A guide for urogynecologic patient care utilizing telemedicine during the COVID-19 pandemic: review of existing evidence.

INTRODUCTION AND HYPOTHESIS: The COVID-19 pandemic and the desire to "flatten the curve" of transmission have significantly affected the way providers care for patients. Female Pelvic Medicine and Reconstructive Surgeons (FPMRS) must provide high quality of care through remote access such as telemedicine. No clear guidelines exist on the use of telemedicine in FPMRS. Using expedited literature review methodology, we provide guidance regarding management of common outpatient urogynecology scenarios during the pandemic.
METHODS: We grouped FPMRS conditions into those in which virtual management differs from direct in-person visits and conditions in which treatment would emphasize behavioral and conservative counseling but not deviate from current management paradigms. We conducted expedited literature review on four topics (telemedicine in FPMRS, pessary management, urinary tract infections, urinary retention) and addressed four other topics (urinary incontinence, prolapse, fecal incontinence, defecatory dysfunction) based on existing systematic reviews and guidelines. We further compiled expert consensus regarding management of FPMRS patients in the virtual setting, scenarios when in-person visits are necessary, symptoms that should alert providers, and specific considerations for FPMRS patients with suspected or confirmed COVID-19.
RESULTS: Behavioral, medical, and conservative management will be valuable as first-line virtual treatments. Certain situations will require different treatments in the virtual setting while others will require an in-person visit despite the risks of COVID-19 transmission.
CONCLUSIONS: We have presented guidance for treating FPMRS conditions via telemedicine based on rapid literature review and expert consensus and presented it in a format that can be actively referenced.

Introduction

The novel coronavirus (COVID-19) pandemic has drastically changed how patients are evaluated and treated and how they access ambulatory health care. Since there are currently no effective treatments or vaccines to prevent COVID-19, focus is placed on infection prevention through social distancing and quarantine. The Centers for Disease Control and Prevention (CDC) have set forth recommendations to prevent infections in healthcare settings by decreasing or eliminating non-urgent office visits. Telehealth refers to any healthcare process that occurs remotely, including provider training or team meetings, whereas telemedicine specifically describes using technology to connect a patient to a provider. To enable patients to retain access to healthcare, many countries have revised regulations to allow health care providers to use telemedicine and receive appropriate reimbursement [1]. For example, the Centers for Medicare and Medicaid Services in the USA have broadened access to, and reimbursement for, telemedicine services, allowing Female Pelvic Medicine and Reconstructive Surgery (FPMRS) providers the opportunity to provide continuity of care to existing patients who would otherwise remain disconnected.

In the field of FPMRS, telemedicine can limit community exposure to the most vulnerable population while simultaneously granting patients the opportunity to establish or continue care with a provider [2]. However, no clear guidelines exist regarding administering remote care for FPMRS patients.

Our objective was to conduct an expedited review of the evidence and to provide guidance for management of common outpatient urogynecologic conditions to help guide our specialty as we transition the way we provide care during the COVID-19 pandemic.

Materials and methods

Members of the Society of Gynecologic Surgeons (SGS) Collaborative Research in Pelvic Surgery consortium (SGS CoRPS) and the SGS Systematic Review Group (SGS SRG) participated in this project. The SGS CoRPS and SRG include members with expertise in clinical, surgical, and research management in FPMRS as well as systematic reviews and guideline development. No Institutional Review Board approval was required for this work.

We devised a list of questions and scenarios that FPMRS providers are likely to face as they engage patients virtually. We grouped these scenarios into diagnoses that would (1) likely require different treatment with telemedicine compared with in-person treatment or (2) would utilize accepted behavioral counseling and not deviate from current management paradigms. Expedited literature reviews were performed for four scenarios in which virtual management of patients would differ from direct visits [telemedicine in FPMRS patients, pessary management, urinary tract infection (UTIs), and urinary retention]. For scenarios in which the management via telemedicine would be similar to traditional conservative management (urinary and fecal incontinence, prolapse, defecatory dysfunction, and fecal incontinence), established algorithms and existing systematic reviews of conservative management were reviewed and summarized. Finally, expert consensus compiled and summarized the following; FPMRS conditions that are amenable to telemedicine management, urgent situations requiring in-person visits, symptoms that should alert FPMRS providers for possible COVID-19, and what FPMRS providers should consider when caring for patients with suspected or diagnosed COVID-19.

