Pelvic organ prolapse and incontinence in developing countries: review of prevalence and risk factors
- First Online:
- Cite this article as:
- Walker, G.J.A. & Gunasekera, P. Int Urogynecol J (2011) 22: 127. doi:10.1007/s00192-010-1215-0
Introduction and hypothesis
Information on the prevalence, risk factors and social consequences of pelvic floor dysfunction (PFD) affecting women in 16 low-income and lower middle-income countries is reviewed.
Medline searches were performed for articles dealing with prevalence of PFD.
Thirty studies were identified. The mean prevalence for pelvic organ prolapse was 19.7% (range 3.4–56.4%), urinary incontinence (UI) was 28.7% (range 5.2–70.8%) and faecal incontinence (FI) was 6.9% (range 5.3–41.0%). Risk factors for PFD are similar to those in more affluent countries particularly increased age and parity, but additionally, PFD is associated with other factors including poor nutrition and heavy work. The social consequences of PFD conditions can be devastating.
Pelvic organ prolapse and urinary and faecal incontinence are significant problems in developing countries. Access to health care to manage these conditions is often limited, and women usually have to live with the consequences for the rest of their lives.
KeywordsPelvic organ prolapsePrevalenceRisk factorsUrinary and faecal incontinence
Pelvic floor dysfunction
Pelvic organ prolapse
Interview and examination
The devastating experience of vesico-vaginal fistula among poor women in low-income countries has been increasingly recognised over the past two decades . However, the large number of women without fistula suffering from pelvic floor dysfunction (PFD) has largely been neglected.
Pelvic floor dysfunction covers a range of conditions, most significantly pelvic organ prolapse (POP), urinary incontinence (UI) and faecal incontinence (FI) . Pelvic organ prolapse describes the abnormal location of the pelvic organs, including the bladder, uterus, rectum and/or small intestine, into or outside of the vagina . Urinary and faecal incontinence refer to the involuntary voiding of urine and liquid or solid stool through the vagina or rectum, which is a social and hygienic problem. These conditions are integrally related to women's reproductive history, especially from difficult vaginal deliveries and the trauma that can occur giving birth. Even in developed countries, where prolapse is among the most common indication for gynaecological surgery , there are not many epidemiological studies of incidence or prevalence . In developing countries, the extent and consequences of the burden of disease due to pelvic floor dysfunction is even more poorly understood .
This article reviews information on the epidemiology of pelvic floor dysfunction and risk factors for the development of pelvic organ prolapse, urinary and faecal incontinence among women in low-income and lower middle-income countries. Information is also presented on the social consequences for women's lives of these conditions. Possible interventions to prevent and improve the prevention and management of pelvic floor dysfunction in resource-poor settings are discussed.
Materials and methods
Separate Medline searches for the years 1985 to April 2010 were performed using the keywords: “pelvic floor dysfunction”, “pelvic organ prolapse”, “vaginal prolapse”, “urinary incontinence”, “faecal incontinence”, “anal incontinence”, combined with “epidemiology” and “prevalence”. Articles dealing with these issues in countries categorised by the World Bank  as low-income economies and lower middle-income economies were reviewed. Other studies were identified by checking secondary references in the original citations. No language restrictions were applied. Articles dealing with these conditions during or immediately after pregnancy and with obstetric fistula were excluded.
