Telemedicine and VUR

In this episode of the PedSpace, Dr. Aaron Martin discusses how telemedicine can be a vital tool for vesicoureteral reflux (VUR). In his practice he has seen a significant percentage of children with VUR who also have bladder and bowel dysfunction (BBD). With telemedicine now being used routinely, it is a valuable tool for enhancing treatment. This conversation dives deep into the benefits of telemedicine in enhancing patient care and increasing patient compliance for treatment protocol.

Dr. Aaron Martin completed his urology residency at Mayo Clinic Arizona and pediatric urology fellowship at Children’s National in Washington, DC. He practices at Children’s Hospital New Orleans where he also serves as Telemedicine Medical Director. His research interests focus on the intersection of medicine, technology, and healthcare delivery with several projects involving telemedicine and surgical device innovation.

Transcript

Welcome back to the PedSpace.

I’m Simone Howell, Head of Medical Affairs for Palette Life Sciences.

Palette Life Sciences, sponsor of this podcast, is committed to bringing educational tools such as The PedSpace, for sharing best practices and compelling conversations across a wide variety of pediatric urology and VUR topics.

Today’s episode is the second podcast for Dr. Aaron Martin, a pediatric urologist at LSU Children’s Hospital in New Orleans. As an addendum to his very interesting first podcast about the art of telemedicine, Dr. Martin now goes into more specifics on how telemedicine has helped him to improve patient care, specifically treating VUR and Bowel disorder.   The content in this podcast is solely the opinion of Dr. Martin.

And now, it is my pleasure to again introduce - Dr. Aaron Martin.

First I’d like to thank Palette Life Sciences for providing this opportunity and inviting me to record this podcast. As we all know they provide Deflux which gives us a truly minimally invasive treatment for vesicoureteral reflux in children. It is only fitting that I talk about reflux and how telemedicine can play a role. There's a great editorial that Dr. Coyle, who's a senior author in the journal Pediatric Urology in 2017 entitled ‘coming full circle with vesicoureteral reflux from hutch to bladder and bowel dysfunction’. This is a great summary of the history of the thinking behind treatment and cause a vesicoureteral reflux over the years and I encourage you to read it, but towards the end of the article they quote Sir William Osler saying “only the answers change the problems remain the same.”

I found this quite fitting when thinking about how to apply telemedicine to reflux. I'm not going to suggest remote telesurgery or any other fancy applications of telemedicine, but I have found telemedicine to be an answer of sorts or more accurately an enhancement of sorts of the care that these families  receive. Recently everyone has been forced to look at their own practices and provide telemedicine basically out of necessity instead of my choice. I personally have been utilizing telemedicine in my practice by choice for several years and would never turn back. The ability to be available for patients and make care more convenient alone is worth the investment. And patients universally love it and I encourage everyone to give it a try if you haven't.

 So, when we think about telemedicine being an answer to the same old problem of reflux-- what is that answer? First you must recognize that the ill-effects, the spontaneous resolution rate in even the success of surgery for reflux all rely on one major issue: the relationship of bowel function on bladder function. Every pediatric urologist dream topic right? We know that the bowels play a huge role, even in the absence of reflux it is the poor bowel management that is usually to blame for incontinence, nocturnal enuresis, chronic vaginitis, and recurrent urinary tract infections. Add reflux to the mix and you have a setup for pyelonephritis and renal scarring. While we can't seem to agree on how to treat it and even perfectly define it-- We do agree it's real and probably more complex than we realize with even some suggesting a congenital origin as opposed to a learned behavior.

So what do we know? Well we know to stop renal damage we need to stop febrile UTIs and then in kids with reflux this does not always mean surgery. We know from multiple large studies and compiled in our AUA guidelines on reflux that fixing bladder bowel dysfunction is key to this and even evident when a child is on antibiotic prophylaxis. None of us went to this field wanting to be a gastroenterologist, at least no one I know. However, if you don't pay close attention to the bowels first and foremost when it comes to avoiding issues-- we will either be doing far too much surgery having poor outcomes especially with deflux or having frustrated parents looking answers elsewhere.

