Applying to Urogynecology / FPMRS, with Dr. Edward Kim

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We welcome back Dr. Edward Kim, an FPMRS fellow at the University of Pennsylvania, who’s talking with us today about how to apply for urogynecology fellowship!

Disclosures: We’re from a large academic institution. What we say may not apply to those from smaller programs or those from community programs! Please feel free to reach out to us though for other specifics or connections on advice.

  1. What is Urogynecology or FPMRS?

    1. Female pelvic medicine and reconstructive surgery

    2. We are a subspecialty of either Ob/Gyn or Urology that focuses on medical management, surgical management and research of women’s pelvic floor conditions. Vast majority of our surgeries are elective and outpatient or at the most overnight stays. Compared to other gyn surgical subspecialties like gyn onc or MIGS, there is very little inpatient care needs or consults. Our patient population is predominantly older patients with exceptions at institutions that do gender affirming surgeries, peripartum pelvic floor care, etc. Our research areas range from basic science to NIH-funded research network.

    3. Historically, the name FPMRS was created to replace or supplement the name urogynecology in order to relay that our scope of practice can go beyond urologic and gynecologic conditions. However, more recently, the name FPMRS is being re-discussed as the word female is not inclusive especially given that more of us are seeing gender diverse patients and perform gender affirming surgeries.

    4. Long story short, urogynecology and FPMRS are synonymous for the time being but it may evolve.

    5. In terms of the duration of training: For Ob/Gyns it’s a 3 year fellowship and for Urologists it’s a 2 year fellowship. For Ob/Gyns, these 3 years include 12 months of research, as it is for all ABOG certified subspecialties.

    6. Your training will cover a variety of pelvic floor conditions as defined by American Urogynecologic Society’s (AUGS) scope of practice:

      1. Urinary Incontinence

      2. Pelvic organ prolapse

      3. Voiding dysfunction

      4. Neurogenic bladder

      5. Urethral diverticula

      6. Vesico-vaginal and recto-vaginal fistulae

      7. Congenital anomalies of the pelvic floor

      8. Fecal incontinence

      9. Recurrent UTI

      10. IC/BPS

      11. Managing pelvic floor surgery complications and mesh complications

      12. And at some programs:

a)    Transgender care and gender affirming surgeries

b)    Peripartum pelvic floor care

c)     Pelvic pain

d)    Etc.

 

  1. Years I - II

    1. NOTE: Urogyn is EARLY application and EARLY match just like Urology. Urogyn timeline is thus a few months earlier than other Ob/Gyn subspecialties. Applications OPEN in NOVEMBER/DECEMBER and CLOSE by January of PGY3 year, interview in SPRING of PGY3 year and match by AUGUST of PGY4 year. So solidifying your interest in urogyn earlier in residency is beneficial.

    2. If you are at a residency with big urogyn presence and have fellowship. Typically you will rotate through or be exposed to urogyn as junior residents. If so,

      1. See what your attendings and fellows do. Talk to them about why they went into it. Do you like major and minor urogyn surgeries? How about the predominantly older patient population?

      2. See what kind of scholarly activities are happening in the division. Ask if you can be more involved with research. This will help you get “plugged in” with the division.

      3. Do well on CREOGs but not a huge deal until your third year. Show an upward trend if you can.

    3. If you are not at a residency with big urogyn presence

      1. Identify a local urogyn faculty or urogyn division.

      2. If your residency and host institution allow, do an away rotation. Try to impress them and get a great letter. Ideally, you should have at least one urogyn write a letter of recommendaiton for you.

      3. At the least, do scholarly work like a book chapter or full on research project.

    4. PGY2s should consider either:

      1. AUGS Resident Scholars Program that gives funding to attend AUGS meeting to network and be exposed to the greater urogyn world

      2. ABLE Scholar Travel Award that is similar to the resident scholars program but focused on residents from diverse backgrounds

      3. You can apply as a PGY3, but by the time you attend AUGS, your fellowship application process will already be in full swing. So try to go in PGY2 year to network if you can.

  2. Third Year

    1. Identify people that can write your letter of recommendation.

    2. Continue your research projects and other scholarly activities

    3. If you haven’t already, apply for either resident scholar programs that I mentioned

    4. Applications open in November/December!

      1. So in the summer/early fall time, look at AUGS’ listing of fellowship programs. Look at each program’s information. Make a list of programs you’d be interested in

      2. Sit down with your mentor/fellows and edit or add to the list

a)    Talk about: research heavy? Academic versus private after graduation? Specific niches like gender affirming care, basic science research, dual degree opportunities?

