Expanding Access to Behavioral Treatments for Urinary Incontinence in Women Veterans Through Mobile Health Innovation
In the study “Remote Access to Urinary Incontinence Treatments for Women Veterans,” researchers explored innovative ways to expand access to behavioral therapies for urinary incontinence (UI) using mobile health technology. In this interview, Alayne D. Markland, DO, MSc, a geriatrician and investigator with the US Department of Veterans Affairs (VA) and the University of Utah, discusses the promising results of the MyHealtheBladder app, the importance of early symptom improvement, and how digital tools can help bridge critical gaps in UI care for women veterans.
Please introduce yourself by stating your name, your title, your organization, and relevant professional experience.
Alayne D. Markland, DO, MSc: My name is Alayne Markland, and I am a geriatrician by training. I have been a VA investigator for the past 20 years. I wear a few hats—I recently moved, after 20 years, from the University of Alabama at Birmingham and the Birmingham Atlanta Geriatric Research, Education, and Clinical Center at the Birmingham VA, to a new role here in Salt Lake City. I’m now an investigator in the Salt Lake City Geriatric Research, Education, and Clinical Center, a professor of internal medicine, and the Chief of Geriatrics at the University of Utah. I also serve as director of our Center on Aging.
More importantly, I’ve spent my career—specifically the last 20 years—trying to find better ways to both understand and treat urinary incontinence among women and men. This study is one of my favorite projects because it takes an important behavioral intervention and increases access to care, which is a key goal of mine from a health systems perspective.
Your study found that women using the MyHealtheBladder app achieved meaningful symptom improvement within four weeks. How should clinicians interpret this rapid improvement with mobile health interventions? Could early gains translate into better long-term adherence or quality of life outcomes for veterans?
Dr Markland: We view that four-week point as an interesting time point. Traditionally, it takes at least six to eight weeks to see change with behavioral treatment for urinary incontinence, which usually involves several components, including pelvic floor muscle exercises. So, we were very excited to see early change at four weeks. I think this period—four to six weeks—is a reasonable timeframe for improvement if someone is dedicated to the program. That’s where the mobile health app comes in. It’s designed as a daily engagement tool, with check-ins, reminders, and adherence prompts to help women stay on track. These frequent touchpoints are essential for behavioral interventions, and it was encouraging to see results at four weeks.
In contrast, even the best clinical encounters—whether in person or via video—are often just one-time touchpoints, which may not be enough. The mobile app’s ongoing engagement may lead to better adherence over time. When users experience early gains, they’re more likely to stick with the exercises, and we did see improvements in quality of life over the longer term. Although we didn’t collect adherence data outside the app, the findings were promising.
At 12 weeks, both the mobile app and video visit groups experienced improvement, though differences were modest. From a clinical practice standpoint, how do you view the relative advantages and limitations of app-based vs video-delivered behavioral therapy for urinary incontinence in veterans?
Dr Markland: We heard from many women that they appreciated the app’s flexibility—it’s truly a self-management program. They could engage with it on their own time, outside a clinical setting. The biggest advantage is accessibility; they didn’t have to coordinate with a provider. Video visits, while still remote, are limited by scheduling logistics, both for the provider and the patient. That can introduce steps, even if minor ones. The app removes those barriers, allowing users to engage whenever it’s convenient.
The booster video visit did not significantly enhance outcomes among non-responders. Were you surprised by the lack of additional benefit? What does this suggest about how clinicians should structure follow-up for patients who don’t initially respond?
Dr Markland: Yes, we were very surprised. We had expected booster visits to be an important component of the trial, given that not all women respond to behavioral therapy. We scheduled the booster at eight weeks, thinking it would help sustain or enhance progress. Interestingly, women who didn’t respond to the initial behavioral treatment had a lower symptom burden than expected. I thought it would be the opposite. This finding suggests we need to look more closely at non-responders’ characteristics. It could be that women with milder symptoms have a higher bar for improvement; they want to go from “some” symptoms to “none,” which might be harder to achieve. We’re still analyzing the data to understand this better, and it’s too early to make definitive clinical recommendations about follow-up.
The trial underscores the need to improve access to behavioral UI treatments, especially within the VA system. What are the key barriers to accessing in-person behavioral therapy for UI among women veterans, and how might digital tools help bridge those gaps?
Dr Markland: That’s an excellent question. Across healthcare systems—not just within the VA—access to experts trained in behavioral treatments for urinary incontinence is limited. However, within the VA, there has been a substantial increase in the number of pelvic floor physical therapists and other specialized providers. Despite this, access barriers remain. Geography plays a big role; many veterans live far from centers offering these services, especially in rural areas. For women, additional challenges include family and work constraints, making it hard to take time for appointments. Mobile health apps can help overcome these barriers by providing accessible, evidence-based behavioral treatment. They can also serve as an interim solution—allowing veterans to start treatment while waiting for an in-person or specialty appointment.
How could these remote modalities be adapted for broader patient populations, such as older adults or those outside the VA? What future studies are most needed to validate these approaches?
Dr Markland: Our team is actively exploring that. While this particular app was developed by and for veterans, we’re now working on adaptations for men within the VA and for non-veteran populations. We’re piloting a new version outside the VA and refining it based on feedback. We’ve also received funding to translate the app into Spanish and Chinese, and we’re updating the platform to include new features and improved navigation. We’re very excited about launching both VA and non-VA versions across multiple centers in the coming year.
