Ge Flashcards
State the treatment of urgency incontinence in women:
Women should be offered bladder training for at-least 6 weeks as first line treatment
Oxybutynin, tolterodine or darifenacin can be used after bladder training has been done
Mirabegron second line
State the treatment of stress incontinence:
Women should trial supervised pelvic floor muscle training for at least 3 months which should include at least 8 contractions performed 3 times per day
Note: duloxetine is not recommended as first line treatment for women with stress incontinence, however it may be used a second line treatment where pelvic floor training has failed
How do antimuscarinic drugs help in urinary frequency and incontinences?
Reduce symptoms of urgency and urge incontinence and increase bladder capacity
How does oxybutynin work?
Has a direct relaxant effect on urinary smooth muscle
What is the monitoring requirement for antimuscarinic drugs?
Every 4-6 weeks until symptoms stabilise and then every 6-12 months
Which TCA can cause cardiac side effects?
Imipramine
What is mirabegron and what is it used for?
Beta3 agonist and is used with overactive bladder
What is the non-drug treatment for nocturnal enuresis?
Enuresis alarm
The bedwetting alarm is made to go off at the first sign of moisture. The alarm will play sounds when it goes off. Some of the alarms will also vibrate
What is the drug treatment for nocturnal enuresis?
Oral/SL desmopressin (5+) when alarm use is inappropriate or undesirable.
Assessed after 4 weeks and continued for 3 months
Desmopressin + oxybutynin/tolterodine (unlicensed) under specialist care and treatment continued for 3 months
Imipramine under specialist care
What is a side effect of desmopressin?
Hyponatraemic convulsions
What advice would you give for patients treated for primary nocturnal enuresis?
Avoid fluid overload - including during swimming
Restrict fluid intake 1 hour before and 8 hours after desmopressin Stop desmopressin in vomiting/diarrhea and avoid in drugs that increase vasopressin secretion i.e., TCAs
State some side effects of antimuscarinics?
Constipation, tachycardia, dry mouth, dyspepsia, dizziness, headache, vomiting, vision disorders, urinary disorders
What are the dose adjustments due to interactions for solifenacin?
Maximum is 5 mg once daily with concurrent use of potent inhibitors of CYP3A4
Maximum 5 mg daily if egfr is less than 30 ml
Solifenacin is a medicine used to treat symptoms of an overactive bladder. These can include: a sudden and urgent need to pee (urinary urgency) needing to pee more often than usual (urinary frequency
it is an antimuscarinic
There are other antimuscarinics that can be used for overactive bladder: oxybutynin. tolterodine.
potent inhibitors of CYP3A4 include: Clarithromycin. Diltiazem. Erythromycin. Fluconazole. Grapefruit juice.
Itraconazole.
Ketoconazole.
Posaconazole. Voriconazole. Verapamil.
What is the treatment of acute urinary retention?
Alpha-adrenoreceptor blocker should be given for at-least 2 days
Acute retention is painful and requires immediate treatment by catheterisation.
Before the catheter is removed an alpha-adrenoceptor blocker (such as alfuzosin hydrochloride, doxazosin, tamsulosin hydrochloride, prazosin, indoramin or terazosin) should be given for at least two days to manage acute urinary retention .
Acute urinary retention is a medical emergency characterised by the abrupt development of the inability to pass urine (over a period of hours).
Chronic urinary retention is the gradual (over months or years) development of the inability to empty the bladder completely, characterised by a residual volume greater than one litre or associated with the presence of a distended or palpable bladder.
What drug increases detrusor muscle contraction?
Bethanechol chloride
Detrusor muscle contraction is when the muscle in the bladder wall squeezes, pushing urine out of the bladder. It’s what makes you feel the urge to pee and helps you empty your bladder.
State the treatment of acute urinary retention in a man:
Alpha-blocker, modified release alfusozin 10 mg a day in men over 65 years of age
What is the treatment of benign prostatic hyperplasia?
Alpha-blocker, alfuzosin, doxazosin, tamsulosin or terazosin
andfor moderate to severe voiding symptoms: give 5a-reductase inhibitor
(finasteride/dutasteride): given in patients with an enlarged prostate, raised prostate specific antigen concentration, those considered at high risk of progression i.e., elderly
Alpha-blocker + 5a reductase inhibitor if symptoms are bothersome moderate to severe voiding symptoms and prostatic enlargement
Benign prostatic hyperplasia (BPH) is when the prostate gland, which is below the bladder in men, becomes bigger than normal. This can squeeze the urethra, making it harder to pee and causing symptoms like frequent urination or trouble starting urination. It’s common as men age.
Severe voiding symptoms refer to significant difficulties or problems experienced during urination
State some common side effects of alpha-blockers?
Postural hypotension, dizziness, blurred vision, tachycardia, palpitations, dry mouth
What are the counselling points for alpha-blockers?
Take first dose at night due to risk of possible first-dose postural hypotension
What is mirabegron contra-indicated in?
Severe high uncontrolled high blood pressure > 180 / > 110
What are the conception and contraception advice whilst taking mirabegron as a female?
Contraception advised in women of child-bearing potential
What should be monitored whilst taking mirabegron?
Blood pressure
What are the indications for dutasteride and finasteride?
benign prostatic hyperplasia
BPH
Finasteride has another indication what is it?
Androgenetic alopecia in men (finasteride 1mg, NOT the 5mg strength!)
Androgenetic alopecia is a genetically predetermined disorder due to an excessive response to androgens.
What are the common side effects of dutasteride/finasteride?
Sexual dysfunction and breast disorder
What is the contraception and conception advise for 5a-reductase inhibitors?
