Towards reducing diagnostic delay in endometriosis in primary care: a qualitative study.

BACKGROUND: Due to a heterogeneity of symptoms, a lack of an adequate diagnostic test and a lack of awareness, diagnostic delay in endometriosis in primary care on average amounts to 35 months. AIM: To determine which interventions are most feasible to reduce time to diagnosis in primary care, focusing on GPs' preferences, the intervention's content, design and implementation. DESIGN & SETTING: We conducted a qualitative study by performing focus groups with GPs and GP trainees between July and October 2021. METHOD: Data collection was continued until saturation was obtained. Focus groups were transcribed and openly encoded. Themes were formulated by three independent researchers. RESULTS: Divided over five focus groups 22 GPs and 13 GP trainees participated. Three themes were formulated: increasing awareness, combined intervention and reaching unaware GPs.Suggestions for a combined intervention strategy were adaptation of guidelines, a diagnostic support tool and compulsory education. To reach unaware GPs, participants felt that education should be offered in regional networks and education for GP trainees should be mandatory. A guideline on menstrual symptoms should be considered, and the term endometriosis should be added to the differential diagnosis paragraphs of existing guidelines. A diagnostic support tool should be linked to a guideline and consist of a flowchart with steps starting with the first presentation of symptoms leading to the diagnosis of endometriosis. CONCLUSION: According to GPs, a combined intervention strategy consisting of an adapted guideline, a diagnostic support tool and education might be successful interventions in reduction of diagnostic delay in endometriosis.

Depressive feelings as mediator in the relation between adverse childhood events and lower urinary tract symptoms in males and females.

BACKGROUND: Adverse childhood events (ACEs) are prevalent and lead to well-established adverse health sequelae in adulthood. Recent literature has claimed that exposure to trauma in early life may worsen lower urinary tract symptoms (LUTS) because emotion can alter the perception of bodily distress in the brain. Specifically, depressive symptoms might influence the association between ACEs and LUTS. We aimed to describe the associations between ACEs and LUTS among males and females and to determine whether depressive symptoms mediated these associations. METHODS: This study was a secondary analysis of the Coevorden observational cohort study (n = 1691, age ≥16 years). For this observational study participants filled in the male or female modules of the International Consultation on Incontinence Questionnaire for LUTS (ICIQ-MLUTS and ICIQ-FLUTS, respectively), the NEMESIS Childhood Trauma Questionnaire (emotional neglect, psychological abuse, physical abuse, and sexual abuse within the family), and the Patient Health Questionnaire (PHQ-9) for depression. RESULTS: Overall, 564 males and 811 females answered all required items related to LUTS and ACEs. A series of regression models were then estimated to test for mediation: LUTS on ACEs, depression on ACEs, and LUTS on both ACEs and depression. The models were also adjusted for the following covariates: age, body mass index, diabetes mellitus, current smokers, educational level, and vaginal delivery (if female). Depressive symptoms were shown to mediate the association between ACEs and LUTS in both males and females. CONCLUSION: Childhood adversity and depression are areas of interest during the clinical assessment of patients with LUTS. Early detection of these conditions might help to manage risk, aid in the prevention of LUTS, and facilitate trauma-informed care.

Patient characteristics and factors contributing to recurrence of bacterial vaginosis presented in primary care.

BACKGROUND: Bacterial vaginosis (BV) is a common problem in primary care. BV symptoms often have a negative impact on patients' quality of life and may predispose to gynaecological problems. Some patients experience recurring episodes of BV. This study's objective is to identify possible factors that may be associated with BV recurrence and describe the characteristics of these patients and interventions performed by general practitioners. METHODS: In this retrospective cohort study, we used data from a primary care registration network in the Netherlands in the period 2015-2020. We analysed differences between patients with recurrent BV and patients with a single episode of BV in terms of characteristics and interventions performed by general practitioners. RESULTS: We found that patients with recently prescribed antibiotics, and a medical history of sexually transmitted infections and/or Candidiasis significantly more often presented with recurrent BV. Patients with recurrent BV had more remote consultations and less in-person consultations than single-episode patients. The reason for encounter was more often a request for medication. Regarding GPs' diagnostic and therapeutic interventions, microbiological tests were more frequently performed in recurrent BV patients. Moreover, most patients in both groups were prescribed oral metronidazole most frequently. CONCLUSIONS: Our findings might help GPs to better recognise patients at risk of recurrence. GPs could re-evaluate their approach to the diagnosis and treatment of recurrent BV, opting for in-person consultation and using standardised diagnostic criteria and microbiological testing in patients with recurrent complaints. Antibiotic use for other conditions in these patients may lead to new BV episodes.

