Abstract
Introduction and hypothesis
The coronavirus (COVID-19) pandemic has impacted health systems worldwide. There is a continuing need for clinicians to adapt practice to facilitate timely provision of medical care, whilst minimising horizontal transmission. Guidance and recommendations are increasingly available, and this rapid review aimed to provide a timely evidence synthesis on the current recommendations surrounding urogynaecological care.
Methods
We performed a literature review using PubMed/Medline, Embase and Cochrane and a manual search of national and international societies for management recommendations for urogynaecological patients during the COVID-19 pandemic.
Results
Nine guidance documents and 17 articles, including 10 reviews, were included. Virtual clinics are recommended for new and follow-up patients, to assess and initiate treatment, as well as triage patients who require face-to-face appointments. Outpatient investigations such as urodynamics and cystoscopy for benign indications can be deferred. Prolapse and continence surgery should be suspended, except in specific circumstances such as procidentia with upper tract complications and failed pessaries. There is no evidence to support a particular route of surgery, but recommendations are made to minimise COVID-19 transmission.
Conclusions
Urogynaecological patients face particular challenges owing to inherent vulnerabilities of these populations. Behavioural and medical therapies should be recommended as first line options and initiated via virtual or remote clinics, which are integral to management during the COVID-19 pandemic. Expanding the availability and accessibility of technology will be increasingly required. The majority of outpatient and inpatient procedures can be deferred, but the longer-term effects of such practices are unclear.
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Introduction
Coronavirus (COVID-19) disease caused by the SARS-CoV-2 virus was first declared as a pandemic by the World Health Organization (WHO) on 11 March 2020 [1]. Since then it has continued to rapidly spread worldwide impacting all aspects of life, not least medical care and how clinicians assess and treat patients. Medical providers worldwide have been required to adapt and streamline services to minimise unwarranted, multiple healthcare facility attendances and patient contact where possible, by conducting remote consultations, delaying non-urgent visits and optimising provision of one-stop services.
The urogynaecology scope of practice involves, to a significant proportion, care and management of elderly and vulnerable patients and therefore these measures are of particular importance. As the pandemic continues, national and international societies and organisations have published guidance for management mainly based on consensus and expert advice given that evidence base to support recommendations is still scarce [2,3,4,5].
Rapid reviews are a method of knowledge or evidence synthesis [6] to produce information in a more timely manner than traditional systematic reviews [7]; therefore, they are particularly useful for new and emerging topics. Rapid reviews involve an expedited process with omission of certain steps usually performed in a systematic review.
Given the rapid evolution of evidence, recommendations, policies and clinical management adaptations, a rapid review on the current evidence and recommendations is highly warranted. Since the COVID-19 pandemic was declared, several publications have appeared providing narrative reviews in order to bring all the relevant information from the guidelines together in one document, to support patient care [8,9,10]. These studies summarise and review published guidelines, original studies, consensus statements, opinions and comments in peer-reviewed journals, and professional organisations and societies.
The aim of this rapid review is to systematically review and evaluate the available evidence from published research, as well as to collate guidelines and recommendations in order to provide guidance on the management of urogynaecological conditions and clinical practices in response to the COVID-19 pandemic. This review has been undertaken by CHORUS, An International Collaboration for Harmonising Outcomes, Research and Standards in Urogynaecology and Women’s Health (i-chorus.org).
Materials and methods
We performed a literature review using the OvidSP search platform and interrogating through this the databases PubMed/Medline, Embase and Cochrane using keywords and MeSH terms including: COVID-19, SARS-CoV-2, coronavirus, incontinence, pelvic organ prolapse, vaginal prolapse, uterine prolapse, cystocele, rectocele, bladder pain, childbirth trauma, perineal trauma, perineal laceration, urogynaecology, urogynecology, overactive bladder (OAB), recurrent cystitis, recurrent urinary tract infections (UTIs); (Appendix 1).
Literature searches were conducted from 1 January to 22 September 2020. We searched the references of the relevant studies manually using the backward snowballing method [11] in order to identify additional eligible references and studies. In addition, a manual search was conducted of national and international specialist societies and organisations in order to identify practice guidance. We searched the websites of the International Urogynecological Association (IUGA), International Continence Society (ICS), European Association of Urology (EAU), British Society of Urogynaecology (BSUG), Royal College of Obstetricians and Gynaecologists (RCOG), Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), American Urological Association (AUA), American Urogynecologic Society (AUGS), Asia-Pacific Urogynecology Association (APUGA), Urogynecologist Asia (UG-Asia), Urological Association of Asia (UAA), South African Urogynaecological Association (SAUGA) and Pan African Urological Association (PAUSA). The latest version of guidelines was used in cases where more than one guideline or update was available. The final decision about the inclusion of guidelines and published articles was based on authors’ consensus.
