INTRODUCTION
COVID-19 pandemic has caused profound changes in medical practice globally. Regular
patient care has been dramatically affected since the focus of both the public and
private health systems being shifted to the management of patients with COVID-19 (1,
2). Avoidance of non-emergency treatments and medical procedures have been recommended
worldwide and are in effect in Brazil since the beginning of March/2020 (3).
Social distancing has been introduced more than four months ago and is plainly effective
throughout the country, with no signs that it will be relaxed in the next weeks. A
recent study showed a dramatic reduction in elective patient visits and surgical procedures
in the whole country (4). Given the continental dimensions and significant geographical
and socioeconomic heterogeneity of the country, the pandemic impact has also been
heterogeneous across different regions in Brazil (5). In addition, governmental statemnts
supporting economy reopening and easing social distancing are also different based
on parameters like the infection rate, hospital bed occupancy and testing and isolation
capacity. Based on a system with progressive phases, different cities and states in
Brazil are in distinct stages of restrictions for non-essential activities.
Another important element that may influence patients’ drive to search for medical
evaluation and treatment of non-emergency conditions is the psychological impact of
quarantine and its fatigue (6). People are becoming more lenient toward unnecessary
trips and outside activities after being quarantined for almost four months since
the pandemic's outset and less adherent to authorities’ recommendations.
More importantly, specialists and patients are becoming increasingly worried about
the potential harm and impact in quality of life caused by deferring medical evaluation
and treatment for a long time (6). In functional urology, it includes lower urinary
tract dysfunction associated with benign prostatic hyperplasia, neurogenic lower urinary
tract dysfunction, overactive bladder, male and female stress urinary incontinence
and other conditions.
In this scenario, we observe a gradual reactivation of urodynamic practices moved
by the growing demand for evaluation. Guidance must be provided about priority changes
regarding urodynamic indications and on recommendations for protective measures to
minimize the risk of infection with the SARS-COV-2 virus for patients and health care
professionals.
This article reviews the most recent guidelines focused on urology and urodynamic
practice during the COVID-19 pandemic from the International Continence Society (7),
European Association of Urology (8, 9) and American Urological Association (10, 11).
Our present document is based on these guidelines and represents the recommendations
of the Brazilian Society of Urology (SBU - Sociedade Brasileira de Urologia) regarding
the practice of urodynamics during the COVID-19 pandemic in Brazil. We provide guidance
based on clinical priority and the state of restrictions for medical practice and
social/economic activities. We also provide recommendations for reducing the risk
of COVID-19 infection for patients and health care professionals when urodynamics
is performed.
A. Urodynamic indications during COVID-19 Pandemic
Practitioners must balance the need to provide necessary services while minimizing
risk to patients and health care professionals. The potential for patient harm if
care is deferred must be considered when making decisions about ordering urodynamic
tests in a similar extent than when making decisions about providing elective procedures,
surgeries, and non-urgent outpatient visits.
DO NOT perform urodynamic evaluation in suspected or confirmed SARS-COV-2 active infections.
In patients who have already had the infection, urodynamics MAY BE PERFORMED after
14 days of hospital discharge (moderate or severe illness) or after 14 days of the
onset of symptoms (mild illness), if the patient is totally asymptomatic (8). If in
doubt, consider performing targeted SARS-CoV-2 testing of asymptomatic patients. Depending
on guidance from local and state health authorities, testing availability, and how
rapidly results are available, facilities can consider implementing pre-admission
or pre-procedure diagnostic testing with authorized nucleic acid or antigen detection
assays for SARS-CoV-2 (9).
According to the local government flexibility of medical practice during the COVID-19
pandemic and the priority of urodynamic indications (7), three situations were analyzed
(Table-1):
Table 1
Recommendations for urodynamic practice according to local government restrictions
and risk classification during COVID-19 pandemic.
LOCKDOWN
Do not perform urodynamics
HIGH RESTRICTIONS FOR MEDICAL PRACTICE AND SOCIAL/ECONOMIC ACTIVITIES
Urodynamics may be performed considering adaptations to the COVID-19 pandemic.
Prioritize high risk patients:
Risk for upper urinary tract deterioration
In evaluation for bladder reconstructive surgery or kidney transplantation.