  1. Applications

    1. Overview: Applications open in November/December and close in January typically. Interview invitations will be sent out around February. Interviews are from March to June. With the match in August.

    2. In early fall of PGY3 year, update your CV and get the application material together.

    3. Write your personal statement and have your mentors review it. Help the readers understand why urogyn and what you want to accomplish in your career.

    4. Most programs will not review the application as soon as the application opens in Nov/Dec. Do submit on the earlier side because you don’t know what the process is like at your top choice programs. But don’t rush at the cost of making mistakes in your application.

    5. All programs will send out interview invites on a single designated day typically in February.

      1. Just like in residency, be prompt about responding to interview invites as to not end up on the waitlist.

  2. Interviews

    1. Back in our day for Nick Fei and I, we spent a lot of money on in-person interviews! Virtual interviews are wallet-friendly and schedule-friendly, but they are also exhausting! Allow yourself some breaks and downtime between interviews if you can and try to optimize the number of interviews you do.

    2. You all know this by this point in your career but:

      1. Do your homework on the program! Some programs have good information about their programs on their websites or on their AUGS program listing. Try not to ask questions that is reasonably evident lest you want to be seen as not interested in the program. Ask people you know about the programs. Networking at AUGS will come in handy.

      2. Know the program faculty and what their interests are

      3. Have a list of questions:

a)    Surgical modality breakdown: robotic, vaginal, laparoscopic, etc.

b)    What kinds of non-bread and butter urogyn things do they do? Gender affirming care, peripartum pelvic floor issues, etc.?

c)     What is their research year structure? One full year? Or 12 months broken up throughout?

d)    What kinds of research do their fellows do? Basic science? Clinical?

      1. For logistical questions like calls, transportations, try to save those for the fellows or perhaps the PD

    1. It’s hard to get a sense on virtual interview days but try to see if the division members seem friendly and collegial with one another.

    2. See if everyone in the division makes it to the interview. Programs that are vested in their fellowship will try very hard to pick a time and day that works for everyone, block out their ORs and clinics, etc.

  1. Rank Lists

    1. Make your rank list and seek feedback from your mentors. Think about geography and what you want in a program. 3 years is a long time and you will have a lot more free time in urogyn fellowship compared to residency or even other ob/gyn subspecialties! So being at a place that you can be with family, friends, or things you like doing are also something to consider.

    2. Be sure to reach out to a few programs that you really loved. You voluntarily telling your top choices that they are your top choices is not against the NRMP rules.

      1. Some programs do not write back at all.

      2. To really support your emails of interest; Ask your mentors to reach out on your behalf.

    3. It’s hard to know which programs want thank you emails or not. Try to lean on the side of doing them. Again, some program and interviewers will not write back. That’s okay!

Colorectal Cancer Screening

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Given that OB/GYNs have one foot in the world of primary care and another foot in the world of specialty care, we thought we’d review these recently updated USPSTF guidelines (5.2021) which have been endorsed by ACOG.

Why do we care?

  • Colorectal cancer (CRC) is the third leading cause of cancer death in the USA for men and women

    • Almost 53,000 deaths from CRC in the US in 2021

  • Most frequently diagnosed among folks aged 65-74, but

    • 10% of cases occur in persons under age 50.

    • 15% increase of incidence in persons aged 40-49 between 200-2016.

  • 26% of eligible adults have never been screened, and 31% are not up to date with screening as of 2018!

What population are we talking about, and who is at most risk?

  • The USPSTF recommendations are limited to “average risk” population, so:

    • Not talking about those with:

      • Genetic syndromes (i.e., Lynch, familial adenomatous polyposis)

      • Inflammatory bowel diseases

      • Personal history of CRC or adenomatous polyps

  • Age is one of the most important risk factors.

    • CRC screening particularly in average risk adults aged 50-75 has significant benefit, and in adults over age 45 also likely has at least moderate net benefit.

      • After age 75, the benefit of CRC screening is lessened, but may still be there for folks who have never been screened.

    • All adults aged 45 or older should be offered screening!

  • Rates of CRC are higher in Black adults, as well as Native adults.

