Chapter 7 - Genito-urinary Flashcards
1
Q
What is urinary incontinence?
A
Involuntary leakage of urine
2
Q
4 main types of urinary incontinence?
A
1) Stress
2) Urgency
3) Mixed
4) Overflow
3
Q
What happens in stress incontinence?
A
Involuntary leakage on exertion/effort e.g. sneezing/coughing - lack of pelvic floor support/urethral sphincter damage
4
Q
What happens in urgency incontinence?
A
Involuntary muscle contractions that cause an urgency to pass urine (difficult to hold it in)
5
Q
What happens in mixed incontinence?
A
Urgency + Stress (one is more predominant)
6
Q
What happens in overflow incontinence?
A
Incomplete emptying of the bladder (frequent loss of small quantities of urine)
7
Q
Situational incontinence may occur during certain activities e.g. sex/giggling. True or false?
A
True
8
Q
Give some risk factors for incontinence.
A
Older age Obesity Pregnancy Vaginal delivery Constipation Smoking Family History Surgical removal which cause lack of support e.g. hysterectomy
9
Q
State some drugs that can cause urinary incontinence.
A
Ace inhibitors –> cause a cough
A-blockers –> e.g. doxazosin relax the bladder and urethra
10
Q
Which conditions can worse incontinence?
A
UTI Oestrogen deficiency Stroke Dementia Parkisons Diabetes Hypercalcaemia
11
Q
What drugs can increase detrusor muscle activity and contribute to incontinence?
A
Cholinesterase inhibitors Anticholinergics Constipation causing drugs Diuretics Alcohol Caffeine
12
Q
Lifestyle modifications for incontinence?
A
- reduce weight if obese (BMI>30)
- reduce caffeine intake
- modify fluids
- Strengthen pelvic muscles e.g. pelvic floor exercises
13
Q
As 1st line for incontinence, bladder training is recommended. How long should this training be done until drug therapy can be initiated?
A
Urgency - 6 weeks
Stress - 3 months (8contractions TDS)
14
Q
What would prompt you to do an urgent referral in women with incontinence?
A
> 45yrs and visible/persistent haematuria but no UTI (could be bladder cancer)
and
> 60yrs: non-visible haematuria + dysuria/increased white cells
15
Q
What should be used 1st line for urgency incontinence?
A
Anticholinergics:
1) IR oxybutynin (also available as transdermal)
2) IR Tolterodine
3) Mirabegron
4) Solifenacin
5) MR Oxybutynin/MR tolterodine
6) Botox (paralyses portion of bladder)
16
Q
If anticholinergics are not tolerated, what would be recommended as 2nd line?
A
Mirabegron (prolong QT and not for uncontrolled hypertension)
17
Q
In what specific type of patient would anticholinergics e.g. oxybutynin not be suitable?
A
Frail, elderly as they are at risk of sudden physical/mental health deterioration.
18
Q
How often should incontinence treatment be reviewed?
A
- every 4 weeks
- if tx is effective then review after 12 weeks
- then annually
- if >75yrs: every 6 months
19
Q
Is duloxetine used 1st line for stress incontinence? why?
A
No - only use if pelvic floor training has failed
Only if mod-severe
Do not withdraw abruptly
20
Q
What is nocturnal enuresis?
A
Involuntary urine discharge whilst asleep. Common in children upto 5yrs. Treatment initiated if still continues upto 7yrs.
21
Q
1st line treatment for nocturnal enuresis in <5yrs?
A
Nil - reassure parents that it is self-limiting
Use bedwetting alarms
22
Q
Non-drug therapy for nocturnal enuresis in <5yrs?
A
Bedwetting alarms (have a sensor that detect wetness which urges the child to get up and go to the bathroom) - use for 2 weeks and r/v in 4 weeks
23
Q
1st line treatment for nocturnal enuresis in >5yrs when alarm is unsuitable?
A
1) desmopressin
2 - if no response) TCA - imipramine
24
Q
Desmopressin counselling for children >5yrs using it for noctural enuresis?
A
Formulation: sublingual/oral
Side-effects: hyponatraemic convulsions as can dilute blood too much.
