BNF - Chapter 7 - Genito-Urinary System Flashcards
What is urinary incontinence?
Urinary incontinence is the involuntary leakage of urine and can range in severity and nature.
What can urinary incontinence be due to?
can be the result of functional abnormalities in the lower urinary tract, or due to other illnesses.
How many sub classes of urinary incontinence are there?
4
What are the subclasses of urinary incontinence?
- Stress
- Urgency
- mixed
- Overflow incontinence
What is stress incontinence?
Stress incontinence is the involuntary leakage on effort or exertion, or on sneezing or coughing, and is associated with the loss of pelvic floor support and/or damage to the urethral sphincter.
What is urgency incontinence?
Urgency incontinence is involuntary leakage which is accompanied, or immediately preceded by a sudden compelling desire to pass urine that is difficult to delay. It is often part of a larger symptom complex known as overactive bladder syndrome. This syndrome is defined as urinary urgency, which may or may not be accompanied by urgency incontinence, but is usually associated with increased frequency and nocturia. The symptoms are thought to be caused by involuntary contractions of the detrusor muscle
What is mixed incontinence?
Mixed urinary incontinence is involuntary leakage associated with both urgency and stress, however, one type tends to be predominant.
What is overflow incontinence?
Overflow incontinence is a complication of chronic urinary retention and occurs when a person cannot empty their bladder completely and it becomes over distended.
This may result in continuous, or frequent loss of small quantities of urine
What are some other types of urinary incontinence?
Other types include continuous urinary incontinence, where there is constant leakage of urine which may be due to the severity of the persons’ condition or may be due to an underlying cause, such as a fistula. Incontinence may also be situational, for example during sexual intercourse or when a person is giggling.
What is the main risk factor for developing any type of incontinence?
- Older age; this is due to the physiological changes that occur with natural aging
Other than age what are some other risk factors of stress incontinence?
pregnancy, vaginal delivery, obesity, constipation, family history, smoking, lack of supporting tissue (such as in prolapse or hysterectomy) and use of some drugs such as ACE inhibitors (can cause cough) and alpha-adrenergic blockers (relax the bladder outlet and urethra).
Which conditions may increase detrusor muscle overactivity and therefore worsen urgency incontinence?
These include conditions that affect the lower urinary tract such as; Urinary-tract infections, urinary obstruction, or oestrogen deficiency, those affecting the nervous system such as; stroke, dementia, and Parkinson’s disease, and systemic conditions such as; diabetes mellitus or hypercalcaemia
Side effects of some durgs may also increase detrusor muscle overactivity or indirectly contribute to urgency incontinence; what do they include?
cholinesterase inhibitors, drugs that cause constipation, and those with anticholinergic effects.
What effect do diuretics, alcohol and caffeine have?
They all increase urine production and can cause polyuria, frequency, urgency and nocturia
What non drug treatment advice is given to women with incontinence?
- modify fluid intake
- if BMI is 30kg/m2 or greater, be advised to lose weight
- For those with an overactive bladder, a reduction in caffeine intake should be trialled.
When can intravaginal and intraurethral devices be used?
Should only be used when required to prevent leakage at specific times, for example during exercise
What is the non drug treatment for urgency incontinence in women?
Women should be offered bladder training for at least 6 weeks as first-line treatment.
If frequency is a problem and satisfactory benefit from bladder training is not achieved, drug treatment for an overactive bladder should be added.
What is the non-drug treatment for stress incontinence?
Women should trial supervised pelvic floor muscle training for at least 3 months, which should include at least 8 contractions performed 3 times per day
What is the non-drug treatment for mixed incontinence?
Women should trial both bladder training for at least 6 weeks and supervised pelvic floor muscle training for at least 3 months, which should include at least 8 contractions performed 3 times per day. If frequency is a problem and satisfactory benefit from bladder training is not achieved, drug treatment for an overactive bladder should be added.