    • This likely reflects complex issues in health disparities and access to screening (which was previously procedural and only colonoscopy or flex-sig based).

      • The USPSTF mentions that this health disparity is not rooted in genetic difference – we appreciate that recognition that race does not equal genetics, and some evidence to back it up.

  • Additional risk factors include:

    • Family history of CRC (even in absence of genetic syndromes)

    • Obesity

    • Diabetes

    • Smoking

    • “Unhealthy” alcohol use

What tests are available for screening, and how do they work?

  • Stool-based tests include high sensitivity guaiac fecal occult blood test (gFOBT), fecal immunichemical tests (FIT), and stool DNA tests. 

    • gFOBT and FIT detect blood in the stool. gFOBT is chemical while FIT uses antibodies.

    • There is one stool DNA test on the market that also includes a FIT component.

    • If one of these tests are employed for screening, it is recommended that:

      • gFOBT or FIT annually

      • sDNA-FIT every 1-3 years

        • FIT and sDNA-FIT annually provides greater benefit than every 3 year schedule, but sDNA annually leads to more colonoscopies; thus, the range is provided to help balance.

        • gFOBT likely has lower sensitivity to detect CRC and advanced adenomas.

          • Positive results on any test should be followed up with colonoscopy.

    • Stool-based tests are quick and non-invasive and don’t require a bowel prep, so likely make screening more available for patients.

      • gFOBT does require some dietary and medication restriction, but FIT and sDNA-FIT do not.

      • gFOBT requires 3 separate bowel movement samples; FIT and sDNA-FIT can be performed from one sample.

        • sDNA-FIT requires collection of an entire bowel movement, though!

    • The benefits of stool-based testing accrue with frequent, repeated testing – so to get max benefit, the annual frequency is definitely recommended!

  • Direct visualization tests look inside the colon and rectum - options are colonoscopy, CT colonography, and flexible sigmoidoscopy. 

    • Flexible sigmoidoscopy uses a scope to visualize the rectum, sigmoid, and descending colon.

    • CT colonography uses x-ray images to visualize the colon.

    • Colonoscopy uses a scope to visualize the entirety of the colon.

      • Flex sig and CT colonography require colonoscopy as a reflex test if an abnormality is found.

    • If one of these tests are employed, recommended screening intervals are:

      • Flexible sigmoidoscopy:

        • Every 5 years alone, or 

        • Every 10 years in combination with annual FIT

      • CT colonography every 5 years

      • Colonoscopy screening every 10 years

        • Colonoscopy and CT colonography provide greater estimated life-years gained versus flexible sigmoidoscopy every 5 years.

    • These are the gold standard in screening, but must be performed in a clinical setting, require bowel preparation, and may require sedation or anesthesia.

Which test should I order?

  • As of the time of the USPSTF recommendation, there were no high-quality trials comparing effectiveness of different strategies to reduce CRC mortality

  • There are also relatively few studies in younger populations (i.e., younger than age 50). 

  • So it’s up to you and your patient’s values/context to decide what will get screening done reliably to reduce their risk!

Telehealth for the Ob/Gyn

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Reading for this podcast:
Committee Opinion 798: Implementing Telehealth in Practice 

What is Telehealth? 

  • Definition

    • Collection of means or methods for enhancing the health care, public health, and health education delivery and support using telecommunications technologies

    • Term of “telehealth” is often used to refer to traditional clinical diagnosis and monitoring that are delivered by technology (ie. doing a visit on Zoom) 

    • Connected health and digital health are also terms that broadly describe similar technology applications in health care 

    • But remember that telehealth can refer to a broad list of healthcare topics, such as diagnosis and management, education (ie. podcasts!), and other related fields of health care 

      • Can include remote monitoring, mobile health care (ie. text messages, apps) 

      • These services can be real time (synchronous) or “store-and-forward” (ie. asynchronous) 

The Data Behind TH 

  • A lot of this data is recent due to the COVID-19 pandemic 

    • This has especially been true in OB care given the need for multiple prenatal visits in a short period of time 

  • One great study that came out in February 2020 (right before COVID!) in the green: 

    • Telehealth Interventions to Improve Obstetric and Gynecologic Health Outcomes, by Dr. Denicola et al 

    • The looked at 47 total studies, which included 31,967 patients 

    • Telehealth improved obstetric outcomes via: 

