Family Medicine Clerkship

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Vaginal and Urinary Symptoms

OVERVIEW

Vaginal and urinary symptoms are common reasons for presentation to the family physician. The student needs to learn an organized approach to these common reasons for office visits.

TOPIC LEARNING GOALS AND OBJECTIVES

(Organized by ACGME Competencies)

Patient Care

GOAL: Students will be able to diagnose and treat a patient who presents with urinary or vaginal symptoms.

OBJECTIVES: Students will be able to:

• Diagnose a patient who presents with a chief complaint of pain with urination, altered pattern of urination, or vaginal discharge.
• Recommend a treatment plan for such problems as urinary tract infection, bacterial vaginosis, non-specific vaginitis, vaginal monialisis, trichomoniasis, cervicitis, and pelvic inflammatory disease.
• Consider how to rule in and out less common, but serious, conditions such as ectopic pregnancy, pyelonephritis, urolithiasis, and appendicitis.

GOAL: Students will discuss appropriately factors that contribute to urinary tract infection, vaginitis, and cervicitis, including the likely sexually transmitted nature of infections such as trichomonas.

OBJECTIVES: Students will be able to:

• Describe pathophysiology of urinary tract infections.
• Explain methods for prevention and management of recurrent urinary tract infections.
• Describe the test characteristics for screening exams such as the DNA probe for cervical infection with gonorrhea or chlamydia.

GOAL: Students will be sensitive to individual and cultural differences in their development of treatment plans.

OBJECTIVES: Students will be able to:

• Discuss with patients and families the importance of lifestyle changes in the management and prevention of recurrent urinary tract infections, bacterial vaginosis, monilial vaginitis, or any sexually transmitted disease such as chlamydia.
• Develop treatment plans in the context of the patient's life and environment.

Medical Knowledge

GOAL: Students will understand the significance of screening for sexually transmitted diseases.

OBJECTIVES: Students will be able to:

• Discuss the epidemiology of urinary tract infections, vaginitis, and cervicitis, including racial, ethnic, and socioeconomic differences.
• Describe the USPSTF recommendations for screening for chlamydia and gonorrhea.
• Discuss the test characteristics of typical screening methods, and apply test results given different pretest probabilities.

GOAL: Students will understand the pathophysiology and risks of untreated urinary tract infection, sexually transmitted disease, or vaginitis

OBJECTIVES: Students will be able to:

• Describe the complications of untreated chlamydia, gonorrhea, or urinary tract infection.
• Describe how to make the diagnosis of urinary tract infection, sexually transmitted disease, or vaginitis.
• Discuss and defend the initial evaluation of a patient with a new diagnosis of urinary tract infection, sexually transmitted disease, or vaginitis

GOAL: Students will understand the rationale for treatment plans for urinary tract infection, sexually transmitted disease, or vaginitis.

OBJECTIVES: Students will be able to:

• Describe the appropriate therapy for urinary tract infection, sexually transmitted disease, and vaginitis.
• Discuss the evidence for the role of lifestyle changes: use of a condom and careful partner selection or abstinence in prevention of sexually transmitted disease.
• Discuss the side effects and costs of commonly used medications.

Practice-Based Learning and Improvement

GOAL: Students will understand the role of screening for asymptomatic bacteriuria and sexually transmitted diseases in practice and community settings.

OBJECTIVES: Students will be able to:

• Describe how the clerkship site monitors care for urinary tract infection, vaginitis, and sexually transmitted diseases.
• Consider the impact of environment and neighborhood on adherence to treatment plans and lifestyle changes.

GOAL: Students will understand the role of practice-based improvement.

OBJECTIVES: Students will be able to:

• Recognize the importance of practice analysis for a population at risk for sexually transmitted diseases.

GOAL: Students will bring up-to-date evidence to the point of clinical care.

OBJECTIVES: Students will be able to:

• Identify gaps in their own knowledge and frame appropriate clinical questions in regard to vaginitis, sexually transmitted diseases, and urinary tract infection.
• Use best evidence to answer clinical questions about vaginitis, sexually transmitted diseases, and dysuria.

Interpersonal and Communication Skills

GOAL: Students will understand the importance of effective communication with patients and families in the management of vaginitis, sexually transmitted diseases, and dysuria / urinary tract infection.

OBJECTIVES: Students will be able to:

• Describe the treatment plans for sexually transmitted diseases, vaginitis, and urinary tract infection.
• Include patients and families in the development of treatment plans.
• Demonstrate effective listening skills and empathy to improve patient adherence to the therapeutic plan, including counseling a patient with a sexually transmitted disease to avoid high-risk sexual behavior.

