alvina 54 ABSTRACT Asymptomatic bacteriuria (ABU) is one of the bacterial infections most frequently found in women in all age groups, particularly in postmenopausal women. Around 10-25% of women suffer from symptomatic urinary tract infection (UTI) all their life. Several risk factors are associated with the occurrence of ABU in females, such as a history of UTI, sexual activity, diabetes mellitus, personal hygiene, sexual hygiene, and menopausal status. The aim of this study was to determine the most important risk factor of influence on ABU in premenopausal and postmenopausal women at the Pasar Minggu Primary Health Center. This was an analytical cross-sectional observational study. The study sample consisted of premenopausal and postmenopausal women aged 40-65 years visiting a Primary Health Center of the Pasar Minggu Subdistrict, South Jakarta, who were selected by consecutive sampling. The data analysis used prevalence ratios and logistic regression. The results of the study showed that the prevalence of positive bacteriuria in females was 45%. Sexual activity, sexual hygiene, menopausal status of the females, and personal hygiene were risk factors of ABU. Personal hygiene was the most influential risk factor on the occurrence of ABU in both premenopausal and postmenopausal women. Since in this study ABU was present in 45% of women, thus making it a common disorder in middle- aged and older women, it is recommended that the primary care physician directly administer therapy to women with symptoms of UTI without performing laboratory analysis. Keywords: Asymptomatic bacteriuria, personal hygiene, sexual activity, women *Professional Study Program, Medical Faculty, Trisakti University Correspondence Farasita Ambarwati, SKed. Professional Study Program, Medical Faculty, Trisakti University Jl. Kyai Tapa No.260 Grogol - Jakarta 11440 Univ Med 2011;30:54-62. Personal hygiene and asymptomatic bacteriuria in women aged 40 to 65 years Farasita Ambarwati*, Maysarah Elfani*, Apriani Margastutie*, and Nurul Mahirah Binti Mohd. Dahuri* January-April, 2011January-April, 2011January-April, 2011January-April, 2011January-April, 2011 Vol.30 - No.1 Vol.30 - No.1 Vol.30 - No.1 Vol.30 - No.1 Vol.30 - No.1 UNIVERSA MEDICINA INTRODUCTION Urinary tract infection (UTI) is a bacterial infection most frequently found in women and with greater frequency in older than in younger women,(1) and particularly in postmenopausal women. In young and middle-aged women the prevalence of UTI is around 5%, rising rapidly with advancing age.(2) In spite of the high prevalence of bacteriuria in postmenopausal women, the predisposing factors of UTI in this group has not been extensively studied in comparison with premenopausal women. However, reports from epidemiological and 55 Univ Med Vol.30 No.1 case-control studies indicate that nonsecretory status and urological factors such as residual v o l u m e , r e d u c e d u r i n a r y f l o w, a n d incontinence, are closely associated with recurrent UTI, particularly in postmenopausal women.(3) In the US the annually recorded numbers of patients with UTI attending clinics is around 8 million, with a recurrence rate of 25% - 50%.(3,4) The underlying mechanism of recurrence has been only partially elucidated, but there is a close association between impairment or cessation of estrogen production and increased risk of UTI.(4) Postmenopausal vaginal changes lead to clinical manifestations that play a role in UTI. More than 50% of women older than 60 years of age experience a variety of urogenital symptoms.(2) UTIs may be divided clinically into symptomatic and asymptomatic infections. The infection is called symptomatic if there is significant bacteriuria (>100.000 cfu/mL) accompanied by clinical symptoms, such as dysuria, frequent micturition, and strangury, with or without fever and lower back pain. The infection is called asymptomatic if significant bacteriuria is found in apparently healthy children or adults without symptoms pointing to UTI.(1) The climacteric, more commonly known as menopause, is the transition period between the reproductive phase and the senile phase (senium), occurring as a result of declining ovarial functionality. The premenopausal period is the period between the age of 40 years and the onset of the climacteric phase. The postmenopausal phase is the period from 12 months after menopause up to the senium.(5) In t h e p o s t m e n o p a u s a l p e r i o d t h e v a g i n a l epithelium is atrophic, due to lack of estrogen. Epithelial atrophy is also found in the urethra, frequently leading to the urethral syndrome, which includes bacterial urethritis.