and the mean parities were 6 and above. Pregnancy and bearing down in the second stage of labour further puts much more tension to these pelvic supporting structures thereby predisposing these women to developing pelvic organ prolapse [1]. Prolonged labour that is labour lasting more than 12 h and unsupervised deliveries are strong determinants [21]. Increased number of pregnancies will cause recurrent repetition of these events, thus, the higher the number of pregnancies, the higher the risk of developing pelvic organ prolapse [1, 8].

The results of this study showed that the prevalence of asymptomatic bacteriuria was 79.2% among women with pelvic organ prolapse. This is greater than the figures from study done in Ekiti state, Nigeria which found a prevalence of 10% among antenatal enrollees in southwest Nigeria [24]. The prevalence is generally far less in pregnant women (< 20%) [2428]. This could be due to increase kinking of ureters, hydroureter, hydronephrosis and stasis of urine in POP patients compared with normal pregnant women. This is greater than the figures from studies done in Mexico (61%) [29]. This could be because of improved personal hygiene and differences in life style among the study population, more so, the Mexican study was a multicenter study. It is also low in a community based study among elderly population done in a Swedish mid-sized town, where the prevalence was 14.8% [22]. This could be because the elderly people used in this study were apparently healthy population and because of improved personal hygiene and life style differences.

In this study, nine (9) bacteria species were isolated from the patients and they included Escherichia coli (34.2%), Streptococcus pneumonia (23.7%), Staphylococcus aureus (7.9%), Proteus species (7.9%), Klebsiella species (5.3%), Streptococcus pyogenes (5.3%), Pseudomonas aeruginosa (5.3%) and Enterobacter species (5.3%). The commonest organisms implicated in asymptomatic bacteriuria were E. coli (34.2%), and Streptococcus pneumonia (23.7%). In the community based study on asymptomatic bacteriuria among the elderly population done in Sweden, E.coli was the predominant organism implicated likewise the study on asymptomatic bacteriuria among the vesico-vaginal fistula clients done in South-East Nigeria and the study on asymptomatic bacteriuria in children done in Sweden, E. coli was named as the commonest organism [24, 2933]. Most studies on asymptomatic bacteriuria in pregnancy also implicated E.coli as the predominant organism [27, 28]. This could be explained due to the fact that it is a normal flora in the lower gastrointestinal tract, and also due to its adhesive ability.

The highest level of microbial sensitivity to the antimicrobials was with ciprofloxacin while the least was with cotrimoxazole. Strept.faecalis was resistant to only erythromycin and cotrimoxazole.

This study is limited by its sample size. Also, a probability sampling method was not used. This should form the basis for future research.

Conclusions

The prevalence of asymptomatic bacteriuria in women with POP presenting for surgery at the National Obstetric Fistula Centre from this study was rather very high (79.2%). Several microorganism (E. Coli, Streptococcus pneumonia, Staphylococcus aureus, Proteus Spp, Strept faecalis, Klebsiella spp, Enterobacter, Strept pyogenese, Pseudomonas aeruginosa) were implicated in asymptomatic bacteriuria among patients with pelvic organ prolapse The highest level of microbial sensitivity was with ciprofloxacin while the least was with cotrimoxazole. It is therefore recommended that ciprofloxacin should be the drug of choice in the treatment of patients with urogenital prolapse especially in the post-operative period.

Abbreviations

BA: 

Blood agar

CLED: 

Cystine lactose electrolyte deficiency

E coli: 

Escherichia coli

POP: 

Pelvic organ prolapse

Spp: 

Specie

TSI: 

Tripple sugar iron

UTI: 

Urinary tract infection

VVF: 

Vesicovaginal fistula

Declarations

Acknowledgements

None.

Funding

None.

Availability of data and materials

We consider our data as private and the corresponding author will make it available when requested.

Authors’ contributions

KE, IS, ME and MI were major contributors in the conception and drafting of the manuscript. HU, PE, KE, BD and EY were major contributors in the study design and data analysis. All authors read and approved the final version of this manuscript.

Competing interest

The authors declare that they have no competing interests.

Ethics approval and consent to participate

Ethical approval was obtained from Ethics and Research committee of the National Obstetric Fistula Centre, Abakaliki. Patients that gave consent were those that participated in the study. Consent forms were signed by the study participants Refusal to give consent did not influence management of the patient involved.

