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Genito-pelvic pain/penetration disorder is a relatively new term encompassing both dyspareunia (recurrent pain with intercourse) and vaginismus (involuntary contraction of the pelvic floor with attempted penetration). Symptoms are often multifactorial. Thus, a detailed history and sensitive patient-centered examination are essential to identify and treat the underlying cause(s). Additional laboratory or imaging studies are not routinely indicated but may be helpful to rule out infectious etiologies or evaluate pelvic organ pathology in cases of deep dyspareunia. Treatment may include patient education about the condition, avoidance or modifications of irritants or triggers, use of vaginal lubricants and moisturizers, hormone therapy, pelvic floor physical therapy, and psychosocial interventions as indicated. Vulvodynia is a separate but related condition and is a diagnosis of exclusion. It is defined as vulvar pain for at least 3 months without another clearly identifiable cause. High-quality studies on the treatment of vulvodynia are limited. However, pelvic floor physical therapy and psychosocial interventions such as cognitive behavior therapy have the most consistent evidence of benefit.

Urinary incontinence is the involuntary loss of urine. It is a prevalent and bothersome condition in females, with subtypes including stress, urge, mixed stress/urge, and overflow. Evaluation begins with a history to identify symptoms of the different subtypes and information about comorbid conditions, incontinence frequency and severity, and effect on quality of life. Based on patient history, other assessments could include urinalysis, a voiding diary, pelvic examination, urinary stress testing, and measurement of postvoid residual urine volume. Treatment varies by subtype, but begins with lifestyle modifications, including decreasing caffeine intake, engaging in physical activity to strengthen pelvic floor muscles, and avoiding excessive fluid consumption. Pelvic floor physical therapy can help with urge and stress incontinence, pessaries and vaginal inserts can help with stress incontinence, and timed or prompted voiding can be useful for both subtypes. Pharmacotherapy for urge incontinence has typically involved anticholinergic drugs, but because of adverse effects, beta-3 adrenergic agonists are being more widely used. If needed for urge incontinence, procedural treatments can be considered, including onabotulinumtoxinA injections, percutaneous tibial nerve stimulation, and sacral neuromodulation. Numerous procedural treatments are available for stress incontinence; placement of midurethral slings is the most common. For overflow incontinence, treatments include catheterization or targeting the source of obstruction or detrusor hypoactivity.

Sexually transmitted infection rates are increasing in the United States, with significant increases in the rates of syphilis among patients of reproductive age and, subsequently, congenital syphilis. Syphilis screening is recommended in sexually active patients 15 to 44 years of age in communities with high syphilis rates and in all pregnant patients at the time of diagnosis or prenatal intake, in the third trimester, and at delivery. Screening for chlamydia and gonorrhea is currently recommended in asymptomatic, sexually active patients younger than 25 years, as well as in older patients with risk factors. When clinicians are diagnosing active infections, patients with anogenital ulcerations should be tested for syphilis and herpes and treated empirically while awaiting test results. Treatment of syphilis depends on the disease stage; first-line regimens all involve penicillin G. Patients with vaginal discharge and dysuria should be tested for gonorrhea and chlamydia using nucleic acid amplification testing. Doxycycline should be used to treat chlamydia because it is more effective in rectal chlamydia, which often coexists with vaginal infection. Single-dose azithromycin is an alternative in populations at risk for poor medication adherence or confidentiality concerns. Ceftriaxone should be used to treat gonorrhea. Increasing drug resistance to gonorrhea is a growing public health threat, and clinicians must work with public health departments in cases of suspected treatment failure.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a likely underdiagnosed chronic pain syndrome consisting of pelvic pain lasting longer than 6 weeks plus lower urinary tract symptoms in the absence of infection or other identifiable cause. It is more common after 40 years of age. The etiology is unclear, but some patients have inflammatory findings in the bladder known as Hunner lesions. Due to its variable presentation, there is no standardized evaluation for diagnosis of IC/BPS. The history should include pain and urinary symptoms; associated comorbid disorders, including autoimmune and mental health conditions; and symptoms suggestive of other causes (eg, infection). Cystoscopy is not required but should be considered for patients with refractory symptoms and when Hunner lesions are suspected, such as in those older than 50 years or with comorbid autoimmune disorders and/or bladder-centric presentation (eg, predominance of urgency, frequency, low urine volumes). Treatment is often multimodal, including behavior modifications, stress management, and nonpharmacologic therapy (eg, pelvic floor physical therapy). Oral pharmacotherapy can be considered, but no guidelines exist on preferred agents. Referral for procedural treatments can also be considered for refractory cases. Patients should understand that no treatments are definitively successful, and recurrences and flare-ups often occur.

