468 - Urinary Incontinence, Syphilis Screening, Traveling the Longest Yard

From the Cochrane Library 

1) Conservative Management of Urinary Incontinence 

You may have noticed an increased emphasis on asking our Medicare patients about urinary incontinence since it has become a HEDIS measure. Fortunately, a recent Cochrane overview has reviewed “conservative” interventions for urinary incontinence (UI) in women, so we can feel more confident about addressing this issue. UI affects approximately a quarter of all women, but only a fifth of those actually bring it up to their doctors. The reviewers note that in most guidelines, conservative therapy is recommended prior to medication or surgery – so a comprehensive overview of available conservative therapies is important. 

This was an overview of Cochrane reviews – meaning they searched for and reviewed existing Cochrane systematic reviews. Why? Because the Cochrane library is getting pretty large, and systematic reviews usually tackle questions about a single type of intervention. Bringing all this data together is important work to translate the evidence into practice. 

The overview looked at treatments for stress, urge and mixed urinary incontinence. “Conservative” is defined as what it is not - i.e., it is not medication or surgery. It includes mechanical devices, physical therapies, educational/behavioral/lifestyle advice, psychological interventions or alternative/complementary therapies.  The review was done to the usual good quality Cochrane standards and included a stakeholder panel (including patients and clinicians) as part of the research team to assist in development of the protocol and discuss the applicability of the findings. 

The overview found 29 reviews for analysis, containing 84 meta-analyses for stress UI (SUI), 47 meta-analyses for urge UI (UUI), and 61 meta-analyses for mixed UI (MUI). When the authors used the term “meta-analysis” here, they don’t mean an entire review, but a combination of data for a single comparison (intervention vs. control), single outcome, and single time point. The included reviews were generally at low risk of bias, but the quality of evidence in the reviews themselves was often limited to single studies and therefore the conclusions are of low certainty. 

Overall, the authors found that there is moderate-high certainty evidence that supports pelvic floor muscle training (PFMT) for both improvement of all types of incontinence and improvement in quality of life. PFMT works even better when the exercise is more intense, supervised by a health professional, and supported for continued use. In terms of cure or improvement, vaginal cones are beneficial for SUI, electrical stimulation is beneficial for UUI, and weight loss helps for all urinary incontinence. There was no useful data for psychological therapies or complementary/alternative therapies. 

John’s Comments:

It can be confusing to interpret the levels of study quality and analysis in “overviews of reviews”, but they helpfully outline gaps in evidence and summarize broad clinical topics like this one. Ultimately, PFMT should be our go-to recommendation, and consider referral to pelvic floor physical therapy if the patient needs assistance, or if more intense therapy is needed. There are several things we can try before resorting to drugs or surgical referrals for this common condition. 

Reference: 

·         Todhunter-Brown A, Hazelton C, Campbell P, Elders A, Hagen S, McClurg D. Conservative interventions for treating urinary incontinence in women: an Overview of Cochrane systematic reviews. Cochrane Database of Systematic Reviews. 2022;(9).  Link 

From the USPSTF

2)  Screening for Syphilis

After reaching a record low in 2000, rates for the sexually transmitted infection syphilis have been increasing over the past 20 years.   While men account for the majority of cases (83% of primary and secondary syphilis cases in 2019), rates among women nearly tripled from 2015 to 2019.

The USPSTF recently published an update of their 2016 recommendation regarding screening for syphilis in nonpregnant adolescents and adults who have ever been sexually active and are at risk for infection.  The Task Force commissioned a reaffirmation evidence update focusing on targeted key questions evaluating the performance of risk assessment tools and the benefits and harms of screening for syphilis in nonpregnant adolescents and adults.

Consistent with their 2016 recommendation, the Task Force recommends screening for syphilis in nonpregnant adolescents and adults who are at increased risk for infection. (A recommendation), concluding with high certainty that there is a substantial net benefit of screening.  Those who are at higher risk include men who have sex with men; persons with HIV or other STIs; persons who use illicit drugs; and persons with a history of incarceration, sex work, or military service.  However, in determining risk, clinicians should be aware of how common syphilis infection is in their community and assess a patient’s individual risk.

It should be noted that in 2018 the USPSTF recommended screening for syphilis in all pregnant women (A recommendation).

Options for screening tests include:

·         Traditional screening algorithm:  Screen with an initial nontreponemal test (VDRL or RPR test).  If positive, confirm with a treponemal antibody detection test ( eg, Treponema pallidum particle agglutination (TP-PA test).

