High rates of anorectal chlamydia in women: a cross-sectional study in general practice.

BACKGROUND: Genital and anorectal Chlamydia trachomatis (CT) frequently present together in sexually transmitted infection (STI) clinics. AIM: To investigate the prevalence of co-occurrent genital and anorectal chlamydia infection, and to study whether sexual behaviour is associated with anorectal infection. DESIGN & SETTING: A cross-sectional study in general practices in the north of the Netherlands. METHOD: Women attending general practice with an indication for genital chlamydia testing were included and asked to complete a structured questionnaire on sexual behaviour. Anorectal infection prevalence was compared according to testing indications: standard versus experimental (based on questionnaire answers). Variables associated with anorectal chlamydia were analysed by univariate and multivariate logistic regression analyses. RESULTS: Data could be analysed for 497 of 515 women included. Overall, 17.8% (n = 87/490) were positive for CT; of these, 72.4% (n = 63/87) had co-occurrent genital and anorectal infection, 13.8% (n = 12/87) had genital infection only, and 12.6% (n = 11/87) had anorectal infection only. Rectal infection was missed in 69.3% of cases using the standard indication alone, while adding the sexual history still missed 20.0%. Age was the only variable significantly associated with anorectal infection. CONCLUSION: The prevalence of anorectal disease is high among women who visit their GP with an indication for genital CT testing. Many anorectal infections are missed despite taking comprehensive sexual histories, meaning that standard treatment of genital infection with azithromycin may result in rectal persistence. Performing anorectal testing in all women with an indication for genital CT testing is, therefore, recommended.

Feasibility of anorectal chlamydia testing in women: a cross-sectional survey among general practitioners.

BACKGROUND: Anorectal Chlamydia trachomatis (CT) may be clinically relevant for women in general practice. Although anorectal CT testing in this setting may prevent underdiagnosis and undertreatment, its feasibility is questioned as GPs currently rarely order anorectal CT tests, for yet unknown reasons. OBJECTIVE: To explore the feasibility of anorectal CT testing in women in general practice. METHODS: GPs across the Netherlands were invited directly (n = 1481) and by snowball sampling (n = 330) to join an online cross-sectional survey that asked about the acceptability of and barriers for (standard) anorectal testing in women during CT-related consultations. Data were analysed with univariable and multivariable logistic regression models. RESULTS: The questionnaire was opened by 514 respondents (28%, 514/1811) and 394 fully completed it. GPs' acceptability of anorectal testing by either self-sampling or provider-sampling was high (86%). Twenty-eight percent of GPs felt neutral, and 43% felt accepting towards standard anorectal testing. Nevertheless, 40% of GPs had never tested for anorectal CT in women, which was associated with a reported difficulty in asking about anal sex (odds ratio [OR]: 3.07, 95% confidence interval [CI]: 1.21-7.80), infrequency of anal sexual history taking (OR: 11.50, 95% CI: 6.39-20.72), low frequency of urogenital CT testing (OR 3.44, 95%-CI: 1.86-6.38) and with practicing in a non-urban area (OR: 2.27, 95% CI: 1.48-3.48). Acceptability of anorectal testing was not associated with the studied factors. CONCLUSION: This quantitative survey shows that anorectal CT testing is feasible based on its acceptability, but is likely hindered by a lower awareness of (anorectal) CT in GPs.

BACKGROUND: Chlamydia trachomatis (CT) is a sexually transmitted disease that occurs both vaginally and anorectally (anally) in women. Testing for anorectal CT may improve treatment outcomes, but GPs currently rarely order anorectal CT tests. It is therefore uncertain whether anorectal CT testing is feasible. OBJECTIVE: To find out whether anorectal CT testing in women by GPs is feasible. METHODS: We sent an online survey to GPs across the Netherlands and asked about (1) the acceptability of and (2) barriers for anorectal CT testing in women. RESULTS: GPs thought anorectal CT testing, either when the patient self-sampled or when the GP sampled, was acceptable (86%). Twenty-eight percent of GPs felt neutral, and 43% felt accepting towards standard anorectal testing. Nevertheless, 40% of GPs had never tested for anorectal CT in women. These GPs were more likely to find it difficult to ask women about anal sex, to do so less frequently, to less frequently offer CT tests all together and to work in a non-urban area. These factors imply a lower awareness of (anorectal) CT. CONCLUSION: This study shows that anorectal CT testing is feasible based on its acceptability, but is likely hindered by a lower awareness of (anorectal) CT.

Reasons of general practitioners for not prescribing lipid-lowering medication to patients with diabetes: a qualitative study.

BACKGROUND: Lipid-lowering medication remains underused, even in high-risk populations. The objective of this study was to determine factors underlying general practitioners' decisions not to prescribe such drugs to patients with type 2 diabetes. METHODS: A qualitative study with semi-structured interviews using real cases was conducted to explore reasons for not prescribing lipid-lowering medication after a guideline was distributed that recommended the use of statins in most patients with type 2 diabetes. Seven interviews were conducted with general practitioners (GPs) in The Netherlands, and analysed using an analytic inductive approach. RESULTS: Reasons for not-prescribing could be divided into patient and physician-attributed factors. According to the GPs, some patients do not follow-up on agreed medication and others object to taking lipid-lowering medication, partly for legitimate reasons such as expected or perceived side effects. Furthermore, the GPs themselves perceived reservations for prescribing lipid-lowering medication in patients with short life expectancy, expected compliance problems or near goal lipid levels. GPs sometimes postponed the start of treatment because of other priorities. Finally, barriers were seen in the GPs' practice organisation, and at the primary-secondary care interface. CONCLUSION: Some of the barriers mentioned by GPs seem to be valid reasons, showing that guideline non-adherence can be quite rational. On the other hand, treatment quality could improve by addressing issues, such as lack of knowledge or motivation of both the patient and the GP. More structured management in general practice may also lead to better treatment.

Detrusor overactivity in spina bifida: how long does it need to be treated?

AIMS: To determine whether a lasting therapeutic effect can be expected from long-term antimuscarinic therapy for neurogenic detrusor overactivity in spina bifida and to answer the question whether detrusor overactivity in spina bifida children with detrusor/sphincter dyssynergia is primarily based on the neuropathy or, in part, can be a secondary detrusor reaction to the functional urethral obstruction. METHODS: Fifteen spina bifida patients, aged between 1 and 12 years, all on a regime of clean intermittent catheterisation (CIC) and oxybutynin since shortly after birth, underwent three consecutive urodynamic studies (UDS). One prestudy UDS for treatment control, one UDS after withdrawal of oxybutynin for 3-5 days and one UDS after reinstallment of oxybutynin treatment. Urodynamic results were compared concerning detrusor overactivity, cystometric bladder capacity, and compliance. RESULTS: Detrusor overactivity was seen in two patients on the prestudy UDS. After several days of withdrawal of oxybutynin overactivity was seen in 11 patients. After oxybutynin withdrawal, bladder compliance was within safe margins for two patients only, after reinstallment, safe vesical pressures were seen in 11 patients. CONCLUSION: The functional obstruction due to detrusor/sphincter dyssynergia has been by-passed chronically in all these children by CIC and oxybutynin. Due to the fact that detrusor overactivity recurs immediately after withdrawal of medication after long-term treatment with oxybutynin, one can conclude that there is no long-lasting therapeutic effect of pharmacological suppression. This suggests that in children with detrusor/sphincter dyssynergia, detrusor overactivity is primarily of neuropathic origin.