The methods, criteria, and literature flow for the expedited literature reviews, and salient meta-analysis details are reported in Appendix 1 [3]. Bullet-pointed summaries of our expedited literature reviews and expert consensus are listed in the body of this article. Additional information and details regarding the literature supporting these summaries can be found in Appendix 2.

Results

Telemedicine in FPMRS patients

The adoption and integration of telemedicine into a urogynecology practice is now possible, thanks to rapid advances in communications technology and widespread wireless access in many modern households. Still, FPMRS patient populations are diverse in age, socioeconomic status, and health literacy, and technologic devices and internet access are not universally available. Therefore, a multidimensional approach is necessary to provide a variety of options for patients seeking urogynecologic care.

Based on review of the literature (9 studies) [4-12] and expert consensus (EC):

Patient satisfaction

Virtual visits provide similar patient satisfaction by building strong therapeutic relationships with patients through education, active listening, and shared decision-making [9].

FPMRS patients living in rural settings may be more likely to attend follow-up visits when conducted remotely, although providers must consider limited internet access and technical capabilities for some elderly patients [12].

Postoperative care

Patients whose postoperative visits are conducted using telemedicine reported high levels of satisfaction and experienced no increase in adverse events, emergency room visits, or primary care visits [10].

Postoperative patients after midurethral slings with no symptoms of incontinence or after native tissue pelvic organ prolapse repairs can be appropriately assessed with telephone follow-up [4, 10].

General principles for FPMRS telemedicine

Established patients not requiring a physical examination are ideal candidates for virtual visits (EC).

New patients appreciate establishing a relationship with a provider, even before an in-person visit is possible, and will benefit significantly from non-surgical treatment options [7].

Patients whose surgery has been canceled because of COVID-19 can replace their scheduled preoperative visit with a virtual discussion of alternative therapies as well as provide an opportunity for public health education related to COVID-19. In addition, rescheduling the patient’s surgery will confirm a plan for providing definitive care. Alternatively, previously scheduled preoperative visits could be held as patients are likely to eventually have surgery (EC).

There are many existing society websites with handouts and videos that can be used to supplement patient counseling (EC). They are available in many languages and in large print format. Some examples are:

International Urogynecological Association (IUGA) Patient Leaflets [13], https://www.yourpelvicfloor.org/leaflets/

American Urogynecologic Society, (AUGS) Voices for Pelvic Floor Disorders [14], https://www.voicesforpfd.org/resources/fact-sheets-and-downloads/

National Association for Continence [15], https://www.nafc.org/learning-library

Regulatory access to telemedicine Services in the US

Until COVID-19, telemedicine had not been utilized in most clinical settings. To expedite its use in the US, the Stafford Act, enacted in mid-March 2020, enabled the Centers for Medicare and Medicaid Services (CMS) to broaden access for Medicare telemedicine services. See Table 1 for CMS guidance to billing.

Table 1

CMS guidance for billing during the COVID-19 pandemic*

Type of service	What is the service?	HCPCS/CPT CODE	Type of visit
Video visit	A video visit between a provider and a patient (billed by time)	99,201–99,215 (Office or other outpatient visits)	For new or established patients
Telephone or electronic visit (e-visit)	A phone or secure portal communication between a patient and provider	99,421 (5–10 min) 99,422 (11–20 min) 99,423 (≥ 21 minu)	For new or established patients

CMS = Centers for Medicare and Medicaid Services

HCPCS = health care common procedural coding system

CPT = current procedural terminology

*Starting March 6, 2020, and for the duration of COVID-19 Public Health Emergency, CMS will enforce payments for Medicare telemedicine services furnished to beneficiaries in any healthcare facility and in their home. In telemedicine visits, the following must be documented: patient consented, use of video vs. audio (and reason if video not used), if video then general appearance of the patient, if audio the impression of how the patient sounds, and minutes spent in the visit [16]. Use of a specific telemedicine encounter is preferred for tracking and reimbursement purposes over a telephone encounter (typically used for sharing of discrete information)