Counsel: - restrict fluid intake 1hr before and 8hrs after
- STOP in vomiting/diarrhoea
25
Give examples of some anti-muscarinic drugs.
Oxybutynin
Tolterodine
Solifenacin (max 5mg if egfr <30)
26
What drug class does mirabegron fall under?
Beta-3 agonist
27
Contra-indications for anti-muscarinic drugs?
```
angle-closure glaucoma
GI obstruction
Severe ulcerative colitis
Toxic megacolon
Urinary retention
```
28
Side-effects of antimuscarinic drugs?
```
Dry mouth
blurred vision
constipation
dizzy/drowsy
palpitations
vomiting
```
29
Cautions and STOPP criteria for antimuscarinic drugs?
Caution: elderly
1) Treating EPS of antipsychotics (increased risk of antimusc toxicity)
2) With delirium/dementia (exacerbation of cognitive impairment)
3) 2/more antimusc drugs = risk of antimusc toxicity
30
Antimuscarinic drugs CAL
Can affect driving - do not drive/operate heavy machinery/tools
31
Antimuscaranics prolong QT, true or false?
True
32
What is the maximum dose of solifenacin in someone with an egfr < 30?
5mg
33
Which drug used for incontinence requires the use of effective contraception?
Mirabegron
34
if a patient is on mirabegron and is prescribed a CYP3A4 inhibitor, what dose reduction is required?
Normal dose mirabegron: 50mg OD
Concominant inhibitor/mild hepatic impairment: reduce dose to 25mg OD
35
Give examples of CYP3A4 inhibitors.
Sickfaces.com
```
Sodium valproate
Isoniazide
Clarithromycin/macrolides
Ketoconazole/antifungals
Fluconazole
Alcohol
Cimetidine
Erythromycin
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole
```
+ grapefruit juice, amiodarone, quinidine
36
What is urinary retention?
The inability to voluntarily urinate.
37
Drugs that can cause urinary retention?
Anti-muscuranics
Sympathomimetics
TCA
38
What is the most common cause of urinary retention in men?
BPH (benign prostatic hyperplasia) - enlarged prostate
39
How would you manage acute urinary retention?
inability to pass urine over hours (medical emergency).
| 1) immediately catheterise (give a-blocker 2 days before catheter)
40
Give examples of a-blockers.
```
DIPT
Doxazosin
Prazosin
Indoramin (can exacerbate parkinsons)
Tamsulosin (take ON)
```
41
What should be offered for mod-sev symptoms of urinary retention in men?
a-blockers e.g. tamsulosin, doxazosin
42
How often should a-blocker treatment be reviewed?
after 4-6weeks then every 6-12months
43
How do a-blockers work in BPH?
They relax smooth muscles in BPH causing an increase in urinary flow and an improvement in obstructive symptoms
44
What drug treatment would be recommended for those with an enlarged prostate, raised prostate specific antigen and at high risk of progression (eg elderly)?
5a-reductase inhibitors e.g. finasteride/dutasteride
| use combo with a-blockers if symptoms are persistent
45
A-blockers side-effects and counselling?
e.g. tamsulosin/doxazosin: can cause postural hypotension (dizzy, blurred vision, tachycardia, palpitations)
Rare - SJS
Contra-indicated: postural hypotension
Counsel: 1st dose at bedtime due to PH, can make you drowsy so avoid driving/alcohol/heavy machinery
46
A doctor would like to switch a patient from IR doxazosin to MR, he asks if this requires a change in dose, what would you advise.
They are both bioequivalent so prescribe the same dose.
47
Usual dose of tamsulosin for BPH?
400mcg ON
48
Can tamusolin be sold OTC? If so, what are the conditions?
Yes.
Age: 45-75yr old men
Max: 6 weeks supply before doctor r/v
Pack size: 14 capsules
49
How do 5-alpha reductase inhibitors work?
Inhibit 5-a reductase that metabolises testosterone into its active form of dihydrotestosterone.
50
Side-effects of 5-a reductase inhibitors (dutasteride/finasteride)
1) Breast disorders - can cause male breast cancer so report lumps, pain/nipple discharge
2) Sexual dysfunction
51
Patient x has been initiated on finasteride and reports changes in texture of his nipple - what is this indicative of?