Help-seeking behaviour in primary care of men and women with a history of abuse: A Dutch cohort study.

BACKGROUND: Previous studies show an association between a history of abuse and higher care demand. However, studies in general practice regarding help-seeking behaviour by patients (mainly male patients) with a history of abuse are scarce. OBJECTIVES: To analyse help-seeking behaviour in general practice of men and women with a history of abuse. METHODS: A cohort study using data from a Dutch primary care registration network from 2015 to 2019. We included all patients aged ≥ 18 years who indicated on a questionnaire that they did or did not have a history of abuse. We analysed differences in contact frequency, types of contact, reason for encounter and diagnoses between men and women with or without a history of abuse. RESULTS: The questionnaire had a response rate of 59% and resulted in 11,140 patients, of which 1271 indicated a history of abuse. Men and women with a history of abuse contact the general practitioner (GP) 1.5 times (95% CI 1.42-1.60) more often than men and women without a history of abuse, especially for psychological (rate ratio 1.97, 95% CI 1.79-2.17) and social (rate ratio 1.93, 95% CI 1.68-2.22) problems. Moreover, when diagnosed with a psychological or social problem, patients with a history of abuse contact the GP twice more often for these problems. CONCLUSION: Compared to men and women without a history of abuse, men and women with a history of abuse visit their GP more often, particularly for psychological and social problems.

Sex-Gender Differences in the Effectiveness of Treatment of Irritable Bowel Syndrome: A Systematic Review.

BACKGROUND: In recent years, research on sex-gender differences in health care has increasingly recognized that men and women differ in the way symptoms occur, in risk factors for certain conditions and in the way they respond to the same treatment. A disease that is known to often present differently in women and men is irritable bowel syndrome (IBS). Given the difference in prevalence, predominant symptoms and possible other pathophysiology, it is conceivable that a difference in treatment effectiveness in men and women is a discovery waiting to be found. PURPOSE: To determine whether there are differences in treatment effectiveness between men and women with irritable bowel syndrome. MATERIALS AND METHODS: We searched on PubMed and EMBASE, selecting randomized controlled trials comparing IBS treatment in men and women over 18 years old. One researcher performed the inclusion process, and two researchers independently performed a quality assessment. A descriptive analysis was conducted. RESULTS: Twelve studies, randomizing 1847 men and 3562 women, were included in this review. Treatment with serotonin antagonist alosetron, treatment with ibodutant and crofelemer and adding cognitive behavioral therapy to medical treatment found significant differences between men and women in favor of effectiveness towards women in either satisfactory relief of overall IBS symptoms or percentage of pain-free days. CONCLUSION: Sex-gender can be a determining factor in the effectiveness of IBS treatment. Due to the limited number of studies per treatment option, no recommendations can be made on the choice of a specific treatment. It is clear, however, that so as not to miss beneficial treatment options for either sex, the inclusion, analysis and description of data on the basis of sex is of the utmost importance.

Views of Dutch general practitioners about premenstrual symptoms: A qualitative interview study.

BACKGROUND: General practitioners (GPs) encounter women suffering from premenstrual symptoms. Often women with premenstrual problems experience little understanding from GPs. Views of GPs will influence their approach to these women and their care. Insight into these views is lacking but could help in designing educational programmes for GPs. OBJECTIVES: To explore the views of Dutch GPs towards aetiology, diagnostic process, and preferred treatment of premenstrual symptoms. METHODS: In 2017, we conducted a qualitative, semi-structured, interview survey among 27 GPs, varying in age, gender, and practice setting. RESULTS: Important themes emerged from the interviews: 'no need for a symptom diary,' 'PMS defined as illness' exclusively in case of disruption of normal functioning, and 'symptomatic treatment' as preferred approach. Most GPs considered PMS to be a physiological phenomenon, with taking history as an adequate diagnostic tool. Almost all GPs regarded a normal cyclical hormonal cycle as causal; many also mentioned the combination with personal sensitivity. Some pointed to a dividing line between physiological condition and illness if women could not function normally in daily life. Lastly, the approach GPs preferred was focussing on relieving symptoms of individual patients. In addition to explaining the hormonal cycle and lifestyle advice, all GPs advocated oral contraceptives, and if necessary psychological support. GPs expressed negative feelings about prescribing antidepressants. CONCLUSION: GPs considered physiological changes and personal sensitivity as aetiological factors. We recommend more training to improve GPs knowledge and more insight into the burden of women with PMS. A symptom diary is an essential diagnostic tool for GPs.