All searches were restricted to English-language publications or those with the facility to translate to English, guidelines and best-practice statements. We did not exclude original articles, comments or perspectives. Inclusion criteria were the presence in the articles of guidance or practical advice for the management of urogynaecology patients during the COVID-19 pandemic.
Exclusion criteria were non-English-language articles with translation not readily available, guidelines unavailable to the public in full text, not involving urogynaecology care or not involving urogynaecology care during the COVID-19 pandemic.
Study selection was conducted in stages. Following title screening, the abstracts of all articles in the database were examined. Two reviewers scrutinised the full text of each article and evaluated the studies potentially eligible for inclusion against the inclusion criteria. Discrepancies regarding inclusion or exclusion were resolved through discussion.
Ethical approval was not required for this review. One reviewer extracted relevant data from all eligible articles. The content of each guideline or article was tabulated including the title of the guidance or article, issuing association or journal, and date of publication.
The quality of guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument [12] and the quality of reviews assessed using Scale for the Assessment of Narrative Review Articles (SANRA) [13].
Results
Nine guidance documents and 17 articles, 10 of which are reviews, were included (Fig. 1; Table 1).
Quality assessment of guidelines was performed using Appraisal of Guidelines for Research and Evaluation II instrument (AGREEII). Overall assessment scores are shown in Table 1 (1 lowest quality to 7 highest quality). See Appendix 2 for individual domain scores.
Review articles were assessed using the Scale for the Assessment of Narrative Review Articles (SANRA) with a maximum score of 12. See Appendix 3 for the full SANRA scale.
Recommendations
All 12 articles and guidelines that included outpatient clinic recommendations stated that virtual clinics should be used to minimise horizontal transmission. Virtual clinics can be used for all non-urgent indications such as urinary incontinence and prolapse, and for both initial consultations and follow-up appointments. Patient satisfaction is unaffected and clinic attendance may be increased owing to a reduction in non-attendance [19]. When used for postoperative follow-up there is no increase in adverse outcomes [19]. For patients awaiting surgery, virtual clinics can be conducted to rediscuss alternative therapies.
During virtual clinics, patients can be triaged and limited face-to-face appointments arranged if necessary. When seen face to face, appropriate screening should be undertaken, personal protective equipment (PPE) worn, physical distance maintained, and sanitation available [31].
It has been reported that COVID-19 transmission could be as high as 12.8% at a physical distance of less than 1 m compared with 2.6% at a distance of more than 1 m, reflecting the importance of maintaining physical distance [34].
In keeping with these findings, the Scientific Advisory Group for Emergencies (SAGE), who provide scientific and technical advice to support government decision makers in the UK, reported that COVID-19 transmission could be 2-10 times higher at a physical distance of 1 m compared with 2 m [35]. See Table 2 for a summary of guidance for virtual clinics and inpatient admissions.
Of 15 articles and guidelines providing recommendations regarding the management of urinary incontinence and OAB, 12 advise behavioural therapies as the first line.
Two recommend use of smart phone apps to supplement education, for example, for Kegel exercises [19, 26]. Suspension of invasive therapies for urinary incontinence is advised, except where stage 1 sacral neuromodulation is in place or in cases of neurogenic bladder with a high risk of upper renal tract complications [33]. Pelvic floor muscle training is recommended as the first-line for symptomatic prolapse [16, 17, 19, 23, 26]; however, in one editorial, suspension of pelvic floor muscle training is suggested to maintain physical distancing [36].
Use of pessaries is recommended, whilst prolapse surgery is deferred [16, 26, 36], and the pessary change interval can be extended by 3–6 months unless the patient has symptoms of ulceration or fistulation [3, 24, 27]. See Table 3 for a summary of guidance for urinary incontinence and prolapse.
Acute retention or a blocked catheter warrants urgent review for catheterisation [20].
If an indwelling catheter is in situ, routine changes can be deferred for 2–4 weeks, unless the patient has a history of difficult changes or recurrent UTIs [24]. Deferring suprapubic catheter changes [3, 20] for up to 3 months has been suggested and changes in the community rather than in the hospital setting are preferred [3, 36].
Urinary tract infections can be managed via virtual consultation [17, 19, 23, 25]. If the patient has recurrent UTIs conservative measures and non-antibiotic therapies should be encouraged [17]. If antibiotics are required, they should be prescribed according to previous culture results. Face-to-face review should be arranged if the patient has complicated UTI or is refractory to treatment [19]. See Table 4 for a summary of voiding dysfunction and urinary tract infection.