Breast cancer - report STAT
52
There is an MHRA warning with one of the 5-a reductase inhibitors, which is it and what does the warning state?
Finasteride
| Risk of suicidal thoughts/depression - Stop STAT
53
What indication can 5-a reductase inhibitors be used for?
1) Urinary retention due to BPH - dutasteride/finasteride
| 2) Male pattern hair loss (androgenic alopecia) - (Not on NHS primary care) finasteride
54
what is the conception and pregnancy advice regarding 5-a reductase inhibitors?
1) Women of child-bearing age should avoid handling broken/crushed tablets
2) finasteride is excreted in semen and so condoms should be used if partner is pregnant/likely to become pregnant. (birth defects in male babies)
55
What are the 2 different types of contraception?
1) Combined
| 2) Progestogen only
56
What formulations are available for combined contraception?
- Oral
- Transdermal - Evra
- Vaginal ring - Nuva ring
57
What ingredients are in combined contraception?
Oestrogen and progestogen
58
Give examples of oestrogen in contraception?
Ethinylestradiol
| Estradiol
59
Give examples of progestogen in contraception?
Levonorgestrel
Desogestrel
Norethisterone
60
What formulations are available for progestogen only contraception?
1) oral - deso/levo and norethisterone
2) parenteral - medroxyprogesterone, norethisterone injections
3) intrauterine device
61
What is the difference between monophasic and multiphasic preparations?
Monophasic - fixed amount of oestrogen and progestogen
Multiphasic - varying amounts of oestrogen and progestogen
62
Give examples of some common contraception brands that are combined?
```
Gedarel
Femodette
Loestrin
Marvelon
Yasmin
Microgynon 30
Cilest
Rigevidon
```
63
What contraception is considered 'highly effective'?
Copper IUD
Levonorgestrel intrauterine system
Progestogen-only implant
64
If going for surgery, when should COC be stopped and restarted?
Stop 4 weeks prior and restart 2 weeks after full mobilisation.
65
How does combined oral contraception work?
Inhibits ovulation
66
How does Progestogen only contraception work?
alters (thickens) cervical mucus and prevents sperm penetration that could inhibit ovulation
67
How would you counsel a patient newly starting COC?
Once daily for three weeks followed by one-week pill free period for withdrawal bleed.
Start taking it anytime during the cycle. If taken on day 6 or later, use barrier method for seven days
68
COCs are contra-indicated in what age category?
Over 50yrs (risk of VTE/STROKE increases)
69
Risks of COCs?
1) VTE
2) Travel >3hrs - use stocking/compression socks
3) Cervical and breast cancer
4) Stroke
5) Liver dysfunction
6) High blood pressure (>160/95) - contraindicated
70
How many risk factors of VTE would prompt you to get a patient to avoid COCs?
2 or more
71
Name some risk factors for VTE?
- obese BMI>30/90kg
- on progestogen pills too
- smoking
- family history
- Diabetes with complications
- hypertension
- migraine without aura
- immobility
72
What BP would deem unsuitable for a COC (where it is contra-indicated)
>160/95
73
When would you stop a COC?
1) VTE - chest pain, unilateral swelling and calf pain, breathless, coughing blood
2) Stroke - neuropsychiatric reactions e.g. headache, vision disorders, hearing and speech difficulties, numbness
3) Liver dysfunction - abdominal pain, dark urine, pale stools, jaundice, pruritus
4) BP >160/95
74
Benefits of COCs?
Reduced risk of endometrial and ovarian cancer
Helps with dysmenorrhoea and menorrhagia
75
If a patient vomits on a COC what would be the advise?
Vomit <2hrs: take one STAT
| Vomit >24hrs or severe: use barriers for 7 days
76
If a patient misses a COC for more than 24 hrs what would you advise?
Take one STAT and the next at the normal time even if it means you take two.
77
A patient misses 2 or more pills of their COC what are her options
Take one STAT then use condoms for 7 days
| if missed 2 or more within last 7 days then omit pill free period
78
When would you recommend EHC for a patient that has missed COC pills?
