Title: Effect of pelvic floor muscle training using mobile health applications for stress urinary
incontinence in women: a systematic review.
Version: 0 Date: 29 Jun 2022
Reviewer's report:
I commend the authors on a valuable contribution to the literature with this systematic review
of randomized controlled trials evaluating the impact of mobile application (app) delivered
behavioral modification treatment on stress urinary incontinence. While there is another recent
systematic review on this topic that was published within the last two years, this one incorporates
two additional databases and includes data from Asia that was not included in the other recent
review. I have several suggestions that I hope will make your work more accessible to the reader
but do not have any serious methodological questions.
Specific Suggestions in chronological order, not order of importance:
1 ) On page 5 in the paragraph that starts "Evidence-based incontinence treatment can be
separated broadly into ..." Pessaries are not mentioned and should be since you are providing
a comprehensive list.
2) On page 5 at the bottom of the page there is a paragraph that starts talking about the impact of
COVID-19 on pelvic floor disorder treatment and also talks about telemedicine, neither of which
are relevant to your work and thus serve to distract the reader. Recommend removing these
sentences and just making this paragraph about the use of smart phones and apps for incontinence
and health. Would remove the following: "The Covid-19 outbreak has greatly impacted access
to care for people with pelvic floor dysfunction. During the pandemic, about 32.9% of the
healthcare providers reported some use of telemedicine for pelvic floor disorders patients(16).
Another study found that 85% of patients would have favored telemedical consultation(17).
Telemedicine practice covers different application areas including live videoconferencing,
asynchronous transfer of recorded data, remote patient monitoring and mobile health."
3) I don't understand what this sentence on page 8 means: "All stages were performed to reduce
the risk of selection and publication bias." How did your methods reduce the risk of publication
bias?
4) METHODS. The best place to describe the instruments used to describe impact on symptoms /
QOL is in the paragraph that starts at the bottom of page 8 and continues onto page 9, similar
to how you describe the Broome scale in the next paragraph. Right now you provide a rather
lengthy description in the discussion section, which is not an appropriate location for such
details. Given that you summarize the total number of participants in all studies, you should
probably state in your methods how you made sure that different publications did not include
the same participants, or how you came to your total number if some publications did include
the same participants (at subsequent time points, for example).
5) this sentence at the bottom of page 10 is unclear - please revise. "The results about the PGI-
I were described by frequency (percentage)." You probably want to describe how you recorded
PGI-I responses (improved, neutral, worsened, or improved vs. other, etc.)
6) Figure 1 - Since you did not plan to do a meta-analysis, I would remove the very last row in the
figure.  If you did plan to do a meta-analysis but were unable to do so because of heterogeneity
of studies, then OK to include that row in the figure, but would also state that you had planned
to do a meta-analysis in the methods, and state in the results that it was not feasible because of
study heterogeneity.
7)  On page 12, I don't understand why the question of blinding was not applicable :  "The
individuals responsible for analyzing the results knew from which group they were collecting
the data, therefore, question 4 also was considered “Not applicable” for all studies." We can
collect self-reported data from two groups of patients, those with and without exposure to an
app, and analyze those data without knowing the exposure status of the individual participants,
so I don't understand why this question was considered not applicable.  I can understand why
participants could not be blinded if the app is being compared to usual care, because they know
they are using or not using an app, but the folks analyzing the data should be able to be blinded.
8) Results section 3.1 is very difficult to follow and can be shortened significantly. I would
suggest reorganizing tables 3-5 by instrument rather than study, so that the reader can easily see
all the scores for a single instrument next to one another. Table 1 is perfect and is appropriately
arranged by study and also clumps studies of the same app together. Tables 3-5 would be more
accessible if the rows were rearranged so that all ICIQ-UI data for all studies were reported
together - this organization would mean that an individual  study's outcomes would be separated
from their current clustering but would make it easier for the reader to interpret the main
information. In table 4 the scoring of the Broome scale is difficult to interpret (why just a single
number without a standard deviation in some places but number with standard deviation in
others?)
9) Discussion - the first paragraph should really summarize your main findings and then situate
them within the larger context of what is known. I would remove all of this information, which
distracts from the focus of your paper: "A multicenter randomized controlled trial conducted by
Hagen S et al(33) showed that there was no evidence of any statistically or clinically important
difference in the severity of urinary incontinence between the PFMT plus electromyographic
biofeedback group and the PFMT alone group after 24 months follow-up. The routine use of
electromyographic biofeedback in PFMT is not recommended, other ways to maximize the
effects of PFMT should be studied." I would also move the description of the ICIQ-LUTS on
page 17 to the methods as mentioned previously.