Archives of Academic Emergency Medicine. 2022; 10(1): e37 OR I G I N A L RE S E A RC H Impact of COVID-19 Pandemic on Emergency Depart- ment Referrals with Urologic Complaints; a Retrospective Cross-Sectional Study Anahita Ansari Jafari1, Babak Javanmard2, Amirhossein Rahavian3∗, Ahmad Reza Rafiezadeh4, Nasrin Borumandnia5, Seyyed Ali Hojjati2, Seyyed Mohammad Hosseininia2, Hormoz Karami3† 1. Laser Application in Medical Sciences Research Center, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2. Urology Department, Shohada-e-Tajrish Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 3. Andrology Research Center, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran. 4. Professor Alborzi Clinical Microbiology Research Center (PACMRC; henceforth), Shiraz University of Medical Sciences, Shiraz, Iran. 5. Urology and Nephrology Research center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: February 2022; Accepted: March 2022; Published online: 17 May 2022 Abstract: Introduction: Medical and surgical priorities were dramatically changed during the COVID-19 pandemic. This study aimed to evaluate the impact of this pandemic on presentation to emergency department (ED) with uro- logic complaint. Methods: This cross-sectional study was conducted at a tertiary urology referral center in Tehran, Iran. The data of all ED admissions were collected and the frequency of admissions with urologic com- plain and their outcomes were compared between two 90-day periods (before and during COVID-19 era). Re- sults: 480 ED admissions were studied. The number of patients visiting the ED with urologic complaint during COVID-19 era was significantly lower than the same period in the pre-COVID-19 period (125 vs. 355 admissions; p = 0.01). The mean hospitalization days for patients in the pre-COVID-19 period were significantly higher (5.6 ± 4.4 vs. 3.2 ± 4.2 days; p <0.001). The most common patient complaints before and during COVID-19 period were flank pain (32.7%) and gross hematuria (32.8%), respectively. The number of patients discharged against medical advice in the COVID-19 period was significantly higher than before (22 (17.6%) vs. 10(2.8%); p < 0.001). The number of patients who developed severe complications was significantly higher in the COVID-19 period than in the pre-COVID-19 period (p = 0.001). Conclusion: During the COVID-19 pandemic we were faced with decreasing frequency of admission with urologic complaint, change in the pattern of referrals, decrease in the duration of hospitalization, increase in the number of patients discharged against medical advice, and increase in the number of cases with irreversible urologic complications or complications requiring surgery due to de- ferred treatment. Keywords: COVID-19; Emergency Service, Hospital; Pandemics; Urology Cite this article as: Ansari Jafari A, Javanmard B, Rahavian A, Rafiezadeh AR, Borumandnia N, Hojjati N, Hosseininia SM, Karami H. Impact of COVID-19 Pandemic on Emergency Department Referrals with Urologic Complaints; a Retrospective Cross-Sectional Study. Arch Acad Emerg Med. 2022; 10(1): e37. https://doi.org/10.22037/aaem.v10i1.1563. ∗Corresponding Author: Amirhossein Rahavian; Andrology Research Center, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran. Tel: 00989134514983, Email: amirrahavian@yahoo.com, ORCID: http://orcid.org/0000-0003-4173-2673. † Corresponding Author: Hormoz Karami; Andrology Research Center, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sci- ences, Yazd, Iran. Tel: 00989131575705, Email: hormozkarami@yahoo.com, ORCID: http://orcid.org/0000-0001-7384-2944. 