Barriers and facilitators to the timely diagnosis of endometriosis in primary care in the Netherlands.

BACKGROUND: Endometriosis is an invalidating gynaecological condition in women of reproductive age, and a frequent cause of infertility. Unfortunately, the condition is characterized by a long interval between onset of symptoms and diagnosis. GPs in the Netherlands are educated to provide basic gynaecological care and serve as gatekeepers for specialist medical care. Therefore, it is of great importance that they recognize signs and symptoms possibly caused by endometriosis to initiate adequate actions. OBJECTIVE: The main objective of this study was to identify barriers and facilitators to the timely diagnosis of endometriosis from the GPs' perspective. METHODS: Semi-structured focus group discussions with GPs were organized throughout the Netherlands. The participants were encouraged to brainstorm about their perspective on daily practice regarding endometriosis and suggestions for interventions to enable early diagnosis and treatment. Analysis was based on grounded theory methodology. RESULTS: Forty-three GPs participated in six focus groups. Analysis of the transcripts revealed relevant determinants of practice in four main themes: professionals' experience and competence, patient characteristics, guideline factors and professional collaboration. A lack of knowledge and awareness appeared to result in a low priority for establishing the diagnosis of endometriosis, especially in young women. Infertility, patient engagement and a recent serious case or training facilitated referral. CONCLUSION: Several factors in daily primary health care contribute to the diagnostic delay in endometriosis. Future interventions to reduce this delay may be aimed at increasing awareness by means of education, incorporating the subject into national clinical guidelines and improvements in interdisciplinary collaboration.

Women's appraisal of the management of vulvodynia by their general practitioner: a qualitative study.

BACKGROUND: Provoked Vulvodynia (PVD) is the most common cause of vulvar pain. General practitioners (GPs) are insufficiently familiar with it, causing a delay in many women receiving correct diagnosis and treatment. Besides patients factors, this delay can partly be explained by the reluctance of GPs to explore the sexual context of PVD and by their negative emotional reactions such as helplessness and frustration when consulted by patients with medically unexplained symptoms like PVD. OBJECTIVE: To gain insight into how women with PVD perceive and evaluate condition management by their GP, in order to support GPs in the consultation of women with PVD. METHODS: We performed face-to-face in-depth interviews with women diagnosed with PVD. The interviews were recorded, transcribed verbatim and thematically analysed. The Consolidated Criteria for reporting Qualitative Research (COREQ-criteria) were applied. RESULTS: Analysis of the interviews generated four interrelated themes: Doctor-patient relationship, Lack of knowledge, Referral process and Addressing sexual issues. Empathy of the GP, involvement in decision-making and referral were important factors in the appreciation of the consultation for women with PVD who were referred to a specialist. Because women were reluctant to start a discussion about sexuality, they expected a proactive attitude from their GP. The communication with and the competence of the GP ultimately proved more important in the contact than the gender of the GP. CONCLUSION: Women with PVD prefer a patient-centred approach and want GPs to acknowledge their autonomy and to address sexuality proactively.

[Drug-facilitated sexual assault; frequently used substances, symptoms and toxicological investigation]. / Verkrachting onder invloed.

Drug-facilitated sexual assault (DFSA) is a term used to describe incidents of sexual assault in which the victim is incapacitated and/or unable to provide consent to the sexual act as a result of drug or alcohol consumption. There are two types: 'proactive' in which the victim is covertly administered an incapacitating or disinhibiting substance by an assailant for the purpose of sexual assault; and 'opportunistic' in which a perpetrator engages in sexual activity with a victim who is profoundly intoxicated by his or her actions, to the point of near or actual unconsciousness. Alcohol is the drug most commonly found in alleged sexual assault cases. It is followed by non-opiate analgesics, illicit drugs and benzodiazepines. The possibility of DFSA should be considered in sexual assault cases. If there is suspicion, drug and alcohol screening has to be done as soon as possible because delay may lead to false-negative results.

Mixed feelings: general practitioners' attitudes towards eHealth for stress urinary incontinence - a qualitative study.

