BNF Chapter 7: Obs, Gynae, Urinary Tract And Genitalia

Question 1

What treatments can be used to treat vaginal and vulval conditions/changes?

Answer 1

Estriol 0.1% cream (Ovestin)
Estriol 30mcg pessary (Imvaggis)
Estradiol 10mcg vaginal tablets (Vagirux)

Question 2

What medication can be used to treat vaginal and vulval infections?

Answer 2

Clotrimazole:
- Pessaries 200mg x 3
-Pessary 500mg x 1
Cream 2%
Vaginal cream 10%

Question 3

What does NICE recommended for the treatment of vaginal candidiasis?

Answer 3

Clotrimazole pessary or oral fluconazole

Question 4

Vaginal and Vulval Infections: Imidazole drugs are effective against candida in short courses of 1-14 days according to the preparation used; treatment can be repeated if initial course fails to control symptoms or if symptoms recur. Note: imidazoles damage latex condoms and diaphragms.

Answer 4

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Question 5

For patients on hormonal contraceptives, how often should they be reviewed?

Answer 5

Annually at least

Question 6

What are examples of ‘long-acting reversible contraceptives’ (LARC methods)?

Answer 6

Intrauterine devices (IUDs)
Intrauterine systems (IUSs)
Injectable contraceptives
Implants

Question 7

LARC contraceptives are more cost-effective than the combined oral contraceptive pill.
True or False?

Answer 7

True (IUDs, IUSs and implants are also more cost effective than injectable contraceptives).

Question 8

What is an anal fissure?

Answer 8

A tear or ulcer in the lining of the anal canal. Bleeding and persistent pain on defecation are common symptoms.

Question 9

How is an acute anal fissure (less than 6 weeks) normally treated?

Answer 9

Bulk-forming laxatives to ensure stools are soft and easy to pass (lactulose as an osmotic laxative is an alternative)

Topical lidocaine, or analgesics such as paracetamol and ibuprofen may be used too

Question 10

How can a chronic anal fissue (longer than 6 weeks) be treated?

Answer 10

Glyceral trinitrate rectal ointment

Question 11

What is endometriosis?

Answer 11

The growth of endometrial-like tissue outside the uterus

Question 12

What are the typical symptoms of endometriosis?

Answer 12

Pelvic pain
Painful periods
Subfertility

Question 13

Endometriosis Drug Treatment

-Most treatments work bu supressing ovarian function, or are surgical and aim to remove endometriotic lesions
-A short trial of paracetamol and/or an NSAID should be considered for first-line treatment of pain.
-Hormonal treatment should be offered to some patients.

Question 14

What is Erectile Dysfunction?

Answer 14

The persistent inability to attain and maintain and erection that is sufficient to permit satisfactory sexual performance.

Question 15

What are some risk factors for erectile dysfunction?

Answer 15

Sedentary lifestyle
Obesity
Smoking
Hypercholesterolaemia
Metabolic syndrome

Question 16

Drug Treatment of Erectile Dysfunction

-Combination of lifestyle changes and drug treatment
-An oral phosphodiesterase type-5 inhibitor is the first-line drug treatment- acts by increasing the blood flow to the penis (does not initiate an erection, stimulation is still required).

Choice of the drug depends on the frequency of intercourse and response to treatment:
-Avanafil, sildenafil or vardenafil are suitable for occasional use.
-Tadalafil is longer-acting; can be used on a low, daily dose to allow for spontaneous (rather than scheduled) sexual activity, or for those who have frequent sex.

Question 17

When would it be appropriate to prescribe tadalafil for erectile dysfunction?

Answer 17

If a patient wants to have spontaneous sexual activity, or has sex frequently.

Question 18

What causes gallstones?

Answer 18

When hard mineral or fatty deposits form in the gallbladder

Question 19

What is gallstone disease?

Answer 19

The presence of one or more stones in the gallbladder or in the bile duct, and the symptoms and complications that they may cause.

Question 20

Drug Treatment of Gallstones

-No need to treat if the patient is asymptomatic
-If symptomatic- offer paracetamol or NSAID for the pain.
-Intramuscular diclofenac or intramuscular morphine if severe pain.

Question 21

What is the first-line antibacterial for bacterial vaginosis?

Answer 21

Oral metronidazole (5-7 days)

Can use topical metronidazole for 5 days

Question 22

What are the first-line antibacterial options for treating uncomplicated genital chlamydial infection, non-gonococcal urethritis and non=specific genital infection?