Gross haematuria requires urgent investigation with cystoscopy; however, microscopic haematuria investigations can be deferred. A systematic review of telemedicine in urology, however, reported that data indicate that virtual clinics for initial evaluation are feasible, effective, and associated with a high degree of patient satisfaction [23].
Bladder pain syndrome investigations should be deferred, but oral treatments can be started [5, 28].
Fourteen articles reported recommendations for outpatient procedures, including cystoscopy, intravesical Botox and urodynamics. All urodynamics and cystoscopy for benign indications should be deferred. See Table 5 for a summary of guidance for haematuria, bladder pain syndrome and outpatient procedures.
Recommendations regarding surgery advise regional or local anaesthesia where possible, in order to reduce aerosol generation with general anaesthesia [2, 19, 25, 28]. Screening for COVID-19 symptoms and testing preoperatively is advised, as evidence has shown poorer surgical outcomes for asymptomatic COVID-19 patients, therefore surgery may worsen or accelerate progression [2, 4, 5, 8, 14, 21, 28, 30]
Although better able to maintain physical distance and potentially shorter hospital stays with laparoscopic surgery than with open surgery [8], no evidence is available to support a specific route of surgery; therefore, this is at the surgeon’s discretion [5, 20].
Recommendations to reduce horizontal transmission in surgery include having essential staff only in theatre, low electrocautery settings, closed smoke evacuation and minimising blood and fluid droplet spray [4, 5, 8, 14, 16, 20, 27, 28]. See Table 6 for a summary of guidance for elective surgery and techniques to minimise horizontal transmission.
Continuing or restarting surgery during the pandemic requires prioritisation of cases, taking into account the severity of the pathology, patient comorbidities and the impact on physical and mental health and quality of life. Seven documents specified prioritisation guidance. See Table 7 for a summary of the prioritisation of surgery.
Strengths
We followed a standardised rapid review methodology in order to provide a summary of recommendations and practice guidelines in a timely manner. We performed a comprehensive literature search including published articles, articles in press and association guidelines to ensure that we identified and included all available evidence regarding management of urogynaecology patients during the COVID-19 pandemic.
There is a high degree of consensus regarding the use of virtual clinics, management outpatient procedures, and surgical techniques to minimise horizontal transmission of COVID-19.
However, variations in recommendations exist and are summarised in this review. Therefore, it can be used as a resource to support adjustments in practice as local conditions evolve.
As further evidence emerges, resources change and the pandemic continues, this synthesis of available guidance can be used as a reference for clinicians to guide management.
Limitations
Given the aim to issue a summary without delay using rapid review methodology, some studies may have been omitted, which is an inherent limitation of rapid reviews. There is susceptibility to bias in streamlining a systematic review process, for example, in choosing studies for inclusion or exclusion and in data extraction, as fewer independent reviewers conduct each step.
Recommendations are predominantly based on expert opinion and, given the rapidly evolving nature of the COVID-19 virus, there is often a lack of robust scientific evidence [8] for clinically relevant questions.
Indeed, the COVID-19 “infodemic” has been described by WHO as an “overabundance of information—some accurate and some not—that occurs during an epidemic” [37].
This is an inherent limitation of all reviews in this area given the unprecedented public health crisis and the epidemiological characteristics of the current pandemic.
As the COVID-19 pandemic continues, and our understanding and resources change, there is high potential for modifications within recommendations and publication of further guidance, which may have already occurred during publication of this rapid review.
Conclusion
The COVID-19 pandemic has changed the way in which we conduct healthcare and will do so for the foreseeable future. Evidence suggests that a large proportion of urogynaecological conditions might be able to be managed using virtual consultations utilising behavioural measures, lifestyle changes and medical therapy. Outpatient procedures in one-stop clinics to investigate and treat conditions such as refractory OAB can be maximised to avoid inpatient admissions, and to reduce the frequency of visits and the use of general anaesthesia.
Technology is required to maintain and develop the quality of virtual consultations and this is particularly important for remote teaching of clean intermittent self-catheterisation, home trial without catheter, pessary management and triaging symptoms. For those unable to use or without access to the required technology, smaller ad hoc face-to-face clinics with PPE and physical distancing should be considered.
Various healthcare providers and organisations have developed and published guidance for practice, which should always be observed, as it is linked and adapted to local policies, sociodemographic and epidemiological conditions, as well as infrastructures. This review is aimed at providing a wider perspective on practice recommendations that have been published to date and can be adapted or even considered for implementation at local levels.
