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Article Information
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Authors:
Paul O. Dienye1
Precious K. Gbeneol1
Affiliations:
1Department of Family Medicine, University of Port Harcourt Teaching Hospital (UPTH), Nigeria
Correspondence to:
Paul Dienye
Email:
pdienye@yahoo.com
Postal address:
Department of Family Medicine, University of Port Harcourt Teaching Hospital, Nigeria
Dates:
Received: 22 June 2010
Accepted: 14 Oct. 2010
Published: 21 Apr. 2011
How to cite this article:
Dienye PO, Gbeneol PK. Contraception as a risk factor for urinary tract infection in Port Harcourt, Nigeria:
A case control study. Afr J Prm Health Care Fam Med. 2011;3(1), Art. #207, 4 pages.
doi:10.4102/phcfm.v3i1.207
Copyright Notice:
© 2011. The Authors. Licensee: OpenJournals Publishing. This work is licensed under the Creative Commons Attribution License.
ISSN: 2071-2928 (print)
ISSN: 2071-2930 (online)
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Contraception as a risk factor for urinary tract infection in Port Harcourt, Nigeria: A case control study
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In This Original Research...
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Open Access
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• Abstract
• Introduction
• Research significance
• Ethical considerations
• Method
• Design
• Subject selection
• Sampling method
• Analysing
• Results
• Discussion
• Conclusion
• Acknowledgements
• Authors’ contributions
• References
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Background: The concerted effort of government and donor agencies to limit fertility by the use of
contraceptives has been reported in some studies to predispose to urinary tract infection (UTI). Similar
studies have not been conducted in the General Outpatient Department (GOPD) of the University of Port Harcourt
Teaching Hospital (UPTH).
Objectives: This study was aimed at assessing the role of contraceptives in the development of UTI
amongst adult females attending the GOPD of UPTH.
Method: A case control study in which contraceptive users who attended the GOPD of the UPTH in
four months, and an equal number of age-matched controls, were screened for UTI. The information obtained
from them was entered into a specially designed pre-tested questionnaire for analysis. The results were
analysed using SPSS version 14.
Results: A total of 150 contraceptive users and controls were evaluated. Their age range was
18–50 years, with a mean of 27.8 ± 5.3 years. Most of the participants belonged to the lower
socioeconomic classes. The combined prevalence of UTI amongst the contraceptive users and the controls
was 23.7%, with the contraceptive users at 35.3% and the controls at 12.0%. The association of UTI
with contraceptive use was statistically significant, with McNemar’s χ2 = 16.28,
p = 0.000, odds ratio (OR) = 2.9, 95% confidence interval (CI) = 1.7 – 5.3, attributable
risk (AR) = 23.3, population attributable risk (PAR) = 11.7. The users of barrier contraceptives were
more predisposed to UTI (OR = 17.30, 95% CI = 7.49 -39.96).
Conclusion: Contraceptive use is a significant risk factor for acquiring urinary tract infection,
with the barrier methods being more predisposing. Health education for the hygienic and safe use of family
planning methods will prevent long-term complications.
One of the most serious problems that developing countries still have to solve is the rapid and uncontrolled
increase in population.1 Although it has been estimated that the population of these countries,
including Nigeria, will double in the next thirty years,2 there is a high incidence of unwanted
pregnancies and abortion amongst sexually active Nigerian adolescents as a result of limited access to family
planning services.3 To stem this trend, there are concerted efforts by government and
donor agencies to limit fertility through the use of contraceptives.4
Worldwide, contraceptive use has increased substantially over the past two decades, with improvements in
existing contraceptive methods and the development of several new, more effective and acceptable methods
with fewer side effects.5 The efforts to improve contraceptive usage are commendable, but there
has been increased concern about their safety.6 Many studies highlight the side effects and
complications of different contraceptive methods.7,8,9,10 These studies mostly looked at hormonal
contraceptives in which nausea, high blood pressure, varicose veins, menstrual disorders and breast cancer
were reported.7
Previous studies identified urinary tract infection as a complication of contraceptive use.11,12
The predisposition of women to urinary tract infection (UTI), facilitated by the heavy colonisation of their
lower vagina and periurethral area by uropathogenic bacteria,13,14 is aggravated by contraceptive use.