What should be performed in all women presenting with incontinence?
A urine dipstick test should be performed in all women presenting with incontinence to test for active infection or haematuria, and analysed along with the patients symptoms.
When should women be referred to see a specialist?
if there is:
persistent bladder or urethral pain;
pelvic mass that is clinically benign;
associated faecal incontinence;
suspected neurological disease, or urogenital fistulae;
history of previous incontinence surgery, pelvic cancer surgery or pelvic radiation therapy;
recurrent or persistant UTI for those aged over 60; see Urinary-tract infections
palpable bladder after voiding, or symptoms of voiding difficulty.
When is an urgent referral required?
Urgent referral should occur in women aged 45 years or older if there is unexplained visible haematuria without UTI, or visible haematuria persisting or recurring despite successful treatment of UTI. Urgent referral is also required in women aged 60 years or older with unexplained non-visible haematuria and either dysuria or raised white cell count.
What is the drug treatment for urgency incontinence?
An anticholinergic drug should be considered for women who have trialled bladder training, where frequency is a problem and symptoms persist.
What is first-line drug-treatment for urgency incontinence?
Immediate release oxybutynin hydrochloride, immediate release tolterodine tartrate, or darifenacin can be used first-line
In which women should immediate release oxybutynin not be used in?
mmediate release oxybutynin should not be used in frail, older women at risk of sudden deterioration in their physical or mental health.
Is transdermal oxybutynin an option?
Transdermal oxybutynin hydrochloride may be used in those unable to tolerate oral treatment.
Which drug may be used if treatment with an anticholinergic is contraindicated, ineffective or not tolerated?
Mirabegron
Within how long should treatment be reviewed?
After 4 weeks or sooner if required
If treatment is effective review the woman again at 12 weeks, then annually thereafter, or every 6 months if the woman is over 75 years of age.
What can be done for urgency incontinence if first anticholinergic drug has not been effective or not tolerated?
an alternative anticholinergic drug can be used, the current dose adjusted or, mirabegron trialled; review again after 4 weeks.
Which alternative anticholinergics can be used?
Alternative anticholinergics include, an untried first-line drug, or one of the following; fesoterodine fumarate, propiverine hydrochloride, solifenacin succinate, trospium chloride, or an extended release formulation of either oxybutynin hydrochloride or tolterodine tartrate.
For women who have tried taking medicine for overactive bladder but treatment has failed who should they be referred to?
should be referred to secondary care, where treatment with botulinum toxin type A or surgical methods may be considered
which drugs should not be used for incontinence in women?
Flavoxate hydrochloride, propantheline bromide, or imipramine hydrochloride should not be used as treatment options.
In women who have troublesome nocturia what may be used?
Desmopressin may also be used
What can be used in women who are post-menopausal and have vaginal atrophy?
Intravaginal oestrogen therapy can be used in those women who are post-menopausal and have vaginal atrophy.
Treatment should be reviewed at least annually to re-assess the need for continued treatment and monitor for symptoms of endometrial hyperplasia or carcioma
Which drug can be used for stress incontinence in women?
Duloxetine is not recommended as first-line treatment for women with stress incontinence. It may be used second-line where conservative treatment including pelvic floor training has failed, and only if surgery is not appropriate or the woman prefers pharmacological treatment, but should not be offered routinely.
Whats the drug treatment for mixed incontinence?
Women with mixed urinary incontinence should be treated according to the predominant type, refer to Urgency incontinence or Stress incontinence for drug treatment options.
What are the symptoms of pelvic organ prolapse?
Symptoms can include a vaginal bulge or sensation of something coming down, urinary, bowel and sexual symptoms, and pelvic and back pain. These can all affect a woman’s quality of life.
For pelvic organ prolapse - women should be given what advice?
Women should be given advice on minimising heavy lifting, preventing or treating constipation, and if their BMI is 30 kg/m² or greater, encouraged to lose weight. A programme of supervised pelvic floor muscle training for at least 16 weeks may also be tried for some women.
