With the growing use of technology by patients in managing their health, it becomes increasingly important to evaluate mobile health applications (apps) that patients use for credibility, accuracy, and utility. The aims of this study are to evaluate applications designed for Pelvic Organ Prolapse (POP) and Stress Urinary Incontinence (SUI) using the Xcertia guidelines for medical app quality, as well as to analyze user sentiment of the apps.

Mobile medical apps were found on the Apple App Store with keywords “pelvic organ prolapse,” “incontinence,” or “bladder.” Exclusion criteria included apps that were not free or were not updated in the past year. Apps were evaluated along the Xcertia Guidelines, categories including app Operability, Privacy, Security, Content, and Usability. The number of ratings and reviews on the Apple App Store were collected for each app and a sentiment analysis of reviews was conducted. A positive review contained only positive feedback, a negative review contained only negative feedback, and a neutral review contained both positive and negative feedback.

From the Apple App Store, a total of 27 mobile medical apps were found and 8 apps met inclusion criteria. Based on Xcertia guidelines, all apps had simple and problem-free download/launch, visuals, and usability (Table 2). None of these apps required input of personal identifying information and none were linked to the EHR in any way. The content of the apps varied in that 62.5% of the included apps incorporated an educational or informational component. Further, only 37.5% of the apps clearly delineated the sources for their information, while the others had no way to verify the validity of the content. PRIVY-US Urinary Health and Tat: Pelvic Floor Muscle Exercises incorporated questionnaires for evaluating the degree of urinary incontinence, however only PRIVY-US Urinary Health provided users with interpretations for the results. 50% of the apps had the option of purchasing an upgrade to access additional features. 

The average number of reviews among the 8 apps was 124.8, with an average of 118.5 positive reviews, 2.6 negative reviews, and 3.8 neutral reviews. Sentiment analysis showed that 5 apps had majority positive sentiment (Table 1). The percentage of positive reviews was 96% for Easy Kegel out of 225 reviews, 80% for Kegel Nation out of 5 reviews, 96% for Kegel Trainer PFM Exercises out of 741 reviews, and 100% for both PRIVY-US Urinary Health and Tat: Pelvic Floor Muscle Exercises, which each had 1 review. Only 1 app, Squeeze Time, had majority negative reviews, with 75% negative out of 4 reviews. Vesica had 50% neutral reviews out of 16 total. Kegel Trainer had equal positive, negative, and neutral sentiment in 6 reviews. Some of the complaints that users brought up in reviews across several apps included crashes, required payment for additional features, and incompatibility with other Apple devices such as the Apple Watch.

The importance of mobile health apps following Xcertia guidelines increases as patient use of mobile based technology is increasing. Apps have little oversight or regulation with the possibility of inaccurate and unreliable information being passed on to users. The quality of content in our analysis was variable. Some apps did not have any informational component and were simply instructional without explanation, limiting their utility. The incorporation of educational elements into apps would help make them well-rounded resources to consider. Additionally, only 38% cited sources from which their content was derived, therefore accuracy of educational content may be limited.

Sentiment analysis of app reviews must be considered with the total number of reviews for each app. While some apps had hundreds of reviews, others had very few, as low as 1 in some cases. There is also volunteer bias where some users may only submit a review when they come across a problem or notice significant improvement with the app. Making sure that the most popular apps are also the ones with the best content is important when considering that new users are more inclined to try apps that are positively reviewed and highly rated. In our analysis, the two highest reviewed apps had nearly almost all positive reviews (96%) for both, indicating that these are well-liked and highly utilized. Similarly, the apps with over 100 ratings had an average rating of 4.4 or higher, supporting that highly used apps are also highly rated.

Most apps were well received by users based on ratings/reviews and met most functional guidelines of Xcertia. However, the quality of the app content varied. Only some of the apps had an informational component, and even less had sources listed. This brings the credibility of some apps into question and leaves physicians and patients unable to verify the educational information. Optimal apps should include accurate, useful educational content with sources cited and meeting functional guidelines. Providers considering recommendation of health apps to patients should highly consider those that meet Xcertia guidelines, have an educational component, list their sources, and do not require payment for features. For future studies, evaluation of the quality of app educational content and evaluation of mobile health apps available through other platforms is encouraged.