Professionalism

GOAL: Students will demonstrate the ability to care for patients with sexually transmitted diseases, dysuria, and vaginitis from diverse patient backgrounds and at different points in their illness.

OBJECTIVES: Students will be able to:

• Demonstrate sensitivity and responsiveness with patients who are not adhering to treatment plans.
• Reflect on personal frustrations when patients are not adherent to plans, such as completing a course of antibiotics.
• Reflect on values that differ from patients, specifically those relating to sexual behavior and risk of contracting sexually transmitted diseases.
• Demonstrate understanding of the relationship of contracting sexually transmitted diseases to culture, age, gender, and disabilities.

Systems-Based Practice

GOAL: Students will understand the impact of health care systems and environment on the screening/diagnosis, management, and prevention of urinary tract infections, sexually transmitted diseases, and vaginitis.

OBJECTIVES: Students will be able to:

• Describe cost-effective strategies for treatment of urinary tract infection, sexually transmitted disease, or vaginitis using different formularies.
• Analyze barriers to effective screening for sexually transmitted diseases.
• Consider the role of other disciplines (e.g., pharmacy, nursing, social work, and allied health) in the early diagnosis and prevention of sexually transmitted diseases.

EDUCATIONAL METHODS AND RESOURCES

Published Material

• Bachmann G and Nevandunsky N. Diagnosis and treatment of atrophic vaginitis. Am Fam Physician 2000; 61:3090-6.
  Article at Am Fam Physician
• Egan M and Lipsky M. Diagnosis of vaginitis. Am Fam Physician 2000; 62:1095-104.
  Article at Am Fam Physician
• Roberts RG and Hartlaub PP. Evaluation of dysuria in men. Am Fam Physician 1999; 60:865-72.
  Article at Am Fam Physician
• Kurowski K. The woman with dysuria. Am Fam Physician 1998.
  Article at Am Fam Physician
  Patient information handout
  http://www.aafp.org/afp/980501ap/980501b.html
• Bremnor JD and Sadovsky R. Evaluation of dysuria in adults. Am Fam Physician 2002;65:1589-96, 1597.
  Article at Am Fam Physician

Web Sites

• Dysuria / UTIs at http://family practice notebook.com
  "This site is derived from a peripheral brain collection of medical notes, and is divided over 4316 topics within 616 chapters and 31 subspecialty books...Information is gleaned from reputable sources, referenced where possible, taken from lectures and workshops, peer-reviewed articles and bulletins, and key texts. New approaches to medical problems are referenced with supporting studies, and further reading is often suggested on general medical issues. Images, sounds, worksheets, patient education materials, and links to other sites are interwoven with the text, at no extra charge...Peer review of this site would be a very welcome addition, but as of yet I rely on email feedback to correct errors and misinformation. This site is personally funded by the site author, Scott Moses. Additional funding is obtained via advertising support; all paid advertisements are clearly delineated as such..."
  http://www.fpnotebook.com/URO129.htm
• STD guidelines for 2002 from the CDC web site
  http://www.cdc.gov/STD/treatment/TOC2002TG.htm
• Diseases characterized by vaginal discharge
  http://www.cdc.gov/STD/treatment/5-2002TG.htm
• Bacterial vaginosis facts sheet
  http://www.cdc.gov/std/BV/STDFact-Bacterial-Vaginosis.htm
• Interesting Web site on homeopathy and bacterial vaginosis
  http://www.cdc.gov/std/BV/STDFact-Bacterial-Vaginosis.htm
• British Association for Sexual Health and HIV
  http://www.bashh.org/guidelines/ceguidelines.htm

Lead Authors: Alexander Chessman, MD and Ann O'Brien Gonzales, PhD
Clerkship/Post-Clerkship Workgroup members: Ann O'Brien-Gonzales, PhD (Chair), Alexander Chessman, MD (EC Liaison), Caryl Heaton, DO, Janice Nevin, MD, MPH, Lauren Oshman, MD, Deborah McPherson, MD, Mark. E Quirk, EdD, David Schneider, MD, MSPH, William B. Shore, MD, Richard Usatine, MD

Family Medicine Curriculum Resource (FMCR) Project HRSA Contract 240-00-0107.

Revised September 22, 2003

For questions or comments, please contact Webmaster or Ardis Davis

This page last updated October 17, 2005