Consent for publication

not applicable.

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Authors’ Affiliations

(1)
National Obstetric Fistula Centre, Abakaliki, Nigeria
(2)
Federal Teaching Hospital, Abakaliki, Nigeria

References

  1. Linda C. Prolapse, 5th edition Dewhurst, Blackwell Science Ltd. London.1996. pg 642–652.Google Scholar
  2. Rabiu KA, Adewunmi AA, Badmus SA, Akinola OI, Akinlusi FM. Pelvic organ prolapse in Lagos. Nigerian Journal of Clinical Medicine. 2009;2(2):25–31.Google Scholar
  3. Okonkwo JEN, Obiechina NJA, Obionu CN. Incidence of pelvic organ prolapse in Nigerian women. J Natl Med Assoc. 2003;95:132–6.PubMedPubMed CentralGoogle Scholar
  4. TNA J. Genital Prolapse. In: Jeffcoates TA, editor. Principles of gynaecology. 7th ed. India: Jaypee; 2008. p. 324–34.Google Scholar
  5. Lewis AC. Major Gynaecology surgery in the elderly. J Int Fed GynaecolObstet. 1968;6:244–58.View ArticleGoogle Scholar
  6. Ogunbode O, Aimakhu VE. Uterine prolapse during pregnancy in Ibadan. Am J Obstet Gynaecol. 1973;16:622–5.View ArticleGoogle Scholar
  7. Cespedes RO, Cross CA, MeGuire EJ. Pelvic prolapse: diagnosing and treating uterine and vaginal vault proplapse. Women’s Health J. 1998;3:3–4.Google Scholar
  8. Molton PJD. Uterovaginal prolapse. In: Studd J, editor. Progress in obstetrics and Gynaecology, vol. 7. Edinburgh: Churchill Livingstone; 1989. p. 319–30.Google Scholar
  9. Osinusi BO, Adeleye JA. The symptomatology and clinical presentation of uterovaginal prolapse in Ibadan. Niger Med J. 1976;8:451–4.Google Scholar
  10. Tindall VR. Genital Prolapse. In: Tindall V, editor. Jeffcoates principle of gynaecology. 5th ed. London: Butterworths and Co. Publishers; 1987. p. 260–74.Google Scholar
  11. O’ Leary JA, O’ Laery JL. The extended Manchester operation: a review of 289 cases. Am J Obstet Gynecol. 1990;107:564–59.Google Scholar
  12. John CT, Inimgba NM. Uterovaginal prolapse and stress incontinence. In: Ikpeze OC, editor. Fundamentals of obstetrics and Gynaecology. Onitsha: Africana First Publishers Plc; 2009. p. 346–50.Google Scholar
  13. Lindsay EN, Sussan B, Richard C, James CR, Anthony S, Thomas MH. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. IDSA guidelines for asymptomatic bacteriuria CID 2005:40 (1 March).Google Scholar
  14. Monga A, Dobbs S. Gynaecology by Ten Teachers. 18th ed. 2006. Chapt 17. Pelvic Organ Prolapse. Bookpower. London. Pg 200–206.Google Scholar
  15. Giacomo NA, Mariangela M, Vincenzo F, Walter A. Critical assessment of pelvic floor surgical reconstruction outcome. European Association of Urologist. 2006;4:202–13.Google Scholar
  16. Evans DA, Williams DN, Laughlin LW. Bacteriuria in a population-based cohort of women. J Infect Dis. 1978;138:768–73.View ArticlePubMedGoogle Scholar
  17. Kunin CM, McCormack RC. An epidemiologic study of bacteriuria and blood pressure among nuns and working women. N Engl J Med. 1968;278:635–42.View ArticlePubMedGoogle Scholar
  18. Ojiyi EC, Dike EI, Anolue FC, Nzewuihe AC, Ejikeme CC. Uterovaginal prolapse at a university teaching hospital in south-East Nigeria. Orient Journal of Medicine. 2013;25:3–4.Google Scholar
  19. Cheesbrough M. District laboratory practice in tropical countries. Part 2. Cambridge University PressUK. 2000:34–243.Google Scholar
  20. Forbes BA, Sahm DF, Weissfeld AS. Bailey andScott’s diagnostic microbiology. 12th ed. St. Louis, Missouri: Mosby, Elseiver Inc; 2007. p. 1031.Google Scholar