BACKGROUND: Stress urinary incontinence (SUI) is the most prevalent subtype of urinary incontinence and is a bothering condition in women. Only a minority of those with SUI consult a general practitioner (GP). EHealth with pelvic floor muscle training (PFMT) is effective in reducing incontinence symptoms and might increase access to care. The role of the GP regarding such an eHealth intervention is unknown. The aim of the study is to gain insight into the attitudes towards a PFMT internet-based, eHealth, intervention for SUI. METHODS: A qualitative study was conducted. Data were collected through semi-structured interviews among purposively sampled GPs. Audio records were fully transcribed, and analysed thematically. RESULTS: Thirteen GPs were interviewed, nine females and four males. Three themes emerged: appraisal of eHealth as a welcome new tool, mixed feelings about a supportive role, and eHealth is no cure-all. GPs welcomed eHealth for SUI as matching their preferences for PFMT and having advantages for patients. With eHealth as stand-alone therapy GPs were concerned about the lack of feedback, and the loss of motivation to adhere to the intervention. Therefore, GPs considered personal support important. The GP's decision to recommend eHealth was strongly influenced by a woman's motivation and her age. GPs' treatment preferences for elderly are different from those for young women with SUI; both PFMT and eHealth are perceived less suitable for older women. CONCLUSION: EHealth with PFMT fits into the GPs' routine practice of SUI and adds value to it. Although there is evidence that eHealth as a stand-alone intervention is effective, GPs consider personal support important to supplement the perceived shortcomings. Probably GPs are not aware of, or convinced of the existing evidence. Training should address this issue and should also focus on common misunderstandings about regular care for women with SUI, such as the idea that PFMT is not suitable for the elderly. Improving GPs' knowledge that eHealth can be a stand-alone therapy for SUI facilitates the implementation in daily care.

Women's expectations and experiences regarding e-health treatment: A systematic review.

There is a gap in knowledge of women's perceptions of e-health treatment. This review aims to investigate women's expectations and experiences regarding e-health. A search was conducted in MEDLINE, EMBASE, CINAHL and PsycInfo in March 2016. We included articles published between 2000 and March 2016, reporting on e-health interventions. The initial search yielded 2987 articles. Eventually, 16 articles reporting on 16 studies were included. Barriers to e-health treatment were lower for women than barriers to face-to-face treatment, such as feelings of shame and time constraints. Women were able to develop an online therapeutic relationship. As reduced feelings of obligation and lack of motivation were women's greatest challenges in completing e-health treatment, they expressed a wish for more support during e-health treatment, preferably blended care. e-Health lowers the threshold for women to seek healthcare. Combining e-health interventions with face-to-face sessions may enhance women's motivation to complete treatment.

Expectations regarding eHealth among women with stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Stress urinary incontinence (SUI) is a common condition with a major impact on quality of life (QoL). Various factors prevent women from seeking help. However, eHealth (Internet-based therapy) with pelvic floor muscle training (PFMT) is an effective and satisfying intervention for these women. We hypothesize that women with symptoms after regular therapy will profit from eHealth. This study explores the expectations regarding an eHealth intervention among women who still suffer from SUI despite treatment. METHODS: A qualitative study with semistructured interviews was conducted using a grounded theory approach. The study included women with SUI who had ever sought help for their condition. RESULTS: Thirteen women were interviewed, most whom had experience with PFMT and still suffered from moderate-to-severe incontinence. Two themes emerged from data analysis: the need to meet, and eHealth as a tool to bridge obstacles. Women greatly emphasized that a healthcare professional, preferably one they know, should be available with eHealth. Several women indicated that the absence of personal contact caused lack of trust in success. However, several women were willing to use eHealth because its anonymity and flexibility could overcome obstacles in regular care. CONCLUSIONS: eHealth based on PFMT is currently not a preferable treatment modality for women who still suffer from SUI despite treatment. eHealth cannot act as a substitute for their positive experience with personal contact. Some women are willing to use eHealth because of its advantages over regular care. Future experiences with eHealth might enable women with SUI to trust digital care.

Urine cultures and antibiotics for urinary tract infections in Dutch general practice.