Primary care physicians play an integral role in the identification and management of alcohol use disorder, which has implications for the safety and physical and mental health of patients, their families, and the public. Screening to identify risky drinking behavior is recommended by the US Preventive Services Task Force but is not always performed consistently or correctly in primary care. When alcohol use disorder is identified, collaboration with patients is essential to determine an appropriate treatment approach. Abstinence may not always be the answer. Approximately one-half of patients with alcohol use disorder experience symptoms of alcohol withdrawal syndrome when decreasing alcohol use abruptly or substantially. Physicians must be adept at recognizing and managing signs of alcohol withdrawal. They should be aware of the range of management options and recognize that pharmacotherapy has been underused.

The number one cause of preventable disease, disability, and death in the United States is tobacco use. According to data from the National Health Interview Survey, 18.7% of US adults (46 million people) currently use a tobacco product. Smoking causes lung, laryngeal, hepatocellular, and colorectal cancers and possibly breast cancer. Nicotine is the highly addictive component of tobacco that releases dopamine when it binds to alpha-4 beta-2 nicotinic acetylcholine receptors in the brain. This produces reward sensations that become associated with specific behaviors and relieves stress and negative emotions. Public policy changes, behavioral interventions, and pharmacologic approaches have been shown to reduce tobacco use. Combining behavior therapy with pharmacotherapy increases cessation rates. The US Food and Drug Administration has approved five nicotine replacement therapies and two no-nicotine oral medications to assist with smoking cessation. Medications are categorized as controllers or relievers based on their pharmacokinetics. Nicotine replacement therapy delivers lower amounts of nicotine and needs to be titrated to alleviate patient cravings. Varenicline is a selective partial agonist at the alpha-4 beta-2 nicotinic acetylcholine receptor and is recommended over bupropion for smoking cessation.

Most overdose deaths in the United States involve opioids. Identification and management of opioid use disorder by primary care physicians is a critical need in health care. Substance use disorders share neurobiological dysregulation of the central motivation and reward pathway (powered by dopamine) that manifests as a cycle of addiction driven by impulse and compulsion. It is important that concern for opioid use disorder does not disrupt appropriate treatment of pain and that analgesic narcotic use is adequately monitored, especially in patients at risk of opioid use disorder. Most patients with opioid use disorder do not receive treatment. Those who do receive treatment will experience uncomfortable, but not life-threatening, symptoms of withdrawal. These symptoms can be managed with alpha2-adrenergic and opioid agonists that also reduce the reinforcement of drug use and help prolong recovery. The 2023 Mainstreaming Addiction Treatment Act removed the waiver requirement for buprenorphine prescribing, which closes the substantial gap in access to medication for opioid use disorder existing across gender, racial, and socioeconomic groups. Treatment plans that include medication for opioid use disorder have been shown to substantially reduce mortality.

Practice guidelines consistently encourage short-term use of benzodiazepines for the management of common medical conditions. However, these medications are often prescribed long-term for unclear or variable indications. These prescribing patterns may be attributed to perceived low risk and low rate of benzodiazepine use disorders (0.2% of US adults). Compared with other addictive substances, benzodiazepines may have less overall risk and fewer adverse outcomes. Benzodiazepines have limited accessibility compared with alcohol and tobacco. When used alone, benzodiazepines have less risk of lethal overdose than when they are coprescribed with opioids. Although benzodiazepine use for pain management is declining, this use often co-occurs with opioid analgesics, which is associated with greater risk of adverse events. Physician prescribing patterns have a tremendous impact on benzodiazepine use disorder and misuse. Primary care physicians play a vital role in preventing these conditions and in the management of benzodiazepine withdrawal. Effective management of benzodiazepine use disorder and misuse relies on targeted screening and intervention. Concomitant conditions associated with benzodiazepine misuse (eg, chronic pain, anxiety, insomnia) should be adequately addressed in treatment planning. Due to questionable effectiveness of alternative medications in managing benzodiazepine withdrawal, intervention should entail a gradual dose reduction that is facilitated by patient-centered tapering schedules.