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pre reg > Chapter 7: Genito-urinary > Flashcards

Chapter 7: Genito-urinary Flashcards

1
Q

What is first line for urinary frequency, enuresis and incontinence?

A

FIRST LINE: ANTIMUSCARINIC DRUGS

  • oxybutynin (direct relaxant of urinary muscle; available as a transdermal patch)
  • tolterodine
  • festoterodine
  • darifenacin
  • solifenacin
  • flavoxate
  • propantheline bromide
  • propiverine
  • trospium
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2
Q

What is second line for urinary frequency, enuresis and incontinence?

A

SECOND LINE: BETA3 AGONIST

- mirabegron (caution: QT interval prolongation, c/i: severe uncontrolled hypertension)

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3
Q

What is used for stress incontinence?

A
  • duloxetine (moderate to severe stress incontinence in women only, avoid abrupt withdrawal)
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4
Q

First and second line for nocturnal enuresis in children?

A

FIRST LINE: enuresis alarms, continue until 2 weeks of uninterrupted dry nights

SECOND LINE: desmopressin in 5+ years

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5
Q

Desmopressin use, side effects and counselling?

A

Use: sublingual or oral. do not give intranasally for nocturnal enuresis due to increased side effects

Side effects: hyponatraemic convulsions

Counselling: for patients treated for primary nocturnal enuresis

  • avoid fluid overload (incl during swimming); restrict fluid intake 1 hour before and until 8 hours after desmopressin
  • stop desmopressin in vomiting/diarrhoea until normal fluid balance. Avoid concomitant drugs that increase vasopressin secretion e.g. TCAs
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6
Q

What drugs are used for urinary retentin in benign prostatic hyperplasia?

A
  • alpha blockers (e.g. tamsulosin)

- 5alpha-reductase inhibitors (e.g. finasteride)

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7
Q

What is the MOA of alpha blockers?

A

Relaxes prostatic smooth muscle

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8
Q

Alpha blockers examples?

A
  • terazosin
  • doxazosin
  • indoramin
  • alfuzosin
  • tamsulosin
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9
Q

Alpha blocker side effects?

A
  • hypotension, notably postural hypotension (dizziness, fainting, blurred vision, tachycardia, palpitations)
  • intra-operative floppy iris syndrome
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10
Q

Alpha-blocker contraindications?

A
  • postrual hypotension
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11
Q

Alpha blocker counselling?

A
  • take first dose at bedtime - risk of first-dose postural hypotension
  • driving can be impaired
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12
Q

Finasteride side effects?

A
  • male breast cancer: report breast symptoms e.g. lumps, pain or nipple discharge
  • depression and suicidal thought (MHRA warning - stop and report depression (rare reports)
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13
Q

Finasteride and conception/pregnancy?

A
  • use condoms if partner is pregnancy or likely to get pregnant; excreted in semen
  • women of child-bearing potential; avoid handling crushed finasteride tablets and leaking dutasteride capsules
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14
Q

What guidelines should be followed when prescribing contraceptives to under 16yrs?

A

Fraser guidelines

  • understands doctors advice
  • cannot be persuaded to inform parents
  • very likely to continue having sex
  • unless she recieves contraception her mental and physical health will suffer
  • in her best interests to provide treatment
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15
Q

How do COC contraceptives work?

A

Inhibits ovulation, contains oestrogens and progestogens

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16
Q

How to: COC?

A
  • take 1 tablet daily for 21 days + 7 day pill-free interval with withdrawal bleeding
  • start any time in menstrual cycle; is started on day 6 or later use protection for 7 days
  • not for women above 50 yrs
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17
Q

Monophasic COC?

A

fixed amount of oestrogen and progestogen

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18
Q

Phasic preparation COC?

A
  • varying amount of oestreogen and progestogen
  • for women who do not have withdrawal bleeding
  • OR have breakthrough bleeding with monophasic preps
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19
Q

Every day COC ?

A
  • pill free interval replaced with inactive pills

- ED

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20
Q

Low-strength oestrogen preparation COC?

A
  • risk factor for circulatory disease (20mg ethinylestradiol)
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21
Q

What do oestrogens increase the risk of ?

A
  • Venous thromboembolism, + more risk factors:
    • type of progestogen: desogesterel, gestodene, drosperinone
    • obesity BMI
    • smoking
    • primary relative with VTE under 45
    • superficial thrombophlebitis
    • long-term immobilsation
    • age >35 yrs
  • Increased risk of arterial thromboembolism + more risk factors:
    • diabetes, hypertension, migraine without aura

AVOID IF 2 OR MORE RISK FACTORS PRESENT

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22
Q

Contraceptives and surgery? COC

A

STOP 4 WEEKS BEFORE

  • for major surgery and all surgery to the legs or surgery that results in prolonged immobilisation of a lower limb
  • POC is alternative
  • restart usual contraceptive on first menses after at least 2 weeks after full mobilzation
  • thromboprophylaxis in emergency surgeru or if combined contraceptive was not stopped
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23
Q

Contraceptives and travel? COC

A

Journeys longer than 3 hours:

- reduce risk by wearing compression stocking and leg exercises

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24
Q

Reasons to stop contraceptive (applies to combined contraceptives and oestrogen-containing HRT)?