Prevalence studies of pelvic organ prolapse, urinary and faecal incontinence in low-income and lower middle-income countries
Country; reference(s) to study; year of study
Type of survey: interview only (I); interview and examination (I&E); number included (N)
Age of women in sample
Prevalence of pelvic organ prolapse (POP), urinary incontinence (UI) and faecal incontinence (FI)
Gambia Scherf  1999
I&E, random cluster sample in a rural community (N = 1,034)
POP: mild—uterine prolapse into vagina with cystocele and rectocele; moderate—cervix visible at introitus with cystocele and rectocele; severe—uterine descent outside of introitus, cystocele and rectocele; UI ‘difficulty controlling urine’
POP 46.1%, mild 31.9%, moderate 12.7%, severe 1.2%, UI 7.1%
Ghana Adanu  2003–2004
I&E, random sample attenders at ultrasound clinic in Accra (N = 200)
17 to 70 years
Stress UI is current loss of urine on coughing; urge UI is urgent need to pass urine with fear of leakage
UI 48.2%; stress UI 43.4%, urge UI 10.3%
Ghana Wusu-Ansah  Prior to 2007
I&E, random cluster household sample in a rural community (N = 174)
15 to 81 years
Short form of ‘pelvic floor distress inventory’ (PFDI) and pelvic floor impact questionnaires used. POP defined as the protrusion of the pelvic organs out of the vaginal canal and classified into: anterior, posterior, cervix and apical/cuff. Staging used simplified POPQ system.
POP 12.1%, anterior 4.6%, posterior 1.1%, both anterior and posterior 1.7%, anterior, posterior and uterine prolapse 4.6%
Nepal Bonetti  2001
I&E, attenders at rural clinic (N = 2,072)
12 years and older
POP: first degree—uterine prolapse into vagina; second degree—cervix visible at introitus; third degree—uterine descent outside of introitus
POP 25.1%, equally first, second and third degree
Nepal Ministry of Health and Population  2006
I, nationally representative sample (N = 10,794)
Parous women aged 15–49 years
POP: asked if they had signs of ‘something coming down in the vagina’
I, random sample attenders at gynaecology clinic for reasons other than pelvic organ dysfunction, rural communities in southeastern Nigeria (N = 3,963)
20 years and over
Structured pre-tested 41-item POPQ used. Anal incontinence included involuntary and unwanted passage of gas, liquid or solid stool
Stress UI 19.5%, urge UI 21.8%, FI 4.9% (2.7% liquid and 2.2% solid stool)
Pakistan Sajan  1996
I, community sample in urban squatter settlements (N = 717)
15 to 49 years ever-married
‘Ever had a feeling of something coming down or out of vagina, especially when walking/coughing/sneezing’
Pakistan Rizvi  2001–2002
I, attenders at gynaecology clinic in Karachi for menstrual symptoms or infertility (N = 186)
15 years and over
UI: involuntary leakage of urine two or more times in a month
UI 44.4%, stress UI 17.2%, urge UI 9.7%, mixed 16.1%
Pakistan Andrades  2002
I, attenders at city health centre for reasons other than prolapse (N = 250)
18 to 70 years
Stress UI 38.4%, urge UI 18.8%
Lower middle-income countries
I, random community sample in Fuzhou city (N = 4,684)
20 years and over
Questionnaires were adapted from the Bristol Female Lower Urinary Tract Symptoms questionnaires. UI an involuntary urine loss in previous month; stress UI involuntary leakage when exercising physically or cough or sneeze; urge UI involuntary urine loss following sudden urge to void or uncontrollable voiding with little or no warning
UI 19.0%, stress UI 16.6%, urge UI 10.0%, mixed 7.7%
China Zhu  2005
I, random community sample in Beijing (N = 5,300)
20 years and over
Used International Consultation on Incontinence Questionnaire UI: more than one episode in last month; stress UI ‘a leak or loss of urine caused by sneezing, coughing, exercising, lifting or physical activity’, urge UI ‘urge to urinate but unable to reach toilet before leaking’
UI 38.5%, stress UI 22.9%, urge UI 2.8%, mixed 12.4%
I, random community samples in six regions (N = 19,024)
20 to 99 years