BACKGROUND: Urinary tract infections (UTIs) are common in general practice, and antibiotic resistance is often seen. Urine cultures are advised by the Dutch national UTI guideline for patients at high risk of UTI complications. Prudent use of antibiotics and taking into account national guidelines and urine culture results are important to combat antibiotic resistance in general practice. AIM: To identify subgroups of UTI patients in which the use of urine cultures and antibiotic prescriptions deviates from the national guidelines. METHODS: We investigated associations of several characteristics with urine culture orders in patients with UTI in 2015 from seven Dutch general practices (n=1295). These included subgroups at risk for UTI complications, comorbidities, age and history of UTI recurrence. In addition, we assessed the level of adherence to the guideline for antibiotic prescriptions in subgroups at risks for UTI complications. FINDINGS: Urine cultures were ordered in 17% (n=221) of patients, more frequently in high-risk patients (32%) than in low-risk patients (7%), for UTI complications (OR=6.4; 95% CI 4.6-9.0). In low-risk patients, 91% received antibiotics that were recommended in the guideline. For high-risk patients this percentage ranged widely, and was particularly low in the risk groups with signs of tissue invasion (29-50%). Diagnostic and therapeutic adequacy can still be improved by increasing the adherence to the guideline in UTI patients at high risk for complications. This may contribute to containing antibiotic resistance in UTI by ordering urine cultures and use the results to adjust prescriptions to antibiotic susceptibility of the uropathogen.

The Relationship Between Vulvovaginal Candidiasis and Provoked Vulvodynia: A Systematic Review.

BACKGROUND: Provoked vulvodynia (PVD) is a chronic vulvar pain condition affecting up to 8.3% of the female population. Despite many years of research, no clear cause for PVD has been identified. Several risk factors have been studied, including vulvovaginal candidiasis (VVC). However, to date, the role of Candida infections in PVD has remained unclear. VVC and PVD have an overlap of symptoms that may contribute to diagnostic inaccuracy and mistreatment. AIM: To systematically review the literature on the relationship between VVC and PVD. METHODS: Cohort and case-control studies were included that compared women with PVD with healthy controls with respect to the presence of a history of Candida vulvovaginitis. PVD had to be diagnosed by Friedrich's criteria or the International Society for the Study of Vulvovaginal Disease criteria. The inclusion process as well as the quality appraisal of the studies, using the Newcastle-Ottawa Quality Assessment Scale, were performed independently by 2 authors. MAIN OUTCOME MEASURE: Outcomes of the population-based case-control studies were listed as odds ratio. Outcomes of the pathophysiological studies were based on local pro-inflammatory responses on Candida in vitro. RESULTS: We included a total of 14 studies, both population and clinic-based case-control, and pathophysiological research. 7 studies were of low methodological quality, and 7 studies were of medium methodological quality. The population-based case-control studies showed a significantly increased odds ratio for self-reported VVC in PVD cases compared with controls. The pathophysiological studies revealed a tendency for an increased local proinflammatory response on Candida in vitro in patients with PVD. Owing to the substantial heterogeneity of the studies, meta-analysis was not performed. CLINICAL IMPLICATIONS: Health care providers may consider a diagnosis of PVD in women with self-reported VVC, and to act on this properly. Reiteration of antifungal prescriptions by physicians without a decent diagnosis, will lead to mistreatment. Women should be informed by their health care provider that intercourse during (or shortly after) the treatment of VVC might worsen the vulnerability of the vulvar skin. STRENGTH AND LIMITATIONS: This is the first systematic review performed to describe the relation between VVC and PVD. An independently performed in- and exclusion process and quality appraisal, ensured optimal internal validity. However, there were important methodological limitations and the size of heterogeneity prevented establishing a meta-analysis. CONCLUSION: This systematic review is unable to draw conclusions regarding a relationship between actual VVC and PVD because studies were based on self-reported VVC. Until new evidence becomes available, we advocate that PVD should be considered as an unexplained chronic pain condition. In women with recurrent or persistent VVC-like complaints, physicians should consider a diagnosis of PVD. Leusink P, van de Pasch S, Teunissen D, et al. The Relationship Between Vulvovaginal Candidiasis and Provoked Vulvodynia: A Systematic Review. J Sex Med 2018;15:1310-1321.

Facilitators and barriers in the diagnostic process of vulvovaginal complaints (vulvodynia) in general practice: a qualitative study.