A

VTE

  • sudden severe chest pain, breathlessness or cough with blood stained sputum (PE)
  • unexplained swelling or severe pain in calf of one leg (DVT)

STROKE

LIVER DYSFUCTION
- jaundice, hepatitis, liver enlargement, severe stomach

BLOOD PRESSURE
- above systolic 160mmHg or diastolic 95mmHg

PROLONGED IMMOBILITY AFTER SURGERY OR LEG INJURY

DETECTION OF A RISK FACTOR WHICH C/I TREATMENT

  • smoking 40+ a day
  • personal history of venous/arterial thrombus
  • migraine with aura/severe migraine frequently lasts over 72 hours, migraine treated with ergot derivatives
  • diabetes with complications
  • heart disease associated with pulmonary hypertension or risk of embolus
  • valvular heart disease (increased risk of stroke)
  • BMI >35
  • over 50yrs
  • transient ischaemic attack without headache
  • hypertension systolic 160mmHg or diastolic 95mmHg
  • severe or multiple risk factors (2 or more) for VTE/arterial thromboembolism
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25
Q

POC MOA?

A

Prevents pregnancy by thickening the mucus in the cervix to stop sperm reaching an egg

Alternative when oestrogens i.e COC is c/i. Mentrual irregularities; heavy/light is common

26
Q

POC; how to take?

A
  • take one tablet daily on a continuous basis, starting on day 1 of cycle and taken at the same time each day
  • if started after day 5 menstrual cyclem addditional precaution is required for 2 days
27
Q

Hormonal contraceptives other side effects?

A

Cancer side effects:

  • combined: increase the risk of cervical and breast cancer
  • poc: increase the risk of breast cancer
28
Q

Benefits of combined oral contraceptives ?

A
  • reduces risk of ovarian and endometrial cancer
  • reduces dysmenorrhoea and menorrhagia, premenstrual tension, reduced risk of PID, less benign breast cancer, less symptomatic fibroids or functional ovarian cysts
29
Q

How many days extra precautions needed for 2 or more missed COCs?

A
  • 7 days barrier method
  • 9 if zoely/qlaira
  • omit pill free interval
  • EHC if missed in first 7 days and unprotected sex occurs
30
Q

How many extra precautions needed for missed POC?

A
  • missed pill >3 hours (desogesterel >12 hours)

- barrier method for 2 days

31
Q

What does missed patch mean?

A

“missed” refers to detachment or delayed application

32
Q

How to use Evra patches and how to deal with ‘missed’ patch ?

A

1 cycle; weekly patch for 3 weeks, then 1 week patch free
- detached for >24hr
- OR delayed application at beginning of cycle
- apply new patch ASAP
- start a new day 1 cycle + barrier method for 7 days
- delayed application in the middle of cycle; beginning of week 2 (day 8) or week 3 (day 15)
48 hours = start a new day 1 cycle + condom for 7 days

33
Q

Missed ring contraception?

A

missed refers to expulsion, delayed insertion, broken ring

34
Q

Enzyme inducers and contraceptives?

A

REDUCED CONTRACEPTIVE EFFECTIVENESS:

  • carbamazepine
  • phenytoin
  • phenobarbital
  • st johns wort
  • rifampicin
  • rifabutin

Use copper IUD/PO injections until 4 weeks after stopping the interacting drug

35
Q

EHC and drug interactions?

A
  • ellaone efficacy reduced by drugs that increase the gastric pH (antacids, h2 receptor antagonits, PPI)
36
Q

EHC first line and second line ?

A

first: copper IUD ?* most effective form of ehc
second: hormonal methods (ellaone and levonelle)
* if >70kg use ellaone or double dose levonelle

37
Q

Levonorgestrel MOA?

A

Prevents ovulation and fertilisation

38
Q

Levonorgestrel dose and cautions?

A

Dose: 1500mg <72hrs of UPSI, if vomiting <3hrs of taking dose; give another dose

Cautions: crohns (severe malabsorption syndromes), past ectopic pregnancy, ciclosporin (toxicity)

39
Q

Ulipristal MOA (ellaone)?

A

Progestogen receptor modulator inhibits or delays ovulation. More effective than levonorgestrel

40
Q

Ulipristal use, dose, cautions, c/i?

A
  • up to 120 hours after UPSI
  • dose: 30mg
  • cautions: severe asthma treated by oral corticosteroids (not recommended), avoid in severe liver impairment
  • c/i: repeated use within the same menstrual cycle (repeated use with levonelle not c/i but manufacturers advise to avoid, due to increased menstrual irragularities)
41
Q

Ellaone counselling?

A
  • reduces effectiveness of contraceptives, use additional barrier for 14 days COC, 16 days qlaira, 9 days POC and 14 days parenreral POC
  • also wait 5 days before re starting hormonal contraception
42
Q

Hormonal contraception counselling?

