The published studies were between 2016 and 2020 and were undertaken in Sweden, Canada, Brazil, and China. Of the four trials, three were complete trials, and one a two-year follow-up post completion of an RCT. A variety of primary and secondary outcomes were assessed across the trials. Outcomes documented in the trials were adherence to PFMT, symptom severity, QOL, bladder neck function, sexual activity, cure rates and use of incontinence products. Three studies [10,11,12] included symptom severity and adherence as primary outcomes. One study  continued with the same outcomes from the Asklund, Nyström  trial as they conducted the 2 year follow up. Each study clearly defined the primary and secondary outcomes and time to follow-up varied across the studies.
Quality of included studies
The JBI quality appraisal tool, a 13-point checklist for randomised controlled trials was used to assess the quality of the four studies (Appendix 3). The methodological quality of the studies was assessed based on methods of randomisation, allocation concealment, blinding, outcomes, statistical analysis, and loss to follow-up. True randomisation, allocation concealment and similar baseline were unanimous across the studies except for the two-year follow-up trial. Blinding was true amongst all participants in the studies conducted by two studies [10, 11]. Blinding for participants was declared not feasible by two studies [12, 13]. Those delivering treatments were blinded in only one study . True blinding of outcome assessors did not occur in the four studies.
The findings synthesised into three categories, appendix 4 presents an overview of the study characteristics.
Adherence to PFMT using a mobile application and perceived value of using a mobile application
Data from four studies contributed to this finding [10,11,12,13]. The four studies determined the success of adherence to PFMT using a mobile application by evaluating self-reported measures, urinary symptoms, app utilisation and self-efficacy. The study by Araujo et al. (2020) reported higher adherence rates in the mobile application group 1-2 months post the onset of the intervention (P < 0.001). One study reported a higher adherence rate in the mobile application group, they report that 41% performed pelvic floor exercises daily and this was vastly different to the control group who recorded a 3.3% adherence rate to daily pelvic floor exercise . A study by Hoffman and colleagues  followed up the original study  and of the 46 women who participated in the follow-up, all 46 women had downloaded and kept the mobile application and 17.4% were still using it 2 years later. Frequent users who intend to use mobile applications on a regular basis, indicated higher PFMT adherence compared to those performing stand-alone exercises … “based on our results women who used it not only exercised more than the other group, based on exercise sections duration but also felt more committed to exercising”(10, p.6). Also, people who used mobile applications in the short term were satisfied about the outcome: “with the present study we have shown the app treatment to be effective in the short term” (11, p.1375). The high-level adherence rate of PFMT using an application resulted in participants suffering less from pelvic floor injury, less bladder neck descent and improved pelvic floor strength: “participants receiving the app-based audio guidance indicated more positive effect to 6 months postpartum” (12,p.7). Patients who used mobile applications to undertake exercise reported positive aspects of the application: “the reminder notes were important to exercise adherence and preferred to continue using the said feature” (10, p.6).
Findings from three studies, [10, 11, 13] contributed to this synthesised finding. QOL measures are an estimation of wellbeing which can be assessed by measuring improvements in areas like healthcare and are based on an individual’s perception and expectations of treatment outcomes. For example, a study by Asklund , considered condition-specific QOL. In this study, the majority of participants in the intervention group (98.4%) were still engaged in the PFMT at follow-up, and 41.0% (25/61) performed PFMT daily. In comparison to the control group, 26.7% reported that they had not performed any PFMT and only 3.3% had performed PFMT daily. Therefore, self-reported QOL was higher in the intervention group compared to the control group, the groups significantly different (P < 0.001) . Improvement in QOL 2 years post intervention was reported in another study, but there was no between the application group and control groups (P = 0.003) . It is also reported that application group maintained the results of PMFT (P < 0.001) for a longer time which reflected on the improvements of their QOL . The use of incontinence protection products reduced and almost 67% of participants reported that their leakage improved, and they used less incontinence protection products . Discovering long term benefits of PFMT delivered via an app is an area for further study where to date the research has … “yielded promising long-term results in terms of a condition that can severely affect QOL” [13, p.1185].
Findings from three studies [10,11,12] contributed to the synthesised finding of symptom improvement. Symptom reduction measured by validated assessment tools and methods provides valuable data and true insight into the condition “people experience greater improvement in symptom severity with a mean reduction in ICIQ scores” (11,p. 1372) and “we found that PFMT improves symptoms of UI, according to validated questionnaires” (10,p.6). Furthermore, the cost and burden associated with continence aids is high and patients frequently ask during consultation when they will be able to cease using pads . “Outcome measurements at follow-up determined 56% of the app group as no leakage or>50% fewer leakage episodes than at baseline” (11,p. 1372). Physically, a strong pelvic floor can improve and maintain continence as well as delay surgical intervention and the associated risks of major surgery . Pelvic floor strength and less bladder neck descent has been noted in frequent users of mobile applications for pelvic floor muscle training: “participants had significant improvements in symptom severity after 3 months” (12, p.5), reiterating the practicality of an accessible PFMT program and the importance of conservative management of UI.