Lower Urinary Tract Symptoms (LUTS) are very prevalent, tend to increase with the age and affect individuals in a unique way, hindering their quality of life. Epidemiological studies differ in the sampling selection method, the data collecting technique, the sample size and even in the definitions adopted. The main population studies were initially carried out in the Western world and form the base knowledge in this field. Similar studies have been carried out in other regions of the globe, especially in Asia and Australia, but in other areas these studies are sometimes smaller and with important methodological limitations, resulting in a great lack of regional data.
This work seeks to face the lack of data on the population prevalence of LUTS in Africa and to study its characteristics and determinants.

Between 2014 and 2017, a data collection was conducted on a sample of the male population of São Tomé and Príncipe aged 30 years or older, stratified by district and age. Each individual completed the International Prostate Symptom Score (IPSS), the Visual Analogue Scale for Urinary Symptoms (VASUS), and a free-flow uroflowmetry. 
Blood was drawn for PSA analysis, and a urine sample was obtained for the exclusion of infection (exclusion criteria: PSA ≥ 10 ng/mL, positive Combur test, history of treatment, for LUTS).

A total of 812 valid responses were obtained. The weighted prevalence of moderate to severe lower urinary tract symptoms (LUTS M/S) was 29.7%. LUTS related to voiding was found to increase the odds ratio (OR) of reducing the Quality of Life (QoL) by 14.6 times.
Upon subgroup classification of symptoms, the majority of individuals presented with storage symptoms (n=556), followed by voiding symptoms (n=214) and post-micturition symptoms (n=182). Additionally, 46% of individuals presented with simultaneous symptoms.
The IPSS data disaggregation by age intervals allows for the detection, with statistical significance, of an increase in the prevalence of more severe LUTS with age, associated with a decrease in individuals with none to mild results, IPSS 0-7. QoL, measured by question eight of the IPSS (IPSS Q8 ≥4), followed this trend, with an increase in results associated with an increase in symptoms (p<0.0001).

When evaluating the IPSS data by district, Cauê stands out for its low prevalence of LUTS M/S, contrasting with the high prevalence in Lobata, highlighting that its distribution is not independent of district (p<0.0001). Using Água Grande as a reference and controlling for multivariate analysis for age, residence, education, and fixed work hours, we found that living in Cauê conferred a 73.8% lower chance of having LUTS M/S and that living in Mé-Zóchi conferred a 35.9% chance.
Evaluation of storage symptoms, controlled for age, literacy, education, and employment, revealed a statistically higher likelihood of having LUTS M/S for those living in Lembá (+110%). Living in Cauê decreases the chance of voiding and post-micturition LUTS by 78.3% and 88.6%, respectively. In evaluating post-micturition LUTS, we also found that living in Lembá and Mé-Zóchi decreased the likelihood of M/S symptoms with statistical significance (-65% and -61%, respectively).
For IPSS question 8, which measures QoL, those aged 70 or above had a high prevalence of QoL<4 (16.9%) compared to the overall weighted prevalence of 6.1%. Until age 60, the prevalence remains relatively constant with a slight decrease, followed by a sharp increase. Geographically, Mé-Zóchi had a relatively high value (9.7%), and Cauê had the lowest (2.1%). Voiding symptoms were the only ones that remained in the final model and resulted in a 14.6 times higher chance of decreasing QoL (measured as IPSS Q8 ≥ 4) in multivariate analysis.
The univariate analysis of risk factors for the presence of LUTS in males revealed a statistically significant association with increasing age (+44%), urban residence (+66%), education level of more than 6 years (-47%), having a fixed work schedule (-47%), and a prostate volume ≥ 30cc (PSA ≥ 1.5 ng/ml). 
In the multivariate logistic regression analysis, increasing age (+22%), urban residence (+156%), education level of more than 6 years (-53%), and having a fixed work schedule (-36%) remained as risk factors. The analysis of LUTS subtypes showed that age remained a risk factor for storage LUTS (+74%), while education level, fixed work schedule, and outdoor work were risk factors for voiding LUTS (-56%, -44%, and +57%, respectively). For post-micturition LUTS, age, toilet facility availability, and urban residence were risk factors (+28%, +122%, and +232%, respectively).

The study found that the prevalence of moderate to severe LUTS in the male population was 29.7%, with voiding symptoms being the most common and impactful symptoms affecting quality of life.
The study's prevalence rates were weighted by age and district to compensate for underrepresented groups. Comparisons were made with historical data, but caution was advised given the correlation with age and the definition of cases used. Despite this, the prevalence of LUTS in the African country was found to be slightly higher than that of the Asian and Australian regions and considerably higher than those of Africa and Central and South America.
Further analysis of the data revealed that when the age range of the sample was restricted to those aged 40 and over, the prevalence of LUTS increased to 34.6%. The analysis of the sociodemographic variables studied indicates that age has a statistically significant effect on LUTS, as expected. Each decade confers an increase in the likelihood of having LUTS of 43.7%. Urban residence, low education level, having a fixed work schedule, and an enlarged prostate volume were also found to influence the chance of LUTS with a significance level of 5%. These factors, except for prostate volume, remained in the multivariate regression model.
The PSA quantification, which allows inferring prostate volume, was only observed 164 times and was not included in the final model as it penalized the sample excessively.
Having a fixed work schedule was found to decrease the likelihood of LUTS by 36%. This finding may be explained by the impact of symptom unpredictability on patients and the structured context associated with a fixed work schedule. The effect of bladder repletion on micturition quality should not be underestimated, as it can lead to better quality micturitions, thereby reducing associated symptoms.
The determinants of LUTS, such as age and education level, had already been previously validated and were confirmed in our sample. In conclusion, we can say that increasing age, low education level, urban residence, and not having a fixed work schedule are a set of risk factors with a higher likelihood of having LUTS.
Overall, this study sheds light on the prevalence of LUTS in an African country and highlights the need for further research in this area to better understand the underlying causes and risk factors associated with LUTS.

The prevalence of LUTS for a global population in an African country is higher than known, social determinants as age, urban residence, low education level and having a fixed work schedule have an impact on this prevalence.  Voiding symptoms are preponderant in determining QoL.

Continence 7S1 (2023) 100832
DOI: 10.1016/j.cont.2023.100832