Questionnaires were adapted from the Bristol Female Lower Urinary Tract Symptoms questionnaires. Stress UI: discharge of urine unintentionally when coughing, sneezing straining or lifting; urge UI: exude urine before arriving at lavatory
UI 30.9%, stress UI 18.9%, urge UI 2.6%, mixed 9.4%
Egypt, Arab Republic Younis  1989–1990
I&E, random community sample in rural communities (N = 509)
Ever-married aged 14 to 60 years
‘Genital prolapse was diagnosed for either anterior or posterior vaginal wall and/or uterine prolapse when they descended below normal position’
POP 56.4%, posterior or anterior vaginal 27.9%, posterior and anterior vaginal 20.9%, vaginal and uterine 7.9%
Egypt, Arab Republic El-Azab  2005
I, community sample in Assiut (N = 1,652)
20 years and over
Definitions of the International Continence Society using the urogenital distress inventory questions
UI 54.8%, stress UI 14.8%, urge UI 15.0%, mixed 25.0%
El Salvador Ozel  2005
I, attenders at general medical and gynaecology clinics in rural area (N = 236)
31 to 75 years
Used the Urodynamic Distress Inventory (UDI-6) questionnaire UI: usually experience leakage of urine
UI 70.8%, stress UI 61.1%, urge UI 49.3%, mixed 39.4%. FI of solid or liquid stool 41.0%. Vaginal bulging—somewhat 14.2%, moderate 10.8%, quite a bit 12.9%
India Bhatia 1994 
I&E, community sample in Karnataka State (N = 385)
12% aged <20 years, 44% 20–24 years and 44% aged 25 years and above
Descent of anterior or posterior vaginal wall together with uterine descent
India Kumari  1996
I, community sample in a shanty area in Chandigarh (N = 2,990)
Married women 15 years and over
Self reported: considered to have a prolapse if positive answer when asked if having ‘a mass of flesh in her vagina’ or used local term for uterine prolapse or complained of mass coming out of her vagina.
Islamic Republic of Iran Sadeghi-Hassanabadi  1990
I&E, random community sample of semi-nomadic group in Fars Province (N = 1,010)
Median age 37.4 years
POP 53.6%, cystocele 65%, rectocele 40.4%, cystocele and rectocele 39.3% UI 27.0%
Islamic Republic of Iran Garshasbi  2002
I&E, attenders for routine (annual) health examination in three primary health care clinics (N = 3,730)
POPQ system of International Continence Society Stage 1, most distal portion of prolapse > 1 cm above hymen; stage 2, most distal portion of the prolapse = or > 1 cm to the plane of the hymen; stage 3, most distal portion of prolapse > 1 cm below the plane of the hymen but protrudes no further than less than the total vaginal length
POP 53%, stage 1, 23.1%; stage 2, 18.3%; stage 3, 11.6%
Islamic Republic of Iran Sobhgol  Before 2008
I&E, attenders gynaecology clinics for routine examination or counselling in Tabriz (N = 330)
15 to 49 years
UDI-6 questionnaire used UI: more than one episode of involuntary loss of urine in last month. Stress UI ‘lose urine during sudden physical exertion, lifting heavy items, laughing, coughing or sneezing’, urge UI ‘a strong sudden urge to void that you leak before reaching the toilet’. Pelvic organ prolapse quantification (POPQ) system used.
Stress UI 31.8%, urge UI 25.5%, mixed 19.4%
Jordan Al-Qutob  1997
I&E, random community sample north of Amman (N = 137)
Menopausal women, median age 49 years
POP 41.0%, UI 38.0%
Jordan Mawajdeh  1997
I&E, random community sample (N = 317)
18 to 49 years
Genital prolapse ‘noting heaviness from below’ and confirmation on examination UI: ‘passing urine when laughing or coughing’
POP 21.9%, ‘anterior or posterior’ 9.6%, ‘anterior and posterior’ 9.2%. UI 23.5%
I, random community sample in three governorates (N = 182)
Ever-married aged 50–65 years
UI is involuntary loss of urine from the bladder. Stress UI is the involuntary leakage of urine on exertion as in coughing, sneezing, laughing, bending over, or with exercise as in jumping. Urge UI is the inability to postpone urination with strong urge to void and may lead to involuntary leakage of urine.