Drug is excreted in semen so use of condom is recommended
Women of child-bearing potential should avoid handling crushed or broken tablets/capsules
Advise females to wear gloves if putting these drugs in medicine dosette trays
State the patient and carer advice for 5a-reductase inhibitors?
Report any changes in breast tissue such as lumps, pain or nipple discharge
State the MHRA advice for finasteride?
Reports of depression and suicidal thoughts have reported. Report to GP urgently
What are the advantages of a combined oral contraceptive?
Reliable and reversible
Reduced premenstrual tension
Reduced risk of pelvic inflammatory disease
Reduced risk of ovarian. and endometrial cancer
Less benign breast disease
Less symptomatic fibroids and functional ovarian cysts
What age is COC not advised for?
50+
How many weeks before should an estrogen containing contraceptive be discontinued before major elective surgery?
4 weeks
When is immediate action required for a patient taking COCS
Sudden severe chest pain
Sudden breathlessness (or cough with blood-stained sputum)
Unexplained swelling or severe pain in calf of one leg
Severe stomach pain
Severe prolonged headache / complete loss of vision / sudden disturbance of hearing / dysphasia / bad fainting / first seizure / marked numbness
Hepatitis / jaundice / liver enlargement
160 mmHg / 95 mmHg
State two parenteral POPS:
Medroxyprogesterone acetate (Depo-Provera, sayana press) - prolonged action
Both lasts for 13 weeks protection
Occasionally, Noristerat may be given, which lasts for 8 weeks
State one side effect of the above when given in the immediate puerpium?
Troublesome bleeding (advice: delay first injection until after the first 6 weeks)
When should the pop injection be given once a patient has given birth?
5 days after post-partum
What are the side effects of medroxyprogesterone?
Delayed return to fertility and menstrual irregularities
How long does norethisterone enantate (noristerat) protect a patient for?
8 weeks - short term
How long does etonogestrel-releasing implant (Nexplanon) last for?
3 years - single flexible rod which is inserted sub dermally into lower surface of upper arm
Bruising and itching can occur at insertion site
What is the MHRA warning on Nexplanon implant?
Implants may reach the lung via pulmonary artery
Which IUD is licensed as a contraceptive, primary menorrhagia and for prevention of endometrial hyperplasia?
Mirena
How long does Mirena last?
5 years
How long does Levosert and Jaydess last?
3 years
What is an advantage of an IUD?
Method of choice for women who have excessively heavy menses
Can be used as an alternative to COC before a major elective surgery
What is the advantage of Progestogen-IUD over copper IUD?
May improve dysmenorrhoea
Reduces blood loss
Frequency of PID reduced
Menstrual bleeding significantly reduced within 3-6 months
What is a side effect of nonoxynol spermicidal contraceptive?
Associated with genital lesions
What are emergency hormonal contraception methods?
Levonorgestrel 1500 mcg =
less than 72 hours of unprotected sexual intercourse (licensed from 16+ age)
Ulpristal acetate 30 mg =
less than 120 hours of unprotected sexual intercourse (licensed from childbearing potential i.e., age 13+)
Why is it less suitable for prescribing IUD in patients under 25?
Due to risk of pelvic inflammatory disease
What is the referral red flags for uterine perforation?
Severe pelvic pain after insertion, sudden change in periods, pain during sex, increased bleeding for moe than few weeks, unable to feel threads
What advice to give if copper IUD is removed after day 3 of menstrual cycle?
To abstain from sex for 7 days or use barrier method
Give examples of phosphodiesterase type-5 inhibitors: (all oral)
Sildenafil - 1 hour before sex
Avanafil - 15 minutes before sex
Tadalafil - 30 mins before sex
Vardenafil - 60 minutes before sex
What is a side effect of alprostadil (prostaglandin analogue)
Harmful to pregnant women - stimulates uterine contractions and can cause miscarriages
What are the side effects of phosphodiesterase type-5 inhibitors?
Hypotension, headache, migraine, tachycardia, palpitations, nasal congestion
What are the interactions with phosphodiesterase type 5 inhibitors?
Nitrates, alpha-blockers, CCBs and Nicorandil
What is the classic definition of non-responder for erectile dysfunction?
6 doses of medicine and it’s failed
State one major side effect?
Priapism (erection for 4 hours prolonged) this is a medical emergency
Urgent A&E referral or call ambulance if patient presents to pharmacy
Define premature ejaculation?
Common male sexual disorder characterised by brief ejaculatory latency, loss of control and distress
What is the treatment of premature ejaculation?
Psychosexual counselling, education and behavioural treatment in patients for whom premature ejaculation causes few if any problem or who prefer to take no drugs for it
Dapoxetine to be used when required basis (not continuous daily use) for patients with life-long premature ejaculation
Citalopram, fluoxetine, fluvoxamine, escitalopram, sertraline, paroxetine, clomipramine - these drugs can be used as daily use as an unlicensed indication
Which TCA can be used for premature ejaculation but is unlicensed use?
Clomipramine
Which SSRI is used as first line for premature ejaculation?
Short acting dapoxetine (short acting ssri)
Which two drugs are used to induce abortion or induce or augment labour and minimise blood loss?
Prostaglandins and oxytocic’s
(oxytocin, carbetocin, ergotmetrine maleate, prostaglandins)
What to use to terminate pregnancy?
Mifepristone is followed by administration of gemeprost/mistoprostol
Which is another use for misoprostol:
Ulcers, gastric, peptic ulcer
What is used for treatment of ectopic pregnancy?
Systemic methotrexate
