Research waste has become a great concern in recent years, affecting a significant proportion of primary research studies due to a lack of comparability and overall quality. Given that systematic reviews and meta-analyses are not only dependent on these primary studies but are also essential for medical guidelines, poor quality primary studies could thus produce a significant negative impact on patient health. A method for improving the quality of primary studies would be by the development of core outcome sets (COS). Furthermore, qualitative studies provide valuable perspectives and insights into the process COS development (1). The CHORUS methodology for the development of core outcome sets in various areas of pelvic floor research and practice includes analysis of both quantitative and qualitative studies. 
This study aimed to perform a meta-synthesis of primary qualitative studies, analyse perspectives of Overactive bladder (OAB) management and complete a quality assessment using the Critical Appraisal Skills Program (CASP) checklist. Insights from thematic synthesis can then be used for Core Outcome Set development.

This study utilised a qualitative meta-synthesis model as advised by the ENTREQ (enhancing transparency in reporting the synthesis of thematic research) criteria. The central design for the study was based on the thematic synthesis method developed by Thomas and Harden (2). Following the ENTREQ criteria (3), the following crucial steps were stated and followed: inclusion and exclusion criteria, literature search and paper selection, bias assessment, analysis of papers using coding and collation of codes, construction of descriptive themes from codes, inference of meta-themes from descriptive themes and conducting final synthesis. This meta-synthesis was in line with the PRISMA checklist for reporting systematic reviews and meta-analyses.
Included studies had to utilise qualitative methodology, include women’s views of OAB management and be written in English language. Excluded studies utilised quantitative or mixed methodology, focused on the impact of OAB solely (i.e., without reference to management) and studies including only men. The search strategy consisted of a systematic review of qualitative studies identified from MEDLINE, EMBASE, PsycInfo and Cochrane databases from inception to December 2020. The most recent search was conducted in April 2021. Bias assessment was completed by two researchers independently using the CASP tool. The results of the literature search and consequent screening are shown in Figure 1. This meta-synthesis used Microsoft Excel for data extraction and code collation. Separate sheets were used for the formation of descriptive themes from related codes and synthesis of meta-themes.

Eight qualitative studies were analysed, covering the experience of a total of 197 female patients aged 28-91 from the UK, US and Hong Kong. All eight studies were quality assessed by two researchers independently using the Critical Appraisal Skills Programme (CASP) tool. 50% of studies passed all ten criteria, with the rest achieving a score of at least seven out of ten. Coding yielded 56 codes which were then grouped into 14 descriptive themes. From these descriptive themes, six meta-themes were constructed: ‘Communication’, ‘Transparency’, ‘Focus’, ‘Embarrassment’, ‘Control’ and ‘Desperation. The meta-themes and their constitutive descriptive themes are shown in a bubble diagram depicted in Figure 2, which indicates the prevalence of the meta-theme within the eight studies by the size of the bubble as well as by the number in brackets. The most prevalent theme was ‘Desperation’, which was indicated in all eight studies.

Taking into account to two most prevalent meta-themes, ‘Desperation’ and ‘Control’, one is able to depict the major struggle faced by women with OAB: coping with the inability to control a vital life function whilst dealing with inefficacious medication. The root issue that underpinned the meta-theme of ‘Desperation’ was the general sense of despair that accompanied OAB. This despair arose from any of the symptoms of OAB syndrome: whether damage to self-esteem from urinary incontinence, or loss of sleep from nocturia that threatened psychological wellbeing and productivity. Furthermore, the meta-theme of ‘Control’ was concerned with the loss agency suffered by the patient to OAB: travel was restricted to known locations with toilets; attire had to accommodate the chance of incontinence episodes; and abstinence from social gatherings were the norm in order to try and avoid public embarrassment. 
Embarrassment and the anxiety of potential embarrassment were major constituents of the meta-theme of ‘Sensitivity’, which conveyed the holistic impact of OAB. Whether in consultation, social gatherings or among family, OAB patients felt pressure from everywhere and everyone and were keenly sensitive to any possibility of leakage. Furthermore, sensitivity is not restricted to the bearer of the syndrome but to their immediate family members and spouses. It has been shown that the anxiety adopted by OAB patients was further borne by close relations, who feel the need to help in the search for bathrooms; and who feel distress at the OAB patient’s embarrassment. 
Desperation, embarrassment and the loss of control were exacerbated by the ineffective clinician-patient interactions that were critical to the meta-themes of ‘Communication’, ‘Transparency’ and ‘Focus’. Where Communication concerned the lack of effective engagement and the conveyance of engagement exhibited by the clinician, Transparency concerned the amount of information about OAB that clinicians explained to patients. The lack of effective communication and transparency resulted in treatment regimens not being reflective of patient wishes nor directed at aspects of OAB that patients felt were most pressing; this gave rise to the meta-theme of Focus. Taken together, these three meta-themes stress the importance for clinicians, when treating a syndrome associated with significant desperation, to ensure that their approach is clear, informative and reflective of patient concerns.

This meta-synthesis is the first of its kind for qualitative studies on OAB management, and is limited by the paucity of qualitative research into the area. The primary qualitative studies on OAB met most of the quality criteria. These six meta-themes present pertinent issues from women’s perspectives and indicate that the biggest challenge to women suffering from OAB is desperation due to OAB symptoms. Therefore, it would be prudent for clinicians to ensure that OAB management addresses desperation in patients and reflects patient concerns. To actualise this, more qualitative research is needed into OAB and OAB management. Furthermore, these six meta-themes should also be considered during the development of COS, in order to ensure core outcomes are in line with patient perspectives.

Kirkham JJ, Davis K, Altman DG, Blazeby JM, Clarke M, Tunis S, et al. Core Outcome Set-STAndards for Development: The COS-STAD recommendations. PLOS Med [Internet]. 2017;14(11):e1002447. Available from: https://dx.plos.org/10.1371/journal.pmed.1002447
Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8.
Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012;12.