UI 31.3%, stress UI 23.1%, urge UI 26.4%, mixed 18.1%
Morocco Mikou  1998
I, community sample of women in Casablanca (N = 1,000)
18 to 85 years
UI: more than one episode involuntary loss of urine in last month
UI 27.1%, stress UI 13.4%, urge UI 11.6%
Philippine National Statistics Office  1993–1994
I, nationally representative sample (N = 6,112)
Parous women 15 to 49 years
POP 13.5%, UI 5.2%
Sri Lanka Premachandra  Prior to 2008
I, patients without gastrointestinal problems at referral hospital (N = 151)
15 to 91 years
FI 5.3% (4.0% liquid and 1.3% solid stool)
Thailand Sakondhavat  2004
I, menopausal and gynaecological clinics (N = 229)
Mean age 55.8 years
Stress UI is an involuntary urethral loss of urine associated with coughing, laughing, sneezing or physical exercise. Urge UI is an involuntary loss of urine proceeded by a sensation of urgency or by rapid and uncontrollable voiding with little or no warning.
UI 38.9%, stress UI 4.8%, urge UI 2.2%, mixed 31.9%
Thailand Manonai and Chittachareon  prior to 2004
I, attenders menopausal clinic, Bangkok (N = 956)
40 to 81 years
Stress incontinence defined as the involuntary loss of urine with an increase in intra-abdominal pressure such as coughing, sneezing, running and lifting; urge incontinence is the involuntary loss of urine associated with a strong desire to void.
Stress UI 58.3%, urge UI 6.6%
Thailand Manonai and Poowapirom  2003–2004
I, random community sample in a rural district (N = 1,126)
15 to 95 years
UI: more than one episode in last month
UI 36.5%, stress UI 33.6%, urge UI 11.0%, mixed 8.1%
Tunisia Keskes  Prior to 1988
I, attenders gynaecological and family planning clinics (N = 500)
Mean age 32.9 years
UI 44.6%, stress UI 13.4%, urge UI 13.2%, mixed 18.0%
Information from the studies indicates that POP, UI and FI are common debilitating conditions. Approximately 83,000 women were surveyed overall; the mean prevalence of pelvic organ prolapse was 19.7% (range 3.4–56.4%), urinary incontinence was 28.7% (range 5.2–70.8%) and faecal incontinence was about 7% (range 5.3–41.0%) (Table 1). In view of the limitations of these studies, it is not useful to further summarise the prevalence of the three conditions by subgroups such as study type, different definitions used and whether based on symptoms or clinical examination.
In addition to the studies identified dealing with prevalence of PFD, four other studies were found concerned with risk factors [43–46]. Several risk factors for pelvic floor dysfunction among women in low-resource countries are similar to those found among women in affluent countries .
Age and parity are both clearly related to the prevalence of POP [9–12, 14, 15, 34, 35, 37, 43, 44]. For instance, a study from Iran  shows a clear relationship between age and the prevalence of POP (age ≤ 19 years 12.2%; 20–29 years, 28.5%; 30–39 years, 57.2%; 40–49 years, 67.3%; 50–59 years, 61.1%; 60 years and over, 68.6%) and with parity (nulliparous, 0; parity 1–3, 25.3%; 4–6, 51.9%; 7 and over, 68.2%). However, as a study from the Gambia  shows when multivariate logistic regression analysis is used, it reveals high parity to be the strongest risk factor for pelvic organ prolapse when other significant demographic, fertility and gynaecological variables are taken into account (adjusted OR, 95% CI) nulliparous 1, para 1–3, 6.39 [2.24–18.22], para 4–7, 11.69 [4.0–34.13], para 8+ 14.95 [4.94–45.24]. Highly parous women with eight or more deliveries had 15 times the odds of prolapse (p < 0.0001) compared with nulliparous women. The second strongest risk factor was advanced age, with women aged 45–54 years having almost twice the odds of prolapse compared to 15–24 year olds (p < 0.0001).
Excessive stretching and tearing and multiple deliveries seem to be the main independent predisposing obstetric risk factors for symptomatic pelvic floor dysfunction. Caesarean delivery appears to have a protective effect on the development of POP [15, 45]. In relation to prolapse, early age at marriage and first delivery [8, 11, 35, 44], regular heavy physical work including lifting [8, 43, 44, 46] and poor nutrition, including anaemia [34, 43], are likely to be particularly relevant to women living in low-resource countries.