Pessary management

Seven studies provided data on risk of adverse events with long-term pessary use (without removal or cleaning) [17-23]. Nine additional articles were reviewed that provided information of interest during the pandemic [24-32]. Our analysis included three randomized controlled trials, three prospective cohorts, and one retrospective cohort. By meta-analysis (see Appendix 1), we estimated the following risks with continuous pessary use (no interval cleaning or examination) between 6 and 24 months: vaginal erosion or bleeding 5.0% (95% CI 1.9, 9.0), vaginal discharge 5.8% (95% CI 3.6, 8.5), vaginitis 1.8% (95% CI 0.2, 4.6), voiding dysfunction 4.7% (95% CI 1.4, 9.8), and fistula 0% (95% CI 0, 1.1).

Based on review of the literature (16 studies) and expert consensus:

Patients can safely extend the time interval between pessary cleanings to 6 months (and, in some cases, up to 24 months) with minimal risk of adverse events [17-23].

Patients capable of pessary removal and reinsertion should be encouraged to self-clean their pessary [27, 31–35].

Providers should consider empiric vaginal estrogen to minimize adverse events for patients not already using vaginal estrogen [17, 18, 28, 31, 33].

For patients reporting copious vaginal discharge or bleeding, it may be appropriate to encourage home self-removal and to observe for symptoms such as voiding dysfunction until patients can safely be evaluated in the office (EC).

Empiric treatment for bacterial vaginosis could be considered (EC).

Empiric treatment of UTI

In total, 60 articles provided information. Twenty-three contributed to the narrative summary and are cited in the paper. These included 2 RCTs [36, 37], 13 nonrandomized comparative studies [6, 8, 38–48], and 7 single group studies [49-55], and the remaining articles [5, 7, 39, 41, 43, 46, 50, 53, 56–83] included consensus documents, cost-effectiveness analyses, and narrative reviews.

Of note, most of our literature review and review of expert opinion was in line with the International Guidelines from the Infectious Disease Society of America (IDSA) and European Society for Microbiology and Infectious Disease (ESMID) recommendations, including choice of antibiotic for first-line therapy [84]. With recurrent UTI patients, although recent recommendations by the American Urological Association (AUA), Canadian Urological Association (CUA), and Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) cited grade C evidence for cultures with every episode, the same level of evidence supports offering patient-initiated treatment when awaiting urine cultures [65].

Based on review of the literature (60 articles) and expert consensus:

Telemedicine with empiric antibiotic therapy is effective and lowers costs, but results in more prescribing and therefore may negatively impact antibiotic resistance [5, 8, 6, 57–60, 76].

The symptoms of dysuria, worsening frequency or urgency, gross hematuria, and lack of vaginal symptoms are significantly predictive of the presence of a UTI [44, 61].

Prior culture results within the past year correctly correspond to subsequent cultures and sensitivities and thus should be used to guide empiric therapy, even in neurogenic bladder patients [47, 48, 52, 62].

Patient factors such as age (> 65 years), immunosuppression, diabetes mellitus, catheter use, UTIs in the last year, and recent exposure to antibiotics should be assessed during telemedicine visits as these factors predict resistance to first-line antibiotics [45, 63, 51, 54, 64]. Fever and diabetes are risk factors for more severe infections or bacteremia and might guide treatment decisions about triage in person [43]. Providers should bear in mind that fever and various atypical symptoms may also indicate COVID-19 infection.

