CH7: GENITO CLINICAL Flashcards
What are 3 types of urinary incontinence
• Stress incontinence: involuntary leakage on exertion/ sneezing/ coughing…
• Urgency incontinence: urgent need to urinate – difficult to delay (overactive bladder)
• Mixed incontinence: both urgency and stress – one type usually more predominant
Risk factors of urinary incontinence
- age
- pregnancy/vaginal delivery
- Family history
- Meds (diuretics, alcohol, caffeine - increase urine production)
- Obesity
- smoking
- constipation
What is the first line treatment for urgency incontinence
bladder training for 6 weeks
what is the 2nd line treatment for urgency incontinence
antimuscarinics
Oxybutynin, tolterodine
other: fesoterodine, solifenacin, trospium, darifenacin (7.5-15mg/day)
what is the 3rd line treatment for urgency incontinence
beta agonist = Mirabegron
Treatment for stress urinary incontinece
1st line - pelvic floor training for 3 months
2nd line - surgery or duloxetine (SSRI)
Treatment for Mixed urinary incontinence
1st line - bladder training for 6 weeks AND pelvic floor training for 3 months
2nd line - will depend on the predominant type of urinary incontinence
What is nocturnal enuresis in children
involuntary urination during the night
At what age would we not consider interventions for treating a child’s nocturnal enuresis?
under the age of 5
What are the non-pharmacological treatments of nocturnal enuresis in children
- advise on fluid intake, diet and toilet training
- no improvements = urinating 1-2 times a week = initiate 1st line
Briefly state the treatment pathway for nocturnal enuresis in children
1st line - Euresis alarm
2nd line - Desmopressin (+/- euresis alarm)
3rd line - Desmopressin (+/- antimuscarinic e.g. oxybutynin/tolterodine - specialist initiation)
4th line - Imipramine (TCA)
Counselling for nocturnal enuresis in children
- avoid fluid overuse - stop 1hr before bed (8 hrs after taking desmopressin
- stop desmopressin if N/V until fluid balance is restored.
what is urinary retention & its cause
inability to urinate voluntarily
cause - urethra blockage, medication (TCAs, antimuscarinics and sympathomimetics)
treatment & management for ACUTE urinary retention
- medical emergency (abrupt development/over period of hours)
- immediate catheterisation = alleviate pain
- alpha blocker (doxazocin, tamsulosin, terazosin, alfuzocin) - giver for 2 days before catheter removable
treatment & management for CHRONIC urinary retention
- gradual over months
- long term use of catheter
- at risk of recurrent UTIs, urethra trauma, pain, stone formation
What is BPH
Benign prostatic hyperplasia (BPH)
- it is a type of chronic urinary retention
- common in men when they age
- enlargement of the prostate
- symptoms: frequency, urgency, urinary retention and nocturia
Treatment of BPH
- Alpha blockers = to relax the smooth muscles
- 5 a-reductase inhibitors (e.g. finasteride/dutasteride)
- if pt is at high risk of progression/ has the BPH antigen
Can be combined if symptoms remain problematic
Examples of non-hormonal contraceptives
Barrier methods
- Condoms, diaphragms, cervical caps
- Petroleum jelly (Vaseline), baby oil and oil-based products can damage condoms, contraceptive diaphragms and caps made from latex rubber – can damage
Spermicidal contraception
-Used in ADDITION only (not alone)
IUD
-Copper coil – most effective out of all contraceptives
-Contraindications: pelvic inflammatory disease or unexplained vaginal bleeding
Briefly state the procedure of supplying contraceptives to pts under 16 years old
• Follow Fraser guidelines – can provide contraception without parental consent if:
- She understands doctors’ advice
- Cannot be persuaded to inform her parents
- Very likely to continue having sex
- Unless she received contraception her mental and physical health will suffer
- In her best interests to provide treatment
Examples of progesterone only contraceptives
- Levonorgestrel
- desogestrel
- norethisterone
Briefly explain how POPs are taken?
• No pill free period – take every day
• No additional precaution needed if:
- Started in the first 5 days of cycle
- Need 2 days of other contraception if taken outside of the first 5 days
(takes 2 days to have effect basically)
• Take at the same time each day for maximum efficacy
state how many hours desogestrol can be taken until it is considered as a missed pill?
to be taken within 12 hours
state how many hours until other POPS can be taken until it is considered as a missed pill?
to be taken within 3 hours
State the 2 types of POPs & how long they last for?
