Priya Padmanabhan, MD, MPH

The coronavirus disease 2019 (COVID-19) pandemic has triggered a rapid rise in the use of telemedicine across all specialties, including female pelvic medicine and reconstructive surgery (FPMRS). In an attempt to flatten the curve of transmission, we have made radical changes in the way we provide quality, comprehensive care for our patients.

Telemedicine has classically been useful for providing behavioral therapy, conservative and pharmacological treatment. In these cases, treatment is based on symptom improvement and not physical exam. FPMRS encompasses a spectrum of conditions with varied treatments. An initial challenge exists in identifying the appropriate patients for postoperative telemedicine visits. The nature of the condition, the follow-up questions, and the necessary tests dictate the need for an office-based postoperative visit. For example, subjective questions may assess the response to a midurethral sling. This is not the case, however, for recovery after genitourinary fistula surgery.

The effectiveness of virtual postoperative tension-free vaginal tape visits was first highlighted by Jefferis et al.

 Recently, in an international, prospective, multi-institutional, randomized control trial, the use of telemedicine in the early postoperative follow-up period after midurethral sling was presented at the 2020 American Urological Association Virtual Experience.

 A total of 237 patients were randomized 1:1 to telemedicine or office-based 3-week follow-up. Seventy percent of patients were equally “very satisfied” with their surgical outcomes. Predictors of satisfaction included non-Caucasian ethnicity and no college-level education. Sixteen (13.2%) of the patients requested crossover to office-based visits. Age greater than 65 years was the only predictor of this crossover. The telemedicine group was the most adherent to 3- to 5-month office-based follow-up.

Patients undergoing midurethral sling placement are ideal for postoperative virtual visits. Clinicians may assess success in most cases with subjective questions and quality-of-life questionnaires and, again through appropriate questions, easily identify irregularities. Complications such as an obstructing sling or mesh erosion create symptoms that a patient will easily notice. In such cases, clinicians may ask the patient to come in for a physical exam and testing.

The use of early virtual follow-up provides a balance of patient satisfaction, clinical utilization, and resource conservation. Reimbursement is based on a 90-day global period post sling. With equal satisfaction of both types of visits, a 3- to 5-month office-based visit is beneficial to the patient and clinic. Prior to COVID-19, only 15% of providers reported using telehealth regularly. This was related to obvious barriers that are rapidly being overcome, including lack of training, gaps in technology access and familiarity, apprehension around adoption of the new platform, and reimbursement.

With the foray into telemedicine during the COVID-19 pandemic, we have witnessed rapid growth in our knowledge and patient accessibility. It is clear that virtual visits are a viable option, well liked by patients and physicians alike. Both virtual and office platforms may provide excellent care without compromising quality. The changes in reimbursements are promising. Time will tell how FPMRS further utilizes telemedicine.

® Editorial Council, is a professor of urology at Oakland University William Beaumont School of Medicine, Royal Oak, Michigan.

1. Jefferis H, Muriithi F, White B, et al. Telephone follow-up after day case tension-free vaginal tape insertion. 

2016;27(5):787-790. doi:10.1007/s00192-015-2891-6

2. Derisavifard S, Rueb J, Kocher N, et al. Telemedicine optimizes early post-operative follow up after synthetic mid-urethral sling (MUS): a randomized multi-institutional control trial. Paper presented at: 2020 American Urological Association Virtual Experience; June 27-28, 2020

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"Patients undergoing midurethral sling placement are ideal for postoperative virtual visits," writes Priya Padmanabhan, MD, MPH.

Foray of FPMRS into telemedicine during the coronavirus pandemic

 Editorial Council, is professor of urology, Oakland University William Beaumont School of Medicine, Royal Oak, MI.

 The abstract by Dr. Chancellor et al discussed in this editorial was selected for coverage in Urology Times by Dr. Padmanabhan while she was associate professor of urology at the University of Kansas Medical Center.

The significance of the “elixir of life” dates back to 1889 when Charles Edouard Brown-Sequard injected himself with liquid extracted from dog or guinea pig testicles. Testosterone has since been well studied for its anabolic, metabolic, and developmental properties in men and women. With the number of Americans 65 years and older doubling from 2018 to 2060, there is much focus on the effects of these associated hormone changes.

A large portion of serum testosterone is not biologically active. Total testosterone levels include both free testosterone and bound testosterone. Ninety-eight percent of testosterone circulates in the body bound to proteins (60% to albumin and 40% to sex hormone binding globulin). The remaining 2% is free (floating). Only the free and albumin-bound hormone are truly “bioavailable” to the cells.

There are multiple factors, such as smoking, obesity, and muscle mass, that impact total testosterone levels. Testosterone production has a circadian rhythm, which creates additional challenges for measurement. Testosterone levels decline in men, starting as early as 30 years, yet levels decline in women only after menopause. This decline has many associated signs and symptoms including, but not limited to: change in sleep patterns, worsening of sleep apnea, and physical, sexual, and emotional changes.

Positive dipstick does not preclude BTX injections

A recent study from Michael B. Chancellor, MD, of Oakland University William Beaumont School of Medicine assessed the correlation between decreased testosterone levels and urinary incontinence in older women who participated in the Health, Aging and Body Composition Study (see article 

 Nearly half of women >50 years of age experience incontinence, which continues to increase with age. Androgen receptors throughout the pelvic floor and lower urinary tract play an important role in pelvic floor musculature and function.

Prior studies have alluded to the diminishing effects of low testosterone on the pelvic floor musculature, yet the relationship between postmenopausal testosterone level and incontinence is unknown. This study was successful in collecting data from a large, healthy group of women and men 70-79 years old. Measurement of serum free testosterone and total testosterone was performed along with quality of life surveys and self-reported daily urinary leakage. The collection of free testosterone is important for the detection of bioavailable testosterone.

Results indicated that serum testosterone is decreased in women with urinary incontinence less than once per month and showed a trend toward higher free testosterone in women with incontinence more than once per month.

It is challenging to study the impact of testosterone level alone on postmenopausal incontinence, given the equally significant effects of diminished estrogen. The circadian rhythm and overall lower concentration of testosterone in women limits the reliability of measurement. 

Ideally, free and total testosterone should be drawn first thing in the morning and at alternate time points to ensure reliability of the test results. With involvement of urologists in the future, confounding factors-smoking , obesity, sleep patterns-should also be included in the evaluation to more accurately reflect the correlation.

Hormone replacement has become a fad, with creams, gels, and troche being created like designer jeans. Incontinence represents an expensive, multifactorial, health care beast. Testosterone replacement is not a panacea for incontinence. Future research with urologist involvement, to isolate confounding factors and consider serum level variability and other hormone effects, will be useful.

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"Future research with urologist involvement, to isolate confounding factors and consider serum level variability and other hormone
	effects, will be useful," writes Priya Padmanabhan, MD, MPH.

Priya Padmanabhan, MD, MPH

Articles

Foray of FPMRS into telemedicine during the coronavirus pandemic

Testosterone: A panacea for incontinence patients?