Although adaptations and provisions are being made to manage urogynaecological conditions, given that the majority of patients are elderly with comorbidities that increase risk of COVID-19 morbidity and mortality, and with most surgical procedures for quality of life, the resumption of elective activity is expected to be slow. Consequently, there is likely to be a significant impact on quality of life within this cohort of patients and the impact of delayed diagnosis and treatment on the trajectory of the disease is yet to be determined.
References
World Health Organisation Virtual press conference on COVID-19. 2020.
Joint RCOG/BSGE Statement on gynaecological endoscopy during the COVID-19 pandemic. 2020.
Jha S, Pradhan A. BSUG guidance on management of urogynaecological conditions and vaginal pessary use during the Covid 19 pandemic. https://www.rcog.org.uk/globalassets/documents/guidelines/2020-04-09-bsug-guidance-on-management-of-urogynaecological-conditions-and-vaginal-pessary-use-during-the-covid-19-pandemic.pdf. 2020.
Joint statement on minimally invasive gynecologic surgery during the COVID-19 pandemic—general—news | AUGS. Accessed 4 October 2020. Available from: https://www.augs.org/joint-statement-on-minimally-invasive-gynecologic-surgery-during-the-covid-19-pandemic
Ribal MJ, Cornford P, Briganti A, Knoll T, Gravas S, Babjuk M, et al. European Association of Urology Guidelines Office Rapid Reaction Group: an organisation-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era. Eur Urol 2020;78(1):21–8.
Garritty C, Gartlehner G, Nussbaumer-Streit B, King VJ, Hamel C, Kamel C, et al. Cochrane Rapid Reviews Methods Group offers evidence-informed guidance to conduct rapid reviews. J Clin Epidemiol. 2020;130:13–22. https://doi.org/10.1016/j.jclinepi.2020.10.007
Tricco AC, Antony J, Zarin W, Strifler L, Ghassemi M, Ivory J, et al. A scoping review of rapid review methods. BMC Med. 2015;13(1):224. https://doi.org/10.1186/s12916-015-0465-6.
Uwins C, Bhandoria GP, Shylasree TS, Butler-Manuel S, Ellis P, Chatterjee J, et al. COVID-19 and gynecological cancer: a review of the published guidelines. Int J Gynecol Cancer. 2020;30(9):1424–33.
Hasanzadeh M, Azad A, Farazestanian M, Mousavi SL. Covid-19: what is the best approach in gynecological oncology patient management during the coronavirus pandemic? Asia Pac J Clin Oncol. 2020. https://doi.org/10.1111/ajco.13476.
De Leeuw RA, Burger NB, Ceccaroni M, Zhang J, Tuynman J, Mabrouk M, et al. COVID-19 and laparoscopic surgery: scoping review of current literature and local expertise. JMIR Public Health Surveill. 2020;6(2):e18928. https://doi.org/10.2196/18928
Wohlin C. Guidelines for snowballing in systematic literature studies and a replication in software engineering. ACM International Conference Proceeding Series. 2014. https://doi.org/10.1145/2601248.2601268
Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: Advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839–42.
Baethge C, Goldbeck-Wood S, Mertens S. SANRA—a scale for the quality assessment of narrative review articles. Res Integr Peer Rev. 2019;4(1):5.
Ficarra V, Novara G, Abrate A, Bartoletti R, Crestani A, de Nunzio C, et al. Urology practice during the COViD-19 pandemic. Minerva Urol Nefrol. 2020;72(3):369–75.
RANZCOG. COVID-19: outpatient services; office consultations and procedures. Available from: https://ranzcog.edu.au/news/covid-19-outpatient-services;-office-consultation. Accessed 4 October 2020.
Michel F, Gaillet S, Cornu JN, Robert G, Game X, Phé V, et al. French Association of Urology. COVID-19: recommendations for functional urology. Prog Urol. 2020;30(8–9):414–25.
Thakar R, Robinson D, Rantell A, Ness W, Seleme M, Berghmans B. Guidance for the management of urogynecological conditions during the coronavirus (COVID-19) pandemic iuga.org/publications/covid-19-guidance-for-urogynecological-conditions. 2020
Society for Gynecologic Surgeons. Joint statement on re-introduction of hospital and office-based procedures in the COVID-19 climate for the practicing urogynecologist and gynecologist. J Minim Invasive Gynecol. 2020;27(5):1030–32.
Grimes CL, Balk EM, Crisp CC, Antosh DD, Murphy M, Halder GE, et al. A guide for urogynecologic patient care utilizing telemedicine during the COVID-19 pandemic: review of existing evidence. Int Urogynecol J. 2020;31(6):1063–89.
