Genito-urinary system Flashcards
What is the treatment for vulvovaginal candidiasis?
Oral ozale drug
or
Itraconazole
or
Intravaginal imidazole pessary or cream (clotrimazole, econazole or miconazole)
Can repeat course if fails to control symptoms or symptoms recur after 7 days
How do you treat recurrent vulvovaginal candidiasis?
Fluconazole
Initially 150 mg every 72 hours for 3 doses, then 150 mg once weekly for 6 months
What is used to treat urgency incontinence?
(bladder training for at least 6 weeks first)
1st line: Anticholinergic
- immediate release oxybutynin (avoid in frail older women - at risk of deteriorating their physical or mental health)
–> transdermal formulation can be used if oral not tolerated
- immediate release tolterodine
- darifenacin
2nd line: mirabegron or one of the following:
- fesoterodine
- propiverine
- solifenacin
- trospium
3rd line: botulinum toxin A
What should be used to treat urgency incontinence with troublesome nocturia?
Desmopressin
How do you treat stress incontinence?
1st line: pelvic floor muscle training for at least 3 months with at least 8 contractions 8 times a day
2nd line: when surgery inappropriate and women prefers pharmacological treatment = duloxetine
When should an enuresis alarm be considered for children?
more than 1-2 wet beds per week - review after 4 weeks and continue until minimum or 2 weeks with no accidents achieved
What is the drug treatment for nocturnal enuresis?
Children >5 where enuresis alarm inappropriate
- oral of sublingual desmopressin: assess after 4 weeks and continue for 3 months if response to it, can repeat course if required but withdraw gradually at regular intervals e.g. 1 week every 3 months
Specialist supervision: desmopressin + antimuscarinic e.g. oxybutynin
When nothing else works:
- TCA: imipramine - however, relapse common when withdrawn
What are the common side effects of antimuscarinics?
Constipation
Dizziness
Drowsiness
Dry mouth
Dyspepsia
Flushing
Headache
N/V
Palpitations
Skin reactions
Tachycardia
Urinary disorders
Vision disorders (dry eyes)
What are common side effect of transdermal oxybutynin?
GI discomfort and increased risk of infection
Which drugs can cause urinary retention?
Antimuscarinics
Sympathomimetics
TCAs
What is the most common cause of urinary retention in men?
Benign prostatic hyperplasia
When is catheterisation used for urinary retention?
Relieve acute painful urinary retention or when no cause can be found
How do you treat acute urinary retention?
Catheterisation
Before catheter removed - Alpha blocker should be given for at least two days to manage acute urinary retention
- alfuzosin
- doxazosin
- tramsulosin
- prazosin
- indoramin
- terazosin
How do you treat chronic urinary retention?
1st line: intermittent bladder catheterisation
2nd line: indwelling catheter
When can catheters be used long-term?
When urinary retention is causing incontinence, infection or renal impairment and a surgical solution is not feasible
What are the adverse effects associated with catheters?
Recurrent urinary infection
Trauma to urethra
Pain
Stone formation
How can moderate-severe symptoms of urinary retention be treated?
Alpha blocker
- alfuzosin
- doxazosin
- tamsulosin
- terazosin
review every 4-6 weeks then every 6-12 months
When would you consider a 5a-reductase inhibitor for urinary retention in men?
When they have:
- an enlarged prostate
- raised PSA
- considered to be at high risk of progression e.g. elderly
e.g. finasteride or dutasteride
- can be combined with alpha blocker if symptoms remain a problem
What is a common side effect of alpha blockers?
1st dose hypotension - take at bedtime
Dizziness
Sexual dysfunction
Drowsiness
Dyspnoea
Cough
What are the common side effects of tamsulosin?
Dizziness and sexual dysfunction
What is the MHRA warning for finasteride?
Rare reports of depression and suicidal thoughts
What are 2 side effect to be aware of with 5a-reductase inhibitors?
Breast abnormalities and sexual dysfunction
When are patients susceptible to ureteric stones?
Decrease in urine volume and/or an excess of stone forming substances
What are the symptoms of renal and ureteric stones?
abrupt onset of sevre unilateral abdominal pain radiating to the groin accompained by:
- nausea
- vomiting
- haematuria
- increase urinary frequency
- dysuria
- fever: if infection present too
What is the lifestyle advice to avoid stone formation?
Drink 2.5-3L of water - with addition of lemon juice
Avoid carbonated drinks
Maintain calcium intake of 700-1200mg a day
Main salt intake 6g or less a day
How do you manage pain associated with renal and ureteric stones?
1st line: NSAID
2nd line: IV paracetamol
3rd line: opioids
Which class of drugs should be avoided if suspected renal and ureteric stones?
Antispasmodics
When would you consider alpha blockers for renal and ureteric stones?