Age and parity are also related to the development of UI [17, 19–26, 29, 31, 35]. Studies from China illustrate this clearly [19–24]. For instance, multivariate logistic regression analysis in a study of a large random sample of women aged over 20 years in China  found that the adjusted odds ratios for stress, urinary incontinence and age showed a strong significant relationship (p < 0.001) (aged 30–39, 1.60 [1.27–2.01]; 40–49, 2.27 [1.80–2.86]; 50–59, 2.28 [1.73–3.01]; 60–69, 2.31 [1.69–3.16]; 70–79, 2.09 [1.50–2.92]; 80–89, 2.00 [1.30–3.06]; 90 and above, 3.21 [1.58–6.49]. For parous compared to nulliparous women, the adjusted odds ratio was 3.89 (2.77–5.46, p < 0.001).
Evidence from several studies suggests that important risk factors for UI are larger-sized babies [19, 26, 29, 33], particularly in relation to the small body size of most women in developing countries, vaginal delivery [18–23, 26, 30–33, 45], regular heavy physical work, including lifting , and concomitant medical conditions such as diabetes mellitus and chronic cough [19, 23, 25–27, 29, 31, 32].
The causes of pelvic organ prolapse and urinary and faecal incontinence are clearly multifactoral and attributable to a combination of risk factors. Damage to the pelvic support mechanism during childbirth appears to be the main contributory factor for the development of these conditions. Increasing parity, advancing age and vaginal delivery are the most consistent risk factors for both prolapse and urinary incontinence.
Social and economic consequences of pelvic floor dysfunction
Women in developing countries have similar complaints to women in affluent countries as a result of pelvic floor dysfunction and are generally embarrassed by their condition [8, 25, 31, 47]. However, the consequences are usually far more severe than for women in developed countries, and their quality of life is even more drastically affected. In many ways, it further exacerbates the poor position of women in traditional societies. Women with prolapse report difficulty in walking, sitting, lifting and squatting, and often say they have “something falling out” or a “heaviness” . Lower backache, pressure or a dragging sensation in the lower abdomen and a feeling of a mass in the vagina are common symptoms of uterine prolapse . Prolapse affects the performance of daily household chores, particularly in rural South Asia, where women adopt a squatting posture for most household work . The sexual life of women is usually affected because it causes discomfort and pain in the pelvic area [8, 10, 44, 47].
Women with POP in Nepal reported abdominal pain, difficulty in voiding urine and defaecating, together with lower back pain and painful intercourse . This impaired their ability to work and consequently threatened their place in the family. Women were usually too embarrassed to ask for help .
Muslim women with UI face specific problems and complain that their quality of life is profoundly affected. Women in Egypt reported that the most distressing issues were inability to pray (90%), low self-esteem due to feeling unclean (65%), difficulty in performing physical activities such as housework (33%), and leakage of urine during sexual intercourse (18%) .
Women suffering with UI in a study from China  reported adverse effects on quality of life. They had to change and wash clothes frequently, use the toilet very often, and their sex life was negatively affected. They could not walk without becoming wet and felt progressively more isolated, alone and embarrassed, with feelings of shame, annoyance, frustration, depression and being dirty.
However, many women with PFD in developing countries often accept that prolapse and incontinence are “normal” [16, 17, 34]. A study from the Gambia found that while on examination, 46% of women had some degree of prolapse; without probing, only 12.5% of the women reported symptoms related to PFD. The authors concluded this was probably because “women in many developing societies are socialised to endure pain and discomfort, particularly if these result from conditions related to their reproductive functions” . Most women with prolapse did not seek modern health care [10, 14, 17, 36]. The main reasons they gave were reluctance to mention it and shyness together with lack of money and high cost of care. In many cultures, restrictions were placed on them by their husband and families. The women often considered that they must suffer in silence because there was no recourse. They internalised suffering as part of their ethics and endured the pain and discomfort emanating from their reproductive and sexual roles.