Even though UTI is a cause of morbidity, mortality and great economic loss,15,16 there is no known
prospective study that has determined the role of contraceptives as a risk factor for urinary tract infection
in the general outpatient department (GOPD) of the University of Port Harcourt Teaching Hospital (UPTH). This
study is aimed at addressing this gap in knowledge.
Research significance
Although UTI has been known as a cause of morbidity, mortality and great economic loss, there is no known
prospective study to determine the predisposing role of contraceptives in the general outpatient department
(GOPD) of the University of Port Harcourt Teaching Hospital. This study will therefore fill this gap in
knowledge and justify the need to intensify health promotion and education on contraceptive use.
Ethical approval was obtained from the ethics committee of the University of Port Harcourt Teaching Hospital before the commencement of this study.
Design
This was a matched case-control study in which consenting adult females (18–50 years old) who attended
the GOPD in the UPTH, Port Harcourt within the four-month study period were recruited.
Subject selection
All consenting adult female contraceptive users within the age bracket of 18–50 years were recruited.
Pregnant patients; patients with diabetes; patients experiencing vaginal discharge, dysuria, lower abdominal
pains, loin pains; patients identifying with antimicrobial use during the last 14 days; patients who have
participated in sexual intercourse within the last 24 hours and those hospitalised or catheterised during
the four weeks before enrolment were excluded from the study.
Sampling method
One in every two qualified patients who presented to the GOPD, University of Port Harcourt Teaching Hospital
was recruited into the study. Consecutive contraceptive users were recruited from amongst this group of
patients by specifically asking them questions about their utilisation of contraceptives, sexual activity
and frequency of sexual activity, as well as history of pain on micturation, loin pains and lower abdominal
pains. For each contraceptive user identified, an age- and marital status-matched non-contraceptive user was selected randomly.
A total of 1504 pre-tested numbered interviewer-administered questionnaires were completed for all the
recruited participants by the two researchers and two research assistants who were recruited as part of
the study after being taught how to fill in the questionnaires and conduct the interviews. The questionnaire
asked participants about their socio-demographic characteristics such as age, occupation and educational
status, sexual history (activity and frequency) and types of contraceptives used, and symptoms of UTI
such as dysuria and loin pain. Socioeconomic classes were determined using the method of
Oyedeji.17 Cases and controls were clinically examined by the researchers. To maintain
anonymity, the names of the participants were not written on the questionnaire but were coded serially.
The participants were assured of confidentiality and informed that the information would only be used for scientific purposes.
The participants were requested and instructed to collect about 15 mL of ‘clean catch’
mid-stream urine in sterile bottles; this sample was sent to the microbiology laboratory of the
teaching hospital for microscopy, culture and sensitivity. Those with positive bacterial culture
in their urine were treated on the basis of the result.
Analysing
The data retrieved from the questionnaires were analysed using the Statistical Package for Social
Sciences (SPSS) version 14 and the Microsoft Excel (MS) software program. The proportions of patients
(prevalence) with urinary tract infections were calculated as a percentage. The degree of association
of urinary tract infection with contraceptive use and the type of contraception were determined using
McNemar’s Chi-square test, odds ratio (OR) and attributable risk (AR). Tables were constructed
to present the results. Statistical significance was set at the 95% confidence level (CI, confidence
interval) or at a p-value of less than or equal to 0.05 (p-value ≤ 0.05).
From the 1504 women recruited during the study period, 150 (9.97%) contraceptive users were identified.
The contraceptives used were barrier methods, Billing’s method, implants, injectables, intrauterine
contraceptive device (IUCD), oral contraceptives, bilateral tubal ligation (BTL) and the withdrawal method.
The barrier contraceptives used included male condoms [47 (82.46%)], female condoms [3 (5.26%)],
foaming spermicide tablets [6 (10.53%)], and the diaphragm [1 (1.75%)]. The participants’ ages
ranged from 18–50 years, with a mean age of 27.8 ± 5.3 years. The majority of the participants
[63 (42.0%)] belonged to the 21–30-year age group, and 117 (78%) were married (Table 1). It was
found that 35.3% of the contraceptive users and 12.0% of the controls had UTI. There was a significant
association of UTI with contraceptive use (McNemar’s χ2 = 16.28, p = 0.000,
OR = 2.9, 95% CI = 1.7 – 5.3, AR = 23.3, PAR = 11.7) (Table 2). The prevalence of UTI in the
various socioeconomic classes was similar amongst the contraceptive users, but amongst the controls
it was higher in classes 2–4. The differences in the prevalence amongst the contraceptive
users and the controls were statistically significant in all the groups, apart from classes 3 and 4
(p < 0.05) (Table 3). The prevalence of UTI amongst the barrier contraceptive users was
71.9% and they were found to be more predisposed to UTI (OR = 17.30, 95% CI = 7.49 – 39.96).
