Chapter 7: Genito-urinary system Flashcards
How do you manage acute urinary retention?
Catheterisation
alpha blocker such as tamsulosin, doxazosin should be given at least 2 days beforehand
What is the pharmacological management of chronic urinary retention in men?
An alpha-adrenoceptor blocker (alfuzosin hydrochloride, doxazosin, tamsulosin hydrochloride or terazosin). Treatment should initially be reviewed after 4–6 weeks and then every 6–12 months.
What is the pharmacological treatment for benign prostate hyperplasia and raised PSA and high risk of progression eg elderly?
5a-reductase inhibitor - finasteride, dutasteride
This can be combined with an alpha blocker if symptoms remain an issue
What can be used for the pharmacological management of urinary incontinence?
Oxybutinin
Tolterodine
Fesoterodine
Solifenacin succinate
Mirabegron - only if antimuscarinics ineffective/not suitable
What is the suggested duration of treatment for an uncomplicated lower UTI in men and women?
7 days for men
3 for women
What 3 antibiotics can be used for long term low dose lower UTI prophylaxis?
Trimethoprim
Nitrofurantoin
Cefalexin
What antibiotics should be used for management of upper UTIs (acute pyelonephritis)?
How long should the treatment be?
IV Broad spectrum antibiotic e.g. cephalosporin, quinolone
Or IV gent if severely ill
10-14 days
What would be the most appropriate antibiotic classes for a pregnant lady with a UTI?
Penicillins or cephalosporins
If non drug treatment is unsuccessful (e.g. using an alarm, fluid intake) in children who have nocturnal enuresis, what would be the pharmacological management?
Oral desmopressin if > 5 years
For children under 5 years, this should resolve spontaneously
When starting alpha blockers for urinary retention/benign prostate hyperplasia, when should the first dose be taken and why?
At bedtime ideally as can cause hypotension and possibly a collapse
What is the MHRA warning regarding the use of finasteride?
Rare reports of depression and suicidal thoughts
What is used for the alkalinisation of urine?
Potassium citrate
Sodium bicarbonate
If a patient requires major elective surgery and is on an oestrogen-containing contraceptive, how is this managed?
Should be stopped 4 weeks before if it means the surgery will result in prolonged immobilisation of lower limbs
Should be restarted at the first menses occurring at least 2 weeks after full mobilisation
A progesterone only contraceptive may be provided as an alternative
Before surgery, if an oestrogen-containing contraceptive cannot be stopped beforehand, what is recommended?
Thromboprophylaxis
What would be the reasons to immediately stop combined hormonal contraceptives or HRT?
- Sudden severe chest pain (even if not radiating to left arm)
- Sudden breathlessness (or cough with blood-stained sputum)
-Unexplained swelling or severe pain in calf of one leg;
severe stomach pain
- Serious neurological effects including unusual severe, prolonged headache
- Hepatitis, jaundice, liver enlargement
- Blood pressure above systolic 160 mmHg or diastolic 95 mmHg; (in adolescents stop if blood pressure very high)
- Prolonged immobility after surgery or leg injury
What is an associated risk of the IUD in women under 25 years?
Increased risk of pelvic inflammatory disease
Copper has higher risk over the progesterone only IUD
Other than patient choice, in what groups of patients would you consider the progesterone only pill over the combined hormonal contraceptive?
When oestrogens are contra-indicated (including those with history of VTE, heavy smokers, those with hypertension above systolic 160 mmHg or diastolic 95 mmHg, valvular heart disease, diabetes mellitus with complications, and migraine with aura)
Intravesical is administration into where?
Bladder
Combined oral contraceptives reduce the risk of what types of cancer?
Ovarian and endometrial cancer
It is recommended that combined oral contraceptives are not continued beyond what age?
50 years as there are more suitable alternatives
Low strength preparations of combined contraceptive pill contain how much ethinylestradiol?
When would you use this?