(2,5,6) In the majority of UTIs the etiology is commonly found to be bacterial. Several studies have reported a higher prevalence of bacteriuria in postmenopausal w o m e n c o m p a r e d w i t h t h a t i n y o u n g o r premenopausal women, (2,4) but data from developing countries are scarce. It is unclear whether women in developing countries have a higher frequency of UTI and more severe symptoms, when compared to women in developed countries.(6) There are also reports stating that the prevalence of bacteriuria in premenopausal women is higher than in postmenopausal women, as it tends to be c o r r e l a t e d w i t h t h e f r e q u e n c y o f s e x u a l r e l a t i o n s , u s e o f s p e r m i c i d a l a g e n t s , contraception by means of diaphragms, and history of past UTIs, but data on the prevalence rate of bacteriuria are still lacking.(7) It has also been reported that diabetic women have a higher risk of asymptomatic bacteriuria (ABU) and UTI,(8,9) although it is unclear whether postmenopausal diabetic women have a higher r i s k o f b a c t e r i u r i a i n c o m p a r i s o n w i t h nondiabetic women. Some investigators view A B U a s a c o m p l i c a t i o n o f d i a b e t e s i n women.(10,11) Our study is based on the contradictory results of previous studies and the lack of data on the prevalence of bacteruria in pre- and p o s t m e n o p a u s a l w o m e n , e s p e c i a l l y i n Indonesia. Additionally this study also aims to find a relationship between risk factors of ABU in premenopausal and postmenopausal women. METHODS Research design The present study was an analytical observational study with cross-sectional approach, conducted from 3 January until 21 January 2011 at Pasar Minggu Subdistrict Primary Health Center, South Jakarta. Research subjects and sampling T h e s t u d y s u b j e c t s w e r e p r e - a n d postmenopausal women on their first visit to the Pasar Minggu Subdistrict Primary Health Center, South Jakarta, recruited by non- p r o b a b i l i t y c o n s e c u t i v e s a m p l i n g . T h e 56 inclusion criteria were: i) women in the age range of 40-65 years, with monthly periods (premenopausal women) or without monthly periods in the last year (postmenopausal women), and volunteering to participate. E x c l u d e d f r o m t h e s t u d y w e r e menstruating or pregnant women, and those on antibiotic therapy for infections. Sample size The optimal sample size needed in this study was calculated according to the following formula:(12) ( ) ( ) ( ) ( ) 2 21 221111 1112n ⎥ ⎥ ⎦ ⎤ ⎢ ⎢ ⎣ ⎡ − −+−−− = ππ ππππππ βα ZZ For á = 0.05, Zá = 1.96 and for â = 0.20, Zâ = 0.845. The prevalence of bacteriuria in p o s t m e n o p a u s a l w o m e n i s 0 . 0 9 a n d i n premenopausal women 0.03,(13) giving a sample size of 50 subjects in each group. Data collection T h i s s t u d y u s e d a q u e s t i o n n a i r e a s research instrument for collecting personal data (name, age, marital status, education, occupation, income), sexual activity, history of UTI, incontinence, and diabetes mellitus. Personal hygiene was assessed by means of a questionnaire consisting of 4 items on hygienic m e a s u r e s t a k e n b y t h e r e s p o n d e n t s i n connection with ABU. Sexual hygiene was assessed using a questionnaire of 4 items, comprising measures taken by the respondents in connection with sexual relations with their partner. Sexual activity was measured by asking the respondents about the frequency of sexual relations with their partner within the last month. Personal hygiene, sexual hygiene, and sexual activity was divided into two categories, i.e. excellent and poor. LABORATORY METHODS Collection of urine specimens Before collecting the urine specimens, the external genitalia were washed with soap and water, then rinsed with clean water. The initial urinary stream was discarded and only 20 mL of the midstream urine was collected in a sterile container.(14) Transport of urine specimens The containers holding the urine specimens were labeled with the identity of the subject, and were subsequently placed in a thermos bottle filled with ice for transport to the Microbiology Laboratory of the Medical Faculty, Trisakti University within 4 hours after collection. The urine specimens that could not be transported in time were stored in a cooling box at the study location and were sent to the laboratory within 24 hours. Micobiological culture Upon arrival at the laboratory the urine specimens were directly processed according to standard conventional methods.