What is nocturnal enuresis?
Nocturnal enuresis is the involuntary discharge of urine during sleep, which is common in young children.
By what age is it expected for children to stop wetting the bed?
expected to be dry by a developmental age of 5 years, and historically it has been common practice to consider children for treatment only when they reach 7 years;
however, symptoms may still persist in a small proportion by the age of 10 years.
Is treatment for nocturnal enuresis recommended for children under 5?
No
treatment is usually unnecessary as the condition is likely to resolve spontaneously. Reassurance and advice can be useful for some families.
What non-drug treatment advice can be given for nocturnal enuresis?
Initially, advice should be given on fluid intake, diet, toileting behaviour, and use of reward systems. For children who do not respond to this advice (more than 1–2 wet beds per week), an enuresis alarm should be the recommended treatment for motivated, well-supported children. Alarms in children under 7 years should be considered depending on the child’s maturity, motivation and understanding of the alarm. Alarms have a lower relapse rate than drug treatment when discontinued.
Treatment using an alarm should be reviewed after how many weeks?
After 4 weeks and continued until a minimum of 2 weeks’ uninterrupted dry nights have been achieved.
If complete dryness is not achieved after 3 months but the condition is still improving and the child remains motivated to use the alarm, it is recommended to continue the treatment.
If the initial alarm treatment is not working which drug may be used alone or combination with the alarm?
Combined treatment with desmopressin, or the use of desmopressin alone, is recommended if the initial alarm treatment is unsuccessful or it is no longer appropriate or desirable.
What formulations of desmopressin can be used in children for nocturnal eneruses?
- Oral or sublingual desmopressin
Desmopressin is recommended for ages over what?
Over 5 years old. when alarm use is inappropriate or undesirable, or when rapid or short-term results are the priority (for example, to cover periods away from home).
Can desmopressin be used alone?
Desmopressin alone can also be used if there has been a partial response to a combination of desmopressin and an alarm following initial treatment with an alarm alone.
Treatment should be assessed after 4 weeks and continued for 3 months if there are signs of response.
Can repeated courses of desmopressin be used?
Repeated courses of desmopressin can be used in responsive children who experience repeated recurrences of bedwetting, but should be withdrawn gradually at regular intervals (for 1 week every 3 months) for full reassessment.
Which tricyclic antidepressant can be used for children who have not responded to all other treatments and have undergone specialist assessment?
- Imipramine;
however relapse is common after withdrawal and children and their carers should be aware of the dangers of overdose. Initial treatment should continue for 3 months; further courses can be considered following a medical review every 3 months. Tricyclic antidepressants should be withdrawn gradually.
What class of drug does mirabegron belong to?
A beta 3 agonist - licensed for the treatment of urinary incontinence associated with overactive bladder syndrome
What are the side effects of antimuscarinics?
- constipation
- dizziness
- drowsiness
- dry mouth
- dyspepsia
- flushing
- headache
- nausea
- palpitations
- skin reactions
- tachycardia
- urinary disorders
- vision disorders
- vomiting
Give examples of some antimuscarinics?
- Darifenacin
- Fosoterodine
- Flavoxate
- Oxybutynin
- propiverine
- Solifenacin
- Tolterodine
- Trospium chloride
Give an example of Beta adrenoreceptor 3 agonist?
Mirabegron
Used for urinary frequency, urgency and urge incontinence
What is urinary retention?
The inability to voluntarily urinate
What may urinary retention be due to?
It may be secondary to urethral blockage, drug treatment (such as use of antimuscarinic drugs, sympathomimetics, tricyclic antidepressants), conditions that reduce detrusor contractions or interfere with relaxation of the urethra, neurogenic causes, or it may occur postpartum or postoperatively.
What is acute urinary retention?
Acute urinary retention is a medical emergency characterised by the abrupt development of the inability to pass urine (over a period of hours)
What is chronic urinary retention?