Empiric treatments with either trimethoprim-sulfamethoxazole (TMP-SMZ) or nitrofurantoin are cost-effective choices [42, 56, 85–88]. Uncomplicated UTIs should be treated with one of the following empiric antibiotic strategies as supported by cost guidance, guidelines, and antimicrobial susceptibility: (1) TMP-SMZ 160/800 mg orally twice daily for 3 days where antibiotic resistance does not exceed 20%, (2) nitrofurantoin monohydrate macrocrystals 100 mg orally twice daily for 5 days in patients with normal kidney function (CrCl > 30 ml/min), particularly if there are contraindications or high resistance to TMP-SMZ, (3) fosfomycin 3 g once, or (4) pivmecillinam 400 mg twice daily for 5 days [36, 40, 46, 50, 62, 64, 65, 38, 55, 81, 89, 53, 66, 77].

Antibiotic durations of 3–7 days are advisable and have better efficacy than single-dose therapy (with the exception of fosfomycin, which is an efficacious single dose regimen) [67, 72, 90].

Fluoroquinolone therapy should be reserved for higher-risk patients, locales where antibiotic resistance to alternative agents (particularly TMP-SMZ) exceeds 20%, or when poor kidney function is known in the patient [39, 41, 68, 78–81, 91].

Complicated UTIs in the current pandemic merit empiric treatment with a broader spectrum systemic fluoroquinolone antibiotic course to decrease hospital admissions, with plans to proceed to admission for parenteral antibiotics if severe symptoms occur or lack of response to oral antibiotics (e.g., intolerance to oral intake, high fever, severe pain, disorientation) [49, 69, 70, 92].

Elderly patients and patients with diabetes should be given broader spectrum antibiotics (e.g., cephalosporins or fluoroquinolone therapy) for longer durations (7 days vs. single dose vs. 3 days) [53, 66, 71–73, 82, 83].

Relief of symptoms can be used as a surrogate for UTI resolution in this pandemic (EC).

Other strategies to avoid antibiotics could include fluid hydration, cranberry supplements, or bladder soothants (e.g., phenazopyridine) (EC).

Laboratory alternatives include over-the-counter urine dipstick products, urine PCR [74], or utilizing remote laboratory locations to minimize exposure in hospital settings (EC).

Strategies to avoid UTIs that do not require in-person visits include vaginal estrogen or use of D-mannose 1000 mg twice daily [75] (EC).

Recurrent UTI patients may be offered patient-initiated treatment based on past urine cultures, as supported by grade C evidence in the AUA/CUA/SUFU guidelines. They further recommend culture with every episode but this may be suspended during the COVID-19 pandemic when the risk of healthcare exposure outweighs the need for culture [65] (EC).

Voiding dysfunction and retention

We found 23 articles, of which 10 had data extracted [93-102]. Thirteen additional articles provided information pertinent to management of voiding dysfunction during this pandemic [103-115].

Based on review of the literature (23 articles) and expert consensus:

Chronic urinary retention (PVR > 300 ml for > 6 months) puts patients at risk of upper urinary tract injury. Imaging and/or laboratory evaluation along with appropriate catheterization should be considered [111].

Factors that suggest a patient is at low risk for postoperative urinary retention (following pelvic surgery) include: voiding > 200 ml after being retrograde filled with 300 ml, voiding > 50% of the retrograde-filled volume, and women who subjectively feel that the postoperative force of their urinary stream is at least 50% of their baseline force of stream [102, 108, 112].

Regional anesthesia is unlikely to substantially increase the risk of postoperative urinary retention and can be considered for vaginal surgery in an effort to decrease the potential risk of aerosolization of COVID-19 with general anesthesia [113] (EC).

Clean intermittent self-catheterization (CISC) may be preferable to an indwelling catheter for urinary retention when possible [104, 107, 108]. Risk factors that predict poor success with CISC include obesity, poor dexterity, cognitive impairment, and pain with catheterization [105-107].

When patients call with symptoms of possible urinary retention, consider instruction in behavioral modification prior to recommending CISC. This includes encouraging the patient to create a relaxing environment with adequate time for voiding while taking slow deep breaths and relaxing their pelvic floor muscles [94]. Patients could also be instructed to double or triple void [116] or in the use of the Crede maneuver (expert consensus).