(1) Volumes of 0.01 and 0.001 mL noncentrifuged urine were plated on blood agar and McConkey agar. The agar plates were then incubated under aerobic conditions at 350 C for 20-24 hours, after which a count was made of the growing colonies, and the mean number of colonies per mL urine was calculated. Identification of the isolates were done according to standard methods. Colony counts of <10.000 cfu/mL were considered not indicative of bacteriuria; colony counts in the range of 10.000 – 100.000 cfu/mL were probably due to contamination; while colony counts of >100.000 cfu/mL definitely indicated bacteriuria.(14) ABU is a microbiologic diagnosis on urine specimens collected with minimal contamination and rapidly transported to the laboratory to limit bacterial growth. Ambarwati, Elfani, Margastutie, et al Personal hygiene of asymptomatic bacteriuria 57 Univ Med Vol.30 No.1 Data analysis U n i v a r i a t e a n a l y s i s w a s u s e d f o r explaining the frequency distribution curve against the variables under study, while for determining the presence of an association of s e v e r a l k e y v a r i a b l e s w i t h a s y m t o m a t i c bacteriuria the prevalence ratio (PR) was used. Logistic regression is a statistical method which can be used to estimate the probability of disease for a given covariate pattern. The results of logistic regression lead naturally to an estimate of the odds ratio but may also be used to estimate the PR.(15) The statistical tests were considered significant for p <0.05. The Statiscal Package for the Social Sciences version 15.0 (SPSS Inc., Chicago, IL) was used for the statistical analysis. Ethical clearance A f t e r w e r e c e i v e d p e r m i s s i o n a n d administrative clearance from the head of the Pasar Minggu Subdistrict Primary Health Center, the subjects meeting the inclusion criteria were entered into the study after giving written informed consent. Initially the subjects were informed of the purpose and the general outlines of the study. After the subjects understood and agreed they were given an informed consent form for signing. The present study received ethical clearance from the Ethics Commission of the Medical Faculty, Trisakti University. RESULTS This study recruited 100 women who were willing to participate in the study. Fifty women in the age range of 40-50 years and 50 women a g e d 5 1 - 6 5 y e a r s w e r e a s s i g n e d t o t h e premenopausal and postmenopausal groups, respectively. Mean age of the subjects was 50.5 ± 6.55 years, 54% of subjects had higher education (SMA + University) and 80% still had a partner. The prevalence of diabetes was 26% (Table 1). Subjects with UTI were 46 in number (46%) and those with excellent sexual hygiene totaled 64%. In this study the overall number o f s u b j e c t s w i t h A B U , a m o n g b o t h premenopausal and postmenopausal women, was 45 (45%). The results of bacteriological culture showed that Escherichia coli was the principal causative organism of bacteriuria in women, being present in 26 subjects (57.8%). The Variable n = 100 Age (years) Marital status Single (unmarried + widowed) Married Educational level Low (uneducated + primary school) Intermediate (junior high) High (senior high + university) Employment history Employed Unemployed Menopausal status Premenopause Postmenopause History of diabetes mellitus Present Absent Sexual hygiene Excellent Poor Personal hygiene Excellent Poor Sexual activity Frequent Rare/none History of UTI Present Absent History of incontinence Present Absent Asymptomatic bacteriuria Present Absent 50.5 ± 6.55 20 (20) 80 (80) 8 (8) 38 (38) 54 (54) 48 (48) 52 (52) 50 (50) 50 (50) 26 (26) 74 (74) 64 (64) 36 (36 88 (88) 12 (12) 46 (46) 54 (54) 46 (46) 54 (54) 51 (51) 49 (49) 45 (45) 55 (55) Table 1. Description of demographic characteristics, history of diabetes mellitus and UTI, and sexual activity of the respondents 58 remaining infections were caused by Klebsiella spp. (15.6%), Staphylococcus epidermidis (20.0%), Enterococcus spp. (2.2%), and Bacillus spp. (4.4%) (Table 2). Ta b l e 3 p r e s e n t s a s u m m a r y o f t h e relationship between several key variables and the prevalence of ABU in female subjects. In subjects with past UTI the risk of bacteriuria was 3.05 times that of subjects without past UTI (PR=3.05;95% C.I. 1.84-5.05). Similarly, subjects with frequent sexual activity with their partners had a risk of ABU of 1.6 times that of subjects who