      • Increased smoking cessation and increased breastfeeding 

      • Also decreased need for high-risk obstetric monitoring office visits, but did not lead to worse maternal and fetal outcomes 

      • Also effective for continuation of oral and injectable contraception 

      • TH provision of medication abortion services had similar outcomes compared with in-person care and improved access to early abortions 

Providing Equitable Telehealth Care 

  • Just like in any time of health care, there will always be barriers to equity 

  • Healthcare practitioner factors 

    • Includes attitudes and perceptions, inherent biases and assumptions 

    • Studies have shown that when looking at patient portal use, Latino, Black and individuals with low income were less likely to be offered patient portal access and had significantly lower uptake 

  • Health system factors 

    • Safety net health systems and community health centers often lag behind in offering telemedicine 

    • Possibly due to lack of supportive infrastructure 

  • Patient factors 

    • Absence of technology or reliable internet coverage

    • Low health and digital literacy 

    • Non-English speakers can also have a barrier to telemed use 

    • Disproportionately affect those in rural areas, those identify as BIPOC, and those living on low incomes 

  • Payor and Policy Factors 

    • State Medicaid programs continue to restrict coverage of telemedicine and other remote management services 

    • Before COVID-19, only 19 state Medicaid programs explicitly recognized patient’s home as an eligible originating site for telemedicine 

    • States also require practitioners to be licensed within the state where the patient was receiving their care, so this limits patients from accessing telehealth services from out of state practitioners 

    • Also there is limited coverage for audio-only services 

  • Recommendations to mitigate these barriers 

    • Individual practitioners to acknowledge and mitigate implicit biases 

    • Systems should ensure that telehealth platforms are secure and widely usable 

    • Provide technological and clinical infrastructure including patient-centered education tools 

    • Allow for telephone visits when video visits are not feasible or desired

    • Conduct rigorous quality assurance efforts  

    • Payers should make telemedicine a standard coverage benefit and cover at-home monitoring equipment 

    • Payers can also provide mobile devices with data plan or Wi-Fi 

    • Require reimbursement of audio-only visit 

    • Ensure payment parity across sites and types of visits 

    • Expand ability to practice telemedicine across state lines and remove existing barriers to multi-state licensure

Surgery: The McDonald Cerclage

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What is a McDonald cerclage? 

  • Definition: a suture placed around the cervix in a purse-string fashion and tied anteriorly 

  • Purpose: to decrease the risk of preterm birth in patients with

    • History of preterm birth and short cervix 

    • Second trimester with open cervix <24 weeks 

  • For more indications, please see our prevention of preterm birth episode! 

UPTODATE

Today we will focus on the surgical steps:

  • For pictures, we still like Atlas of Pelvic Surgery: 

    Pre-operative 

    • Surgical consent 

      • Review the way the procedure is done 

      • Discuss risks, benefits, and alternatives

        • Risks: injury to organs around the cervix (ie. bowel, bladder, vagina), small risk of breaking the bag of water and losing the pregnancy, infection, bleeding, etc.  

        • Benefits: could decrease preterm birth before 37 and 34 weeks compared to women who did not get cerclage (RR 0.77, 95% CI 0.66 to 0.89 based on a Cochrane review) 

        • Alternatives: doing nothing, using vaginal progesterone, etc. 

    • Preoperative work up 

      • Most providers will not need a CBC or other additional work up in young, healthy patients 

      • Some hospitals may require a type and screen for all patients going to the operating room, and most hospitals nowadays may also require a COVID swab 

        • Patients who are Rh negative: typically do NOT give Rhogam just for cerclage, given that any bleeding caused is presumably only cervical bleeding and we are not traumatizing the pregnancy.

      • Ultrasound, genetic screening 

        • General practice is to perform genetic screening if a patient desires it (ie. we don’t want to put a cerclage into a pregnancy that is affected by aneuploidy in a patient who may desire termination) 

        • Ultrasound - make sure there are not obvious fetal malformations early on (ie. anencephaly), make sure there is a fetal heartbeat before the procedure.

