A Guide for Urogynecologic Patient Care Utilizing Telemedicine During the COVID-19 Pandemic: Review of Existing Evidence - Beyond the Abstract

As the COVID-19 pandemic evolves, we have determined evidence-based guidance for the care of women at female pelvic medicine and reconstructive surgery (FPMRS) practices. With certain medical conditions, past literature, and/or national and international guidelines exist that guided the care of patients when they could not be seen in person. While with other conditions, the management of FPMRS patients was similar to standard management with an emphasis on non-surgical or non-procedural management. We hypothesized that adequate literature existed to guide FPMRS practice while avoiding or minimizing patient contact to decrease the risk of viral spread. For topics with inadequate literature, our team developed expert consensus guidelines.

Our group utilized rapid systematic review methodology to screen for articles related to four topics (1) telemedicine in FPMRS; (2) pessary management; (3) urinary tract infections; and (4) urinary retention. We additionally addressed four other topics based on past systematic reviews and national or international society guidelines: (1) urinary incontinence, (2) vaginal prolapse, (3) fecal incontinence, and (4) defecatory dysfunction. We pooled clinical experience and expertise to reach consensus on four remaining areas: (1) management of FPMRS patients in the virtual setting, (2) scenarios requiring in-person visits, (3) symptoms that should alert providers to COVID-infection, and (4) special consideration for management of patients with known or suspected COVID-19 disease. The following includes the results of the rapid review and outlined expert consensus.

Virtual visits:
  • Virtual visits present similar levels of satisfaction to in-person visits, and build patient-provider relationships.
  • Patients remote from care or have other barriers to in-person care would be more likely to attend virtual visits of some type.
  • There are many online and society-endorsed resources available to supplement patient counseling in the virtual setting.
Pessary management:
  • Patients can safely extend the interval for in-person pessary care up to six months.
  • Patients should be encouraged to self-clean and self-remove/replace the pessary.
  • Post-menopausal women with a pessary should be encouraged to use vaginal estrogen.
Urinary tract infection:
  • Women with classic symptoms of dysuria, urgency/frequency, or hematuria, should be treated empirically for a urinary tract infection.
  • Empiric antibiotic therapy should be compliant with antibiotic regimens endorsed by the International Guidelines from the Infectious Disease Society of America (IDSA) and the European Society for Microbiology and Infectious Disease (ESMID).
  • Telemedicine visits can be utilized to assess patient risk factors for antibiotic resistance or systemic illness.
  • Antibiotic stewardship, while important, is less of a priority during a pandemic.
  • Patients with signs or symptoms of bacteremia or upper urinary tract infection (high fever, inability to tolerate oral treatment, and altered mental status) should be evaluated in-person and appropriate testing performed.
Urinary retention:
  • Chronic urinary retention (defined as PVR >300 ml for more than 6 months) puts patients at risk of upper urinary tract injury. In these patients, bladder drainage strategies and workup/imaging should be considered.
  • Patients with new signs/symptoms of urinary retention may be initially managed with voiding strategies (e.g. double voiding, voluntary pelvic floor relaxation, and the Credé maneuver).
  • Patients with new-onset of urinary retention symptoms who fail outpatient management strategies should be offered clean intermittent self-catheterization, which is preferable to indwelling catheters.
  • Patients with postoperative urinary retention who need indwelling catheterization can be instructed regarding safe removal of the catheter on postoperative day 7 at home without an office visit.
  • Antibiotic prophylaxis should not be routinely used in women with long-term catheterization.
Urinary incontinence:
  • Recommend conservative management such as avoiding dietary triggers, pelvic floor muscle training, voiding training, and medications (anticholinergics, beta-agonist) for treatment.
  • Patients that have formerly received third-line treatments may revert back to first or second-line treatments during the COVID-19 pandemic to avoid an in-person office visit.
  • Smartphone applications are available for pelvic floor muscle exercises.
Pelvic organ prolapse:
  • Pelvic organ prolapse usually advances slowly, and few women will have notable advancement within two years.
  • Behavioral modifications such as weight loss, smoking cessation, and pelvic floor exercises have proven to relieve symptoms.
  • Place a large tampon or splinting with voiding or bowel movements are simple strategies patients can perform at home to relieve symptoms.
Defecatory dysfunction/fecal incontinence:
  • Dietary changes and fiber supplementation (insoluble fiber) can improve stool consistency and help with stool evacuation. Soluble fiber can help solidify stool which may improve fecal incontinence or diarrhea.
  • Osmotic or stimulant laxatives can help defecatory dysfunction and postoperative constipation.
  • Bowel schedules, tap water enemas, glycerine or bisacodyl suppositories, can help patients to reliably evacuate the rectum and avoid bowel accidents.
  • Position changes by elevating the legs or splinting during bowel movements can improve defecation and complete emptying.
  • Food triggers that cause fecal urgency and incontinence can be identified on food diaries.

COVID-19 considerations and situations:
  • Patients with evidence of severe or urgent postoperative complications should be evaluated in the office.
  • Patients with acute worsening of stress incontinence due to cough and upper respiratory symptoms or acute worsening fecal incontinence due to loose stool should be screened for COVID-19 signs or symptoms.
  • Surgeons should discuss the unique risks of nosocomial COVID-19 infection during the consent process for elective or urgent surgical treatments.
  • Patients with suspected COVID-19 infection should be referred for appropriate testing and precautions taken.
We are pleased that we can provide guidance for FPMRS practitioners during this confusing and difficult time. We used a combination of a rapid systematic review and expert consensus to provide comprehensive guidelines. The strengths of this review include our use of an expedited review method, the team's extensive experience conducting systematic reviews, as well as seasoned FPMRS practitioners. Limitations of this review included the rapid methodology and lack of data regarding many of the pertinent questions.

With rapid changing national guidelines regarding patient care during a pandemic there are many unknowns of how this will affect our FPMRS patients. These recommendations provide guidance on how to manage and care for FPMRS patients while utilizing telemedicine and prudently triaging patients to decrease unnecessary exposure.

Written by: Kate V. Meriwether, MD1; Cara L. Grimes, MD, MAS2; Ladin A. Yurteri-Kaplan, MD, MS3

  1. Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico
  2. Departments of Obstetrics and Gynecology and Urology, New York Medical College, Valhalla, New York
  3. Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
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