Chronic urinary retention is the gradual (over months or years) development of the inability to empty the bladder completely, characterised by a residual volume greater than one litre or associated with the presence of a distended or palpable bladder.
What is the most common type of urinary retention in men?
- benign prostatic hyperplasia
Men with an enlarged prostate can have lower urinary tract symptoms associated with obstruction, such as urinary retention (acute or chronic), frequency, urgency or nocturia.
When is catherisation used?
It is used to relive acute painful urinary retention or when no cause can be found
What is used to correct mechanical outflow obstructions?
Surgical procedures or dilation are often used to correct mechanical outflow obstructions
Is acute retention painful?
Yes
What does acute retention require treatment by?
Acute retention is painful and requires immediate treatment by catheterisation
For the treatment of acute retention before the catheter is removed which drug is given?
Before the catheter is removed an alpha-adrenoceptor blocker (such as alfuzosin hydrochloride, doxazosin, tamsulosin hydrochloride, prazosin, indoramin or terazosin) should be given for at least two days to manage acute urinary retention.
What is the treatment for chronic urinary retention?
- intermittent bladder catherization should be offered before an indwelling catheter
- Catheters may be used as a long-term solution where persistent urinary retention is causing incontinence, infection, or renal dysfunction and a surgical solution is not feasible.
Can drug treatment be used for urinary retention?
In men who have symptoms that are bothersome, drug treatment should only be offered when other conservative management options have failed
Which drug treatment can be used for urinary retention?
Men with moderate-to-severe symptoms should be offered an alpha-adrenoceptor blocker (alfuzosin hydrochloride, doxazosin, tamsulosin hydrochloride or terazosin).
How often should treatment be reviewed?
Treatment should initially be reviewed after 4–6 weeks and then every 6–12 months
Do you treat urinary retention due to benign prostate hyperplasia straight away?
Watchful waiting is suitable for men with symptoms that are not troublesome and in those who have not yet developed complications of benign prostatic hyperplasia such as renal impairment, urinary retention or recurrent infection
What is the recommended treatment of benign prostatic hyperplasia?
The recommended treatment of benign prostatic hyperplasia is usually an alpha-adrenoceptor blocker
what effect do alpha blockers have in benign prostatic hyperplasia?
The alpha1-selective adrenoceptor blockers relax smooth muscle in benign prostatic hyperplasia producing an increase in urinary flow-rate and an improvement in obstructive symptoms.
In which patients may a 5alpha-reductase inhibitor such as finasteride or dutasteride be used?
In patients with an enlarged prostate, a raised prostate specific antigen concentration, and who are considered to be at high risk of progression (such as the elderly)
Can a combination of alpha blocker and 5alpha-reductase inhibitor be used?
Yes - A combination of an alpha-adrenoceptor blocker and a 5α-reductase inhibitor can be offered if symptoms remain a problem.
Is surgery an option?
Surgery is recommended for men with more severe symptoms that do not respond to drug therapy, or who have complications such as acute urinary retention, haematuria, renal failure, bladder calculi or recurrent urinary-tract infection.
What effect should be advised and noted about the first dose of an alpha blocker?
- The first dose may cause hypotension, so it should be taken at night, following this the next doses should be taken in the morning
Is dutasteride and finasteride excreted in semen?
Yes and use of condom is recommended if sexual partner is pregnant or likely to become pregnant
What should be noted for women of childbearing age handling open tablets of dutasteride and finasteride?
women of childbearing potential should avoid handling leaking capsules of Dutasteride and crushed or broken tablets of Finasteride
Cases of what cancer have been associated with 5 alpha reductase inhibitor use?
cases of male breast cancer have been reported. Patients should report any changes in breast tissue such as lumps, pain or nipple discharge.
What else has the MHRA released warning of with finasteride?