Injections: 99.8% effective when used correctly
• Depot medroxyprogesterone acetate or norethisterone: every 13 weeks
Implants: 99.95% effective in correct usage
• etonorgestrel: lasts up to 3 years
what are the risks of ‘depot medroxyprogesterone acetate or norethisterone’ injection POPs?
- loss of bone density may occur
- delayed return to fertility up to 1 year after treatment stopped
what are the risks of ‘etonorgestrel’ implant POPs?
- MHRA warning: neurovascular injury and migration of the implant – remove ASAP
what are the examples (drugs and preparations available) of combined hormonal contraceptives (CHC)?
- MoA: inhibits ovulation
- Preparations: Tablets, patches, vaginal rings
Examples
Oestrogen: ethinylestradiol, oestradiol, mestranol
what are the contra-indications of CHC
• Hypertension
• Age over 35 who smoke
• Women with multiple CVD risk factors (if one factor might be okay, but avoid with multiple)
- Smoking
- Hypertension
- BMI >30
- Dyslipidaemia
- Diabetes
• Migraine with aura
• New onset of migraine without aura during use of CHC
Briefly explain the two different ways CHC can be taken?
Monophasic
• Fixed amount of oestrogen and progesterone in each active tablet
Multiphasic
• Varying amounts of 2 hormones
• To improve adherence, non-active tablet can be taken during pill free period
- Some packs have 28-day supply for month (21 active and 7 non-active)
• 7-day withdrawal bleed = hormone free interval
state the precautions that should be taken for switching CONTRACEPTIVE to DIFFERENT CHC
No additional contraception
state the precautions that should be taken for switching CONTRACEPTIVES to POPs
7 days extra precaution
state the precautions that should be taken for switching CONTRACEPTIVES to LEVONORGESTREL IUD
7 days extra precaution needed
state the precautions that should be taken for switching CONTRACEPTIVES to COPPER IUD/OTHER NON-HORMONAL METHODS
< if starting CHC in 1st 5 days of cycle >
No additional contraception
state the precautions that should be taken for switching CONTRACEPTIVES to COPPER IUD/OTHER NON-HORMONAL METHODS
< if starting CHC after 5 days of cycle >
7 days extra precaution needed
state the precautions that should be taken for switching CHC to Copper IUD
< in week 1 or day 3-7 of pill free interval + no sex since pill free interval >
No extra precaution
state the precautions that should be taken for switching CHC to POPs
< in week 1 or day 3-7 of pill free interval + no sex since pill free interval >
2 day precautions
state the precautions that should be taken for switching CHC to OTHERS
< in week 1 or day 3-7 of pill free interval + no sex since pill free interval >
7 day precautions
state the precautions that should be taken for switching CHC to OTHERS contraceptives
< in week 1 or day 3-7 of pill free interval + sex during pill free interval >
- Carry on with CHC until 7 consecutive days taken
- Then continue as week 2/3
state the precautions that should be taken for switching CHC to OTHER contraceptives
< in week 2 or 3>
no extra precautions needed
State the reasons to stop CHCs
• Calf pain, swelling/ redness -> DVT
• Chest pain, SOB, coughing up blood -> PE
• Loss of motor/ sensory function -> stroke
• Severe stomach pain -> hepatotoxicity
• Very high blood pressure -> haemorhhagic stroke
Briefly explain the procedure of taking CHCs in surgery
• Discontinue for 4 weeks if:
- Major planned surgery
- Any surgery of legs/ pelvis
- Surgery that involves prolonged immobilisation of lower limb
• Use alternative contraceptive
• CHC can be restarted 2 weeks after full mobilisation
• If CHC can’t be stopped/ emergency surgery
- Consider thromboprophylaxis
Side effects of all hormonal contraceptives
• Headache
• Unscheduled bleeding (breakthrough bleeding)
• Mood change
• Weight gain
• Libido change
Missed doses of POPs
- when to take the pill?
- any extra protection?
• Take pill ASAP even if 2 taken on same day
• Take the next pill at the usual time
• Need extra protection:
- 7 days for desogestrel
- 2 days for other POPs
• Emergency contraception if:
- Unprotected sex between missed pill and 2 or 7 days after restarting medication
Missed doses of CHCs, if pt. is hormone free interval been over >9 days (starting new pack late)?