1. Introduction Pneumonia of unknown etiology was reported in China at the end of December 2019, probably related to a seafood market (1). The authorities closed the market by the 1st of January 2020 and applied strict epidemiological investigations. As a result, scientists were able to isolate and perform genome se- quencing of the 2019 novel Coronavirus (2019-nCOV ) on the 7th of January and gave it to the World Health Organization This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. Ansari Jafari et al. 2 (WHO) on the 12th of January 2020 (2). The first confirmed Coronavirus disease (COVID-19) infec- tions in Iran were announced on 19 February 2020 (3). The World Health Organization declared the outbreak a Public Health Emergency of International Concern on 30 January 2020 and recognized it as a pandemic on 11 March 2020 (4, 5). The COVID-19 virus is arguably the most significant chal- lenge world healthcare systems have faced in the modern era. Medical and surgical priorities were dramatically changed at the time of this pandemic. To save facilities and resources for urgent cases and COVID-19 patients, all outpatient and elec- tive activities were postponed by most of the world’s hospi- tals (6). Stricter healthcare measures were also adopted, like suspending all non-urgent elective surgeries (7, 8) and limit- ing inpatient and outpatient services to critically ill patients, while increasing the critical care capacity (8-10). Many studies were conducted to evaluate the effect of COVID-19 outbreak on the field of urology. Some of them as- sessed the impact of COVID-19 on the education of urology students and residents (11, 12), and others revealed the effect of the COVID-19 pandemic on patients with non-COVID-19 health problems, including urologic emergencies (13). All re- ported the negative effects of the COVID-19 outbreak. We experienced an interesting situation in our hospital (a ter- tiary referral center for urology and one of the leading cen- ters for admission of COVID-19-positive patients during the COVID-19 outbreak). In addition to a reduction in the num- ber of emergency urology patients, we also encountered an increase in ill patients’ request for discharge against medi- cal advice, even after they were told that this could endanger their lives. In this study, we attempt to evaluate the impact of the COVID-19 outbreak on urology emergency patients and fol- low the outcomes of patients who were discharged against medical advice. 2. Methods 2.1. Study design and setting This retrospective cross-sectional study was conducted in Shohada-e-Tajrish Hospital, a tertiary urology referral cen- ter in Tehran, Iran. We reviewed the data of all patients ad- mitted to the emergency department with urologic problems in two 90-day time periods, first, from February 20th to May 20th, 2019 (pre-COVID-19 epidemic period), and the sec- ond, from February 20th to May 20th, 2020 (COVID-19 epi- demic period). Then the frequency of ED admissions with urologic complaint and their outcomes were compared be- tween the two studied periods and possible causes were dis- cussed. The protocol of the study was approved by Ethics committee of Shahid Beheshti University of Medical Sciences (code: IR.SBMU.RETECH.REC.1400.211). Researchers ad- hered to confidentiality of patients’ information and princi- ples of Helsinki declaration regarding the ethical considera- tions in biomedical researches. 2.2. Participants All patients who were admitted to ED with urologic com- plaints in those specific periods of time were included and patients who were admitted due to trauma and surgical com- plications were excluded. Also, patients who were managed by other specialists were excluded. 2.3. Data gathering Using a pre-designed checklist, the patients’ demographic characteristics, chief complaints, final diagnosis, and out- comes were recorded. In addition, patients who were dis- charged against medical advice during these two time peri- ods were listed, and a telephone follow-up was conducted to determine their final outcomes. The outcomes were catego- rized into three groups: group one, those who died due to postponing their treatment. Group two included those who developed severe complications (irreversible complications or complications requiring surgery) due to deferred treat- ment, including renal failure, erectile dysfunction, orchiec- tomy, and penile chordee. Group three included patients for whom a delay in treatment had no effect on their outcome or who were treated at another center. 2.4. Statistical analysis The data were analyzed using SPSS (version 23). Continuous variables are presented as mean ± standard deviation (SD). Categorical variables are presented as numbers (%). Statisti- cal analyses such as chi-square and independent t-test were used. The significance level was set at 0.05. 