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Key principles of rheumatoid arthritis (RA) management include early patient evaluation by a rheumatologist and early initiation of pharmacologic therapy in patients at risk for chronic disease. Early diagnosis and appropriate management are essential to prevent joint damage. Patients with RA usually report pain and swelling in multiple joints and prolonged stiffness in the morning that improves with activity. Joint involvement typically is bilateral and symmetric. RA affects large and small joints, particularly the metacarpophalangeal and proximal interphalangeal joints of the hands. Patients with RA may be started on nonsteroidal anti-inflammatory drugs, glucocorticoids, or conventional synthetic disease-modifying antirheumatic drugs (DMARDs) before evaluation by a rheumatologist. Patients who have a poor response to conventional synthetic DMARDs or aggressive arthritis at initial evaluation may be prescribed biologic or targeted synthetic DMARDs. Anti-tumor necrosis factor alpha agents also may be used. Patients typically are managed with a treat-to-target strategy to achieve and maintain low disease activity or remission. Regular monitoring visits using formal assessment of disease activity have been shown to improve outcomes. RA and the medications used in its treatment are associated with increased risks of infections and malignancy. Integrative medicine therapies with limited evidence include acupuncture, mind-body therapies (eg, yoga, tai chi), and dietary supplements.

Septic arthritis is acute onset of monoarticular inflammation of a joint due to an infectious etiology. It is usually bacterial but can be viral or fungal. Septic arthritis causes significant morbidity and mortality and requires prompt diagnosis and treatment. Risk factors include age older than 80 years, smoking, comorbid conditions (eg, diabetes, rheumatoid arthritis, skin infection, HIV infection, osteoarthritis), and other factors (eg, recent joint surgery, joint prosthesis, previous intra-articular injection). The clinical presentation of septic arthritis can overlap with those of many other joint conditions, which can make diagnosis challenging. Poor functional outcomes, such as amputation, arthrodesis, prosthetic surgery, and severe functional deterioration, occur in approximately 24% to 33% of patients with septic arthritis. Due to the significant sequelae associated with septic arthritis, it is critical for physicians to maintain a high index of suspicion for this condition. Management involves a combination of medical and surgical treatments tailored to infection severity, causative pathogens, and overall patient condition. Medical treatment is not inferior to surgical treatment. However, 30% of patients with septic arthritis ultimately require surgical treatment. The 90-day mortality rate of knee septic arthritis is 7% in patients 79 years and younger and from 22% to 69% in patients older than 79 years.

Approximately 800,000 total knee arthroplasties and 450,000 total hip arthroplasties are performed annually in the United States. These procedures provide significant pain relief and restore function in patients with advanced osteoarthritis, rheumatoid arthritis, and other degenerative joint conditions. Patient evaluation before surgery includes a history, physical examination, laboratory tests, and imaging. After surgery, the rapid recovery protocol typically is used. This involves early mobilization of the replaced joint with ambulation as soon as 4 to 8 hours after surgery. Postoperative analgesia may include nerve block local infiltration anesthesia within the first 24 hours, along with opioids, cyclooxygenase-2 selective inhibitors, and acetaminophen. Periprosthetic joint infections are the primary reason for revision arthroplasty; they occur in 1% to 2% of patients. Risk factors include obesity, diabetes, poor nutritional status, and smoking. Routine use of anticoagulants has decreased the postoperative rate of venous thromboembolism. Rehabilitation includes stretching, muscle strengthening, and exercises to increase range of motion and improve gait, balance, and neuromuscular function. This can be performed in an in- or outpatient setting. In the postoperative period, most patients can resume a majority of daily activities within 6 weeks. After 3 months, most patients are functioning at 90% capacity, with full recovery by 1 year.

Knee and hip osteoarthritis (OA) are two of the leading causes of disability globally. Knee OA is characterized by gradual degeneration of articular cartilage, leading to pain, stiffness, and functional limitations. Patients older than 50 years typically present with knee OA, but it can manifest earlier, particularly following traumatic knee injuries. Symptoms include pain, effusion, stiffness, and reduced range of motion. Radiographs commonly are used to confirm a diagnosis of knee OA. Nonsurgical management options include weight loss, lifestyle interventions, orthotic and assistive devices, pain medications (eg, nonsteroidal anti-inflammatory drugs, acetaminophen), and intra- articular injections. The main injectable treatments are corticosteroids, platelet-rich plasma, and hyaluronic acid. These are used as adjunctive therapies for knee OA. It is essential to differentiate between knee and hip OA and understand differences in patient characteristics, treatment approaches, and outcomes. Knee OA can be successfully managed with nonsurgical treatments. Many patients with knee OA can achieve pain relief and improved function without surgery. In contrast, for hip OA there is no evidence that delaying total hip arthroplasty is beneficial. Total hip arthroplasty is considered one of the most effective orthopedic procedures and typically results in pain relief and restoration of joint function in patients with hip OA.

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.

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.

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.

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.