Urinary retention or other complications
Defer Urodynamics in low risk patients:
Stress urinary incontinence, overactive bladder, non-neurogenic male and female LUTS
with low risk for upper urinary tract deterioration
LOW RESTRICTIONS FOR MEDICAL PRACTICE AND SOCIAL/ECONOMIC ACTIVITIES
Urodynamics may be performed for all guideline-recommended conditions
LUTS = Lower Urinary Tract Symptoms
Lockdown.
If your city is under lockdown and only emergencies and urgent medical procedures
are allowed, DO NOT PERFORM urodynamic evaluation.
High restrictions for medical practice and social/economic activities
This is the present situation of most cities in Brazil. Urodynamics MAY BE PERFORMED
considering adaptations to the COVID-19 pandemic. High risk patients should be prioritized
and urodynamics should be deferred in low risk patients. The following risk stratification
is based on international recommendations (7, 11) and our expert opinion:
High risk patients:
–
Patients under risk for upper urinary tract deterioration: those with spinal cord
injury, spinal dysraphism, multiple sclerosis and other neurological conditions known
to generate increased bladder pressure.
–
Patients being considered for a bladder reconstructive surgery such as bladder augmentation,
urinary diversion, or kidney transplantation.
–
Patients with urinary retention or other complications (i.e., hydronephrosis, bladder
stones, diverticulum) when the confirmation of bladder outlet obstruction is considered
critical for patient management.
Low risk patients:
–
Patients with stress urinary incontinence, overactive bladder and others non-neurogenic
conditions associated with LUTS in men and women that carry a low risk for upper urinary
tract deterioration.
Low restrictions of medical practice and social/economic activities
Urodynamics MAY BE PERFORMED for all guideline-recommended conditions, always balancing
the need to provide necessary evaluation while minimizing risk to patients and health
care professionals.
Recommendations for COVID-19 prevention and control when performing urodynamics: minimizing
risks for patients and health care professionals.
Our present recommendations are based on statements issued by international societies
(7–11) in order to reduce the risk of COVID-19 infection for patients and health care
professionals. Additional prevention and control practices are to be used along with
the standard proceedings of the urodynamic tests. They are summarized in Table-2 and
include measures to be implemented before and during the urodynamic test (Figure-1).
Figure 1
Adaptations for urodynamic performance include: single-use gloves, apron, mask; and
eye protection for staff; mask for the patient and maintenance of 2 meters distance
between examiner and patient; the patient is standing for stress incontinence maneuvers
(straining) with a pad placed on the floor to facilitate observation of urine leakage
from distance.
Table 2
Adaptations for Urodynamic performance during COVI-10 pandemic.
Before Urodynamics
Phone Contact to:
Evaluate COVID-19 symptoms or contact
Collect patient history
Inform about mask use and companions’ restriction.
Schedule patients with longer interval
Standard Urodynamic rooms can be used
Standard ventilation and air conditioning
Urodynamics Day
Establish a route to the Urodynamic room to minimize contact
Provide conditions for frequent hand hygiene
Screen for COVID-19 symptoms
Temperature measurement
Assure mask use all times
Keep personal distance of 2 meters
PPE
Patients and companions
Always wear a mask
Examiner and staff
Single-use gloves, aprons, and mask
Face visor or protection glass disinfected with 70% liquid alcohol
Stress Incontinence Test
Favor standing or squatting position
Favor Valsalva maneuver instead of cough
If needed, cough with protection
PPE = Personal Protective Equipment
Prior to the exam
Make a detailed phone contact to:
–
Investigate if the patient has symptoms of COVID-19 (i.e. fever, cough, myalgia or
fatigue (12)) close to the day he/she is scheduled to the urodynamic test or had contact
with someone who had the disease in the last two weeks. Urodynamics must be postponed
in any of these circumstances and the patient instructed to seek proper COVID-19 evaluation.
–
Ensure a comprehensive patient history, avoiding history taking during personal contact
to minimize exposure time for patients and staff.
–
Reinforce the need to wear a face mask at all times.
–
Restrict the presence of companions and the need for them to also comply with prevention
measures.
Schedule patients with longer intervals to avoid contact between patients and their
companions and ensure physical distancing. Standard urodynamic rooms can be used,
since a negative pressure environment is not required, and positive pressure rooms
are not recommended (7, 13). Urodynamic tests are not considered to be aerosol-generating
procedures and there is no need for full air change in the room between patients and
no need to change ventilation or air conditioning in the room (7, 9, 14).