3. Results 3.1. Baseline characteristics 480 ED admissions were studied. The number of patients visiting the ED with urologic complaint in the studied 90- day period after the beginning of the COVID-19 epidemic was significantly lower than the same period in the previ- ous year (125 vs. 355 admissions; p = 0.01), despite the in- crease in total admission rate during COVID-19 pandemic. The male/female ratio was similar in the pre-COVID-19 pe- riod and during the COVID-19(289/66 vs. 107/18, respec- tively; p = 0.33). Total hospitalization time for patients in the pre-COVID-19 period was significantly higher (5.6 ± 4.4 vs. 3.2 ± 4.2 days; p <0.001). This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2022; 10(1): e37 Table 1: Comparing the frequency of patients’ chief complaints before and during the COVID-19 period Chief complaint Pre-COVID-19 During COVID-19 P value Flank pain 116 (32.7) 22 (17.6) 0.001 Gross hematuria 81(22.8) 41 (32.8) 0.032 Testis pain 40 (11.3) 27 (21.6) 0.006 Urinary retention 37 (10.4) 4 (3.2) 0.014 Lower urinary tract symptoms 30 (8.4) 0 (0) <0.0001 LUTS and fever 21 (5.9) 11 (8.8) 0.297 Abdominal pain 17 (4.8) 6(4.8) 0.401 Nausea and vomiting 7 (2) 4 (3.2) 0.488 Penile pain 6 (1.7) 10 (8) 0.002 Total patients 355 (100) 125 (100) <0.001 Data are presented as frequency (%). LUTS: Lower Urinary Tract Symptoms. Table 2: Characteristics of patients discharged against medical advice in the pre-COVID-19 period and their three-month follow-up N Age Sex CC Underlying Diagnosis Treatment* Follow-up 1 14 Male Testis pain Non Testicular torsion Surgery Orchiectomy in another center 2 12 Male Testis pain Non Testicular torsion Surgery Spontaneous Pain resolution 3 67 Male Scrotal pain DM,HTN Fournier gangrene Surgery Expired 4 30 Female Flank pain and fever Non Pyelonephritis Admission and medical treatment Revisit to emergency and admission 5 39 Male Flank pain and N&V Non Urethral stone Surgery Spontaneous stone passage 6 55 Female Flank pain and fever DM,IHD Emphysematous pyelonephritis Surgery Nephrectomy in another center 7 60 Male Gross hematuria HTN Bladder mass Surgery Revisit 2 weeks later 8 70 Male LUTS CVA Neurogenic bladder Catheter insertion and evaluation Revisit to another center 9 76 Male Testis pain and fever DM Testicular abscess Surgery Orchiectomy 10 80 Male Gross hematuria Prostate cancer Hemorrhagic cystitis Admission and evaluation Relative spontaneous recovery Ages are presented in years; N: number; *: recommended treatment; CC: chief complaint; DM: Diabetes mellitus; HTN: Hypertension; IHD: Ischemic heart disease; N&V: Nausea and vomiting; LUTS: Lower urinary tract symptoms. 3.2. Chief complaints Table 1 compares the frequency of patients’ chief complaints before and during the pre-COVID-19 periods. In pre-COVID- 19 period, flank pain (32.7%) was the most common patient complaint, followed by gross hematuria (22.8%) and testis pain (11.3%). But in the COVID-19 period, gross hematuria (32.8%) was the most common complaint, followed by testis pain (21.6%) and flank pain (17.6%). The number of patients discharged against medical advice in the COVID-19 period was significantly higher compared to the pre-COVID-19 pe- riod (22 (17.6%) vs. 10(2.8%); p < 0.001). 3.3. Discharge against medical advice and its outcomes Tables 2 and 3 show the characteristics of patients discharged against medical advice in the pre-COVID-19 and COVID-19 periods with their three-month follow-ups, respectively. The most common reason for discharge against medical advice in the pre-COVID-19 period was their willingness to seek treat- ment at other centers (70%), treatment being unaffordable (20%), and uncertainty about treatment staff (10%); how- ever, during the COVID-19 period, fear of getting COVID- 19 in the hospital (80%) was the most common reason for self-discharge. The outcomes of patients discharged against medical advice in pre and during COVID-19 era are com- pared in table 4. The number of patients in group two (pa- tients who developed severe complications) was significantly higher in the COVID-19 period compared to the pre-COVID- 19 period (p < 0.001). 