Chapter 7: Genito-Urinary System Flashcards
Ben, a 7-year-old went swimming with his friends from school as part of physical Education activities . His teacher realizes that Ben’s records show that he takes Desmopressin regularly. Which of the following advice should the teacher give Ben. Choose most relevant option below.
A. Ben should be warned he could vomit whilst swimming due to his current medication .
B. Ben could feel thirsty as a result of the drug he is taking.
D. Ben should avoid swimming altogether.
E. Ben should be isolated and asked to swim in a separate pool.
C. Ben should not drink water from the pool whilst swimming. (moderate water intake, too much water, reduces concentration of sodium causing hyponeatrima possibly leading to convulsions/seizures)
NOCTURNAL ENURESIS (bedwetting) IN CHILDREN
AGE - 1yrs–5yrs
▪ use Natural and non-drug treatment first (fluid control: closer to bedtime limit amount of fluids, enuresis alarm: set an alarm/take them to restroom at set times, reward system)
do not put under the age of 5 or under on medication, definitely over 5yrs (can start giving medication), as young as 6, ideally from 7yrs
➢ Desmopressin (diabetes insipedus: nephrogenic type, used to diagnose, action: anti-diuretic hormone helps retain water, desmopressin and sodium: if sodium goes down, absorbs more desmopressin, leads to convulsion, drugs that increases hyponatreamia: excessive water, low sodium diet, SSRI, loop diuretics, carbamazepine, TCAs)
➢ Oxybutinin (antimuscarinic side effects: water retention, side effects used to treat incontinence, dry mouth, blurry vision, drowsiness, oxybutinin and clozapine: constipation=>intestinal obstruction=>fatal consequences, antihistamines: antimuscarinic side effects, can be due to taking alongside oxybutinin, stop antihistamine as not clinically important)
➢ Imipramine (TCA, off license use, also used in noctual enuresis apart from mental health)
URINARY FREQUENCY, incontinence
➢ Antimuscarinics: first line, antimuscarinics–oxybutynin, solifenacin
➢TCA - unlicensed, imipramine (2nd line)
➢Mirabegron – can cause increase in BP, monitor/check BP, use of contraception women of childbearing as can cause issues.
3 TYPES
>Don’t give duloxetine in women with stress incontinence as first line.
> tamsulosin (flomax, POM and P): can get on PGD, 45-75yrs
URINARY RETENTION (unable to pass urine)
Causes: in men (benign prostatic hyperplasia: enlargement of prostate gland)
Acute – catheterization (fitting the catheter/removal of can cause infection)
Alpha blockers (relax vessels to allow urine through): alfuzosin, prazosin, tamsulosin, doxazosin
Finasteride (can only be taken by men, not be taken by women, can cause breast cancer in men, increase risk of suicide/notice any changes in behavior/mood, use gloves and tweezers when handling (methotrexate)
Stella, a young lady , is a new dispenser who is about to make dossette
boxes for the first time . She is instructed to wear gloves and use
tweezers when handling certain drugs. Which of these drugs do NOT require Stella to use gloves or tweezers when handling?
A. Dusteride (same family as finasteride)
B. Methotrexate (cytotoxic)
C. Chlorpromazine (1st gen antipsychotic, causes contact sensitisation: skin will peel off)
D. Finasteride
E. None of the above
E. None of the above
HRT
> HRT IS THE REPLACEMENT OF HORMONES SUCH AS OESTROGEN AND PROGESTERONE THAT WOMEN LOSE DUE TO MENOPAUSE. (early menopause before 50 no period 2 yrs, late menopause after 50 no period 1 yr)
Gina eligibility: not for patients with early menopause, must be 50+ and not have period for 1 yr
MENOPAUSE SYMPTOMS: vaginal atrophy, mood swings, sweating, hot flushes, irritable, dryness, poor concentration (imagine having HRT scarcity for menopausal women)
HRT PRODUCTS ARE AVAILABLE AS PATCHES , TABLETS , GELS ETC
PATIENTS CAN CHOOSE WHICH FORM THEY PREFER.
Menopausal but still SEEING PERIODS- GIVE CYCLICAL HRT (CONTAINS BOTH HORMONES)
STOPPED PERIOD OVER A YEAR – GIVE CONTINOUS HRT HAVE A REVIEW EVERY YEAR.
HRT
> FOR PATIENTS WHO HAVE HAD A HYSTERECTOMY (womb removal) – DON’T NEED PROGESTERONE (protects womb lining). GIVE OESTROGEN ONLY HRT!!!
SIDE-EFFECTS – headaches, breast tenderness, mood changes, nausea, spotting (may need to be referred).
Consider changing doses or forms if patients complain of ongoing side- effects after 6 to 8 weeks.