Ensure that environmental cleaning and disinfection procedures are properly performed
by applying disinfectants for use against SARS-CoV-2 that are recommended by health
authorities. This should be done at frequent intervals in the waiting area and all
rooms of the urodynamic unit and specially in the urodynamic room after each test
(7).
On the day of the exam, establish a route for patients and companions once they arrive
at the hospital or clinic to minimize contact with other visitors. Provide conditions
for all visitors to perform frequent hand hygiene with alcohol-based gel or by thoroughly
washing their hands with water and soap at healthcare facility entrances, waiting
rooms, and patient check-ins.
Screen all patients and companions entering the urodynamic unit for signs and symptoms
of COVID-19 (i.e. fever, cough, myalgia, or fatigue (12)) as well as known exposures.
Perform temperature measurement to check if patient or companions have fever (> 37.8
C). Reschedule the appointment if needed. Patients and companions must use mask during
all the time. Spare masks must be available.
During the exam.
Standard precautions, including appropriate hand and respiratory hygiene, personal
protective equipment (PPE) use, appropriate waste management, environmental cleaning,
and patient-care equipment sterilization procedures should always be followed.
Only the patient and essential staff should be present during urodynamic procedures.
Companions should be avoided whenever possible. Two meters distance should be kept
between the patient and staff, except for procedures such as catheterization and examination
of the patient (7, 15).
PPE for patients and companions
Patients must always wear a face mask. They should perform hand hygiene when entering
and leaving the procedure room, by using alcohol hand-gel or thoroughly washing their
hands for at least 20 seconds (7, 8). The same instructions apply to a companion,
if absolutely needed during the test.
PPE for the examiner and staff
The proper use of PPE is the most important method to avoid contamination of health
care professionals. Single-use gloves, aprons and masks are recommended during urodynamic
evaluation for all the staff. Because the test may involve body fluids, contact and
coughs, eye protection with a face visor or protection glasses should also be used
(7, 8, 13). Gloves, aprons and masks should be discarded after the exam. Face visors
and protection glasses must be disinfected with 70% liquid alcohol (15).
Stress incontinence tests
Maneuvers to increase abdominal pressure either to confirm signal quality or to provoke
stress urinary leakage should be performed through straining (7). Since coughing results
in airborne particles, it should be avoided whenever possible. Instead, Valsalva maneuvers
should be used. If strictly necessary, cough must be directed away from the staff
and with the protection of the elbow or a handheld tissue which must be discarded
promptly. The mask must not be touched. Since urinary leakage must be detected by
the examiner, female patients should be standing or squatting during stress maneuvers
to allow leakage to be seen from distance. During video urodynamics this is not necessary
since the fluoroscopic images may confirm urinary leakage.
COMMENTS
Urodynamics is an essential diagnostic tool in the evaluation of lower urinary tract
dysfunction. After a few months when these tests were virtually deleted from urological
practice due to the COVID-19 pandemic, a slow return towards the reestablishment of
urodynamic practice is on the way. This process needs adaptations and medical societies
are urged to provide guidance. Our current recommendations on good urodynamic practices
during the COVID-19 pandemic are mainly based on the risk stratification system proposed
for surgical procedures (7, 11). In the last few months, expert opinion-based criteria
have been validated by international medical societies, prioritizing high-risk patients
for upper urinary tract deterioration but also considering factors such as current
coronavirus spread rate, flexibilization of social distancing, availability of human
resources and capacity of local health systems. SARS-COV-2 prevention and control
recommendations regarding urodynamic practice are organized into two different levels,
including pre-urodynamic and peri-urodynamic adaptations.
Pre-urodynamic recommendations start by prioritizing patients for examination based
on the risk for upper urinary tract deterioration and whether performing the urodynamic
test would alter the current treatment of the patient, especially if it may involve
a surgical procedure.
Other important measures include reducing the number of daily performed exams to ensure
physical distancing, ample use of phone contact to reduce the length of stay in the
urodynamic unit and to screen for symptoms of infection (i.e., fever, cough, fatigue,
myalgia) as well as known exposure to COVID-19 patients.
Peri-urodynamic measures comprise proper use of personal protective equipment for
both patients and health-care professionals, maintaining ample physical distance and
avoiding cough maneuvers during urodynamic tests.
It is important to emphasize that given the dynamic evolution of the pandemic as well
as the regional differences in our country, the urodynamic practitioner should reconcile
the current recommendations to the local situation.