By Gretchen Lentz, MD
Professor and Division Director of Urogynecology at the University of Washington Medical Center, Dr. Gretchen Lentz has spoken countless times for Symposia Medicus over the last decade. Dr. Lentz offers her timely take on the topic of telemedicine as it pertains to gynecologic care—particularly during the pandemic.
The telemedicine gynecologic jokes and photos started flying around in April 2020 with the COVID-19 lockdown. We were all rapidly struggling to figure out how to do telemedicine for gynecology and urogynecology visits. I’m not going to share photos of women straddling their laptops to show their “privates” on telemedicine, as perhaps only gynecologists would find this amusing. While my patients refrained from doing that, we did have patients sharing photos of their vulvas on our secure EPIC platform.
I must say, it did help decide if they needed to come into clinic or not–Bartholin’s abscess? Yes, come in. Urethrocele? No, don’t come in. Hemorrhoid? No, don’t come in.
We were fortunate. Obstetricians were already using telemedicine for some routine OB visits and had given out the care kits with BP cuffs and urine dipsticks. Also, the urology clinic where I work was already using telemedicine. We had template consents and verbiage to gain consent, online training for credentialing, HIPAA-compliant Zoom, and the physical equipment in place.
What Worked & What Didn’t in Telemedicine:
WHAT WORKED:
- Overactive bladder visits and follow-up. This is often behavioral counseling on fluid management, avoidance of dietary irritants, bladder retraining, and medication management.
- Recurrent urinary tract infection visits and follow-up. We can offer behavioral suggestions on increasing water intake if appropriate, non-antibiotic suggestions, and medication management.
- Post-ops! This surprised me, but most people do fine and telemedicine worked to decide whether someone needed to come in or not.
- Pelvic floor PT. I said it was impossible, but my PTs tell me otherwise (see below).
- Pre-ops! We had to sign the written consent sheet the day of surgery and update the physical exam, but it didn’t take that long.
- Counseling on surgery for pelvic organ prolapse and urinary incontinence. Surgery discussions take far longer now when needed to address mesh implantation and risks. Telemedicine is a good way to bill based on time for these lengthy visits. Also, the increased interest in uterine preservation at the time of prolapse surgery necessitates even more discussion.
- Same-day discharge. We had been doing this for vaginal hysterectomy, total laparoscopic hysterectomy, and mesh slings, but not after hysterectomy with additional prolapse repairs. Due to the hospital being full and not allowing patients to stay overnight, we sent them home with a Foley catheter and vaginal packing. We saw them back in clinic the next day for removal of both. We rarely had problems, although a few needed to stay overnight for nausea or pain control.
WHAT DIDN’T:
- Pelvic organ prolapse. We need to examine patients for this.
- Pain. We need to examine patients for this.
- Incontinence was plus/minus. We need to do an exam and get urinalysis and post-void residual urine at some point. But initial assessment and treatment on telemedicine was reasonable.
If a patient insists on telehealth to begin with, we discuss the limitations, I pick a direction for treatment based on their history and symptoms, and give it a try. If I am not seeing the results, then I ask them to come in when they feel safe or ready.
Pessary & Estring Use During COVID-19
Early on, I wrote a document for our three-hospital system with guidelines called, “PESSARY & ESTRING USE DURING COVID.”
- Pessaries (ring, dish, Gellhorn) can be left in for six months if long-term user and no vaginal bleeding or increased discharge. (Reference OB/GYN January 2020, Vol 125, Issue 1, p 100-105)
- Cube pessary cleaning needs to be individualized. The ideal management should be removed before bedtime, cleaned, and left out overnight. If using longer, the provider determines necessity and timing of visit. See patient urgently if vaginal bleeding or foul discharge occurs. Consider leaving a cube pessary out during COVID-19 if possible to avoid the vaginal ulceration complications. But, for treatment of urinary retention or other serious problems (hydronephrosis), consider leaving in or consider option #3.
- If pessary falls out or needs to be left out, offer V Brace by FEMBRACE (purchase on Amazon for $78.66)
- MD or ARNP should assess in clinic if vaginal bleeding or foul discharge rather than only RN visit
- ESTRING can be left in longer than 90 days with little harm. ESTRING still has 1mg of estradiol left in the ring at 90 days. Probably not much defuses out after that, but no harm in leaving in.
Later, a paper on national recommendations came out (Propst K, et al. Timing of Office Based Pessary Care. Obstet Gynecol 2020;135:100).
Pelvic Floor Therapy—Impossible?
Two of our PT experts said…
“I feel like I have been able to give some pretty good care via telemedicine specifically for patient education in bladder retraining, bladder habits, defecation mechanics, pressure management for prolapse, and beginning some training regarding pelvic pain. For the pregnant/postpartum population, it has worked well for me to do training in body mechanics, lifting techniques, and core strengthening, etc.”
– Tina Allen, PT
“My pregnancy and postpartum patients have converted to telehealth nicely, particularly those with musculoskeletal complaints. The postpartum patients with pelvic floor complaints I have been able to follow up very quickly postpartum, often earlier than I would see them in the clinic. For education, suggestions on how to return to pelvic floor strengthening tailored to their delivery experience, reminders on body mechanics, and answer questions regarding return to exercise, etc. This often works best if I already have an established relationship with the patient and know they can properly perform a pelvic floor contraction and understand the instructions.”
– Valerie Bobb, PT
Both agreed that patients need to come in for assessment of the pelvic floor to be sure they are doing their pelvic floor strengthening correctly or for training with pelvic pain/dyspareunia at some point. But, after the initial assessment, patients can do at least a few sessions via telemedicine to assist them with progressing their program. Generally, a “hybrid” approach works best with some in-person sessions and some telemedicine sessions. For example, for a patient with urgency/frequent urination, some education is done well over telehealth. Urinary incontinence doesn’t always mean the pelvic floor muscles are elongated and weak, it can mean lack of coordination or that the pelvic floor muscles are overactive and weak. That is best found on the exam.
The University of Washington Medicine system tracked telemedicine visits with over 31,000 visits in April 2020 and over 33,000 visits in May 2020. When we locked down again, we saw 29,000 visits in December 2020. Even as the pandemic eventually subsides, our system anticipates that telemedicine will continue to account for roughly 20% of ambulatory clinic visits.
After the University of Washington’s 100,000th telemedicine visit in June, they conducted a provider survey. 80 percent of providers strongly agreed that they’ll continue to offer telemedicine in the future. 56 percent of providers rated their overall experience as an 8 or higher (out of 10). That obviously leaves room for improvement.
Telemedicine pros in our system:
- Patient-centered care, improved access, convenience, fewer no-shows
- Patient and provider safety during COVID-19, preserving PPE
- Technology functioning well, EPIC integration working well, Zoom interpreters working well
- Great for particular patients’ needs like medication discussions
Telemedicine improvements needed:
- Improved instruction and technical support for patients and patients with interpreter needs
- Processes to prevent patients from scheduling telemedicine for clinically inappropriate issues
Telemedicine is here to stay—even for gynecology!
Dr. Lentz is a professor at the University of Washington Medical Center. She lives in Seattle, Washington.