If behavioral modifications fail, patients should be given the option of CISC. A prescription for catheters can be called into a pharmacy (delivery may be available), and remote teaching of the CISC technique can be attempted. If video conferencing is available, patients could be taught to use a clean technique with a mirror. Initially, the patient lies down and inserts a small-gauge (e.g., 10, 12, or 14 French) catheter. When proficient with the mirror, she can be instructed to insert the catheter by feel in the sitting or standing position. Online instructional videos are also available (https://vimeo.com/261183016) [95, 117] and online patient handouts are available as well (https://www.yourpelvicfloor.org/media/Intermittent_Self_Catheterization.pdf) [13] (https://www.voicesforpfd.org/assets/2/6/ISC.pdf) [13, 14] (EC).

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 by cutting the balloon port and/or desufflating the catheter balloon. Consider having the patient remove the catheter early in the day to allow for an in-person office visit later on the same day if necessary [114].

While antibiotics may reduce the incidence of asymptomatic bacteriuria during short-term catheter use, there is no strong evidence supporting the use of prophylactic antibiotics after hospital discharge in women being catheterized for postoperative urinary retention [96, 97].

Antibiotic prophylaxis should not be routinely used in patients with long-term catheterization, and there is insufficient evidence to make recommendations about routine catheter change (e.g., every 2–4 weeks) in patients with long-term indwelling transurethral catheterization [115].

There is no strong evidence supporting the use of oral medication (e.g., alpha-adrenergic antagonists) in the treatment of voiding dysfunction or urinary retention in women [93, 99, 100].

Urinary incontinence

A recent systematic review was published on treatment options for women with urinary incontinence [118]. This systematic review focused on studies of adult women with stress urinary incontinence (SUI), urgency urinary incontinence (UUI), or mixed urinary incontinence (MUI); women were excluded if they were pregnant or hospitalized. We updated this review with additional studies published since August 2018 [118-124].

Based on this recent systematic review, six additional studies [118-124], and expert consensus:

SUI, UUI, and MUI can be discussed and treated with telemedicine (EC).

Behavioral therapy including bladder training, pelvic floor physical therapy or Kegel exercises, weight loss, and yoga have demonstrated significant improvement and/or complete resolution of SUI and UUI symptoms [125].

Patients can implement behavioral interventions without leaving home (EC).

Patient-initiated options such as incontinence tampons (Poise Impressa®) or a patient fitted pessary (Uresta®) could be recommended [119, 124].

Patients currently treated with third-line treatments for UUI such as intradetrusor onabotulinum toxin A or percutaneous tibial nerve stimulation could revert back to behavioral modifications and medications (anticholinergic or ß3-adrenoceptor agonist) until they can return for in-person office visits (EC).

Consider balancing the risk of exposure to COVID-19 versus the risk of dementia from anticholinergic use [120]. It is unlikely that short-term use during healthcare interruption due to this pandemic will result in long-term dementia effects (expert consensus).

Consider the risk of hypertension with ß3-adrenoceptor agonists. However, two recent systematic reviews reported no difference in hypertension risk between mirabegron and placebo [121, 122].

Smartphone applications (apps) can be used to help teach and track Kegel exercises [123].

The free app Kegel Trainer or paid app Kegel Trainer Pro® were the highest rated apps based on a recent review [123].

Pelvic organ prolapse, defecatory dysfunction, and fecal incontinence

Existing AUGS Best Practice guidelines, American College of Obstetricians and Gynecologists (ACOG) guidelines, American Society of Colon and Rectal Surgeons (ASCRS) clinical practice guidelines, and systematic reviews were summarized to guide treatment of prolapse, fecal incontinence, and defecatory dysfunction via telemedicine [126-129]. Pelvic organ prolapse can be challenging to evaluate without a physical examination. However, the virtual visit provides an opportunity to counsel patients on the pathophysiology, possible treatment options, and techniques to prevent progression. Similarly, for defecatory dysfunction and fecal incontinence, conservative measures listed in the table can be initiated to help alleviate patients’ symptoms. It is important to note that a change in bowel habits, weight loss, and rectal bleeding may warrant referral to a gastroenterologist or colorectal surgeon to rule out colorectal cancer [128, 129]. Of note, if a patient reports new onset fecal incontinence or acute worsening of fecal incontinence, she should be screened for other COVID-19 symptoms and then referred for the appropriate care, as diarrhea is a possible symptom of COVID-19.