20 micrograms
If risk factors for circulatory disease are present
Standard strength preparations of combined contraceptive pill contain how much ethinylestradiol?
30 or 35 micrograms
Phased preparations of the combined contraceptive pill is appropriate for what individuals?
Who either do not have withdrawal bleeding or who have breakthrough bleeding with monophasic products
Can progesterone only contraceptives be used during surgery?
Yes
Women taking oral contraceptives are at an increased risk of deep vein thrombosis during long periods of travel over how many hours?
Over 3 hours
At what part of the cycle can you start combined oral contraceptive?
When would you need to have additional barrier method and for how long for?
If reasonably certain woman is not pregnant, first course can be started on any day of cycle
If starting on day 6 of cycle or later, additional precautions (barrier methods) necessary during first 7 days.
If a patient is on combined oral contraception and is changing to another combined oral contraception containing a different progesterone, how is this done?
If previous contraceptive used correctly, or pregnancy can reasonably be excluded, start the first active tablet of new brand immediately
May need additional precautions but depends on specific preparations
If a patient is on a progesterone only tablet and is changing to a combined oral contraception, how is this does and are additional precautions needed?
If previous contraceptive used correctly, or pregnancy can reasonably be excluded, start new brand immediately, additional precautions (barrier methods) necessary for first 7 days.
If a patient wishes to start combined oral contraception after childbirth (not breastfeeding), how is this done?
When would additional precautions be needed?
Start 3 weeks after birth (increased risk of thrombosis if started earlier); later than 3 weeks postpartum additional precautions (barrier methods) necessary for first 7 days (9 days for Qlaira®).
What is the risk of starting combined oral contraception before the recommended 3 weeks postpartum?
Increased risk of thrombosis
If a patient has had an abortion or miscarriage, when can they start combined oral contraception if they want to?
Start same day
What is the advice surrounding a patient being started on combined oral contraception if breastfeeding?
Avoid until weaning
Or
Avoid for 6 months after birth (adverse effects on lactation).
What are the 6 risk factors for VTE for combined oral contraception?
How many risk factors would deem the patient unsuitable for combined oral contraception?
- Family history of venous thromboembolism in first-degree relative aged under 45 years
- Obesity; body mass index ≥ 30 kg/m2 (avoid if body mass index ≥ 35 kg/m2 unless no suitable alternative)
- Long-term immobilisation e.g. in a wheelchair, leg in plaster
- History of superficial thrombophlebitis
- Age over 35 years (avoid if over 50 years)
- Smoking.
Use with caution if any of following factors present but avoid if two or more factors present
What are the 7 risk factors for arterial disease for combined oral contraception?
How many risk factors would deem the patient unsuitable for combined oral contraception?
- Family history of arterial disease in first degree relative aged under 45 years
- Diabetes mellitus (avoid if diabetes complications present)
- Hypertension
- Smoking (avoid if smoking 40 or more cigarettes daily)
- Age over 35 years (avoid if over 50 years)
- Obesity (avoid if body mass index ≥ 35 kg/m2 unless no suitable alternative)
- Migraine without aura - avoid if with aura
At what blood pressure would you avoid initiating combined oral contraceptives in?
Above systolic 160 mmHg or diastolic 95 mmHg
You would avoid initiating combined oral contraceptives in patients smoking how many cigarettes a day?
40
What is the patient advice surrounding combined oral contraceptives and headaches?
Women should report any increase in headache frequency or onset of focal symptoms (discontinue immediately)
Combined oral contraceptives increase the risk of what types of cancer?
Breast and cervical
What is the patient advice surrounding combined oral contraceptives and vomiting/diarrhoea?
When is it advised to take additional precautions?
If vomiting occurs within 2 hours of taking a combined oral contraceptive another pill should be taken as soon as possible
In cases of persistent vomiting or severe diarrhoea lasting more than 24 hours, additional precautions should be used during and for 7 days after recovery
Patient taking combined oral contraceptives:
If vomiting and diarrhoea occurs during the last 7 tablets, what is the advice?
