Urinary Incontinence (UI) occurs among women of all ages, negatively impacting work, social, and leisure participation, affecting sexual relationships, and creating embarrassment, which may lead to anxiety and depression.1 In Nepal, few studies have examined the prevalence of UI. A community-based survey among 14,469 women found a prevalence of stress- and urgency UI at 24 % and 14 %, respectively2 and one study among women with gynecological disorders reported the prevalence to be as high as 50 %.3 Pelvic floor disorders, including UI, are a significant problem for women in Nepal,2,3 calling for research in this field of women’s health.

The majority of Nepali women live in a conservative and male-dominated society with a lack of autonomy in decision-making, where they are generally restricted to childbearing, household maintenance, and performing informal, unpaid work.4 Thus, a high number of Nepali women are faced with physically strenuous work, little time for rest, and reduced family support, even during pregnancy.4,5 Also, the literacy rate among Nepali women is low compared to the male population.6

A common misconception among women in Nepal is the belief that pelvic floor dysfunction, such as UI, is a normal and inevitable outcome of childbirth and ageing.5 A recent study from Nepal concluded that only 21 % of women aged 40-65 years had good knowledge of UI.7 Studies have shown that patients’ beliefs, misconceptions about the causes and knowledge related to UI, and the availability of treatment can affect treatment-seeking behavior.5,7

There is Level 1 evidence and Grade A recommendation that pelvic floor muscle training (PFMT) should be the first-line treatment for women with UI, the efficacy of PFMT being well established in international guidelines.8,9 To gain an effect in the treatment of UI, it is essential that the women can perform a correct contraction of the PFM.9 Studies from different countries have shown that many women seem to be unable to perform a correct voluntary PFM contraction, and the belief of doing a correct PFM contraction is false in one of five women.10,11 These findings point to an urgent need for comparing women’s self-perceived ability of PFM contraction with clinically assessed digital palpation.12 We believe that many Nepali women with UI lack sufficient knowledge about PFM and PFMT and do not have a reliable perception about their PFM contraction.

Hence, the aims of the current study were to: i. investigate knowledge of UI, PFM, and PFMT in Nepali women with UI, ii. examine their self-perceived ability of PFM contraction compared to actual ability assessed by digital palpation, and iii. investigate association between socio-demographic factors and the ability to perform a correct PFM contraction.

Seventy-two of 75 women consented to participate in the present study investigating the ability to contract the PFM. The three women not consenting to participate in this additional study did not want to be assessed by digital palpation. Table 1 shows the socio-demographic data of the participants. Most women were above 35 years of age and were overweight. All women were married, with 40% below the age of 20, and more than half were multiparous. The women represented a variety of ethnicities, but were dominated by Chettri. One third did not have any formal education and were housewives. Most women reported moderate UI.

As hypothesized, this cross-sectional study found that most participating Nepali women did not have a reliable perception of their PFM contraction. Seventy-one percent of the women believed they could contract their PFM, while only 24 % could do so correctly. The women had poor knowledge about UI, PFM, and PFMT. The socio-demographic factors indicated that the women with physically demanding tasks, such as fetching water and working in a squatted position, were less likely to perform correct PFM contractions.

Our study revealed that few women had heard about UI, and even fewer knew its causes and treatment, corroborating previous findings in Nepal showing that only 21 % of middle-aged women had satisfying knowledge of UI.7 Almost nobody had heard about PFM or PFMT. These results align with another study reporting low knowledge of PFM among Nepali women visiting gynecology departments.12 Similarly, a systematic review on knowledge about pelvic floor dysfunction across ten countries, including Nepal, found low awareness about UI and PFM.20 In contrast, a study conducted in Nigeria,21 reported that 74.3 % of respondents knew about PFMT, and another study of Malaysian women of childbearing age reported good/moderate knowledge (80.1 %) and attitudes (77.3 %) towards PFMT, though 87.2 % did not report exercising or training of the pelvic floor.22 A study from Belgium reported a similar level of satisfactory knowledge about PFMT (73.8 %), but in contrast, half of these women reported they had experience with PFMT.11 Most of these studies suggested that knowledge could be affected by the level of education,12,20,23, thus explaining low health literacy. A recent study from Nepal showed that health literacy was related to socioeconomic factors and health status.24 In our study, 68 % of the women either had no education or had attended only primary school; many were housewives, and almost all reported health issues.