Reports of depression and in rare cases suicidal thoughts in men taking finasteride; patient should be asked to stop finasteride immediately and le their GP know
- ## Also male pattern hair loss;
What is urolithiasis?
Kidney stones (also called renal calculi, nephrolithiasis or urolithiasis) are hard deposits made of minerals and salts that form inside your kidneys. Diet, excess body weight, some medical conditions, and certain supplements and medications are among the many causes of kidney stones
When do renal stones develop?
Renal and ureteric stones are crystalline calculi that may form anywhere in the upper urinary tract.
Are kidney stones painful?
They are often asymptomatic but may cause pain when they move or obstruct the flow of urine.
What are most stones composed of?
- Calcium salts (calcium oxalate, calcium phosphate or both)
The rest are composed of struvite, uric acid, cystine and other substances.
When are patients susceptible to stone formation?
Patients are susceptible to stone formation when there is a decrease in urine volume and/or an excess of stone forming substances in the urine.
What are the risk factors that have been associated with stone formation?
dehydration, change in urine pH, males aged between 40–60 years, positive family history, obesity, urinary anatomical abnormalities, and excessive dietary intake of oxalate, urate, sodium, and animal protein.
Certain diseases which alter urinary volume, pH, and concentrations of certain ions (such as calcium, phosphate, oxalate, sodium, and uric acid) may also increase the risk of stone formation.
Certain drugs such as calcium or vitamin D supplements, protease inhibitors, or diuretics may also increase the risk of stone formation.
What are symptoms of acute renal or ureteric stones?
Symptoms of acute renal or ureteric stones can include an abrupt onset of severe unilateral abdominal pain radiating to the groin (known as renal colic) that may be accompanied with nausea, vomiting, haematuria, increased urinary frequency, dysuria and fever (if concomitant urinary infection is present)
Can stones pass on their on?
Stones can pass spontaneously and will depend on a number of factors, including the size of the stone (stones greater than 6 mm have a very low chance of spontaneous passage),
Are distal ureteral stones or proximal ureteral stones more likely to pass?
the location (distal ureteral stones are more likely to pass than proximal ureteral stones)
What are the non-drug treatments of renal and ureteric stones?
- consider watchful waiting for asymptomatic renal stones if they are less than 5mm in diameter
- Consider stone analysis and measure serum calcium in patients with recurring renal or ureteric stones.
- Along with maintaining a healthy lifestyle, advise patients to drink 2.5–3 litres of water a day with the addition of fresh lemon juice and to avoid carbonated drinks
- Maintain a normal daily calcium intake of 700–1,200mg and salt intake of no more than 6g a day
- For patients with recurrent calcium stones avoid excessive intake of oxalate-rich products, such as rhubarb, spinach, cocoa, tea, nuts, soy products, strawberries, and wheat bran.
- For patients with recurrent uric acid stones, avoid excessive dietary intake of urate rich products, such as liver, kidney, calf thymus, poultry skin, and certain fish (herring with skin, sardines and anchovies).
What is the drug management for renal and ureteric stones?
- Offer NSAIDs as first line treatment for the management of pain associated with suspected renal colic or renal and ureteric stones.
If NSAIDs are not working or are contraindicated then what should be offered next?
Consider intravenous paracetamol
What if both paracetamol and NSAIDs are contraindicated?
Subsequently, opioids can be used if both paracetamol and NSAIDs are contraindicated or not sufficiently controlling the pain
Can antisposmodics be used in patients with suspected renal colic?
No
What is used topically in urethral pain?
Lidocaine hydrochloride gel is a useful topical application in urethral pain or to relieve the discomfort of catheterisation.
Alkalinisation of urine can be undertaken with which compound?
With potassium Citrate
The alkalinising action may relieve the discomfort of cystitis caused by lower urinary tract infections.
Which other drug is used as a urinary alkalinising agent?
Sodium bicarbonate is used as a urinary alkalinising agent in some metabolic and renal disorders.
