Urinary incontinence (UI) is a severe condition that presents a significant socioeconomic burden for individuals and society and affects twice as many women than men, with an estimated prevalence ranging between 25%–45% among women worldwide.1–3 Individuals affected by the condition have a significant reduction in their quality of life, with many reporting impaired emotional and psychological well-being, reduced social interaction and physical activity, presence of sexual dysfunction, and increased risk of falls.4–6 In Brazil, knowledge about pelvic floor dysfunction and its treatment is still low among women.7 Though nearly a third of women live with UI, 32% of female respondents to a nationwide survey did not know for how long the symptoms had been present, 45.7% said they did not know of any treatment for the condition, and more than 60% never sought treatment at all.8,9 A study by the Brazilian Association for Continence indicates that patients with UI spend 25–40% of their average monthly income (R$2116.84) for medications and urethral tubes.10 There is an unmet need for novel approaches that can reduce the burden of UI in Brazil.

Treatment options for UI are based on the predominant type of incontinence (stress, urgency, or mixed urinary incontinence) and the associated symptoms, patient goals and expectations, potential adverse effects, and economic status.11 First-line treatment strategies are non-surgical and mainly include pelvic floor muscle training, in addition to lifestyle changes, including weight loss and fluid intake strategies.12–17 Despite supporting evidence, the uptake of non-surgical treatments like pelvic floor muscle training is low due to a lack of specialized providers in the Brazilian healthcare system, therefore increasing the overall burden of the condition.12,17

Contemporary technologies, such as mobile health (mHealth) applications (apps), offer potential to assist the self-management of UI.18 Patients can be empowered with educational information, reminders, medication diaries, symptom trackers, and peer support to improve treatment adherence, outcomes, and to better perform home exercise programs.15 However, questions about the benefits of mHealth technologies in managing UI still exists.18–23 Therefore, there is significant interest from clinicians, researchers, and patients affected by the condition to determine the quality of current mHealth apps for UI.20,22–25

To guide clinicians and researchers in their decision-making, the current status of mHealth technologies for UI-namely, the availability, functionality, and overall quality of apps-must be comprehensively reviewed. To the best of our knowledge, there are no systematic reviews classifying available mHealth technologies for UI in Brazil. The aim of this study was to systematically assess the availability of Health apps for patients with UI in Brazilian online stores, and to evaluate the apps with respect to engagement, user interface, experience, and information quality. This information will guide the development of more robust patient-centered apps for UI and inform healthcare providers and patients on the quality of mobile technologies available in Brazil.

The focus of this review was mHealth apps for individuals with UI available in the Brazilian Google Play Store (Google Inc) and App Store (Apple Inc). The term “mHealth technology” was defined as the use of technology for health purposes deployed in a mobile phone, smartphone, or tablet. Recommendations proposed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and the Cochrane Collaboration for systematic reviews were used throughout the course of the study.26,27 There was no ethical approval required for this study, as no personal data were collected.

Of the 1111 relevant mHealth apps found by our search, only 12 were eligible for inclusion (Fig. 1). Two apps (Floor App and UrinApp), were not found through our search, but were evaluated for inclusion in the study based on the authors’ knowledge that its content was of relevance to individuals with UI. Ultimately, Floor App was excluded because it did not meet the inclusion criteria (not updated in the last two years). A total of 12 mHealth apps were included in the final review. Most commonly, apps were excluded because they were duplicates, not updated, or not relevant to the topic of this review. Of the 12 included apps, two (16.7%) were found in the App Store exclusively, six (50%) were found in the Google Play Store exclusively, and four (33.3%) were found in both App Store and Google Play Store. There were only two (16.7%) paid apps, ranging in price from R$7.90 to R$18.90. Five apps offered in-app purchases ranging from R$2.99 to R$29.90 each. The characteristics of the included mHealth apps are described in Table 2.

Figure 1.

Flow diagram for mobile health applications (mHealth apps) search results.

Legend: *To ensure software functionality and ongoing technical support to users, only apps developed or updated in 2018–2020 were included. **One app only worked with the purchase of an external device (hardware), and the second app did not meet the language inclusion criteria after installation.

(0.16MB).

Of the 12 included apps, four offered exclusively exercise programs, in which users can access home-based exercise programs passively, through interactive videos or images with descriptions, or actively, by manually creating their own exercise programs. Six offered exercise and educational content about UI and its associated symptoms, pelvic floor anatomy, function, and training in addition to exercise programs. Two apps offered tools to track patient outcomes related to UI, such as daily fluid intake, frequency of urination, and frequency of pad changes. None of the 12 apps were tested as an intervention or part of an intervention in a randomized controlled clinical trial (RCT).