BACKGROUND: The gap between the relatively high prevalence of provoked vulvodynia (PVD) in the general population and the low incidence in primary care can partly be explained by physicians' lack of knowledge about the assessment and management of PVD. OBJECTIVES: To recognize barriers and facilitators of GPs in the diagnostic process of women presenting with recurrent vulvovaginal complaints. METHODS: A qualitative focus group study in 17 Dutch GPs, five men and 12 women. An interview guide, based on the scientific literature and the expertise of the researchers, including a vignette of a patient, was used to direct the discussion between the GPs. The interviews were audiotaped and transcribed verbatim. A systematic text analysis of the transcripts was performed after data saturation was reached. RESULTS: Analysis of the interviews generated three major themes: Identifying and discussing sexual complaints, importance of gender in professional experience, and coping with professional uncertainty. Within these themes, the reluctance regarding sexual complaints, male gender, negative emotional responses when faced with professional uncertainty, as well as lack of education were barriers to the diagnostic process and management of PVD. Female gender and understanding that patients can profit from enquiring about sexual health issues were found to be facilitating factors. CONCLUSIONS: To improve the care for women with PVD, attitude and skills of GPs regarding taking a sexual history and performing a vulvovaginal examination should be addressed, as well as GPs' coping strategies regarding their professional uncertainty.

Is uncertain vulvovaginal candidiasis a marker of vulvodynia? A study in a Dutch general practice research database.

BACKGROUND: A recent Dutch study in general practice showed a clear relationship between the diagnosis of vulvovaginal candidiasis (VVC) and symptoms suggestive of provoked vulvodynia (PVD). PVD accounts for the largest group of vulvar pains, but is often not recognised by GPs. AIM: To investigate whether diagnostic uncertainty about VVC in general practice could also point to the diagnosis of PVD, and whether and how this diagnostic uncertainty affects management. DESIGN & SETTING: An observational study in 2014 in Dutch general practices of the NIVEL Primary Care Database. METHOD: Women with an uncertain diagnosis of VVC were distinguished from those with certain VVC based on the occurrence of recurrent episodes and persisting complaints, despite treatment. Factors known to be associated with PVD were hypothesised to be more prevalent in women with uncertain VVC. Data on symptom management by GPs were collected. RESULTS: In total 7066 women with VVC or uncertain VVC were included. Uncertain VVC was found to account for 28% of these patients. Compared to VVC, the group uncertain VVC included significantly more women with female genital symptoms, tiredness, irritable bowel syndrome (all P<0.001), feeling anxious, reduced sexual desire, depressive disorder, relationship problems, and micturition symptoms (all P<0.05). Compared to VVC, the group uncertain VVC included significantly higher mean numbers of telephone consultations (P<0.001), more referrals to gynaecology (P = 0.009), and higher mean numbers of prescriptions per patient (P<0.001). CONCLUSION: This study's findings indicate that uncertain VVC could be a marker of PVD. GPs might reconsider their diagnostics and management when women present recurrent and persistent vulvovaginal complaints, especially if accompanied by dyspareunia, functional syndromes, micturition symptoms, and psychological conditions.

Treatment by a nurse practitioner in primary care improves the severity and impact of urinary incontinence in women. An observational study.

BACKGROUND: Urinary Incontinence (UI) is a common problem in women. The management of UI in primary care is time consuming and suboptimal. Shift of incontinence-care from General Practitioners (GP's) to a nurse practitioner maybe improves the quality of care. The purpose of this observational (pre/post) study is to determine the effectiveness of introducing a nurse practitioner in UI care and to explore women's reasons for not completing treatment. METHODS: Sixteen trained nurse practitioners treated female patients with UI. All patients were examined and referred by the GP to the nurse practitioner working in the same practice. At baseline the severity of the UI (Sandvik-score), the impact on the quality of life (IIQ) and the impressed severity (PGIS) was measured and repeated after three months Differences were tested by the paired t and the NcNemar test. Reasons for not completing treatment were documented by the nurse practitioner and differences between the group that completed treatment and the drop-out group were tested. RESULTS: We included 103 women, mean age 55 years (SD 12.6). The Sandvik severity categories improved significantly (P < 0.001), as did the impact on daily life (2.54 points, P = 0.012). Among the IIQ score the impact on daily activities increased 0.73 points (P = 0.032), on social functioning 0.60 points (P = 0.030) and on emotional well-being 0.63 points (P = 0.031). The PGIS-score improved in 41.3% of the patients. The most important reasons for not completing the treatment were lack of improvement of the UI and difficulties in performing the exercises. Women who withdraw from guidance by the nurse practitioner perceived more impact on daily life (P = 0.036), in particular on the scores for social functioning (P = 0.015) and emotional well-being (P = 0.015). CONCLUSION: Treatment by a trained nurse practitioner seems positively affects the severity of the UI and the impact on the quality of life. Women who did not complete treatment suffer from more impact on quality of life, experience not enough improvement and mention difficulties in performing exercises.

