App shows promise in managing lower urinary tract symptoms

A recent study published in NEJM Evidence investigated the impact of conservative management, specifically an app-based therapeutic, on lower urinary tract symptoms (LUTS) in men.¹ The 12-week randomized controlled trial involved more than 200 men with LUTS, who were randomly assigned to an intervention group using the app in addition to their usual medication, or a control group maintaining their regular medication.

The app incorporates various modules focusing on physiotherapy, lifestyle adjustments, and other resources aimed at enhancing patient motivation and adherence. It also includes a game that can be played to defer the urge to void. The primary outcome, the International Prostate Symptom Score (IPSS), showed a significant 8-point reduction in the intervention group, whereas no change was observed in the control group. The study also reported significant improvements in overactive bladder symptoms and overall quality of life in the group using the app. Although the individual contribution of each app

Christian Gratzke, MD

component wasn't specifically measured, study author Christian Gratzke, MD, said he believes physiotherapy to be a particularly strong element. “We concluded that by using this app, in addition to the patient's usual medication, it is possible to improve [LUTS] by only looking at conservative measurements,” Gratzke said. In the following interview, Gratzke discusses the study and highlights the app’s utility. Gratzke is professor and chair of urology at the Albert-Ludwigs-University in Freiburg, Germany.

Please provide an overview of this study and its notable findings.

The idea was to look at the improvement of conservative measurements that we do in men with [LUTS]. As you know, we have conservative options, we have medical options, and invasive options. In this trial, we were particularly interested in doing the less invasive treatment options that are all recommended by all the guidelines—by the AUA [American Urological Association], by the EAU [European Association of Urology]. We constructed a randomized controlled trial for 12 weeks where we looked at the improvement of [LUTS] as measured by the IPSS and also overactive bladder as measured by the OAB-q. We did this by using an app. We had more than 200 patients [who were randomly assigned into] 2 groups: an intervention group and a control group. Patients [in the intervention group] were asked to follow the instructions of the app, in addition to the treatment they were already given, and [those in] the control group were just kept on their usual medication.

The app is made up of various modules, which consist of physiotherapy, lifestyle modification, and other modules that reinforced the patient’s motivation to carry on with the app, so it adapted to the individual needs of those patients. We showed in the trial that in the intervention group, the improvement of LUTS was significant as measured by the IPSS. There was a reduction of 8 points, whereas there was no change in the control group, which was an important validation of this study. There was also a significant improvement in overactive bladder symptoms and quality of life. We concluded that by using this app, in addition to the patient's usual medication, it is possible to improve [LUTS] by only looking at conservative measurements.

The study demonstrated a statistically significant improvement in IPSS with app-based therapeutics. Could you elaborate on the specific components of the app-based therapy that you believe contributed most to this improvement? What specific exercises or educational components were included?

We don't know which module was the most important one, because we didn't measure that. We just looked at the whole program, but we will do step analysis and look at individual modules and how much each of them contributed to the improvement of the symptoms. I personally believe that the physiotherapy component is a very strong [part], because, as we know, female patients use physiotherapy all the time, and it improves the pelvic floor, whereas in male patients, we neglect this. I think this study might be a good basis to recommend more physiotherapy. It is a conservative measurement. You have very few [adverse events], if any, and this is a very strong component that contributes to the improvement of LUTS. There's also a knowledge section that provides information on reducing fluid intake at night. It elucidates what [LUTS] actually are. It looks at the anatomy of the prostate. It explains what incontinence actually is, and you get pieces of information every day and every week for those 12 weeks. There is also a stop urge button, which, if you experience a significant urge, you press this button, and then you play a little game, which should defer the desire to void.

The minimal clinically important difference for IPSS is 3 points. The intervention group demonstrated a LSM of -7.0 points. How does this translate to clinically meaningful improvement in your opinion, and how does this compare to other standard LUTS treatments?

For anyone working in the BPH [benign prostatic hyperplasia]/LUTS space, you would expect for anything to work to be in the 3-, 4-point difference when you look at the IPSS. If you have less than that, it's usually not clinically meaningful. By having a 7- or 8-point improvement, that would actually show a clinically substantial improvement in LUTS. If you compare this to gold standard medication—tamsulosin [Flomax], alpha blockers—if you look at what you get by doing a minimally invasive treatment option such as UroLift or iTind, by using this app for 12 weeks, you do achieve a significant improvement. So, compared to what you usually use as a first step, we believe that it is really worthwhile performing that intervention, because it's only the first step, and we don't do it in the very severely obstructed patients. This is really important. This is in mild and moderately [obstructed] patients where this is the first step. If this works, this is great. It’s also good because the patient really thinks about how to behave. It explores the body. Usually, the patient has very little knowledge about what the prostate is and what those symptoms are, and it might help to actually inform the patient better.

You mentioned that physiotherapeutic approaches are often neglected in LUTS management. How does this app-based therapy aim to bridge the gap between traditional medical care and these conservative treatments, and what are the barriers you see to wider adoption?

Physiotherapy might not be used by a patient simply because it’s not reinforced by the doctor or the nurse. Nurses play a major role here. If physiotherapy is instructed by somebody who's really knowledgeable, then that might work by itself, without using the app. But the app, of course, uses various components. It gives you haptic feedback. It's adaptive to the individual patient's needs, and you can do it wherever you are and wherever you work. Many patients, as you know, travel a lot. [You can use this] app no matter where you are. It's very easy to use, so I think the barriers to using any of those conservative measurements might be overcome by [it]. It highlights why you should be actually using the individual components, because physiotherapy is also divided into various components, [such as] the strength component and the endurance component. It highlights why each of those components is important.

Given the app-based nature of the intervention, what are your recommendations for health care professionals in terms of integrating this type of therapy into their clinical practice, and what are the training requirements for patients to use it effectively?

I believe that if you look at a certain algorithm that a urologist would hand out to a patient, this might provide the first step in this algorithm. So, before going into any interventions, whether they are medical or surgical interventions, you might be able to use this app in a meaningful fashion. The training requirements are really minimal. It is very easy to use. It is self-explanatory, so I would give it a go. If I were the urologist, there's nothing to lose. Worst-case scenario, it doesn't help, but the threshold to use it is very low.

REFERENCE

1. Gratzke C, Schönburg S, Eger S, et al. A randomized trial of an app-based therapeutic for lower urinary tract symptoms. NEJM Evid. 2025;4(4):EVIDoa2400290. doi:10.1056/EVIDoa2400290