A
  • next perioud may be early or late
  • use barrier protection until next period
  • if lower abdomal pain; see gp to rule out ectopic pregnancy (also with levonelle)
  • if periods are abnormal take a pregnancy test (3 weeks after UPSI)
43
Q

What is an IUD?

A
  • most effective contraception

- less suitable for prescribing in under 25 years due to increased risk of pelvic inflammatory disease

44
Q

2 types of IUD?

A

1, copper (non-hormonal)

  1. levonorgestrel releasing
    - reduced bleeding and period pain and has a lower risk of pelvic inflammatory disease
    - prescribe by brand as varying indications, duration of use and introducers
    - mirena = 5 years: contraception, oestrogen opposition in HRT, menorrhagia
    - levosert = 3 years: contraception, menorrhagia
    - jaydess = 3 years: contraception
45
Q

IUD side effects?

A
  • pain on insertion and bleeding
  • uterine perforation (MHRA report severe pelvic pain after insertion, sudden change in periods, pain during sex, pain or increased bleeding for more than a few weeks, or unable to feel threads)
  • risk of infection (related to the carriage of existing STI)
  • pre-insertion chlamydia screening for high risk groups e.g. under 25, new partner, multiple partners in last year etc
  • antibiotic prophylaxis if for emergency contraception, treat as emergency if there is sustained pain during next 20 days
46
Q

Removal of IUD?

A
  • do not remove IUD mid-cycle unless additional contraception is used for 7 days
  • if removal is essential and unprotected sex occurs give EHC
  • if pregnanct remove in 1st trimester
47
Q

Parenteral contraceptives:

A

Medroxyprogesterone injection: 2 years
- delay in return to fertility and menstrual irregularites
- osteoporosis risk
Noresthisterone injection: 8 weeks

Etonogestrel implant: 3 years

  • MHRA nexplanon (etonogestrel) contraceptive implants reports of device in vasculature and lung, implants may reach the lung via pulmonary artery.
  • implant must be palpable - otherwise locate and remove asap
  • if unable to locate implant in arm, use chest imaging
48
Q

Spermicidal contraceptives:

A
  • barrier preparations alone (condoms, caps, diaphragms) are less effective but can be reliable in well-motivated couples who also use a spermicide
  • not suitable for those at high risk of STIs; high use associated with genital lesions and increased risk of acquiring infections
49
Q

Drugs used for erectile dysfunction?

A

PHOSPODIESTERASE TYPE 5 INHIBITORS

  • sildenafil (1 hour before sex)
  • tadalafil (30 mins before sex)
  • vardenafil (25-60 mins before sex)
  • avanafil (30 mins before sex)

PROSTAGLANDIN ANALOGUE
- alprostadil (not orally) seek urgent medical help for prolonged erection lasting more than 4 hours (priapism)

50
Q

Phosphodiesterase type 5 inhibitors MOA?

A

Increases blood flow to penis. Delayed effect with food

51
Q

Phosphodiesterase type 5 inhibitors side effects?

A
  • (vasodilation)

- hypotension: flushing, headache, migraine, dyspepsia, nasal congestion, palpitations and tachycardia

52
Q

Phosphodiesterase type 5 inhibitors contra-indication?

A
  • (reduced blood perfusion)
  • myocardial infarction
  • unstable angina or recent stroke
  • hypotension; sytolic <90mmHg or TAKING NITRATES
53
Q

Phosphodiesterase type 5 inhibitors interactions?

A
  • (low blood pressure; vasodilators)
  • nitrates
  • alpha blockers (once stabilised, then initiate)
  • CCBs
  • nicorandil
54
Q

What drugs are used for abortion ?

A
  • gemeprost (prostaglandin analogue)
  • mifespristone (anti-progestogen)
  • misoprostol (prostaglandin analogue)
55
Q

What drugs indude or augment labour?

A
  • dinoprostone (naturally occurring prostaglandin)
  • misoprostol
  • oxytocin (naturally occuring hormone)
56
Q

What drugs are used to prevent and treat bleeding labour/abortion/miscarriage?

A
  • carbetocin
  • carboprost
  • ergometrine
  • misoprostol
  • oxytocin
57
Q

What drug is used to treat ectopic pregnancy?

A

methotrexate - works by blocking the enzymes in the body that maintain
the pregnancy. It stops the tissue from growing bigger and prevents it from rupturing (bursting).
The pregnancy tissue is then gradually reabsorbed by the body.

58
Q

What drugs are used for premature labour?

A
  • salbutamol/terbutaline
  • atosiban (oxytocin antagonist)
  • indometacin (cox-inhibitor stops synthesis of prostaglandins)
  • nifedipine
59
Q

What is used to treat bacterial vaginosis and vaginal trichomoniasis?

A

metronidazole

60
Q

What is used to treat vaginal candidiasis?

A
  • imidazole pessary/internal cream e.g. clotrimazole

- oral treatment: fluconazole, itraconazole

pre reg (73 decks)

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