Pelvic organ prolapse

Only 10–20% of women will have an increase in prolapse stage over 2 years; therefore, most patients can be reassured regarding delay in surgical or pessary management [130, 131, 129].

Weight loss, reducing activities that strain the pelvic floor, smoking cessation, and avoiding constipation may improve symptoms and decrease progression of prolapse [132].

Pelvic Floor muscle training and exercises can decrease prolapse in some patients [132, 133].

For pelvic muscle exercises, providers may suggest online instructions (https://www.yourpelvicfloor.org/media/Pelvic_Floor_Exercises_RV2-1.pdf) [13] (https://www.voicesforpfd.org/assets/2/6/Bladder_Training.pdf) [14]. Home biofeedback devices can be used, such as Leva®, which is an FDA-cleared pelvic floor muscle trainer with visualization technology, smartphone applications, vaginal weights, virtual pelvic floor therapy appointments, or internet pelvic floor training (EC).

Encouraging patients to splint or insert a large tampon may help alleviate symptoms in cases of prolapse causing incomplete bladder emptying (EC).

Defecatory dysfunction

Dietary changes and fiber supplementation (insoluble fiber) can improve stool consistency and help with stool evacuation [126, 127].

Osmotic or stimulant laxatives can help defecatory dysfunction and postoperative constipation [126].

Position changes during bowel movements or a squatty potty can improve defecation [134].

Splinting vaginally or at the perineum may help women with incomplete evacuation from a rectocele (EC).

Fecal incontinence

Protective devices can be utilized [127]. These include pads or adult diapers, adhesive patches (e.g., butterfly pads), and skin care with protective ointments that are zinc based (EC).

A food diary can be used to identify triggers to avoid [127]. Triggers associated with loose stool can include sugar replacements, caffeine, and lactose.

Medications that may cause loose stool should be avoided [135]. Some common medications that cause diarrhea include: antacids, proton pump inhibitors, antibiotics, SSRIs, beta blockers, ACE inhibitors, metformin, and cholestyramine.

Dietary fiber (soluble) with increased fluid intake can provide more bulk to the stool and help achieve the ideal stool consistency [126, 136].

Consider medications ([126, 127]) to treat loose stools and help FI: [126, 127].

Bowel schedules, tap water enemas, glycerine, or bisacodyl suppositories can help patients to reliably evacuate the rectum [126].

A systematic review found anal plugs (not offered in the US) are poorly tolerated but effective [137].

Urgent situations

The COVID-19 pandemic presents a challenge for both patients and providers to determine the appropriate scenario requiring a more thorough evaluation, examination, and/or laboratory testing. When a provider is considering the necessity of an in-office visit, they must weigh the risks of COVID-19 exposure taking into account the current status of the outbreak in that specific region, the severity of the patient complaint, as well as the age and comorbidities of the patient. It appears that older age, diabetes, and immunosuppression increase the risk of morbidity and mortality associated with COVID-19 infection [138]. As there are no guidelines on clinic visits during a pandemic for this specialty, group consensus was obtained, and a list of reasons that may require an in-person visit was generated (Table 2). Providers should also consider a clinic visit if there is a reasonable chance a physical examination or office diagnostic testing may change the course of treatment for an urgent complaint. One must also consider that the course of the COVID-19 pandemic will change over time, which might impact these recommendations.