    • Anesthesia 

      • Most procedures are done with neuraxial anesthesia (ie. Spinal) 

    • Expectations 

      • Patients will go home same day 

      • Some can have some cramping and spotting, but if more than cramping, should come in for evaluation 

  • During the surgery 

    • Patient should have adequate anesthesia in the operating room and be prepped and draped 

    • Positioning: 

      • Dorsal lithotomy - yellowfins vs candy canes 

      • Tip: make sure patient’s bottom is slightly hanging off of the bed; put patients in slight Trendelenburg for visualization  

      • Empty bladder - usually helpful to be able to visualize cervix 

    • Surgical steps

      • Evaluate the cervix after adequate anesthesia has been achieved even if you examined them before anesthesia

        • After anesthesia and relaxation, the cervix can appear different or even more open! 

        • Evaluation should be done visually first in case there are exposed membranes 

      • Achieve visualization 

        • Can place a weighted speculum into the posterior vagina, or can also place 3 Bryskie retractors to visualize the cervix 

        • Place two ringed forceps onto the anterior and posterior lip of the cervix - this allows for maneuverability of the cervix 

        • Visualize the reflection of the bladder on the anterior cervix 

      • Place the suture

        • Permanent suture is used 

          • Types: Mersilene tape or a 0- or 1- Ti-Cron (coated braided polyester suture) - usually will use a large caliber suture

          • If using Ti-Cron, will usually use a mayo needle given large size of the needle that comes with the Ti-Cron 

        •  Usually the suture is placed with 4 or 5 bites 

          • Start at 12 or 1 o’clock on the cervix, as far back as possible without getting into the bladder 

          • The next bites should avoid 3 and 9 o’clock where the vessels are 

          • Assistants should use Bryskie retractors to hold back the vaginal walls, and the surgeon should use the two ringed forceps to maneuver the cervix 

        • Tying the suture 

          • Tighten the suture on both sides and recheck the cervix to make sure the suture is tight and the cervix is closed 

          • Tying: Fei ties 6 knots for Ti-Cron, and 4 for Mersilene tape. Then, for ease of removal later, I will tie an airknot and then tie down four more knots. You can also tag Mersilene tape with another soft non-absorbable suture (i.e., silk).

  • Post-operative 

    • In the hospital, the patient needs to have their spinal/epidural anesthesia wear off before they can go home 

      • Should be able to walk 

      • Should be able to urinate 

      • Check fetal heart tones 

    • Indocin and antibiotics or no? 

      • Er… it depends and there is a lot of conflicting data 

      • There is a randomized controlled trial of only 53 patients in 2014 looking at antibiotics and indocin for exam-indicated cerclages 

        • This showed that there was increased time to delivery for those that received Indomethacin and antibiotics, but gestational age at delivery and neonatal outcomes were the same in both groups 

        • Then a repeat study was done in 2020 that showed similar results (increase in latency):

        • So… I think many people would do Indocin and antibiotics for exam-indicated cerclages 

      • A retrospective study for all cerclages showed that there was no increase in gestational age or neonatal outcomes 

        • So, maybe not use indocin in history-indicated cerclages.

    • Follow-up 

      • Usually 1-2 week follow up for cerclage check in office.

Gonorrhea and Chlamydia

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We talked about most STIs in a series back at the beginning of 2019! This podcast is an update to the treatment guidelines and will replace our last episode on gonorrhea and chlamydia, as these two bugs had some changes in treatment with the 2021 CDC STI guidelines.

First of all, why are we doing these two STDs together? 

  • Because they have a lot of common symptomatology 

  • They may come together (ie. if you have one, you may have the other) 

  • We usually order the two tests together (say it in one breath anyway in the clinic or the ED) 

What are gonorrhea and chlamydia and why do we care? 

  • Both are sexually transmitted infections that anyone can get if they are sexually active (any kind of sex), and there is vertical transmission between mother and child 

  • Gonorrhea 

    • Caused by bacteria Neisseria gonorrhoeae (gram negative diplococci) 

    • 1.6 million new infections annually in the US

      • More than 50% occur in patients aged 15-24

    • Usually symptomless but in men can cause burning with urination, penile discharge, or even testicular pain 

    • In women, 50% are symptomless but can lead to burning with urination, vaginal discharge, intermenstrual bleeding/postcoital spotting, pelvic pain

    • Can also affect other areas like throat or anus 

    • If untreated, it can lead to pelvic inflammatory disease and infertility. Additionally, at risk for disseminated gonococcal infection 

      • Skin pustules/petechiae, septic arthritis, meningitis, endocarditis 

      • Very rare (0.6-3% of infected women and 0.4-0.7% of infected men 

      • In pregnant patients: septic abortion, chorio, neonatal blindness 

  • Chlamydia 

    • Caused by bacteria Chlamydia trachomatis (gram negative bacteria that only replicates in host cells).