Answer 22

Azithromycin or doxycycline

Question 23

What are haemorrhoids/piles?

Answer 23

Abnormal swellings of the vascular mucosal anal cushions around the anus

Question 24

Haemorrhoids Treatment

-Bulk-forming laxatives if constipation is reported
-Paracetamol, avoid opioid analgesics due to constipation, and NSAIDs should be avoided in rectal bleeding.
-Topical preparations- use for a maximum of a few days

Question 25

What is classed as menorrhagia?

Answer 25

Heavy menstrual bleeding at a loss of 80 mL or more and/or for a duration of more than 7 days that results in the need to change menstrual products every 1-2 hours.

Question 26

Drug Treatment of Menorrhagia

-Depends on the presence or absence of fibroids, polyps, endometrial pathology or adenomyosis, co-morbidities and patient preference.
-In patients with fibroids less than 3cm in diameter causing no distortion of the uterine cavity- levonorgestrel releasing IUS.
-Tranexamic acid, an NSAID, a combined hormonal contraceptive or a cyclical oral progestogen as an alternative.

-If fibroids are over 3cm, refer to a specialist.

Answer 26

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Question 27

What are renal and ureteric stones?

Answer 27

Crystalline calculi that may form anywhere in the upper urinary tract

Question 28

Urgency Incontinence Drug Treatment

-Oxybutynin hydrochloride, tolertidone tartrate or darifenacin can be used first-line
-Review treatment after 4 weeks.

Question 29

What are some examples of drugs that can cause urinary retention?

Answer 29

Antimuscarinic drugs
Sympathomimetics
Tricyclic antidepressants

Question 30

Acute urinary retention (medical emergency characterised by the abrupt development of the inability to pass urine).

Chronic urinary retention is the gradual (over months or years) development of the inability to empty the bladder completely,

Question 31

What is the most common cause of urinary retention in men?

Answer 31

Benign prostatic hyperplasia

Question 32

What is the immediate treatment for acute urinary retention?

Answer 32

Catheterisation- before removal of the catheter, an alpha-adrenoceptor blocker should be given.

Question 33

Chronic Urinary Retention: Offer men with moderate-severe symptoms an alpha-adrenoceptor blocker (doxazosin, tamsulosis etc).

Question 34

What are the most common symptoms of a lower UTI?

Answer 34

Dysuria
Increased urinary frequency and urgency
-Strong smelling urine
-Cloudy urine, or containing blood
-Persistent lower abdominal pain

Question 35

Lower UTI Treatment- An Antibacterial is NOT always needed

First-line: Nitrofurantoin or trimethoprim (for both men and non-pregnant women)
Second-line if no improvement: fosfomycin, pivmecillinam or amoxicillin (non-pregnant women only)

-Nitrofurantoin is first-line in pregnancy, and amoxicllin or cefalexin are second-line.

Question 36

Acute Prostatitis Antibacterial Treatment

-Ciprofloxacin or ofloxacin are first-line, trimethoprim is first line if fluoroquinolones are not tolerated.

Pyelonephritis
-Cefalexin or ciprofloxacin
-If pregnant: Cefalexin

Catheter-Associated UTI
-Amoxicillin, nitrofurantoin or trimethoprim (cefalexin if pregnant)

Question 37

Vulvovaginal Candidiasis

-Fluconazole or itraconazole tablets/capsules OR clotrimazole or miconazole intravaginal pessary or cream.
-In pregnancy, treat with an intravaginal application of clotrimazole- 7 days treatment.

Question 38

UTI Treatment

Non-Pregnant Women:
1. Nitrofurantoin (if eGRF 45 or above)- 100mg MR BD for three days
2. Trimethoprim 200mg BD for three days

Pregnant women:
1. Nitrofurantoin 100mg MR BD for 7 days
2. Amoxillin 500mg TDS for 7 days

Men:
1. Trimethoprim 200mg BD for 7 days
2. Nitrofurantoin 100mg MR BD for 7 days

Answer 38

.

Question 39

UTI Treatment in Renal Impairment

• Trimethoprim and Ciprofloxacin???

Question 40

What can be used in cystitis to stop the burning feeling?

Answer 40

Potassium citrate (alkalises the urine)

Question 41

How often should urinary incontinence treatment be reviewed?

Answer 41

Every 4-6 weeks until symptoms stabilise, and then every 6-12 months