Gender-based education during clerkships: a focus group study.

OBJECTIVES: One of the goals of the medical master's degree is for a student to become a gender-sensitive doctor by applying knowledge of gender differences in practice. This study aims to investigate, from the students' perspective, whether gender medicine has been taught in daily practice during clerkship. METHODS: A focus group study was conducted among 29 medical students from Radboud University, Nijmegen, The Netherlands, who had just finished either their internal medicine or surgical clerkships. Data were analyzed in line with the principles of constant comparative analysis. RESULTS: Four focus groups were conducted with 29 participating students. Clinical teachers barely discuss gender differences during students' clerkships. The students mentioned three main explanatory themes: insufficient knowledge; unawareness; and minor impact. As a result, students feel that they have insufficient competencies to become gender-sensitive doctors. CONCLUSION: Medical students at our institution perceive that they have received limited exposure to gender-based education after completing two key clinical clerkships. All students feel that they have insufficient knowledge to become gender-sensitive doctors. They suppose that their clinical teachers have insufficient knowledge regarding gender sensitivity, are unaware of gender differences, and the students had the impression that gender is not regarded as an important issue. We suggest that the medical faculty should encourage clinical teachers to improve their knowledge and awareness of gender issues.

Chlamydia prevalence in the general population: is there a sex difference? a systematic review.

BACKGROUND: The focus of Chlamydia trachomatis screening and testing lies more on women than on men. The study aim was to establish by systematic review the prevalence of urogenital Chlamydia trachomatis infection in men and women in the general population. METHODS: Electronic databases and reference lists were searched from 2000 to 2013 using the key words "Chlamydia trachomatis", "population-based study" and "disease prevalence". Reference lists were checked. Studies were included in the analysis if Chlamydia trachomatis prevalence was reported for both men and women in a population-based study. Prevalence rates for men and women were described as well as highest prevalence rate by age and sex. The difference in prevalence between the sexes in each study was calculated. RESULTS: Twenty-five studies met the inclusion criteria and quality assessment for the review. In nine of the twenty-five studies there was a statistically significant sex difference in the chlamydia prevalence. In all nine studies the prevalence of chlamydia was higher in women than in men. The prevalence for women varied from 1.1% to 10.6% and for men from 0.1% to 12.1%. The average chlamydia prevalence is highly variable between countries. The highest prevalence of chlamydia occurred predominantly in younger age groups (< 25 years). The absence of symptoms in population-based urogenital chlamydia infection is common in men and women (mean 88.5% versus 68.3%). CONCLUSIONS: The urogenital chlamydia trachomatis prevalence in the general population is more similar than dissimilar for men and women. A modest sex difference is apparent. The prevalence rates can be used to inform chlamydia screening strategies in general practice.

Women's positions during the second stage of labour: views of primary care midwives.

AIM: This paper is a report of a study to explore the views of midwives on women's positions during the second stage of labour. BACKGROUND: Many authors recommend encouraging women to use positions that are most comfortable to them. Others advocate encouragement of non-supine positions, because offering 'choice' is not enough to reverse the strong cultural norm of giving birth in the supine position. Midwives' views on women's positions have rarely been explored. METHOD: Six focus groups were conducted in 2006-2007 with a purposive sample of 31 midwives. The data were interpreted using Thachuk's models of informed consent and informed choice. FINDINGS: The models were useful in distinguishing between two different approaches of midwives to women's positions during labour. When giving informed consent, midwives implicitly or explicitly ask a woman's consent for what they themselves prefer. When offering informed choice, a woman's preference is the starting point, but midwives will suggest other options if this is in the woman's interest. Obstetric factors and working conditions are reasons to deviate from women's preferences. CONCLUSIONS: To give women an informed choice about birthing positions, midwives need to give them information during pregnancy and discuss their position preferences. Women should be prepared for the unpredictability of their feelings in labour and for obstetric factors that may interfere with their choice of position. Equipment for non-supine births should be more midwife-friendly. In addition, midwives and students need to be able to gain experience in assisting births in non-supine positions.