Even though a few participants in our study had knowledge about the PFM, over 70 % of the participants still believed they were able to contract, while the remaining were unsure, and no one thought they were unable to contract the PFM. Of those unable to correctly contract, almost 80 % were under the impression that they were doing a correct contraction. In total, less than one fourth of all women in our study were able to perform a correct contraction. Consistent with our findings, a comparable study from Brazil found that only one-third of women had a correct self-perception of their PFM contraction in relation to the physiotherapist’s assessment.10 Furthermore, a study from Belgium, including 500 women with knowledge of the PFM and experience with PFMT, revealed that only 50 %, in spite of having both knowledge and practice, were able to perform a correct contraction of inward motion of the perineum, while one third falsely believed that they were doing a correct contraction.11 Their study was performed within one week after vaginal birth, which likely explains the result, and therefore is not directly comparable with our findings. It was, however, interesting to note that our study showed no significant difference in knowledge between the groups able and unable to contract their PFM. Our findings are similar to the findings of a study by De Freitas et al. (2019) in a low-mid income Brazilian population, including a sample of 133 women. Although they found a low level of PFM knowledge in their sample, no relationship was found with the ability to contract the PFM or the presence of UI.23

Lack of awareness and the subtle nature of the PFM might explain false perception of and difficulties in performing a correct contraction, and also the ability to isolate the PFM activation from other muscles.25,26 Several authors have found that women unable of correct PFM contraction were either unable of any contraction at all or displayed weak or uncertain contractions,11 used other additional gluteal or abdominal muscles, or strained by pushing downward instead of lifting upward and inward.25 The latter might exacerbate pelvic floor dysfunctions such as UI or pelvic organ prolapse (POP).

Our study showed that despite receiving a 30-minute education session on UI and PFMT, the participants’ self-perceived ability did not align with actual PFM contractions. Another study from Nepal found that an illustrative leaflet was insufficient for teaching correct PFM contraction.12 A systematic review highlighted that educational interventions and verbal cues improved PFM proprioception in women of all ages, including those without pelvic floor dysfunction.27 Regular and repeated verbal instructions and guidance have been demonstrated to improve the ability of correct contraction.28 It is interesting though, that more than 70 % of those unable to perform a correct contraction managed to do it correctly after instruction by a physiotherapist.16

Our findings further suggest that demanding working conditions, such as fetching water and working in a squatting position, might be linked to impaired PFM contraction. These results align with prior research in Nepal, where heavy physical labor (e.g., carrying water or firewood) was associated with increased POP and UI, likely due to sustained and repetitive intra-abdominal strain.29 Similarly, it has been shown that women in agricultural roles exhibited reduced PFM awareness and higher UI rates compared to urban populations, underscoring occupational influences on pelvic health.11 However, in our study, carrying heavy loads did not show any link with PFM contraction, which is also similar to a finding from another study in Nepal, which explained physically demanding risk factors for POP.30 The generalizability of the associations found in our study remains uncertain due to the limited sample size, emphasizing the need for larger epidemiological investigations to confirm risk factors.

To our knowledge, this is the first study in Nepal to compare women’s self-perception of their PFM contraction with clinically examined ability to contract the PFM. A strength of the study, supporting generalizability to the larger Nepali population, is that some sociodemographic variables, such as BMI and educational status, are comparable with the findings from a census study describing the sociodemographic profile and health status of Nepali women.31 The sample also included women from rural and urban areas, and a range of parity. Generalizability beyond the Nepalese population should, however, be done cautiously. Limitations and recommendations to be considered for future research protocols may include investigation of larger sample sizes and validation of questionnaires to be used in a Nepali population.32 Additionally, to verify the women’s self-perception of PFM correct contraction, it ideally could have been assessed again after the digital palpation. Although the physical assessment of the PFM was performed by an experienced women’s health physiotherapist in the present study, it could be recommended that the researcher in future studies should be blinded to the women’s self-perception before the physical examination.

Nepali women showed low knowledge about UI, PFM, and PFMT. Despite most women perceiving they could contract the PFM, less than one-third were able to perform a correct contraction. PFMT should not rely solely on self-perception; instead, proper clinical assessment with feedback on the contraction and supervised training are warranted.

The study is funded by the Norwegian Agency for Development Cooperation through the Norwegian Programme for Capacity Development in Higher Education and Research for Development II, Norway.