The association between the type of contraceptive and UTI was statistically significant (p = 0.000)
(see Table 4).
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TABLE 1: Distribution of contraceptive users and controls by age and marital status (n = 150).
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TABLE 2: The prevalence of urinary tract infection amongst contraceptive users and the controls.
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TABLE 3: Distribution of urinary tract infection amongst the participants from different socioeconomic classes.
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TABLE 4: Association of urinary tract infection with type of contraceptive.
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TABLE 5: Estimates of various statistical parameters.
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This study discovered a predominance of participants within the 16–45-year age bracket and those
that were married amongst the contraceptive users. This predominance can be explained by the fact that
this is the reproductive age bracket, when sexual activity is a norm. The reduced number of contraceptive
users in the older age group could be explained by the fact that, with aging, there is a decline in
ovarian hormonal secretion during the menopausal transition, which may alter libido, sexual response
and functioning,18,19,20 with concomitant loss of interest in contraception.
The widely used indicators of socioeconomic status include education, occupational status and
income.17 The contraceptive users in the low socioeconomic classes may be more prone
to UTI due to the interplay of these social indicators.15,21 The expected trend of a
high prevalence of UTI in the lower socioeconomic classes was not observed in our study population,
and this is not in agreement with previous reports.22,23 It could be explained by
the fact that the social indicators did not alter our participants’ exposure to the factors
responsible for UTI amongst contraceptive users. The relevance of this finding is that, in planning
health promotional programmes, equal attention should be given to people in all the socioeconomic
classes.
The overall prevalence of UTI (35.3%) amongst the contraceptive users was high. There was about
a three-fold increased risk of the development of urinary tract infection amongst patients who
were on contraceptives compared to non-users. This finding is consistent with that of other
researchers.24,25,26,27 The fact that the participants were
asymptomatic makes it an unacceptable public health problem that calls for urgent intervention,
in terms of health education and promotion and encouragement of the use of contraceptive methods
that carry lesser risks of urinary tract infection.
The high prevalence of UTI amongst the barrier contraceptive users in this study is in agreement
with earlier studies that reported high prevalence of UTI amongst patients who used both the
diaphragm with spermicide and spermicide-coated condoms.28,29,30,31,32,33
Exposure to spermicides alone has been reported to increase the risk of vaginal colonisation
and bacteriuria with Escherichia coli (E. coli), but not to the degree seen with
the use of a diaphragm and spermicide.25 In the population studied here, the use of
diaphragm and spermicide in the form of foaming tablets was not popular, hence the low prevalence
of their usage. The high prevalence of UTI amongst the barrier contraceptive users may therefore
emanate from unhygienic conditions during application of the condom,29 which was the
commonest barrier method used in this study. Secondly, unlubricated condoms may abrade the vaginal
wall and make it vulnerable to infections. Thirdly, it has been suggested that the users of the
barrier methods are likely to have increased vaginal fluid pH, alterations in normal vaginal flora,
and increased rates of introital colonisation with E. coli – all associated with UTI.28
The part played by the hormonal contraceptives in the aetiology of UTI was to a lesser degree
than that reported in a study by Ziaei and colleagues.26 The effects of progesterone
on muscle tone, peristalsis of the ureters and also on the urinary vasculature may account for
the UTI in women who use hormonal contraceptives.25
On the basis of the findings of this study it can be concluded that contraceptive use is a significant risk
factor for acquiring urinary tract infection, with the barrier methods being more predisposing. This warrants
greater attention being paid to the reproductive health needs of the women, and health education for the
hygienic or safe use of family planning methods. Women who use the barrier methods could be advised to consider
alternative methods, such as oral contraceptives. It is important, however, that the advantages of a method in
terms of UTI prevention be balanced against the loss of protection against sexually transmitted diseases
conferred by barrier methods.
Authors’ contributions
Paul O. Dienye designed the project, collected data and prepared the manuscript. Precious K. Gbeneol assisted
in all the stages of preparation of the manuscript.
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