If pills are missed onthe first 7 days and they have unprotected sex
79
Why would you use a POP over a COC?
if COC contra-indicated e.g. heavy smoker, obese, >50yrs, >160/95, DM + complications
80
How would one take a POP?
One tablet daily and at the same time each day
| if started on day 5 and barrier for 2 days
81
What cancer does POP increase the risk of?
breast
82
What are the time periods for missed POP pills?
>3hrs for all POPs (levonorgestrel, norethisterone) except desogestrel (>12hrs)
83
Which POP is considered a missed pill after 12hrs?
Desogestrel
84
A patient misses a POP pill of desogestrel >12hrs, what would you recommend?
Take one STAT and barrier for 2 days
85
A patient misses a POP pill >3hrs, what would you recommend?
Take one STAT and barrier for 2 days
86
When would you recommend EHC in a patient taking a POP?
if they have missed 2 regular pills and unprotected sex occurs
87
How many hours does one have to vomit between after taking another POP?
If vomit occurs <2hrs
88
If vomiting with a POP is severe and if a patient has not taken the POP within normal time fram (within 3 hrs or within 12hrs of desogestrel) what would you advise?
barrier for 2 days then resume pill once stable
89
What contraceptives are suitable before major elective surgery?
Progestogen-only contraceptives
90
When is a contraceptive patch considered 'missed'
if detached >24hrs or delayed
91
how would you advise dosing a transdermal patch e.g. evra?
1 cycle: weekly patch for 3 weeks and then 1 week patch-free period
92
If a patient has their patch detached >24hrs or delayed at the start of their cycle what would you advise?
1) apply patch STAT
| 2) start a new day 1 cycle and barriers for 7 days
93
If a patient has their patch delayed e.g. middle of cycle (day 8 or day 15) what would you advise?
= 48hrs: new patch and continue as normal
>48hrs - new day 1 cycle and 7 days barrier
94
What drugs reduce contraceptive effectiveness?
Enzyme inducers
CRAPGPs
```
Carbamazepine
Rifampicin
Alcohol
Phenytoin
Griseofulvin
Phenobarbitol
St Johns Wort/sulfonylurea
```
95
Women using combined contraceptives and that have been prescribed concominant inducers, what would be the action step?
change to parenteral prog-only contraceptive e.g. medroxyprogesterone or IUD
(continue this form of contraception for up to 4 weeks after stopping the inducing drug)
96
3 available options for EHC
Copper iUD
Levonorgestrel
Ulipristal
97
1st line for EHC
Copper iUD
98
How long after unprotected sex does copper iUD have to be inserted for effectiveness?
- after 5 days (120hrs) OR up to 5 days after the earliest, calculated ovulation
99
Which EHC is more effective levonorgestrel or ulipristal?
Ulipristal
100
With time _________ decreases
hormonal contraceptive efficacy decreases
101
What is the max time frame after unprotected sex in which levonorgestrel is effective?
3 days after (within 72hrs)
102
What is the max time frame after unprotected sex in which ulipristal is effective?
5 days (max 120hrs)
103
How many hrs after unprotected sex would taking levonorgestrel be unlicensed?
72-96hrs
104
What factors would require you to suggest a double dose of levonorgestrel would be more suitable? is this licensed? What could you do instead?
BMI >26 or >70kg
Unlicensed
Give ulipristal
105
Which EHC is licensed for <16yrs?
Ulipristal
| Levonorgestrel is unlicensed
106
if a patient vomits within 3hrs of taking levonorgestrel, what would be the course of action?
Give another pill however this is unlicensed.
107
how long after EHC levonorgestrel can a woman resume her normal pill?
After levonorgestrel - start STAT + barriers
108
how long after EHC ulipristal can a woman resume her normal pill?
After ulipristal - wait 5 days: use barriers in those 5 days or abstain from sex
109
How does levonorgestrel work, what is the dose for EHC?
Prevents ovulation and fertilisation
| 1500mg STAT or double dose if vomit/obese
110
Cautions for levonorgestrel use as a EHC?
previous ectopic pregnancy
ciclosporin (toxicity
Chrohns
111
How does ulipristal work, what is the dose for EHC?