rarely or never had seksual relations with their partners (PR=1.60;95% C.I. 1.03-2.49). Differring results were found in subjects with excellent sexual and personal hygiene, where the risk of ABU was lower than that of subjects with poor sexual and personal hygiene. Ambarwati, Elfani, Margastutie, et al Personal hygiene of asymptomatic bacteriuria Table 2. Distribution of causative bacteria of ABU in the respondents (n=45) Table 3. Relationship between several key variables and ABU in female subjects Abbreviations: PR: prevalence ratio; CI: confidence interval; UTI: urinary tract infection 59 Univ Med Vol.30 No.1 We constructed a series of multivariable logistic regression models based on a priori hypotheses about potential risk factors. In the final model, 5 variables continued to be associated with ABU: sexual activity, sexual hygiene, personal hygiene, history of UTI, and menopausal status (Table 4). A history of UTI (OR, 0.131; 95% CI, 3.25-5.42) was strongly associated with ABU. Premenopausal women h a d a l o w e r r i s k o f A B U t h a n d i d postmenopausal women. DISCUSSION This study investigated potential risk factors for ABU among women aged between 40 and 65 years. Although ABU is common, its prevalence in populations varies widely w i t h a g e , g e n d e r, a n d t h e p r e s e n c e o f g e n i t o u r i n a r y a b n o r m a l i t i e s . I n h e a l t h y women, the prevalence of bacteriuria increases w i t h a d v a n c i n g a g e , f r o m 1 % a m o n g s c h o o l g i r l s t o > 2 0 % a m o n g h e a l t h y community-dwelling women older than 80 years.13). The findings in our study were similar; there was a prevalence of ABU of 45% in women in the 45-65 year age group, while postmenopausal women had a higher risk of A B U t h a n p r e m e n o p a u s a l w o m e n . A f t e r menopause, the vagina undergoes various changes that lead to vaginal colonization by uropathogenic E. coli and to the development of bacteriuria.(16) Vaginal symptoms of frequent occurrence in the early postmenopausal period reportedly affect around 30% of women, increasing up to around 47% in the late postmenopausal period.(17) Before menopause the vaginal fluid is acid in reaction, but subsequently the pH becomes neutral, thus enabling the proliferation of enteric bacteria a s s o c i a t e d w i t h U T I . ( 5 ) F u r t h e r m o r e , postmenopausal women reportedly also suffer from symptoms of incontinence without prior urinary bladder dysfunction or neurological abnormalities.(18) The declining estrogen level that is part of the menopausal process and is considered to be a risk factor for bacteriuria, results in the loss of the normal vaginal flora, which consists predominantly of lactobacilli. This triggers a rise in vaginal pH and increases the colonization of the introitus by E. coli.(19) The vaginal and urethral epithelia are estrogen r e s p o n s i v e , a s t h e y h a v e a c o m m o n embryological origin, and function to protect these organs against infection. However, with a d v a n c i n g a g e t h e s e e p i t h e l i a u n d e rg o degenerative changes,(4,6) causing a decline in their regulatory capacity in postmenopause and facilitating infection. However, it has been s u g g e s t e d b y H o o t o n ( 2 0 ) t h a t i n h e a l t h y postmenopausal women the incidence of UTI is probably lower than in premenopausal women. In agreement with the generally accepted view that risk factors for UTI in women include sexual activity, our study also found that women with frequent sexual activity had a higher risk of ABU. Sexual activity of the women with their partners constituted a general risk factor for the occurrence of ABU. In addition, the results of our study indicate that history of past UTI is one of the important risk factors for ABU in female subjects aged 40 to 65 years. Several studies also found that a history of previous UTI is an important risk factor for asymptomatic UTI in young and postmenopausal women.(7,21) T h e m o s t f r e q u e n t l y e n c o u n t e r e d microorganism causing UTI in this study was Escherichia coli with a prevalence of 57.8% Table 4. Multivariable logistic regression model with selected variables for ABU Abbreviations: CI: confidence interval; OR: odds ratio; UTI: urinary tract infection 60 in female subjects, followed by Klebsiella pneumoniae. Studies on the etiology of bacteriuria have found that Escherichia coli is the causative agent in more than 80% of all UTIs and causes both ABU and symptomatic UTI. ( 2 2 - 2 4 ) Uropathogenic E. coli possess various virulence traits, enabling these bacteria to attack and infect the normal urinary tract.