International Urogynecology Journal

, Volume 29, Issue 10, pp 1435–1440 | Cite as

Functional pelvic floor anatomy in Nepali women attending a general gynaecology clinic

  • Friyan TurelEmail author
  • Delena Caagbay
  • Hans Peter Dietz
Original Article


Introduction and hypothesis

Limited existing evidence suggests that there is a high prevalence of female pelvic organ prolapse (POP) amongst Nepali women. However, to date, no comprehensive assessment of pelvic floor functional anatomy has been undertaken in this population. Our study aimed to determine functional pelvic floor anatomy in Nepali women attending a general gynaecology clinic.


One hundred and twenty-nine consecutive women attending the clinic were offered an interview, clinical examination [International Continence Society Pelvic Organ Prolapse Quantification system (ICS/POP-Q)] and 4D translabial ultrasound (TLUS). Most presented with general gynaecological complaints. Five were excluded due to previous pelvic surgery, leaving 124.


A POP-Q exam was possible in 123 women, of whom 29 (24%) were diagnosed with a significant cystocele, 50 (41%) significant uterine prolapse and seven (6%) significant posterior compartment prolapse. Evaluation of 4D TLUS data sets was possible in 120 women, of whom 25 (21%) had a significant cystocele, 45 (38%) significant uterine prolapse and ten (8%) significant descent of the rectal ampulla. In 13 cases, there was a rectocele with a mean depth of 14 (10–28) mm. Of 114 women in whom uterine position could be determined, 68 (60%) had a retroverted uterus associated with significant uterine prolapse (P 0.038).


POP is common in Nepali women attending a general gynaecology clinic, with a high prevalence of uterine prolapse (40%). Uterine retroversion was seen in 60% and was associated with uterine prolapse. Patterns of POP in Nepal seem to be different from patterns observed in Western populations.


Nepal Pelvic floor Pelvic organ prolapse Translabial ultrasound Uterine prolapse 



International Continence Society, Pelvic Organ Prolapse Quantification system


4D Translabial ultrasound


Pelvic organ prolapse


Visual analogue scale


Pelvic floor muscle


Pelvic floor muscle contraction


Levator ani muscle


External anal sphincter


Symphysis pubis


Chronic obstructive pulmonary disease



The authors thank the women who participated in this study. We also thank staff at Kathmandu Model Hospital for their assistance and generosity with their limited space. We are especially grateful to Dr. Vishal Kumar Trivedi for excellent assistance during data collection.

Compliance with ethical standards

Conflict of interest

H.P. Dietz has received unrestricted educational grants from GE Medical. F. Turel and D. Caagbay have no conflict of interest to declare.