4. Discussion Based on the findings, during the COVID-19 pandemic pe- riod we were faced with decreasing frequency of admissions due to urologic complaint, change in the pattern of referrals, decrease in the duration of hospitalization, and increase in the number of patients discharged against medical advice. The numbers of cases who developed irreversible urologic This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. Ansari Jafari et al. 4 Table 3: Characteristics of patients discharged against medical advice in the COVID-19 period and their three-month follow-up N Age Sex CC Underlying Diagnosis Treatment* Follow-up 1 54 Male N&V, fatigue HTN,BPH,DM Uremia Catheterization and work up Renal failure & H/D 2 63 Male Gross hematuria Bladder cancer Bladder cancer recurrence Admission & cystoscopy Relative recovery 3 31 Male Flank pain & hematuria Ureteral stone TUL Stone passage 4 64 Male Gross hematuria Bladder mass TURT Relative recovery 5 86 Male Gross hematuria DM,CVA Prostate cancer Admission and work up Expired 6 56 Male Flank pain after ESWL Renal stone Ureteral catheterization Treatment 2 months later 7 72 Male Scrotal pain and swelling DM Fournier gangrene Surgery Died 8 56 Female Flank pain Ureteral stone Nephrostomy insertion Decreased renal function 9 46 Male Flank pain Ureteral stone TUL Treatment in another center 10 70 Male Gross hematuria Bladder cancer Bladder cancer recurrence TURT Radical cystectomy 11 28 Male Penile pain/ ecchymosis Penis fracture Surgery Penile chordee 12 12 Male Scrotal pain Testis torsion Orchiopexy Orchiectomy 24 hours later 13 30 Female Flank pain and fever Pregnancy, renal stone Pyelonephritis Nephrostomy insertion Revisit to another center 14 52 Male Penile pain DM Peyronie’s disease CCB injection Penile chordee 15 78 Male Gross hematuria Prostate cancer Tumor progression Admission and cystoscopy Revisit one month later 16 32 Male Gross hematuria Urethral wart Wart excision Revisit to another center 17 80 Male Scrotal pain and swelling Colon cancer, DM Fournier gangrene Surgery Expired 48 hours later 18 69 Female Flank pain Renal stone TUL Died due to COVID-19 19 70 Male Gross hematuria Asthma Bladder mass TURT Revisit one months later 20 69 Male Urinary incontinency DM,HTN BPH Catheterization Renal failure 21 15 Male Scrotal pain Testis torsion Orchiopexy Orchiectomy 22 30 Male Penile ecchymosis Penis fracture Surgery Erectile dysfunction Ages are presented in years; N: number; *: recommended treatment; CC: chief complaint; DM: Diabetes mellitus; HTN: Hypertension; CVA: Cerebrovascular accident; N&V: Nausea and vomiting; BPH: Benign prostatic hyperplasia; H/D: Hemodialysis; TUL: Transurethral lithotripsy; TURT: Transurethral resection of tumor; ESWL: Extracorporeal shock wave lithotripsy; CCB: Calcium channel blocker. Table 4: Comparing the outcomes of patients discharged against medical advice between pre-COVID-19 and COVID-19 eras Period Total Outcome P value Group 1 Group 2 Group 3 Pre-COVID-19 10(100) 1(10) 2(20) 7(70) 0.001 COVID-19 22(100) 2(9) 12(55) 8(36) P value <0.001 0.16 0.001 0.03 Data are presented as frequency (%). Group one: Those who died due to postponing their treatment; Group two: Those who developed severe complications due to deferred treatment; Group three: Patients for whom a delay in treatment had no effect on their outcome or who were treated at another center. complications or complications requiring surgery due to de- ferred treatment were also increased in the COVID-19 era. The COVID-19 pandemic in 2020 caused a sudden and dou- ble burden on the health care systems of all countries, and different countries dealt with this situation in different ways. For example, in the field of urology, the first step was to sus- pend all non-urgent elective surgeries. The second step was to discharge inpatients at the first opportunity permitted by This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2022; 10(1): e37 the patient’s clinical condition (7). These steps freed up more facilities and hospital beds for COVID-19 patients and de- creased the length of hospital stay for patients with urolog- ical complaints. Our research revealed significant reductions in emergency urologic visits to our hospital at the beginning of the COVID- 19 pandemic. This result was confirmed by other