Table 2

Potential reasons for urgent visits in the FPMRS clinic during a pandemic

Reason	Explanation
Acute pelvic pain or pelvic floor myalgia	Severe pain or worsening pain/flare/need for trigger point injections
Acute interstitial cystitis flare	Flare or need for bladder instillation
Refractory or relapsing UTI	Failed empiric antibiotics or complicating symptoms such as fever or concern for pyelonephritis
Postoperative concerns or complications	Examples: persistent nausea/vomiting, concern for urinary retention, heavy vaginal bleeding, severe abdominal pain, concern for infection or cuff dehiscence
Acute retention	See voiding dysfunction and retention section
Pessary complications	Pessary patient with persistent or significant vaginal bleeding or pain
New onset of genitourinary or rectovaginal fistula	Consider if evaluation in office may change your management (e.g., transurethral catheter or antibiotics)
Acute genitourinary postpartum complaints	Separation of 3rd/4th degree perineal laceration, acute retention, or concern for a fistula
Refractory vaginitis or vulvar complaints	Failed empiric treatment
Urethral or vaginal mass (other than prolapse)	In cases with acute retention or concern for mass causing obstruction, when examination can facilitate referral to a specialist (e.g., gynecologic oncologist)
Mesh complication	New onset complaint or worsening symptoms

COVID-19-specific concerns for FPMRS patients

Patients seen by urogynecologists are likely to have risk factors that increase the chance of complications from COVID-19. Thus, it is important for FPMRS providers to be aware of COVID-19 symptoms that should prompt a referral for further evaluation and testing. For example, upper respiratory symptoms and bowel changes are possible presenting symptoms for COVID-19. A patient with an increase in their stress incontinence due to a dry cough or worsened fecal incontinence due to diarrhea should trigger consideration for further COVID-19 screening based on the regional protocol.

The American College of Surgeons (ACS) has advised postponing elective cases until after the acute COVID-19 crisis abates [139]. General guidance to assist FPMRS and other surgical specialties with staged postponement of surgical cases has been published [140]. During the pandemic, there will be a need for urgent surgical intervention in some situations, and a plan for management of these non-elective cases is required. A brief review of perioperative considerations for non-elective cases including COVID-19 positive cases was generated (Table 3) [141, 142]. When discussing surgical intervention with patients negative for COVID-19 infection, surgeons should discuss the unique risks of nosocomial COVID-19 infection during the consent process, including the efforts undertaken to protect the patient and the challenges of preventing contamination. Also consideration should be placed on ERAS and same-day discharge to decrease risk and exposure to patients.

Table 3

Perioperative considerations: non-elective cases

Operative state	Recommendation
Preoperative	• Screen all patients for symptoms upon arrival to the healthcare setting; triage for testing based on symptoms • Consider universal testing once availability of COVID-19 kits increases • Consider a chest x-ray as a screening tool since it may be obtained faster than confirmatory testing
Intraoperative	• For COVID-19-positive cases: - Operating room staff should have full personal protective equipment, and only essential personnel should be present - Limit movement of personnel in and out of the OR especially during airway management given the increased risk of aerosolization of viral particles - Consider laparotomy vs. laparoscopy by balancing the risks of surgical morbidity to the patient with risk of viral transmission to the provider - Limit use of electrocautery unless absolutely necessary for patient safety. If used, electrocautery devices should be used at the lowest effective setting and in conjunction with deliberate smoke suctioning with filters when energy is used - Insufflation during laparoscopic cases should be kept to a minimum and completely evacuated through a filtration system prior to trocar venting or removal
Postoperative	• Same-day discharge should be encouraged to avoid prolonged hospitalization and reduce hospital burden • For COVID-19-positive cases: - Consider prophylaxis or treatment doses of anticoagulation as COVID-19 infections may produce a hypercoagulable state

Discussion

In this review, we have explored conditions that FPMRS providers are likely to face as they engage patients virtually during the COVID-19 pandemic. We have reviewed the literature and summarized our findings in the sections above. Overall, behavioral and conservative management will be valuable as first-line treatments provided in a virtual setting (via phone or internet communication). There are situations that will require different treatments in the virtual setting than in person, and there are some that will require an in-person visit despite the risks of COVID-19 exposure and spread.

The strengths of this review include our use of expedited evidence review methods as well as the author team’s experience conducting systematic reviews and developing clinical practice guidelines, along with its advanced expertise in FPMRS. The main limitations to this review are the rapid nature of the review and the lack of data regarding many of the pertinent clinical questions. Our expedited evidence methods inevitably missed salient studies. Furthermore, the COVID-19 pandemic is changing our world day by day, and it is impossible to forecast how this will impact our management of common FPMRS conditions in the months to come.