HRT PROTECTS BONES FROM OESTEOPOROSIS (oestrogen in important for the maintenance of bones in woman)
RISKS OF HRT
> Risk of breast cancer
Risk of endometrial cancer
Risk of ovarian cancer
Risk of venous thromboembolism Risk of stroke
Risk of coronary heart disease
**yes there is a risk of these conditions, however the risk is very small, long-term HRT is an increased risk of getting these conditions
Surgery
>Major surgery under general anaesthesia, including orthopaedic and vascular leg surgery, is a predisposing factor for venous thromboembolism and it may be prudent to stop HRT 4–6 weeks before surgery
COC: stop 4 weeks before planned surgery
Warfarin: 5 days
HRT: 4-6 weeks
Insulin: dose adjustment (long-acting insulin: reduce to 80% day before)
WHEN TO STOP HRT
> Hormone replacement therapy should be stopped (pending investigation and treatment), if any of the following occur:
*sudden severe chest pain (even if not radiating to left arm);
*sudden breathlessness (or cough with blood-stained sputum, can cause pulmonary embolism:clots in lungs);
*unexplained swelling or severe pain in calf of one leg;
*severe stomach pain;
*serious neurological effects including unusual severe, prolonged headache especially if first time or getting progressively worse or sudden partial or complete loss of vision or sudden disturbance of hearing or other perceptual disorders or dysphasia or bad fainting attack or collapse or first unexplained epileptic seizure or weakness, motor disturbances, very marked numbness suddenly affecting one side or one part of body;
*hepatitis, jaundice, liver enlargement;
*blood pressure above systolic 160 mmHg or diastolic 95 mmHg;
*prolonged immobility after surgery or leg injury;
*detection of a risk factor which contra-indicates treatment.
Refer patient to urgent medical attention=>A/E
Contraceptives
There are various types of contraceptives
1. Barrier method (condoms, diaphragms)
2. I.U.D (copper, etc)
3. Patches
4. Injections eg depo provera (progesterone)
5. Vaginal rings
6. Oral – COC (oestrogen and progesterone) or progesterone only . (Yazmin, microgynon)
Examples?? Learn Brand names
Miss. Zara, a 23-year-old woman would like to discuss contraceptives options with her doctor. During the discussion, her
doctor mentions that an IUD is less suitable for her. What is the
most accurate reason for the doctor’s response?
A. Increased risk of infertility
B. Increased risk of Ovarian cancer
C. Increased risk of P.I.D.
D. Increased risk of multiple pregnancies
E. Increased risk of breast cancer
C. Increased risk of P.I.D. (female less than 25yrs are at risk of PID)
COC
> Take for 21 days with 7 day break
Not for women over 50 yrs
Monophasic COC: same amount of progesterone/oestrogen in all tablets (more effective for women with regular cycles)
Phasic COC: change of strengths through tablets (more effective for irregular periods)
Everyday preparation (so patients dont forget, taken everyday even though 7 days are placebo/inactive tablets)
Avoid if 2 or more Symptoms are present- Smoking, over 35yrs , BMI 30 or more, Family history of blood clots/DVT, immobilization, etc
when should COC be stopped before major elective surgery??? 4 weeks
Long Journeys/traveling?? Advice: wear compression stockings, increase mobility
COC reduces risk of endometrial and ovarian cancer but increases risk of breast cancer and cervical cancer.
COC – Reasons to stop
> Stroke
Breathlessness: pulmonary embolism
VTE
High Blood pressure ……160/ 95
Liver dysfunction
Prolonged immobility after surgery or injury
Detection of a risk factor eg smoking, over 40, BMI over 35 , diabetes
PROGESTERONE ONLY CONTRACEPTIVES
❑ Take one tablet at the same time every day (keep concentration in blood consistent)
❑ If started after day 5 of cycle additional protection is needed. (period ends, best day to take it is right at the beginning of the cycle, the next day, day 1 is best time to take it)
❑ Increases risk of breast cancer.
❑ Used in Emergency contraception. Eg Levonell one-step
>morning after: Levonell (16+, PGD for under 16, 72 hrs after activity, the earlier to take it the better, the longer you wait the less effective, possible to get pregnant on the morning after pill, if vomit within 2 hrs needs another medication, refer patients on enzyme inducers: carbamazepine, phenytoin, rifampicin, phenobarbitol
❑ If patient has BMI of ..26kg/M2 or more >70kg, give 2 tablets of levonorgestrel (unlicensed, not allowed to sell 2 OTC, must refer for 2) or just sell ELLA-ONE
o Pinky, an 18-year-old who have never taken contraceptives before . Starts a new pack of microgynon but missed a dose within the first 7 days and UPSI occurred during that same period. What advice would you give this patient.
o Sharon , A 25-year-old woman who has been taking Rigevidon regularly for the past 6 months. Reports that she missed a tablet yesterday- within the first 7 days of a new pack and unprotected sexual intercourse occurred last night. What advice would you give this patient.
o Mrs. Happy a 35-year-old woman takes Microgynon regularly, starts Micrigynon on day one of her cycle. She had unprotected sex yesterday(day 6 of cycle ) . She has not missed a pill but worries and would like to know what to do .
WB Questions
MISSED PILL
> COC – missed pill is 24 hours or more.
Qlaira is 12hrs or more
P Only Contraceptive – 3 hours or more
Desogestrel is 12 hours
COC 1 missed – take next as normal, even 2 at once
COC 2 missed – Take next dose and use protection. Consider EHC=>take pill for today, morning after pill if had unprotected sex, use condom for 7 days (Zoey/QLAIRA=9 days)
P only contraceptive- 1 missed – take missed pill Asap plus condoms for 2 days
P only contraceptive- 2 missed – take 1 dose, morning after/EHC if had unprotected sexual intercourse, plus condoms 2 days
missed pill: 24 from point of first missed pill into 2nd one
first 7 tablets in a pack are most important for new/returning patients as body is building up enough protection, if miss a pill during this time can potentially become pregnant, must start all over, use EHC if had unprotected sex and use condoms for 7 days