Amparore D, Campi R, Checcucci E, Sessa F, Pecoraro A, Minervini A, et al. Forecasting the future of urology practice: a comprehensive review of the recommendations by international and European associations on priority procedures during the COVID-19 pandemic. Eur Urol Focus. 2020;6(5):1032–48.
Chiofalo B, Baiocco E, Mancini E, Vocaturo G, Cutillo G, Vincenzoni C, et al. Practical recommendations for gynecologic surgery during the COVID-19 pandemic. Int J Gynecol Obstet. 2020;150(2):146–50.
Grimes CL, Balk EM, Dieter AA, Singh R, Wieslander CK, Jeppson PC, et al. Guidance for gynecologists utilizing telemedicine during COVID-19 pandemic based on expert consensus and rapid literature reviews. Int J Gynecol Obstet. 2020;150:288–98.
Novara G, Checcucci E, Crestani A, Abrate A, Esperto F, Pavan N, et al. Telehealth in urology: a systematic review of the literature. How much can telemedicine be useful during and after the COVID-19 pandemic? Eur Urol. 2020;78(6):786–811.
Katz EG, Stensland KD, Mandeville JA, MacLachlan LS, Moinzadeh A, Sorcini A, et al. Triaging office based urology procedures during the COVID-19 pandemic. J Urol. 2020;204(1):9–10.
Escura Sancho S, Ros Cerro C, Anglès-Acedo S, Bataller Sánchez E, Espuña-Pons M. How did COVID-19 pandemic change the way we attend the patients in an urogynaecological unit. Clin Invest Ginecol Obstet. 2020;47(3):111–7.
Serna-Gallegos T, Ninivaggio CS. A lasting impression: telemedicine in urogynecology during the coronavirus disease 2019 pandemic. Curr Opin Obstet Gynecol. 2020;32(6):456–60.
Heldwein FL, Loeb S, Wroclawski ML, Sridhar AN, Carneiro A, Lima FS, et al. A systematic review on guidelines and recommendations for urology standard of care during the COVID-19 pandemic. Eur Urol Focus. 2020;6(5):1070–85.
López-Fando L, Bueno P, Carracedo D, Averbeck M, Castro-Díaz DM, Chartier-Kastler E, et al. Management of female and functional urology patients during the COVID pandemic. Eur Urol Focus. 2020;6(5):1049–57.
Ghanbari Z, Mostaan F, Eftekhar T, Deldar M, Changiz N, Adabi K. Resumption of elective surgery following COVID-19 outbreak, guideline for female pelvic medicine and surgery. J Family Reprod Health. 2020. 14(1):1–4
Ahmed K, Hayat S, Dasgupta P. Global challenges to urology practice during the COVID-19 pandemic. BJU Int. 2020;125(6):E5–6.
Huri E, Hamid R. Technology-based management of neurourology patients in the COVID-19 pandemic: is this the future? A report from the International Continence Society (ICS) institute. Neurourol Urodyn. 2020;39(6):1885–8.
Mukherjee S, Raza A. Virtual consent for virtual patients: benefits of implementation in a peri- and post-COVID-19 era. Br J Hosp Med (Lond). 2020;81(7):1–3.
Musco S, del Popolo G, Lamartina M, Herms A, Renard J, Manassero A, et al. Neuro-urology during the COVID-19 pandemic: triage and priority of treatments. Neurourol Urodyn. 2020;39(7):2011–5
Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ, et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet. 2020;395(10242):1973–87.
Transmission of SARS-CoV-2 and mitigating measures. EMG-SAGE. 2020. https://www.gov.uk/government/publications/transmission-of-sars-cov-2-and-mitigating-measures-update-4-june-2020
Phé V, Karsenty G, Robert G, Gamé X, Cornu JN. Widespread postponement of functional urology cases during the COVID-19 pandemic: rationale, potential pitfalls, and future consequences. Eur Urol. 2020;78(1):4–5.
Galvão J. COVID-19: the deadly threat of misinformation. Lancet Infect Dis. 2020. https://doi.org/10.1016/S1473-3099
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S.D. has previously had expenses paid by Contura. There are no funding disclosures for this review article.
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Loganathan, J., Doumouchtsis, S.K. & CHORUS: An International Collaboration for Harmonising Outcomes, Research and Standards in Urogynaecology and Women’s Health. Impact of COVID-19 on management of urogynaecology patients: a rapid review of the literature. Int Urogynecol J 32, 2631–2646 (2021). https://doi.org/10.1007/s00192-021-04704-2
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DOI: https://doi.org/10.1007/s00192-021-04704-2