The COVID-19 pandemic is unprecedented in terms of the scope and impact on the world’s healthcare systems. To control and prevent the spread of infection, FPMRS practices will need to utilize telemedicine to safely provide continuity of care to our patients. We have provided literature and expert-based guidance for the practicing FPMRS.

Table 4

Studies reporting adverse outcomes with long-term pessary use (without removal and cleaning)

Outcome	Study	Pubmed ID	Country	Pessary type	Duration (months)	Outcome definition	n/N (%)
Discharge	Cheung 2016	27,275,798	China	Ring	6	Unusual or bothersome discharge	6/132 (4.5%)
	Miceli 2020	32,062,679	Spain	Ring	24	Increase in vaginal discharge	6/115 (5.2%)
	Chien 2019	31,393,340	Taiwan	Gellhorn	12–111 (mean 50.4)	Abnormal vaginal discharge	8/93 (8.6%)
Erosion	Propst 2020	31,809,432	USA	Multiple	3	Type 3 or 4 (epithelial break or erosion)	4/54 (7.4%)
	Thys 2020	31,907,565	USA	Ring	3	Lesion of the vaginal epithelium	0/132 (0%)
	Tam 2019	31,561,819	Hong Kong	Ring	3	Ulceration or erosion	1/29 (3.4%)
	Propst 2020	31,809,432	USA	Multiple	6	Type 3 or 4 (epithelial break or erosion)	1/57 (1.8%)
	Lone 2011	21,575,953	UK	Multiple	6	Discontinue use because of excoriation or bleeding	5/223 (2.2%)
	Tam 2019	31,561,819	Hong Kong	Ring	6	Ulceration or erosion	6/30 (20%)
	Cheung 2016	27,275,798	China	Ring	6	Abnormal vaginal bleeding	9/132 (6.8%)
	Miceli 2020	32,062,679	Spain	Ring	24	Vaginal bleeding/erosion	8/115 (7.0%)
	Chien 2019	31,393,340	Taiwan	Gellhorn	12–111 (mean 50.4)	Vaginal bleeding/erosion	9/93 (9.71%)
Fistula	Propst 2020	31,809,432	USA	Multiple	3	Fistula	0/54 (0%)
	Tam 2019	31,561,819	Hong Kong	Ring	3	Fistula	0/29 (0%)
	Thys 2020	31,907,565	USA	Ring	3	Fistula	0/132 (0%)
	Propst 2020	31,809,432	USA	Multiple	6	Fistula	0/57 (0%)
	Tam 2019	31,561,819	Hong Kong	Ring	6	Fistula	0/30 (0%)
	Lone 2011	21,575,953	UK	Multiple	6	Fistula	0/223 (0%)
	Miceli 2020	32,062,679	Spain	Ring	24	Major complication	0/115 (0%)
	Chien 2019	31,393,340	Taiwan	Gellhorn	12–111 (mean 50.4)	Fistula	0/93 (0%)
Retention	Tam 2019	31,561,819	Hong Kong	Ring	3	Urinary retention	0/29 (0%)
	Tam 2019	31,561,819	Hong Kong	Ring	6	Urinary retention	0/30 (0%)
	Cheung 2016	27,275,798	China	Ring	6	Voiding difficulty, de novo	10/92 (10.9%)
	Chien 2019	31,393,340	Taiwan	Gellhorn	12–111 (mean 50.4)	Voiding/defecating difficulty	4/93 (4.3%)
Vaginitis	Tam 2019	31,561,819	Hong Kong	Ring	3	Vaginitis	0/29 (0%)
	Cheung 2016	27,275,798	China	Ring	6	Bacterial vaginosis	1/132 (0.8%)
	Tam 2019	31,561,819	Hong Kong	Ring	6	Vaginitis	3/30 (10%)
	Miceli 2020	32,062,679	Spain	Ring	24	Candida glabrata	1/115 (0.9%)