studies in different countries (8, 13), with Motterle showing that seeking care in the year 2020 (vs. 2019) was a significant predictor of admission (OR:2.71). The results strongly sug- gest that COVID-19 significantly influenced people’s urologic care-seeking behavior (14). We can conclude that the fear of being infected by COVID-19 made people avoid attending health care centers unless they had no other choice, instead preferring to tolerate or treat their problems conservatively. A reduction in elective urology surgeries and visits during the COVID-19 period is reasonable. However, a decrease in urol- ogy emergency visits is potentially dangerous because a de- lay in treatment for some patients could be life threatening or may cause severe complications. While our hospital is a urology tertiary referral center, dur- ing the COVID-19 pandemic, it became a referral center for COVID-19 patients. Therefore, patients tended to stay in the hospital as little as possible due to fear of COVID-19 infec- tion. As a result, the mean hospital stays were reduced signif- icantly (5.6±4.4 vs. 3.2±4.2 days, p-value <0.001), and the rate of discharge against medical advice increased significantly (17.6% vs. 2.8%, p-value: 0.001). For the first time, we followed up and compared the out- comes of patients discharged against medical advice and found that these patients had more than twice as many com- plications in the COVID-19 period than in the pre-COVID- 19 period, when many complications were prevented with timely procedures. Since we may face similar situations in the future, we need to be prepared. Many of the solutions introduced in this crisis were mainly based on prioritizing patients and surg- eries (14); we would like to provide another solution. We suggest it would be better to determine a certain number of medical centers that would be able to provide the neces- sary emergency services to patients. The patients could then go to these “clean centers” confidently and without fear of contamination. In this plan, patients would not postpone their treatment due to fear of contamination, and perform- ing some elective surgeries is possible. We suggest the idea of establishing “clean centers” for managing emergency pa- tients as a viable solution for similar future situations. 5. Limitations Some of the limitations of our study were the short period studied in this research and the limited amount of data col- lected due to COVID-19’s relatively short history. Future studies should cover the influence of COVID-19 pandemic on long-term urologic services and will be able to utilize a more extensive data set as more time passes. 6. Conclusion Based on the findings, during the COVID-19 pandemic pe- riod we were faced with decrease in frequency of admissions due to urologic complaints, change in the pattern of refer- rals, decrease in the duration of hospitalization, and increase in the number of patients discharged against medical ad- vice. The number of cases who developed irreversible uro- logic complications or complications requiring surgery due to deferred treatment were also increased in the COVID-19 era. 7. Declarations 7.1. Acknowledgments We are thankful to all medical staff for their cooperating in the fight against COVID-19. Also, we appreciate all the ef- forts of personnel in charge of the hospital’s archive of medi- cal records for helping us gather the required data. 7.2. Data availability Authors guarantee that data of the study are available and will be provided if anyone needs them. 7.3. Authors’ contributions AAD: Conception and design, protocol development, gaining ethical approval, BJ: researched literature and conceived the study, NB: patient recruitment and data analysis, SAH and SMH: Collected the data; Contributed data or analysis tools, HK: Critical revision of the manuscript for important intel- lectual content, Supervision, ARR: wrote the first draft of the manuscript, AR: wrote the first draft of the manuscript, data analysis, Supervision 7.4. 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Eur Urol Focus. 2020;6(5):1070-85. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods Results Discussion Limitations Conclusion Declarations References