(25) The reported virulence traits include the presence of fimbriae or pili, which function as l i g a n d s f o r g l y c o l i p i d a n d g l y c o p r o t e i n receptors in uroepithelial cells.(26-28) Another risk factor for ABU in the present study was a past history of urinary incontinence in the female subjects. Studies on behavior in connection with UTI or bacteriuria are very few in number.(22) The behavior in question include personal hygiene, sexual hygiene and sexual activity, all of which are risk factors for ABU, both in p r e m e n o p a u s a l a n d p o s t m e n o p a u s a l women.(22,29) Our study indicates that female subjects with excellent sexual hygiene had a far lower risk than those with poor sexual hygiene. Perineal hygiene is important in women, who should be encouraged to shower after sexual intercourse to reduce colonization by fecal and perineal organisms.(30) Although there are many similarities among the various UTI risk factors in pre- and postmenopausal women, the single basic factor distinguishing both groups is their sexual activity. As stated in several reports, one of t h e d o m i n a n t U T I r i s k f a c t o r s i n premenopausal women is their sexual activity and use of spermicides.(19,22,29) Diabetes melitus results in disturbances of the immune system and other organ functions, thus facilitating the occurrence of infection, among which the most frequent is UTI.(10,31) It has previously been reported by several studies that advancing age with added burden of diabetes may increase the risk of UTI in an individual.(29) However, our study results differred in this respect, as a history of diabetes mellitus in women was not a risk factor for ABU, although we did not enquire in more detail about the treatment given to the study subjects. Indeed, in subjects who were not treated regularly for their diabetes mellitus, the risk of ABU was higher than in subjects under regular treatment, although there was no increase in the odds of UTI in women with diabetes who did not receive treatment.(32) The fact that the rate of ABU increases with advancing age may be explained by the low estrogen levels, atrophy of the vaginal epithelium, impaired voiding, and changes in personal as well as sexual hygiene.(33,34) A B U m a y a l s o r e s u l t i n l o n g - t e r m cardiovascular-renal damage, the possibility of which should always be kept in mind, and a complete search for all possible causes of ABU and treatment modalities should be done to reduce this important cause of chronic disease. To minimize potential bias in this study, particularly to prevent misclassification of ABU, we used a case definition of bacteriuria, namely a bacterial count of >100.000 cfu/mL, t h a t i s m o r e t h a n 9 5 % s p e c i f i c f o r t h i s diagnosis.(14) Since the population consisted of female patients attending the health center, the r e s u l t s m a y n o t b e g e n e r a l i z e d t o o t h e r populations. CONCLUSIONS In the population of the present study, the risk factors for women in the age range of 40 - 65 years reflect the health status of their transitional period towards old age. History of UTI and incontinence, personal and sexual hygiene, sexual activity, and menopausal status were all associated with a higher risk of ABU. P r o s p e c t i v e s t u d i e s i n d i ff e r e n t p a t i e n t populations are needed to better understand the risk factors of UTI. ACKNOWLEDGEMENTS We wish to express our gratitude to the staff of the Department of Community Health, Ambarwati, Elfani, Margastutie, et al Personal hygiene of asymptomatic bacteriuria 61 Univ Med Vol.30 No.1 Medical Faculty, Trisakti University for their guidance and support in conducting this study and writing this report. To dr. Wida Wildani and staff of the Pasar Minggu Primary Health Center, South Jakarta, we also extend our special thanks for their support. Thanks are also due to Ms Rosma who assisted with the laboratory investigations. REFERENCES 1. Boekitwetan P, Suryawidjaja JE, Aidilfit M, Lesmana M. Multimicronutrient supplementation and asymptomatic urineary tract infections in the elderly. Univ Med 2009;28:25–33. 2. Raz R. Hormone replacement therapy or prophylaxis in postmenopausal women with recurrent urinary tract infection. J Infect Dis 2001;183 Suppl 1:S74-6 3. Dwyer PL, O’Reilly M. Recurrent urinary tract infection in the female. 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