To the best of our knowledge, this is the first systematic review evaluating the use of mHealth technologies for UI available in Brazilian online app stores. Our study demonstrates that there is a significant unmet need for the development of new mHealth apps to better support individuals with UI in Brazil. The majority of the existing apps scored poorly on the MARS scale due to a lack of evidence-based information (i.e., whether the app has been scientifically tested or not), mediocre aesthetics, and subpar user interface (i.e., screen flow and visual elements) and/or experience (i.e., the internal experience that a user has as she/he interact with the elements of the app). This study corroborates the findings of a study evaluating the quality of pelvic floor muscle training smartphone apps in New Zealand (English apps only), in which 34 apps were included but were found lacking in their provision of evidence-based information and with respect to the quality of the user interface.25 However, the mean MARS quality score (3.9 ± 0.4; range 2.9–4.4) for the apps in this previous study was higher than the one in the current study, indicating that English apps may be more attractive for individuals with UI perhaps due to a more effective collaboration between industry and research, more funding opportunities, or associated cultural factors.

The lack of evidence-based scientific information provided by the evaluated mHealth apps could be explained by the fact that most included apps (91.7%) were developed for commercial purposes, suggesting the need to promote better partnership between industry and academic institutions to develop healthcare apps. In addition to providing low-quality educational content, none of the assessed apps used validated patient-reported outcome measures to evaluate users’ symptoms, limiting the reliability and external validity of the data collected. The use of validated tools, such as the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and the King's Health Questionnaire, within an app environment, could have promising implications for research focused on UI.37,38

Currently, privacy and security aspects are not addressed by the MARS scoring scale. However, strict laws such as the Health Insurance Portability and Accountability Act (HIPAA) and the General Data Protection Regulation (GDPR) are already used to protect users regarding their health personal data in the United States and the European Union. In Brazil, data protection relies on the “General Law of Data Protection”. In this review, more than 70% of the included apps did not present terms of use or privacy policies to users, and were thus non-compliant with data protection rules of Brazil, potentially posing risks to users’ data security.

Although mHealth apps for individuals with UI are available in Brazil, the evidence for their effectiveness is limited. Of the apps included in our review, none were used as an intervention in a RCT; therefore, their efficacy in improving UI outcomes compared to other traditional treatments used in the clinical setting is unknown. Clinical trials performed outside Brazil have demonstrated potential benefits of using mobile technologies in terms of improvements in UI, satisfaction, adherence, and costs.19 Only one RCT has been conducted in Brazil, and the results suggested that the use of an mHealth app increased the adherence to pelvic floor muscle training in women with UI symptoms when compared to written instructions only. The app used was “Diário Saúde”, developed exclusively by the authors’ research group in partnership with Eldorado Research Institute.39 Unfortunately, the app is not available at online app stores.

To promote sustained usage, it is critical that mHealth apps possess core characteristics to increase usability and improve health outcomes. These characteristics include the possibility of making plans or orders within the app, to save time by not having to interpret the steps required to achieve a desired health goal; data sharing capabilities, including the export of activities/adherence and progress (or setbacks) to share with their health care provider; usability features, in which the layout of an app is efficient, intuitive, and allows for easy input of information; and cost, where affordability is balanced with value for the customer, leading to a better experience and better outcomes.40 In addition, gamification (e.g., as badges, dashboards, scores, goals, and challenges within the app) and educational resources are also essential features to create active patient participation in patient self-management 18,41–43

Strengths of our study include its rigorous systematic approach that follows well-established reporting guidelines.26,27 Investigators underwent structured training in the use of the MARS scale prior to initiation of the study and demonstrated strong agreement. However, due to a lack of direct patient input, we lacked insight into the utility of the reviewed apps for individuals living with this condition. Other limitations are related to app-specific findings that will date quickly if existing apps are revised or improved and if new apps become available at online app stores in Brazil.

The use of mHealth technologies for UI is still a relatively new and unexplored topic, with much potential for future investigation. Our results suggest that an ideal mHealth app for patients with UI should provide content that is grounded in scientific evidence, respect the laws of privacy and security of the country in which it is being offered, include symptom trackers, keep individual records for personalized health goals, and allow for collaboration between users and healthcare professionals to design tailored pelvic floor muscle training programs.19,44 This study calls for the collaboration of an interdisciplinary team of researchers, clinical professionals, patients, and application developers to develop new user-centered mHealth apps that will empower individuals with UI.

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.

The authors declare no conflicts of interest.