 If we can stop febrile UTIs in patients with reflux without using and continuous antibiotics then there is no need for surgery. There's no need for follow-up VCUGs and generally the same treatment cures all their other wetting frequency and urgency issues. 

I remember one of my mentors Dr. Kalu at Children's National always getting teased about curing everything with Fiber Gummies and the cause of every year urologic ailment was constipation. Now obviously she didn't believe that, I get the point now-- now that I have to see my own patients back I realize how close to the truth that actually is. I've become the Dr. Kalu of my practice, in the relationship between the bowel in the bladder is real and success in these patients can be as simple as Fiber Gummies. Now certainly she never believed that caused everything and I don't bring a plastic perfect poop model into my visits like she did, but I now get the point. If we don't stress it thoroughly to patients they too won't believe it for the simple fact that it sounds too simple to be true. I’ve even had patients tell me that ‘this just sounds too easy just can't work’. It really takes some time investment to get patients to buy into such a simple treatment.

So how can telemedicine be an answer to reflux? Telemedicine allows you to put in that time in a manner that is convenient for you and convenient for the patient. To get compliance with any regimen-- it requires frequent check-ins and that seems to be especially true when the treatment is bowel care when they came to you for urinary issues.

Now there is little evidence to suggest one bowel regimen over another and everyone has their own spiel--mine talks about the size of the pelvis and dilation of the rectum with poor rectal emptying. Trying to avoid the ‘c word’ constipation which seems to offend everyone for some unknown reason. I borrow from Doctor Kalu the lovely description of normal bowel movements as daily like ‘chocolate soft serve ice cream in the toilet.’ Because this is the image people have trouble forgetting then I go on to explain a regimen of daily Fiber Gummies or fiber powder followed by Miralax or cleanouts if unsuccessful. Again everybody has her own and consistency is the key not the agent in all likelihood, but I do feel what is more important though is the follow-up. This is where telemedicine comes in handy I follow all voiding disfunction patients including those with reflux every two months with a telemedicine visit either with myself or in our virtual healthy border clinic with my nurse practitioner. I find 2 months is about the limits of any parents patients if I can get them to buy into the regimen and about the time they will start to see real improvements if they have been faithful is around two months. This gives the perfect time to assess how well it is working and give encouragement to continue on or fine tune how things are already going or get them to start.

Once they have proven themselves I space this out further-- maybe going every 4 months or every six months. There's no need for them to travel to see me and this is an easy way to assure them I care about their outcomes and truly want to see their child get better. And they believe this partly because they're coming to see me in 2 months not coming to see me six months down the road. I don't even have him get the child out of school for this visit as long as they know their child's bowel and bladder habits I'm perfectly fine doing with just them. There's nothing on the physical exam I need to get at this point, I’ve  already examined in the office so there really is no sacrifice. At this point I give them just the same visit they would get if they came into the office, except they don't have to wait in the waiting room forever. 

So is this the best way? Maybe--it works for me, my patients love it. We’re working on getting a check to data to see if this is better or my suspicions at least just as good with higher satisfaction overall. I encourage everyone now that you've been forced into telemedicine to give it a try. I'll give you another quote before you go this one is by Voltaire he said “the art of medicine consists of amusing the patient while nature cures the disease”It’s hard to argue he wasn't talking about vascular uritial reflux but I think it certainly applies. Bottom line if we can gain our patients trust to maintain their attention on a proper bowel regimen this will decrease the risk of urinary tract infections which will decrease the risk of renal scarring and improve their odds of spontaneous reflux resolution however when surgery is indicated the bowel regimen continues to be important to improve success after surgery especially in the setting of deflux.

Thanks for joining us this week on The PedSpace!

We hope you enjoyed Dr. Martin’s perspective. Feel free to share with your colleagues while we deliver more pediatric urology-focused content in the coming weeks. There are some great resources for you and your patients for Deflux on www.Deflux.com Additionally, you can learn more about our company and our products on www.Palettelifesciences.com