  1. 1.
    Dietz HP, Franco AV, Shek KL, Kirby A. Avulsion injury and levator hiatal ballooning: two independent risk factors for prolapse? An observational study. Acta Obstet Gynecol Scand. 2012;91(2):211–4.CrossRefGoogle Scholar
  2. 2.
    Bump RC, Norton PA. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin N Am. 1998;25(4):723–46.CrossRefGoogle Scholar
  3. 3.
    Smith FJ, Holman CA, Moorin RE, Tsokos N. Lifetime risk of undergoing surgery for pelvic organ prolapse. Obstet Gynecol. 2010;116(5):1096–100.CrossRefGoogle Scholar
  4. 4.
    Whitcomb EL, Rortveit G, Brown JS, Creasman JM, Thom DH, Van Den Eeden SK, et al. Racial differences in pelvic organ prolapse. Obstet Gynecol. 2009;114(6):1271.CrossRefPubMedGoogle Scholar
  5. 5.
    Abdool Z, Dietz HP, Lindeque BG. Ethnic differences in the levator hiatus and pelvic organ descent: a prospective observational study. Ultrasound Obstet Gynecol. 2017;50(2):242–6.CrossRefGoogle Scholar
  6. 6.
    Cheung RY, Shek KL, Chan SS, Chung TK, Dietz HP. Pelvic floor muscle biometry and pelvic organ mobility in east Asian and Caucasian nulliparae. Ultrasound Obstet Gynecol. 2015;45(5):599–604.CrossRefGoogle Scholar
  7. 7.
    Shek KL, Krause HG, Wong V, Goh J, Dietz HPI. Pelvic organ support different between young nulliparous African and Caucasian women? Ultrasound Obstet Gynecol. 2016;47(6):774–8.CrossRefGoogle Scholar
  8. 8.
    Center for Agro-Ecology and Development (CAED) (2006) Uterine prolapse widespread. Post Report. Nepal. Available from:
  9. 9.
    Bonetti TR, Erpelding A, Pathak LR. Listening to “felt needs”: investigating genital prolapse in western Nepal. Reprod health matters. 2004;12(23):166–75.CrossRefGoogle Scholar
  10. 10.
    Subba B, Adhikari D, Bhattarai T. The neglected case of the fallen womb. Nepal: Himal South Asian; 2003.Google Scholar
  11. 11.
    Gurung G, Rana A, Amatya A, Bista KD, Joshi AB, Sayami J. Pelvic organ prolapse in rural Nepalese women of reproductive age groups: what makes it so common? Nepal J Obstet Gynaecol. 2007;2(2):35–41.Google Scholar
  12. 12.
    Haylen BT, McNALLY G, Ramsay P, Birrell W, Logan VA. Standardised ultrasonic diagnosis and an accurate prevalence for the retroverted uterus in general gynaecology patients. Aust NZ J Obstet Gynaecol. 2007;47(4):326–8.CrossRefGoogle Scholar
  13. 13.
    Haylen BT. The retroverted uterus: ignored to date but core to prolapse. Int Urogynecol J. 2006;17(6):555.CrossRefGoogle Scholar
  14. 14.
    Ulrich D, Guzman Rojas R, Dietz HP, Mann K, Trutnovsky G. Use of a visual analog scale for evaluation of bother from pelvic organ prolapse. Ultrasound Obstet Gynecol. 2014;43(6):693–7.CrossRefGoogle Scholar
  15. 15.
    Dietz HP, Shek C. Validity and reproducibility of the digital detection of levator trauma. Int Urogynecol J. 2008;19(8):1097–101.CrossRefGoogle Scholar
  16. 16.
    Dietz HP, Mann KP. What is clinically relevant prolapse? An attempt at defining cutoffs for the clinical assessment of pelvic organ descent. Int Urogynecol J. 2014;25(4):451–5.CrossRefGoogle Scholar
  17. 17.
    Dietz HP, Lekskulchai O. Ultrasound assessment of pelvic organ prolapse: the relationship between prolapse severity and symptoms. Ultrasound Obstet Gynecol. 2007;29(6):688–91.CrossRefGoogle Scholar
  18. 18.
    Shek KL, Dietz HP. What is abnormal uterine descent on translabial ultrasound? Int Urogynecol J. 2015;26(12):1783–7.CrossRefGoogle Scholar
  19. 19.
    Chan SS, Cheung RY, Yiu KW, Lee LL, Leung TY, Chung TK. Pelvic floor biometry during a first singleton pregnancy and the relationship with symptoms of pelvic floor disorders: a prospective observational study. BJOG. 2014;121(1):121–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Dietz HP, Moegni F, Shek KL. Diagnosis of levator avulsion injury: a comparison of three methods. Ultrasound Obstet Gynecol. 2012;40(6):693–8.CrossRefGoogle Scholar
  21. 21.
    Lien YS, Chen GD, Ng SC. Prevalence of and risk factors for pelvic organ prolapse and lower urinary tract symptoms among women in rural Nepal. Int J Gynecol Obstet. 2012;119(2):185–8.CrossRefGoogle Scholar
  22. 22.
    Bodner-Adler B, Shrivastava C, Bodner K. Risk factors for uterine prolapse in Nepal. Int Urogynecol J. 2007;18(11):1343–6.CrossRefGoogle Scholar
  23. 23.
    Thapa S, Angdembe M, Chauhan D, Joshi R. Determinants of pelvic organ prolapse among the women of the western part of Nepal: a case–control study. J Obstet Gynecol Research. 2014;40(2):515–20.CrossRefGoogle Scholar
  24. 24.
    Swift S, Woodman P, O’boyle A, Kahn M, Valley M, Bland D, et al. Pelvic organ support study (POSST): the distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol. 2005;192(3):795–806.CrossRefGoogle Scholar
  25. 25.
    Dietz HP, Simpson JM. Levator trauma is associated with pelvic organ prolapse. BJOG. 2008;115(8):979–84.CrossRefGoogle Scholar
  26. 26.
    Dhital R, Otsuka K, Poudel KC, Yasuoka J, Dangal G, Jimba M. Improved quality of life after surgery for pelvic organ prolapse in Nepalese women. BMC Womens Health. 2013;13(1):22.CrossRefPubMedGoogle Scholar
  27. 27.
    Sah DK, Doshi NR, Das CR. Vaginal hysterectomy for pelvic organ prolapse in Nepal. Kathmandu University Medical J. 2010;8(2):281–4.CrossRefGoogle Scholar
  28. 28.
    Pixton S, Caudwell Hall J, Turel F, Dietz HP. Predictors of ring pessary success in women with pelvic organ prolapse. Int Urogynecol J. 2017; in print.Google Scholar
  29. 29.
    Fernando RJ, Thakar R, Sultan AH, Shah SM, Jones PW. Effect of vaginal pessaries on symptoms associated with pelvic organ prolapse. Obstet Gynecol. 2006;108(1):93–9.CrossRefGoogle Scholar

Copyright information

© The International Urogynecological Association 2017

Authors and Affiliations

  • Friyan Turel
    • 1
    Email author
  • Delena Caagbay
    • 2
  • Hans Peter Dietz
    • 1
  1. 1.Department of Obstetrics, Gynecology & Neonatology, Sydney Medical School NepeanThe University of SydneyKingswoodAustralia
  2. 2.The University of Sydney, AustraliaSydneyAustralia

Personalised recommendations