Impact of COVID-19 on management of urogynaecology patients: a rapid review of the literature

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. Supplementary information The online version contains supplementary material available at 10.1007/s00192-021-04704-2


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 nonurgent 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 peerreviewed 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).
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 (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.     Use telemedicine to assess need for face-to-face review Postoperative follow-up: equal patient-related outcomes with telemedicine compared with face-to-face [36] Use video or teleconsults for all non-urgent indications [5] Use telemedicine to allow physical distancing and minimise footfall [18] Telemedicine whilst awaiting surgery to help with symptom management [15] Essential staff only in clinic rooms  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   [36] Acute retention: place IDC or SPC, change regularly in the community. Consider ISC if teaching and education possible [30] Obstructive urinary disorders-face-to-face clinics with reduced capacity [5] Voiding dysfunction: teach ISC or catheterise Sepsis/complicated UTI: high priority Blocked catheter requires emergency review [23] Can be managed safely and effectively using telemedicine BSUG British Society of Urogynaecology, EAU European Association of Urology, PVR post-void residual volume, ISC intermittent self-catheterisation, IDC indwelling urethral catheter, SPC suprapubic catheter, US KUB ultrasound of the kidneys, ureters and bladder, UTI urinary tract infection, CISC clean intermittent self-catheterisation, TWOC trial without catheter  Temperature testing and wearing masks on arrival Reduce inpatient beds to allow physical distancing [4] Suspend all elective surgery Low intra-abdominal pressure 10-12 mmHg Universal COVID-19 testing recommended before all surgery Low power settings for electrosurgical devices  [30] Only urgent procedures to minimise inpatient stays Safety of minimally invasive surgery remains undetermined Screening consultation prior to procedure-symptoms in last 2 weeks, any travel Test patients and clinical team prior to procedure Positive pressure on hold during procedure and restarted 20 min after patient leaves Limited personnel in theatre [5] Recommend only high priority/emergency cases, experienced surgeon  [31] All invasive procedures under GA deferred [19] All elective cases deferred Aim for same-day discharge where possible Spinal anaesthesia in preference to general anaesthesia, unlikely to greatly increase voiding dysfunction [25] Transmission of fomites during vaginal surgery appears highly unlikely Regional anaesthesia preferable to general anaesthesia-lower risk postoperative retention, reduces aerosol generation [36] Augmentation cystoplasty, cystectomy, and continent and incontinent diversions all postponed owing to high-dependency in-patient care required 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.

Supplementary information
The online version contains supplementary material available at https://doi.org/10.1007/s00192-021-04704-2 Funding S.D. has previously had expenses paid by Contura. There are no funding disclosures for this review article.

Compliance with ethical standards
Conflicts of interest The authors declare that they have no conflicts of interest.
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