Inhibits or delays ovulation , 30mg (give another dose if vomit in <3hrs)
112
Cautions for ulipristal?
severe asthma treated by corticosteroids (not recommended)
avoid in severe liver impairment
113
Can levonorgestrel be used again in the same menstrual cycle?
otc - unlicensed
| manufacturer: avoid due to irregularities
114
Can ulipristal be used again in the same menstrual cycle?
yes
115
MHRA Advice for copper iud?
uterine perforation: symptoms are severe pelvic pain, pain or increased bleeding, sudden period changes, pain during intercourse, cant feel the threads
116
MHRA advice for ulipristal?
Liver injury and hepatic failure (esmya)
117
Hormonal contraception EHC side-effects?
```
Menstrual irregularities
Next period: early/late
Barrier until next period
report lower abd pain: ectopic pregnancy
abnormal periods: light/heavy/brief/absent and so take a pregnancy test (3wks after unprotected sex)
```
118
What age category is IUD less suitable for?
<25yrs due to risk of pelvic inflammatory disease
119
What are the two types of IUDs?
1) Copper
| 2) Levonorgestrel-releasing
120
Benefits of levonorgestrel-releasing IUD?
Reduced bleeding and period pain
Lower risk of PID
Brand specific due to effectiveness
121
How long are different brands of levonorgestrel-releasing iUDs effective for?
Kyleena - 5yrs
Jaydess - 3yrs
Levosert - 5/6yrs
Mirena - 5yrs
122
Side-effects of IUD
Pain on insertion and bleeding
Uterine perforation
Risk of infection (ab prophylaxis/chlamydia screening)
123
If removing IUD mid-cycle, what would you recommend for contraception cover?
Additional contraceptive for 7 days
124
If removal of IUD is essential and unprotected sex occurs, what do you do ?
EHC
125
A woman on IUD becomes pregnant and wants to keep the baby. When would you remove iUD
1st trimester
126
Give examples of some barrier methods.
Condoms, femidoms, diaphragms and cervical caps
127
Do condoms provide protection against STI?
Yes
128
Are spermicides adequate as stand alone contraception?
No
129
What does IUD increase the risk of?
PID (pelvic inflammatory disease) especially <25yrs
130
Give some oil based lubricants. what are the disadvantages?
vaseline, baby oil - likely to damage condoms and contraceptive diaphragms - render them less effective
131
How many days after childbirth and having unprotected sex, would a woman require EHC?
From day 21 after childbirth
132
How many days after abortion/ectopic pregnancy/miscarriage would a woman require EHC?
from day 5
133
How can hormonal contraception affect the menstrual cycle?
Can cause menstrual irregularities. May get spotting, may get a late/early next period
134
After using hormonal contraception, what would you advise a woman until their next period
Use barriers
135
a 28yr old female who has recently taken levonorgestrel as EHC from your pharmacy walks in. She reports severe lower abdominal pain. What would be your thoughts and what action would you take?
Ectopic pregnancy - refer STAT, go to GP
136
How long after unprotected sex and abnormal periods would you advise a patient to take a pregnancy test?
atleast 3 weeks after.
| Can be light/heavy/brief/absent
137
Give some examples of parenteral contraception
medroxyprogesterone injection - 2 years
norethisterone injection - 8 weeks
etonogestrel implant - 3 years
138
What are the risks with medroxyprogesterone injections?
delay in return to fertility and menstrual irregularities
| osteoporosis risk
139
MHRA advise with etonogestrel implant?
reports of device in vasculature and lungs
| implants can reach lung via pulmonary artery
140
Risks with spermicidal contraceptives?
increased risk of genital lesions and acquiring infections
141
What is erectile dysfunction?
Inability to attain and maintain an erection to perform sufficient sexual performance
142
Erectile dysfunction increases the risk of ___________
cardiovascular disease
143
What drugs can cause ED?
```
antihypertensives
antidepressants
antipsychotics
cytotoxics
recreational drugs
```
144
How do phosphodiesterase inhibitors work in ED?
Increase blood flow to the penis
145
Can PDE5 inhibitors stimulate an erection without sexual arousal?
no - sexual arousal is required
146
Which PDE5 inhibitors are short acting?
