key: cord-0926609-xlbh9kqu authors: Pereira‐Correia, João A.; Gomes, Carlos M. P. P.; Barbosa, Paulo H. N.; Salomão, Bruno A.; Morais, Heitor S.; Muller, Valter J. F. title: Safe urodynamic practices in times of COVID‐19: What can be accomplished and what can be added? date: 2022-04-02 journal: Neurourol Urodyn DOI: 10.1002/nau.24907 sha: 54a76adbac0b96a3a6c5d438f90b809c78492b17 doc_id: 926609 cord_uid: xlbh9kqu AIM: To present feedback, after applying national and international urodynamic study (UDS) recommendations for safe practice during the COVID‐19 pandemic. METHODS: We created a checklist to assess the feasibility of performing UDS recommendations for safe practice during the COVID‐19 pandemic from the first week of May 2021 to the last week of July 2021. RESULTS: One hundred patients were analyzed during the study period. We observed that all preventive recommendations for the steps that precede UDS could be followed in full. However, some guidelines for performing the exam were not feasible in all patients. We have successfully adopted other safety measures for all patients. CONCLUSIONS: The COVID‐19 pandemic will likely persist for several more years. We believe that continuous improvement, revision, and updating of existing protocols and guidelines for the safe practice of UDS in times of COVID‐19, as we propose in this study, should be encouraged. The COVID-19 pandemic has disrupted urological practice substantially. Reductions in the number of surgeries, medical consultations, and elective procedures are examples of impediments due to the social distancing necessary to control SARS-CoV-2 transmission. 1, 2 In this context, the performance of urodynamic studies (UDS) has also been encumbered. Because UDS are generally indicated to diagnose nonurgent conditions, many patients postponed their UDS, and many physicians, in turn, reduced the frequency of performing or simply stopped performing these exams in recent months. 1, 2 However, as UDS are considered the gold standard for the diagnosis of various lower urinary tract disorders, 3 we do not yet know the long-term health consequences of this reduced access to care. Better knowledge of COVID-19 and its transmission dynamics, as well as the introduction of diagnostic methods and vaccines, have led to the publication of recommendations for the safe practice of UDS, to facilitate the delivery of urologic care even in times of pandemic disease. We present our feedback, after applying these recommendations in daily practice, and offer pertinent recommendations for future implementation. After authorization from the local Research Ethics Committee, we prospectively analyzed the manner in which UDS were conducted from the first week of May 2021 to the last week of July 2021 in our urodynamic center, using the latest version of Dynamed™ (Dynamed™), urodynamic equipment (Dynapack Slim™ Hardware and Urocommander™ Software), and following the recommendations for good practice endorsed by the International Society of Continence (ICS). [4] [5] [6] We created a checklist to assess the feasibility of performing UDS based on national 7 and international 8 recommendations for safe practice during the COVID-19 pandemic (Table 1) . Statistical analysis was performed using GraphPad Prism™ software, version 7, applying Kolmogorov-Smirnov's test for normality analysis. For data with a Gaussian distribution, a comparative intergroup evaluation Student's t-test was used. However, for data with a non-Gaussian distribution, the Kruskal-Wallis test was used, adopting the standard significance value of p < 0.05. One hundred patients were analyzed during the study period. Results are shown in Table 2 . We observed that all preventive recommendations for the steps that precede UDS could be followed in full (Table 2 ). However, some guidelines for performing the exam were not feasible in all patients. Maintaining the recommended distance of 2 m between the examiner and the patient was not possible in 28 patients (approximately 30% of cases), due to the dislodging of urethral catheters caused by the loss of adhesion of the catheter to the patients' skin. This occurred in patients who had urinary leakage at minimal effort and/or continuous urination that moistened the region where the adhesive tape was applied, forcing the examiner to approach the patient during the procedure. The replacement of cough by Valsalva maneuver was not possible in 44% of the patients, due to inadequate generation of intra-abdominal pressure that confounded assessments for exertion-related and post-prostatectomy urinary incontinence. Furthermore, examination in the standing position was impossible for patients for whom the combination of perineal electromyography with UDS was indicated (12 patients). The other recommendations applicable during UDS, as shown in Table 2 , could be applied to 100% of the patients. It is noteworthy that ventilation of the examination room was facilitated by keeping the windows open, after confirming that the patient's privacy would be maintained. We have successfully adopted other safety measures in all patients (Table 3 ). We observed that not all recommendations for conducting UDS safely during the COVID-19 pandemic can be implemented in daily practice (Table 4 ). We also realized that even the recommendations that can be fully implemented may be difficult to apply under certain conditions. The replacement of the cough maneuver by Valsalva maneuver, for example, is proposed in safety protocols to avoid the dispersion of aerosols, an important mode of COVID-19 transmission. 9 This intervention, however, was the most detrimental to good urodynamic practice, since in almost half of our sample, it precluded an adequate investigation of bladder function during states of high intraabdominal pressure. Although the International Consultation on Incontinence (ICI) does not recommend Valsalva leak point pressure as a single factor to grade the severity of urinary incontinence, or to predict urinary stress incontinence (recommendation Grade C) and surgical treatment outcomes, 10 optimal urodynamic practice entails the investigation of the effects of pelvic floor stress and external urethral sphincter function under varying degrees of intraabdominal pressure, requiring the use of cough during UDS in the vast majority of patients. Despite these findings, we believe that Valsalva (or other abdominal pressure rises maneuvers) should be tried first, and only then do coughs. Close proximity between the examiner and the patient can facilitate COVID-19 transmission. 