- take pill immediately and use condom until 7 consecutive days taken
- EHC needed if unprotected sex
Missed doses of CHCs, if pt. has missed ONE pill (2-3 days after last active pill)?
- Take ASAP – no further action as long as previous 7 days were consistent.
Missed doses of CHCs, if pt. has missed TWO + pill (>3 days since last active pill)?
< at week 1 of cycle >
EHC if sex within hormone free interval and week 1 and use condom until 7 consecutive days of pill taken
Missed doses of CHCs, if pt. has missed TWO + pill (>3 days since last active pill)?
< at week 2-3 of cycle >
no EHC, take pill ASAP + 7 days condom
Missed doses of CHCs, if pt. has missed TWO + pill (>3 days since last active pill)?
< if 2+ pills missed 7 days before pill free period >
continue taking pill throughout interval
examples of emergency contraceptives
- Copper IUD
- Ulipristal 30mg (EllaOne)
- Levonorgestrel 1.5mg
Hormonal contraceptive can be given more than once in same cycle
When is a copper IUD advised to be inserted & if any precautions?
• 1st line – most effective
• Can be inserted up 5 days after 1st unprotected sex
• Can be inserted up to 5 days after earliest estimated date of ovulation
when can a pt be offered EHC after UPSI after childbirth
after day 21 of child birth
What is the MHRA alert of copper IUD
• MHRA: risk of uterine perforation
- Severe pelvic pain after insertion
- Sudden changes in period
- Pain during intercourse
- Unable to feel threads
When should a copper IUD be replaced?
Every 5-10 years
At what circumstances should copper IUD be removed?
After 1st trimester of pregnancy
How would you differentiate between copper IUD and levonorgestrel IUD?
- Levonorgestrel IUD is known to be less painful and have reduced bleeding SE compared to copper IUD
priapism
erection lasting longer than 4 hours – seek medical attention
advice on restarting combined oral contraception after childbirth
➢ May be started from day 21 and additional contraception should be used for the first 7 days
➢ Increased risk of VTE in users of COC particularly during the first year and possibly after restarting combined hormonal contraceptives following a break of four weeks or more
advice on restarting combined oral contraception after childbirth and breastfeeding
➢ Absolute contraindication if breastfeeding <6 weeks- COC reduce breast milk production in lactating mothers
➢ Caution if breastfeeding 6 weeks to 6 months post-partum
advise a pt on when to start COC
- first day of your next period (days 1-5 of a 28-day cycle)
- if taking after first 5 days of the cycle: use additional contraception for 7 days e.g. condom
- How to take→ one tablet everyday for 21 days with a 7-day
break after
Vulvovaginal candidiasis features ‘genital thrush’
thick white discharge and vulvovaginal irritation.
treatment of vulvovaginal candidiasis in pregnancy
- Treated with vaginal application of an imidazole (such
as clotrimazole), and a topical imidazole cream for vulvitis - Pregnant women need a longer duration of treatment, usually
about 7 days, to clear the infection - Oral antifungal treatment should be avoided during pregnancy
features of bacterial vaginosis
- 50% may be asymptomatic
- Thin, white/grey vaginal discharge - ‘Fishy’ smelling vaginal odour
- not a STI
treatment of bacterial vaginosis (non-pregnancy)
Po Metronidazole (7 days)
or Metronidazole cream (5 days)
or clindamycin cream (5 days)
contraindications of progesteron-only contraception
- Current or past history of breast cancer
- Liver cirrhosis or tumours
- Stroke or coronary heart disease
- Lower efficacy in women over the weight of 70kg
features and causatives of Trichomonas vaginalis
sexually transmitted infection via parasite
features:
- offensive, green/yellow vaginal discharge
- itching
- dysuria - pain, tingling on urination
treatment for trichomonas vaginalis
Refer to GP or sexual health clinic for vaginal swab and treatment
- Oral metronidazole 400–500 mg twice a day for 5– 7 days, OR
- Single 2g dose of oral metronidazole OR
- Oral tinidazole
Sexual abstinence should be advised for at least 1 week and until the person and their partner(s) have completed treatment and follow up.
