Urinary incontinence is a common condition affecting physical, psychosocial, social and economic wellbeing of affected individuals, with a prevalence of up to 30% in young adults rising to 50% in older patients(1).  However, it is often unreported.  Fistula patients apart, it is rare for patients in the gynae clinic to complain of urinary dysfunction. This study sought to assess the prevalence of unreported urinary incontinence in patients in a low resource setting.

The Urogenital Distress Inventory (UDI-6) short form questionnaire was used after translation and validation into the two most common languages used by patients.  The UDI 6 short form has previously been validated in a number of languages including Arabic (2), and it was felt this would be a suitable vehicle to establish the prevalence of urinary incontinence in our population.   The questionnaire was translated into the two languages and by native speakers and then back translated by individuals not involved in the original process.  In the absence of native English speakers with good knowledge of the target languages, health science graduates who had studied to degree level in English were used.  The results were compared and a consensus agreed.  Content / face validity was assessed by piloting the questionnaire to ensure that the questions were meaningful to individuals with differing socio-economic backgrounds. 165 patients attending the gynae clinic and who did not spontaneously volunteer any history of urinary dysfunction were asked after consultation if they would participate in answering the questions. 30 members of staff were also asked the same questions. Over 98% of the patients are illiterate, so the questionnaire had to be administered orally. One person, fluent in both languages, posed all the questions.  Respondents were asked about problems in the preceding one month and if they had a problem, were then asked whether it was small, moderate or large.  
Whilst assessing content validity, it became apparent that although frequency can be translated, it does not have any meaning in this context.  Q1 “Do you suffer with frequent urination?” was replaced by two questions which asked for number of episodes of urination by day and by night.  There was no statistical difference in the two groups of responses.

Average age of patients was 30 (16 – 60) and of staff was 29 (17 – 50).  (The ages are approximate as there are no birth certificates and patients do not keep a record of age.)  
Of the total 195 respondents, 80 (41%) had suffered incontinence in the preceding month, but mostly it was a minor problem – Table 1

Table 1 Prevalence of urge and stress incontinence 
Response	No problem	Small problem	Moderate problem	Big problem
Urge	133  (68%)	55  (28%)	4  (2 %)	3  (1.5%)
Stress	156  (80%)	30  (18%)	4  (2 %)	5  (2.6%)

Looking at the variation with age showed no significant difference, p< 0.5. Unfortunately, it was not possible to consider the effect of parity. Previous studies in other populations across similar ages ranges(1), (3), have shown stress incontinence to be the prevalent type.   In our sample, urge was predominant.

Daytime average number of episodes was 3.7 (1 – 10).  This is lower than usually accepted values but reflects the climatic difference.  The average night time number of episodes was 1.80 (0 – 10) but 45% of the sample population had more than one episode of nocturia. This was surprising finding.  Open defaecation is practised in the bush and people go to a recognised area some way from the habitation.  Animals are corralled at night to protect them from predators such as hyena.  Although temperatures drop slightly at night, there is no dramatic change in temperature in this desert area. However this has been the coldest winter on record, with temperatures occasionally dropping below 20 oC.  It would be interesting to repeat the study in the hottest time of the year when night time temperatures are in the mid-thirties.  Coffee is the national drink and many people drink 3 – 6 cups of strong coffee daily.  So this could also be a factor.

Nocturia was associated with mild symptoms of urgency (p<0.05),  but not with moderate or severe symptoms of urgency or with stress incontinence.

The prevalence of urinary incontinence in the previous one month was 40 % in our population, of whom 8% had a problem which was moderate or severe.   All patients were offered further consultation to explore these problems in more depth.  The finding that 45% had more than one episode of nocturia warrants further investigation.   We plan to routinely inquire about symptoms of incontinence in future to identify and offered assistance for this unmet need.

Hunskaar S, Lose G, Sykes D, & Voss S: The prevalence of urinary incontinence in women in four European countries.  BJU international 2004 93 324-330
Altaweel W, Seyam R, Mokhtar A et al: Arabic validation of the  Short Form of Urogenital Distress Inventory (UDI 6) Questionnaire.  Neurology and Urodynamics 2009 28 330-334
Flegen M, Benson K, Hanson JD, et al The prevalence of urinary incoinence in American Indian women from a South Dakota tribe Int.Urogynecol J 2012 23(4)  473 - 479