What is licensed for the management of common infections of the bladder in patients with an indwelling urinary catheter?
Chlorhexidine solution given as bladder irrigation is licensed for the management of common infections of the bladder in patients with an indwelling urinary catheter.
Does chlorhexidine have a narrow or broad spectrum of activity?
Chlorhexidine has broad spectrum activity against many Gram-positive and Gram-negative bacteria but it is ineffective against most Pseudomonas spp.
What can chlorhexidine solutions cause?
they may irritate the mucosa and cause burning on micturition (in which case they should be discontinued).
What is licensed in bladder infection for use as a routine mechanical irrigant to flush out debris, small blood clots, or tissue in catheters?
Sterile sodium chloride solution 0.9% (physiological saline)
What is licensed for the management of superficial bladder tumours?
Bladder instillations of doxorubicin hydrochloride and mitomycin are licensed for the management of superficial bladder tumours.
What are the two types of hormonal contraception?
- Combined hormonal contraception (oestrogen and a progestogen)
- Progestogen-only contraception
Which methods of contraception are considered to be ‘highly effective’?
male and female sterilisation, and the long-acting reversible contraceptives (LARC)—(copper intrauterine device (Cu-IUD), levonorgestrel intrauterine system (LNG-IUS) and progestogen-only implant (IMP))
What formulations are combined hormonal contraceptives (CHC) available as?
- Tablets (COC)
- Transdermal patches (CTP)
- Vaginal rings (CVR)
What is the failure rate with Combined hormonal contraception?
They are highly user-dependant methods where the failure rate if used perfectly (i.e. correctly and consistently) is less than 1%.
What may contribute to contraceptive failure?
Certain factors such as the person’s weight, malabsorption (COC only), and drug interactions may contribute to contraceptive failure.
After what age is is not recommended to no longer use combined hormonal contraception?
It is recommended that combined hormonal contraceptives are not continued beyond 50 years of age as safer alternatives exist.
What benefits may combined hormonal contraception be associated with?
CHC use may be associated with some health benefits such as:
Reduced risk of ovarian, endometrial and colorectal cancer;
Predictable bleeding patterns;
Reduced dysmenorrhoea and menorrhagia;
Management of symptoms of polycystic ovary syndrome (PCOS), endometriosis and premenstrual syndrome;
Improvement of acne;
Reduced menopausal symptoms;
Maintaining bone mineral density in peri-menopausal females under the age of 50 years.
What is monophasic COC?
Combined oral contraceptives (COCs) containing a fixed amount of an oestrogen and a progestogen in each active tablet are termed ‘monophasic’; those with varying amounts of the two hormones are termed ‘multiphasic’.
Which oestrogens are usually used in COC?
Combined oral contraceptives usually contain ethinylestradiol as the oestrogen component; mestranol and estradiol are also used. The ethinylestradiol content of COCs range from 20–40 micrograms.
Which COC combination is used as first line option?
A monophasic preparation containing 30 micrograms or less of ethinylestradiol in combination with levonorgestrel or norethisterone (to minimise cardiovascular risk), is generally used as the first line option.
In females who weigh 90kg or more is topical combined hormonal contraception suitable?
In females who weigh 90 kg or more, consider non-topical options or use additional precautions with CTP.
How many days pills are in COC?
21 days
then 7 day pill free interval period
Give examples of monophasic COC (21 days preparations)?
Femodette Marvelon Tasmin Femodene Levest Microgynon Ovranette Rigevidon Clique Lizinna
Give examples of monophasic COC (28 day preparations)?
Microgynon ED
Femodene ED
Zoely
Give examples of COC multiphasic preparations?
Logynon/ logynon ED
TriRegol
Synphase
Qlaira
In COC 21 day CHC when would the withdrawal bleed occur?
withdrawal bleed during the 7 day hormone free interval (HFI),
Is continuous use: continuous CHC use with no HFI a licensed use?
No may be used but it is not licensed