The next pill-free interval should be omitted (in the case of ED tablets the inactive ones should be omitted).
Combined oral contraception:
A missed pill is one that is more than how many hours late?
24 hours
If a woman forgets to take one dose of her combined oral contraceptive pill, what is the advice?
If a woman forgets to take a pill, it should be taken as soon as she remembers, and the next one taken at the normal time (even if this means taking 2 pills together).
If a woman misses 2 or more oral combined contraceptive pills, what is the advice?
If a woman misses 2 or more pills (especially from the first 7 in a packet), she may not be protected. She should take an active pill as soon as she remembers and then resume normal pill-taking.
In addition, she must either abstain from sex or use an additional method of contraception such as a condom for the next 7 days. If these 7 days run beyond the end of the packet, the next packet should be started at once, omitting the pill-free interval (or, in the case of everyday (ED) pills, omitting the 7 inactive tablets).
In patients taking oral combined contraceptives, when would EHC be recommended?
Emergency contraception is recommended if 2 or more combined oral contraceptive tablets are missed from the first 7 tablets in a packet and unprotected intercourse has occurred since finishing the last packet.
What is the MHRA warning with IUD contraception?
Uterine perforation most often occurs during insertion, but might not be detected until sometime later
Signs and symptoms include:
- Severe pelvic pain after insertion (worse than period cramps)
- Pain or increased bleeding after insertion which continues for more than a few weeks
- Sudden changes in periods;
pain during intercourse
-Unable to feel the threads
The main risk of infection with copper IUD occurs within the first how many days after insertion?
Within 20 days
But believed to be linked with STIs
What does the BNF say about the progesterone only pill and risk of breast cancer?
The risk of breast cancer in users of POCs is possibly of similar magnitude as that associated with COCs, however the evidence is less conclusive.
What antidepressant can be used for moderate to severe stress incontinence in women?
Duloxetine
What is a common electrolyte disturbance side effect of desmopressin?
Hyponatraemia (and associated convulsions)
What is the patient advice for desmopressin if taking for primary nocturnal enuresis?
To reduce the risk of Hyponatraemia (and associated convulsions):
Should be warned to avoid fluid overload (including during swimming) and to stop taking desmopressin during an episode of vomiting or diarrhoea (until fluid balance normal).
Should not have anything to drink for 1 hour before they take desmopressin, and then for 8 hours after they have taken it.
What is the patient advice needed with tamsulosin?
May affect performance of skilled tasks e.g. driving.
What is the patient counselling with finasteride?
Rare cases of male breast cancer- report any lumps, nipple discharge
What is the contraception advice with finasteride?
Use condoms as it is excreted in semen
Women of child-bearing potential should avoid handling crushed tablets
The combined contraceptive pill is not for women above what age?
50
At what point of the menstrual cycle should you start the progesterone only pill? If this is not possible, how many days of additional precaution do you need?
Start on Day 1
If started after day 5, additional precaution is needed for 2 days
After how many hours is classed as a missed pill for progesterone only?
What is the exception?
How many days will you will you need additional precaution?
3 hours
Desogestrel - 12 hours
2 days of additional precaution needed
When would you need EHC if taking the progesterone only pill?
If you miss a dose and unprotected sex occurs before 2 pills are taken correctly
What is the advice around the progesterone only pill ad vomiting?
If you vomit within 2 hours of taking the pill, take another one ASAP
If you have been unable to take the pill within 3 hours of normal time (12 hours for desogestrel) then additional protection is needed until 2 days after
True or false:
It is not advised to remove an IUD mid cycle
True
What is the MHRA advice with contraceptive implants?
Implants may reach the lung via the pulmonary artery
What is the pharmacological management of benign prostate hyperplasia?
Alpha blocker eg tamsulosin
What is doxazosin used for?
Hypertension or benign prostate hyperplasia
