Background
Urinary incontinence (UI) is a common issue among women veterans. Behavioral treatments — such as pelvic floor muscle exercises, bladder control strategies, fluid management, etc. — are first-line therapy and are known to be effective. However, many veterans face barriers to accessing these treatments in person: geographic distance, lack of trained providers at VA facilities, travel time and cost.
- To address these barriers, the Department of Veterans Affairs launched a trial called PRACTICAL (Optimizing Remote Access to Urinary Incontinence Treatments for Women Veterans) to compare remote delivery methods for behavioral UI therapy.
Study Design
Participants: 286 non‐pregnant women veterans, aged ~23-83 years, with at least three months of urinary incontinence. All had access to email and a device (smartphone, tablet, or computer) for remote interventions.
Locations: The trial was conducted across three VA health care systems in the southeastern U.S.: in Alabama, Georgia, and North Carolina.
Interventions:
A mobile health app called MyHealtheBladder delivering an 8-week program of daily behavioral therapy sessions (pelvic floor exercises, bladder strategies, fluid management, risk factor reduction, self-monitoring, motivational content).
A single video visit with a UI treatment provider via VA Video Connect.
Boosting option: If participants did not show improvement at 8 weeks, they were randomized to receive a booster video visit or to continue with their original intervention.
Outcome measures: The primary outcome was change in UI symptom severity measured by the ICIQ-UI SF (International Consultation on Incontinence Questionnaire – Short Form) at 12 weeks; a drop of 2.52 points is considered minimally clinically important difference (MCID). Secondary outcomes included symptom improvement at earlier/later points, adherence, satisfaction, perceptions of improvement, etc.
Key Findings
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Symptom improvement: At 12 weeks, both groups improved, but those using the app showed a greater average reduction in ICIQ-UI SF score: −3.6 points (95% CI, −4.4 to −2.8) for the app vs −2.3 points (95% CI, −3.1 to −1.5) for the video visit group.
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Clinical meaningfulness: Even though the app group improved earlier (they reached the MCID threshold by ~4 weeks), by 12 weeks the difference between app vs video visit didn’t meet the threshold of being a meaningfully clinically superior option in many respects. In other words, both remote methods worked and the difference was modest.
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Booster video visits: For participants who didn’t respond at 8 weeks, adding a booster video visit did not significantly improve outcomes in either group.
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Timing of improvement: The app group hit the MCID at 4 weeks, while the video visit group took longer for similar clinically meaningful change.
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Retention / adoption: About 85% of randomized participants received the intervention. Dropout was nontrivial (around 30-40% by 12 and 24 weeks), similar between groups.
Implications
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Improved access: Remote delivery of UI behavioral treatments can help overcome known access barriers (distance, provider availability, travel) for women veterans, especially in rural areas. Either an app or video visits are viable.
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Choice and flexibility: Because both modes showed improvement, veterans and VA systems may choose either based on preference, tech access, convenience. Some may prefer a video consult, others the flexibility of an app.
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Early improvement matters: Since the app achieved meaningful improvements earlier, that may have psychological or adherence advantages (if people see benefit quickly they may stick with treatment).
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Limited benefit from booster visits: The data suggest that adding a video “booster” for non-responders at week 8 may not substantially help. This has implications for resource allocation.
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Potential for scaling: This model could be scaled across VA centers, possibly other health systems, to deliver behavioral treatments for UI more widely, especially where in-person resources are limited.
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Limitations & Considerations
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Drop-out / retention: A fair percentage of participants did not complete the full study or had missing data, which affects generalizability.
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Device / tech access: Participants needed access to email and a device with internet. Those without reliable technology or connectivity may be excluded or disadvantaged.
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Booster visit effects: While booster visits weren’t found helpful here, perhaps other forms of follow-up or more tailored clinical engagement could help non-responders.
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Longer term outcomes: The follow‐up extended to 24 weeks for some measures, but longer‐term maintenance of improvement, and whether symptoms recur, etc., are less well explored.
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Diversity & tailoring: While the study included a racially diverse sample, some participants suggested they wanted more tailoring by type of UI (stress, urge, mixed) or more individualization in content. Also, some wanted more interaction with staff.
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Conclusion
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The PRACTICAL trial shows that remote behavioral treatments for urinary incontinence among women veterans are effective. Both a specially designed app (MyHealtheBladder) and video visits produced statistically significant improvements in UI symptoms. The mobile app led to earlier symptom reductions, though by 12 weeks both modalities had meaningful impact, and the difference between them was not large enough to declare one clearly superior in all respects. Booster video visits for non-responders did not yield extra benefit.
Overall, these findings support expanding telehealth and mobile health options for UI care, especially in settings where in-person access is limited. They offer women veterans more options and may improve quality of life, lower barriers, and reduce care disparities.
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