Frequently, health care is not accessible, and the only care available is self-care or from the traditional sector. Traditional remedies in north India  included ingesting special herbs or foods, hanging upside down, and inserting items such as alcohol and herbs soaked in a cloth into the vagina regularly, often weekly.
Interventions to prevent and manage pelvic floor dysfunction
To have any overall impact on the burden due to prolapse and incontinence requires interventions ranging from long-term preventive programmes to surgical repair. Advocacy to increase the age at marriage, delay first pregnancy and limit the number of pregnancies to wanted pregnancy through good access to family planning can, in the long term, lead to a reduction in prolapse and incontinence. Treatment options for women with symptomatic POP include pelvic floor training exercises, use of vaginal pessaries and surgery.
Mechanical devices, particularly vaginal pessaries, are an effective clinical method used as standard care in many Western countries to alleviate the symptoms of prolapse and avoid or delay the need for surgery [48, 49]. Frequently, nurses assist women and fit pessaries .
Most efforts in developing countries have concentrated on surgery to treat the most severe forms of PFD [10, 39, 43, 46]. While women are usually very satisfied with the outcome of surgery , in view of the very limited access to this elective service, this has made very little impact on the size of the problem. Poor access to surgical care in many developing countries means that only a minority of women with severe prolapse are likely to receive it. However, innovative approaches, including surgical camps at rural hospitals  and demand-side subsides to assist poor people to access care at urban hospitals [43, 52] have occasionally been available. Vaginal pessaries are not widely used in developing countries as they depend on the availability of health services, good supply and health personnel to clean and change the pessaries.
Few population-based studies concerned with the prevalence of PFD have been carried out in developing countries, and consequently, there is limited information on these conditions. Representative studies of a population are difficult undertakings and more so if they involve sensitive questions and intimate examinations such as those concerned with PFD. However, the present review indicates that pelvic organ prolapse and urinary and faecal incontinence are common debilitating conditions among adult women in developing countries.
Pelvic floor dysfunction in developing countries is a substantial cause of suffering and burden of disease among adult women, particularly as they get older, but is largely hidden and unacknowledged, although the social economic consequences are often severe. Frequently, women in many developing countries are socialised to endure pain and discomfort, particularly if this is associated with their reproductive functions .
From the studies in this review, we estimate that around a fifth of parous women have prolapse, probably almost a third urinary and about 7% faecal incontinence. The studies included in the review have several limitations, and caution has to be used in the interpretation of information summarised from them. While the majority (60%) of the studies were community-based, the populations covered in the different surveys had differences in sampling procedures and ranged from random sample national interview surveys to patients attending gynaecology outpatient departments and primary health clinics. The age ranges of the women also varied. Some studies depended only on interviews (19/30) while the others also included a clinical examination. In addition, there were differences in the definitions used for the three conditions; only nine of the 30 studies used versions of internationally agreed questionnaires.
It was very difficult to compare prevalence across the different countries as the 30 studies included different age groups, definitions and methods for collecting data. Future prevalence studies should use the standardised definitions proposed by the International Continence Society and include representative populations and similar age groups [54–57].
There needs to be a concerted international action to ensure that policy makers are aware of the extent of prolapse and urinary and faecal incontinence among parous women in developing countries and the debilitating consequences . In order to reduce and prevent these conditions, it is important that more attention is given to advocacy to improving knowledge of the situation and efforts to eliminate the associated social stigma [34, 43]. Specific interventions are required to improve nutrition, particularly of young women; strengthen efforts to delay marriage and childbearing until adulthood and improve access to family planning and safe delivery services [8, 26, 35, 58]. A routine component of postnatal care should include training in pelvic floor exercises to reduce the likelihood of developing incontinence. Due to cost and limited availability of surgeons, reasonable access to surgical repair services will remain unattainable for the majority of women suffering prolapse and incontinence living in low-income countries in the immediate future. However, it is important that health workers are trained in fitting pessaries which can effectively reduce the suffering of many women particularly with mild and moderate prolapse.
Conflicts of interest