Chapter 7: Genito-urinary Flashcards
What is first line for urinary frequency, enuresis and incontinence?
FIRST LINE: ANTIMUSCARINIC DRUGS
- oxybutynin (direct relaxant of urinary muscle; available as a transdermal patch)
- tolterodine
- festoterodine
- darifenacin
- solifenacin
- flavoxate
- propantheline bromide
- propiverine
- trospium
What is second line for urinary frequency, enuresis and incontinence?
SECOND LINE: BETA3 AGONIST
- mirabegron (caution: QT interval prolongation, c/i: severe uncontrolled hypertension)
What is used for stress incontinence?
- duloxetine (moderate to severe stress incontinence in women only, avoid abrupt withdrawal)
First and second line for nocturnal enuresis in children?
FIRST LINE: enuresis alarms, continue until 2 weeks of uninterrupted dry nights
SECOND LINE: desmopressin in 5+ years
Desmopressin use, side effects and counselling?
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
What drugs are used for urinary retentin in benign prostatic hyperplasia?
- alpha blockers (e.g. tamsulosin)
- 5alpha-reductase inhibitors (e.g. finasteride)
What is the MOA of alpha blockers?
Relaxes prostatic smooth muscle
Alpha blockers examples?
- terazosin
- doxazosin
- indoramin
- alfuzosin
- tamsulosin
Alpha blocker side effects?
- hypotension, notably postural hypotension (dizziness, fainting, blurred vision, tachycardia, palpitations)
- intra-operative floppy iris syndrome
Alpha-blocker contraindications?
- postrual hypotension
Alpha blocker counselling?
- take first dose at bedtime - risk of first-dose postural hypotension
- driving can be impaired
Finasteride side effects?
- 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)
Finasteride and conception/pregnancy?
- 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
What guidelines should be followed when prescribing contraceptives to under 16yrs?
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
How do COC contraceptives work?
Inhibits ovulation, contains oestrogens and progestogens
How to: COC?
- 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
Monophasic COC?
fixed amount of oestrogen and progestogen
Phasic preparation COC?
- varying amount of oestreogen and progestogen
- for women who do not have withdrawal bleeding
- OR have breakthrough bleeding with monophasic preps
Every day COC ?
- pill free interval replaced with inactive pills
- ED
Low-strength oestrogen preparation COC?
- risk factor for circulatory disease (20mg ethinylestradiol)
What do oestrogens increase the risk of ?
- 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
Contraceptives and surgery? COC
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
Contraceptives and travel? COC
Journeys longer than 3 hours:
- reduce risk by wearing compression stocking and leg exercises
Reasons to stop contraceptive (applies to combined contraceptives and oestrogen-containing HRT)?
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
POC MOA?
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
POC; how to take?
- 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
Hormonal contraceptives other side effects?
Cancer side effects:
- combined: increase the risk of cervical and breast cancer
- poc: increase the risk of breast cancer
Benefits of combined oral contraceptives ?
- 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
How many days extra precautions needed for 2 or more missed COCs?
- 7 days barrier method
- 9 if zoely/qlaira
- omit pill free interval
- EHC if missed in first 7 days and unprotected sex occurs
How many extra precautions needed for missed POC?
- missed pill >3 hours (desogesterel >12 hours)
- barrier method for 2 days
What does missed patch mean?
“missed” refers to detachment or delayed application
How to use Evra patches and how to deal with ‘missed’ patch ?
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
Missed ring contraception?
missed refers to expulsion, delayed insertion, broken ring
Enzyme inducers and contraceptives?
REDUCED CONTRACEPTIVE EFFECTIVENESS:
- carbamazepine
- phenytoin
- phenobarbital
- st johns wort
- rifampicin
- rifabutin
Use copper IUD/PO injections until 4 weeks after stopping the interacting drug
EHC and drug interactions?
- ellaone efficacy reduced by drugs that increase the gastric pH (antacids, h2 receptor antagonits, PPI)
EHC first line and second line ?
first: copper IUD ?* most effective form of ehc
second: hormonal methods (ellaone and levonelle)
* if >70kg use ellaone or double dose levonelle
Levonorgestrel MOA?
Prevents ovulation and fertilisation
Levonorgestrel dose and cautions?
Dose: 1500mg <72hrs of UPSI, if vomiting <3hrs of taking dose; give another dose
Cautions: crohns (severe malabsorption syndromes), past ectopic pregnancy, ciclosporin (toxicity)
Ulipristal MOA (ellaone)?
Progestogen receptor modulator inhibits or delays ovulation. More effective than levonorgestrel
Ulipristal use, dose, cautions, c/i?
- 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)
Ellaone counselling?
- 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
Hormonal contraception counselling?
- 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)
What is an IUD?
- most effective contraception
- less suitable for prescribing in under 25 years due to increased risk of pelvic inflammatory disease
2 types of IUD?
1, copper (non-hormonal)
- 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
IUD side effects?
- 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
Removal of IUD?
- 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
Parenteral contraceptives:
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
Spermicidal contraceptives:
- 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
Drugs used for erectile dysfunction?
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)
Phosphodiesterase type 5 inhibitors MOA?
Increases blood flow to penis. Delayed effect with food
Phosphodiesterase type 5 inhibitors side effects?
- (vasodilation)
- hypotension: flushing, headache, migraine, dyspepsia, nasal congestion, palpitations and tachycardia
Phosphodiesterase type 5 inhibitors contra-indication?
- (reduced blood perfusion)
- myocardial infarction
- unstable angina or recent stroke
- hypotension; sytolic <90mmHg or TAKING NITRATES
Phosphodiesterase type 5 inhibitors interactions?
- (low blood pressure; vasodilators)
- nitrates
- alpha blockers (once stabilised, then initiate)
- CCBs
- nicorandil
What drugs are used for abortion ?
- gemeprost (prostaglandin analogue)
- mifespristone (anti-progestogen)
- misoprostol (prostaglandin analogue)
What drugs indude or augment labour?
- dinoprostone (naturally occurring prostaglandin)
- misoprostol
- oxytocin (naturally occuring hormone)
What drugs are used to prevent and treat bleeding labour/abortion/miscarriage?
- carbetocin
- carboprost
- ergometrine
- misoprostol
- oxytocin
What drug is used to treat ectopic pregnancy?
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.
What drugs are used for premature labour?
- salbutamol/terbutaline
- atosiban (oxytocin antagonist)
- indometacin (cox-inhibitor stops synthesis of prostaglandins)
- nifedipine
What is used to treat bacterial vaginosis and vaginal trichomoniasis?
metronidazole
What is used to treat vaginal candidiasis?
- imidazole pessary/internal cream e.g. clotrimazole
- oral treatment: fluconazole, itraconazole