·         Reverse sequence algorithm:  Screen with an initial automated treponemal test (e, enzyme-linked or chemiluscence immunoassay).  If positive, confirm with a nontreponemal test. 

Most laboratories perform traditional screening.  Rapid point-of-care (POC) testing for antibodies to T pallidum can provide quick on-site results (typically within 5 to 30 minutes); however, initial real-world data show sensitivity may be low.

Optimal screening frequency for persons who are at increased risk is not well established. Men who have sex with men or persons with HIV infection may benefit from screening at least annually or more frequently (eg, every 3 to 6 months) if they continue to be at high risk.

With regard to treatment, the effectiveness of parenteral penicillin G for the treatment of primary, secondary, and latent syphilis is well established.  Dosage and the length of treatment depend on the stage and symptoms of the infection.  Clinicians are encouraged to refer to the CDC's STI Treatment Guidelines for the most up-to-date treatment guidance.

Mark’s Comments:

I’ve found this is one of those tests that is easy to overlook unless I’m either working up or treating someone for a presumed symptomatic sexually transmitted infection.  It’s also a disease that we don’t want to miss given its potential long-term consequences.  Remember that the average time between acquisition of syphilis and the start of the first symptom is 21 days (range 10-90 days).  Because of this, screening tests may not be positive until many weeks after exposure.  This also makes it easy to miss and if suspicion of possible exposure is high, necessitates retesting at 10-12 weeks if initial test soon after exposure is negative (which it most likely will be). 

Reference:

USPSTF.  Screening for Syphilis Infection in Nonpregnant Adolescents and Adults.  USPSTF Reaffirmation Recommendation Statement.  JAMA. 2022;328(12):1243-1249. doi:10.1001/jama.2022.15322.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  How Hard Can It Be to Travel One Yard? 

"Promise me you'll always remember that you are braver than you believe, stronger than you seem, and smarter than you think." - Christopher Robin to Winnie the Pooh (A.A. Milne)

What’s something you really want or even “need” to change, but for whatever reason, haven’t?  For example, this could be pursuing a health-related goal, learning a new skill, having an important conversation, connecting with another person, or even going on a vacation or adventure.  This is a question I enjoy asking colleagues but find I often avoid asking myself.  With others, it provides me the opportunity to encourage them in their desire, but for me it exposes an often painful gap between “what is and what could be.”  

Recently I’ve found myself in conversations with a few colleagues who expressed that some of their health-related goals had become bogged down or even come to a screeching halt.  They attributed this to “busyness,” but as I reflected on those conversations and my own similar experiences (like the “junk food” that continually calls to me), I concluded there was more at play – that when it comes to change we often find ourselves trapped in the combined gravitational pull of maintaining the status quo and taking the pathway of least resistance, and in both instances don’t have a plan to generate the “escape velocity” to take our lives in our new “desired” direction. 

There is, indeed, more at play.  In fact, there is an entire body of science that has developed around the psychology of human behavior and how we can overcome our “behavioral entropy” in order to make choices and changes that will enhance our lives.  But in order for us to be successful, we’ll have to understand that we humans are not the “rational” creatures we’ve come to believe ourselves to be …. We’ll have to learn how to navigate what I have come to know as the “longest yard.”

The longest yard is the gap between our “knowing” and our “doing.”  It comprises the one-foot distance between head and heart (knowing to believing) and the two-foot distance between heart and hands (believing to doing).  Now you may be thinking, “But it’s only 1 yard … how hard can it be?!”  Well, as the recent experience of my well-educated, well-resourced, and really smart colleagues demonstrates (as well as my own many times over – and likely yours), when it comes to traveling those 36 inches and changing our behavior, it can often seem very hard.  So hard, in fact, that we regularly “give up.”  It is therefore comforting to know that we also regularly make it much more difficult than it has to be.  And there in lies our hope.    

So back to my original question:  What’s something you really want or even “need” to change, but haven’t?   What are your behaviors for which you seem to be stuck “one yard,” or even “two feet,” from initiation?  Over the next few weeks, I’m going to be exploring some of the science focused on helping us to travel that “longest yard,” and will share some practical application of that science.  If you find yourself “stuck” in any area of your life, this is an opportunity you won’t want to miss.  And be sure to bring your PeerRxMed partner along for the ride … they may have a significant role to play.

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org