11, 12 The ideal distance between the patient and examiner was not preserved in 28% of patients, due to repositioning of displaced urethral catheters, especially when the medial surface of the patient's thigh had been moistened after urinary incontinence during exercise testing. We believe that topical adhesives, such as benzoin tincture, could be used in patients with histories of urinary incontinence. The use of the orthostatic position, which facilitates the identification of urinary losses at a distance, was not possible during perineal electromyography, thus obviating the maintenance of an adequate distance between physician and patients. Some studies have shown that performing electromyography in the orthostatic position could compromise the assessment of the test results. [13] [14] [15] Thus, we have a protocol in our urodynamics center not to perform the study in this position. Examination room ventilation is one of the primary safety measures to prevent the spread of COVID-19. 16, 17 Although we managed to keep a wide window open during all UDS without compromising patient privacy, we acknowledge that this approach is not possible in all settings. Some buildings do not have windows in urodynamic exam rooms, and weather conditions such as extreme cold may obviate this recommendation in some locations. In these cases, an upgrade of ventilation systems with portable air cleaners or disinfectants (such as UV lamps or high-efficiency filtration systems) to remove airborne pathogens, including SARS-CoV-2, could be useful. 16 T A B L E 1 Questionnaire designed to prospectively assess the feasibility of applying recommendations for the safe practice of urodynamic testing during the COVID-19 pandemic Before urodynamic studies (UDS) We have implemented additional measures into our practice, and recommend that they be incorporated into the existing protocols. Mathematical models of indoor air circulation suggest that environments with lower occupancy present a diminished risk of COVID-19 transmission. [18] [19] [20] [21] Thus, in addition to decreasing the number of individuals in the UDS room, we also recommend reducing the amount of furniture to further mitigate crowding. Massive testing utilizing RT-PCR is an important strategy to control COVID-19 transmission. 22 Therefore, following the recommendations of the Centers for Disease Control and Prevention, we perform and recommend testing of all patients and health professionals who provide UDS. Another adopted recommendation is complete COVID-19 vaccination of our staff, considering evidence available in our country that associates drastic reductions of COVID-19 incidence and mortality with massive vaccination of the population. 23 The effect of crowding on COVID-19 transmission has been highlighted in several studies, such as the elegant publication by Geng et al. 24 Yasri and Wiwanitkit 25 have highlighted the potential for COVID-19 transmission during the use of public transportation. Consequently, we have implemented and recommended the scheduling of UDS patient appointments at times when vehicular traffic is less intense. Thus, patients who use public transportation will avoid travel in crowded vehicle interiors during rush hours. The COVID-19 pandemic will likely persist for several more years, especially due to vaccine hesitancy and barriers to vaccine access in some population groups. Consequently, we believe that continuous improvement, revision, and updating of existing protocols and guidelines for the safe practice of UDS in times of COVID-19, as we propose in this study, should be encouraged. 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 Challenges in urology during the COVID-19 pandemic Pressure flow urodynamic studies: the gold standard for diagnosing bladder outlet obstruction Good urodynamic practices: uroflowmetry, filling cystometry and pressure-flow studies International Continence Society Good Urodynamic Practices and Terms 2016: urodynamics, uroflowmetry, cystometry, and pressure-flow study Fundamentals of urodynamic practice, based on International Continence Society good urodynamic practices recommendations Interim guidance for urodynamic practice during COVID-19 pandemic Good urodynamic practice adaptations during the COVID-19 pandemic COVID-19 transmission, current treatment, and future therapeutic strategies Urodynamic testing. Incontinence Social distancing alters the clinical course of COVID-19 in young adults: a comparative cohort study Physical distancing or social distancing: that is the question Pelvic floor muscle function differs between supine and standing positions in women with stress urinary incontinence: an experimental crossover study Comparison of vaginal electromyography (EMG) in lying, sitting and standing The effect of aging on the electromyographic activity of pelvic floor muscles. A comparative study among stress incontinent patients and asymptomatic women A systematic review of possible airborne transmission of the COVID-19 virus (SARS-CoV-2) in the indoor air environment Role of indoor aerosols for COVID-19 viral transmission: a review Colorado Department of Public Health and Environment. Social Distance Space Calculator A guideline to limit indoor airborne transmission of COVID-19 Two metres or one: what is the evidence for physical distancing in Covid-19? How can airborne transmission of COVID-19 indoors be minimised? Massive and rapid COVID-19 testing is feasible by extraction-free SARS-CoV-2 RT-PCR Our World in Data. Statistics and Research: Coronavirus (COVID-19) Cases Population agglomeration is a harbinger of the spatial complexity of COVID-19 Safe urodynamic practices in times of COVID-19: What can be accomplished and what can be added? The authors declare no conflict of interest. Study approval number by the local ethics committee: 77023617.6.0000.5284. DATA AVAILABILITY STATEMENT Data Availability Statement is not available.