  21. Okeke TC, Ani VC, Ezenyeaku CCT, Ikeako LC, Enwereji JO, Ekwuazi K. An audit of Uterovaginal prolapse in Enugu, Southeast Nigeria. American. Journal of Clinical Medicine Research. 2013;1(1):23–5.View ArticleGoogle Scholar
  22. Rodhe N, Mölstad S, Englund L, Svärdsudd K. Asymptomatic bacteriuria in a population of elderly residents living in a community setting: prevalence, characteristics and associated factors. Fam Pract. 2006;23(3):303–7.View ArticlePubMedGoogle Scholar
  23. John CT. Genital Prolapse. In: Okonofua FE, Odunsi K, editors. Contemporary obstetrics and Gynaecology for developing countries. Benin City: WHARC; 2003. p. 214–26.Google Scholar
  24. Ade-Ojo IP, Oluyege AO, Adegun PT, Akintayo AA, Aduloju OP, Olofinbiyi BA. Prevalence and antimicrobial suseptibility of asymptomatic significant bacteriuria among new antenatal enrollees in Southwest Nigeria. International Research Journal of Microbiology (IRJM). 2013;4(8):197–203.Google Scholar
  25. Agersew A, Felek M, Yitayal S, KetemaT, Afework K, Belay A, Abebe A. Bacterial profile and drug susceptibility pattern of urinary tract infection in pregnant women at university of Gondar teaching hospital, Northwest Ethiopia. BMC Research Notes 2012;5:197 http://www.biomedcentral.com/1756-0500/5/197.accessed 2nd August 2014 at 19:15.
  26. Aziz MK, Habib-UK, Ihsan-Ullah M, Bushra A, Syed HS. Antimicrobial sensitivity pattern of urine isolates from asymptomatic bacteriuria during pregnancy. Biomedica. 2006;22:9 (A).Google Scholar
  27. Schnarr J, Smaill F. Asymptomatic bacteriuria and symptomatic urinary tract infections in pregnancy. Eur J Clin Investig. 2008;38(S2):50–7.View ArticleGoogle Scholar
  28. Tugrul S, Oral O, Kumru P, Köse D, Alkan A, Yildirim G. Evaluation and importance of asymptomatic bacteriuria in pregnancy. Clin Exp Obstet Gynecol. 2005;32(4):237–40.PubMedGoogle Scholar
  29. Rogers RG, Kammerer-Doak D, Olsen A, Thompson PK, Mark D, Walters ES, Lukacz ES, Clifford Q. A randomized, double-blind, placebo-controlled comparison of the effect of nitrofurantoin monohydrate macrocrystals on the development of urinary tract infections after surgery for pelvic organ prolapse and/or stress urinary incontinence with suprapubic catheterization. Am J of Obstetrics and Gynecology. 2004;191:182–7.View ArticleGoogle Scholar
  30. Adeoye SI, Oladeinde O, Uneke J, Adeoye J. An assessment of asymptomatic bacteriuria among women with VesicoVaginal fistula in south-eastern Nigeria. Nepal Journal of Epidemiology. 2011;1(2):64–9.View ArticleGoogle Scholar
  31. Mikael B, Jodal V, William A, Mikael H, Staffan M, Sten R, Michael S, Wettergren B, Susanne J, Catharina S. Interleukin (IL)-6 and IL-8 in children with febrile urinary tract infection and asymptomatic bacteriuria. The journal of lnfectious. Diseases. 1996;174:1080–4.View ArticleGoogle Scholar
  32. Andabati G, Byamugisha J. Microbial aetiology and sensitivity of asymptomatic bacteriuria among ante-natal mothers in Mulago hospital, Uganda. Afr Health Sci. 2010;10(4):349–52.PubMedPubMed CentralGoogle Scholar
  33. Ad'hiah AH, Al-Sheikh SKF, Jasim AN, Mayouf KZ. AssessmentOf urinary tract infection and cytokine (IL-2, IL-4 and IL-17A) serum levels in Iraqi samples of systemic autoimmune diseases (rheumatoid arthritis, ankylosing spondylitis and systemic lupus erythematosus) patients. The International Medical Journal. 2013;12(1):11–8.Google Scholar

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