Avanafil
Sildenafil
Vardenafil
(suitable for planned sexual activity)
147
Which PDE5 inhibitor is long acting?
Tadalafil - use PRN (suitable for spontaneous activity)
148
How many doses of PDE5 inhibitors is required to deem a person a 'non-responder'?
6 doses at the maximum dose
| specialist input required --> use alprostadil
149
What two PDE5 inhibitors must be taken 30mins before sex?
Tadalafil and avanafil
150
Which PDE5 inhibitors must be taken 60mins before sex?
sildenafil/vardenafil
151
Give an example of a prostaglandin analogue used in ED?
Alprostadil
152
What is the warning sign associated with alprostadil?
Urgent medical attention if the erection lasts >4hrs (priapism)
153
Contra-indications for PDE5 inhibitors and why?
BP: <90 (systolic)
MI
recent stroke
USING NITRATES
Angina especially unstable (as nitrates also vasodilate) can cause post hypotension/heart block due to v.low bp
154
What drug type interacts with PDE5 inhibitors that would prompt you to do a dose reduction?
CYP3A4 inhibitors
155
A patient asks if he can take sildenafil with food, what would you advise?
Taking it with food/heavy carb/large meals prolongs the onset of action of sildenafil
156
Side-effects of pDE5 inhibitors:
Vasodilators so hypotension, dizzy/drowsy, headache, migraine, palpitations and tachycardia
157
PDE5 inhibitor interactions?
Due to LOW BP
- nitrates (further reduce BP)
- alpha blockers - tamsulosin/doxazosin
- CCBs
- nicorandil
158
What are prostaglandins and oxytocics used for?
inducing abortion/inducing labour (contractions) to minimise blood loss from placenta
contractions vary in terms of pain and strength
159
What drugs can be used for abortion?
misoprostol
gemeprost
mifespristone
160
what drugs can be used to induce/augment labour?
Dinoprostone
Oxytocin
Misoprostol
161
what drugs can be used to prevent and treat bleeding in labour, abortion and miscarriage?
```
carbetocin
carboprost
ergometrine
misoprostol (unlicensed)
oxytocin
```
162
What drug can be used in ectopic pregnancy (hint: it can cause pulmonary toxicity)
methotrexate
163
Methotrexate counselling?
1) Gi toxicity - diarrhoea, stomach inflammation
2) liver toxicity - cirrhosis
3) pulmonary toxicity - report dyspnoea, cough, fever
4) blood dyscrasia - bone marrow suppression: monitor white cells and platelets
164
Drugs used for premature labour?
terbutaline/salbutamol
atosiban
indometacin (unlicensed)
nifedipine
165
Safery info with oxytocin?
at high doses can cause volume depletion which can result in water intoxication with hyponatraemia
166
What products are used for vaginal atrophy?
Common in post-menopausal women
topical oestrogens to help relieve dryness: use at the lowest effective dose to avoid systemic effects e.g. hyperplasia and carcinoma. E.g. vagifem
moisturisers include Replens MD
167
What drugs can be used for vaginal candidiasis?
Anti-fungals such as pessaries/internal cream like clotrimazole, miconazole
PO treatment is recommended if compliance is an issue e.g. fluconazole/itraconazole
168
How would you treat vulvovaginal thrush in pregnancy?
Avoid oral antifungals. Can give topical for 7 days e.g. pessary/cream
169
How would you treat recurrent vulvovaginal candidiasis?
6 month treatment (check if pt is diabetic, on oral contraception, pregnant, on antibiotics)
170
What thrush medication is available OTC?
age: 18-60yrs
canesten: cream, pessary, oral capsule 150mg fluconazole
171
OTC oral dose of fluconazole for thrush?
150mg capsule OD
172
Antifungals are_____
CYP inhibitors
173
What species causes thrush?
candida albicans
174
Symptoms of vaginal thrush?
Cottage-cheese like white discharge and fishy smelling
Painful urination
red/swollen vagina
splits in genitalia
175
Metronidazole dose for Bacterial vaginosis or vaginal trichomoniasis?
2g STAT or 400-500mg BD for 5-7 days