    • 4 million new infections annually in the US

      • More than 65% occur in patients aged 15-24

      • Some estimates show at any given time, 1 in 20 sexually active women aged 15-24 has active chlamydia infection in the US.

    • Again, usually symptomless (70-80%), but can cause vaginal discharge and burning with urination in women 

    • In men, can have discharge from penis, burning with urination, pain and swelling in testicles. 

    • Rectal, oral/throat infections are also possible.

    • If untreated, can also cause PID and infertility in women → around 15% of women will develop.

    • Also can cause chlamydia conjunctivitis or trachoma → blindness 

    • Reactive arthritis → can’t see, can’t pee, can’t climb a tree = arthritis, conjunctivitis, urethral inflammation 

How do we diagnose them? 

  • Usually a urine test, but can also do endocervical swab, vaginal swab, rectal swab, or pharyngeal swab 

    • Nucleic acid amplification test = gold standard 

  • Who should be tested? 

    • CDC recommends screening:

      • Of anyone with concern for symptoms;

      • Annually for GC/chlamydia for all sexually active women younger than 25 years 

      • Opportunistic screening for older women with identified risk factors (ie. new or multiple sexual partners or sex partner who recently had an STI) 

    • For men: once a year for GC/chlamydia for all sexually active MSM, and more frequently (q3-6 months) for MSM who have HIV or if they have multiple or anonymous partners 

How do we treat gonorrhea and chlamydia? - note, this is only for adolescents and adults 

  • Treating gonorrhea (NOT disseminated) 

    • Gonorrhea is becoming more and more resistant to antibiotics, and we are down to one class of antibiotic that really treats it: cephalosporins 

    • CDC recommends: ceftriaxone 500mg IM x1

      • This is an update to the previous recommendations, which used 250mg. This reflects the changing state of antibiotic resistance of gonorrhea.

      • Test of cure is recommended for throat infections and for pregnant patients, but not necessarily for genital or rectal infections.

    • If cephalosporin allergic:

      • Gentamicin 240mg IM in single dose, AND Azithromycin 2g orally in single dose.

  • Treating chlamydia 

    • Recommended regimen by the CDC: Doxycycline 100mg PO twice daily for 7 days.

      • Alternative regimens include:

        • Azithromycin 2g orally, single dose

        • Levofloxacin 500 mg orally for 7 days 

    • Azithromycin has lower efficacy amongst persons with concomitant rectal infection, which is why the doxycycline regimen is preferred.

      • Repeat screening may be needed to ensure efficacy of the single-dose azithro regimen.

  • Expedited partner treatment - treat the sexual partner of the patient diagnosed with chlamydia or gonorrhea without first examining the sexual partner 

    • CDC says: EPT is a useful option to facilitate partner management in states where it is permissible, and reduces re-infection risk for the patient while treating the partner.

    • Should always counsel the patient that partner and patient should refrain from having intercourse for at least 7 days after all partners have been treated.

GC/chlamydia in pregnancy 

  • Screen in first trimester and if positive, should be treated

    • Exception: for chlamydia, Azithromycin 1g orally x1 is the recommended regimen.

    • These medications are safe during pregnancy, and risks outweigh the benefits of not treating

    • Expedited partner treatment is recommended where permissible.

    • Test of cure is recommended in three weeks (and should also screen in 3rd trimester again)

  • Pregnancy-specific risks of non-treatment

    • Vertical transmission to newborn 

    • Chlamydia: conjunctivitis (5-14 days after birth), and pneumonia (4-12 weeks of age) 

    • Gonorrhea: conjunctivitis (more purulent compared to watery discharge of chlamydia… both can lead to blindness!) 

      • Gentamicin/erythomycin eye gel helps to prevent these and why we use it!

    • Otherwise: septic abortions, intact chorio, etc. 

A final “fun fact” we had dug out in the original GC/CT episode…

  • There is no consensus as to why gonorrhea is called the clap… but some theories: 

    • Old English word “clappan” means throbbing or beating -- could mean the burning during urination with gonorrhea 

    • Proposed treatment during medieval times of “clapping” the penis or slamming the penis between both hands on a hard surface to get rid of the discharge/pus