In patients with distal ureteric stones less than 10mm in diameter
OR
adjunctive therapy for patients having shockwave lithotripsy for ureteric stones less than 10mm in diameter
When would you consider potassium citrate for prevention of recurrent stones?
Recurrent stones composed of at least 50% calcium oxalate
What is given for urethral pain?
Lidocaine hydrochloride gel
or
alkalisation of urine using potassium citrate - relieves discomfort of cystitis cause by LUTI
Which cancers do combined hormonal contraceptions reduce the risk of?
Ovarian
Endometrial
Colorectal
Which combined hormonal contraception can you use the tailored regimen with?
Only with monophasic CHC containing ethinylestradiol
The tailored regimens:
- shortened HFI: 21 days of continuous use followed by 4 day HFI
- extended use (tricycling): 9 weeks of continuous use followed by 4 or 7 days HFI
- flexible extended use: continuous use for 21 days or more followed by 4 HFI days when breakthrough bleeding occurs
- Continuous use: no HFI
When should CHC stop prior to surgery?
at least 4 weeks prior to major surgery, any surgery to the legs or pelvis, or surgery that involves prolonged immobilisation of a lower limb
Commence 2 weeks after remobilisation
How frequently is the depot medroxyprogesterone injection administered?
every 13 weeks
What adverse effect is the medroxyprogesterone injection associated with?
small loss of bone mineral density - largely recovers after discontinuation
What should patients be made aware of when stopping medroxyprogesterone depot?
There can be a delayed return of fertility of up to 1 year after discontinuation
What do females take when their partner undergoes a vasectomy?
Norethisterone - 8 weeks use until vasectomy effective
It is also used after a rubella immunisation to prevent pregnancy while virus is active
How long is the etonogestrel implant effective for?
3 years
How long is the licensed duration of use for the intra-uterine progesterone-only systems (IUS)?
3-10 years
When should females with an IUS seek medical advise?
If the patient develops symptoms of pelvis infection, pain, abnormal bleeding, non-palpable threads or feel stem of IUS
What is considered as highly effective contraception?
Male and female sterilisation
Long-acting reversible contraception
- Cu-IUD
- LNG-IUS
- Progesterone only implant
How many days after childbirth can UPSI be given emergency contraception for?
21 days - unless criteria for lactational amenorrhoea are met
6 weeks in breastfeeding women
When can a copper IUD be inserted for UPSI as emergency contraception?
Within 120 hours (5 days) of UPSI or up to 5 days after the earliest estimated date of ovulation (within minimum period before implantation) whichever is later
How many days after abortion, miscarriage, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease can UPSI be given emergency contraception for?
5 days
What emergency contraception is recommend in patients with with a BMI of >26kg/m2 or who weight >70kg?
Either ulipristal or double dose of levonorgestrel
What emergency contraception should be considered for a women on CHC and missed a pill during their first week of restarting their contraception?
Levonorgestrel
When should women return to their regular contraception after receiving emergency contraception?
Levonorgestrel - immediately
Ulipristal - 5 days after this to start hormonal contraception - use other forms of contraception in the meantime
Ulipristal but patient on regular combined contraception - restart start after emergency contraception but use condoms for 7 days
Which drugs reduce the effectiveness of hormonal contraception?
Hepatic enzyme inducers:
- carbamazepine
- eslicarbazepine
- nevirapine
- oxcarbazepine
- phenytoin
- phenobarbital
- primidone
- rifabutin
- rifampicin
- ritonavir
- St John’s wort
- topiramate
Which type of hormonal contraception is preferred in patients taking teratogenic medication?
Coppier IUD or
Progesterone-only intra-uterine system (levonorgestrel)
If progesterone only injectable contraception is used - should be in combination with condoms (medroxyprogesterone)
- these should be used during treatment and for 4 weeks after
NOT RECOMMENDED:
- CHC
- progesterone only pills
- etonogestrel implant
What should be done if a patient is taking CHC and requires short-term use (2 months of less) of enzyme-inducing drug (except rifampicin or rifabutin)
CHC can be considered to continue if used consistently and carefully with condoms during treatment anf for 4 weeks after
What should be done if a patient is taking CHC and requires continued use (more than 2 months) of enzyme-inducing drug (except rifampicin or rifabutin)
In exceptional circumstances - monophasic CHC containing ethinylestradiol at a higher daily dose may considered and either used continuously or tricycled
- continue during treatment and for 4 weeks after
If breakthrough bleeding occurs - use additional contraception or chnage to contraception unaffected by enzyme inducers
What is the recommended form of contraception for patients taking rifampicin or rifabutin?
Contraception that is unaffected by enzyme inducers is ALWAYS recommended because they are such potent enzyme-inducers
- depot medroxyprogesterone acetate or intrauterine contraception
Continue for 4 weeks after stopping drug
What is the interaction between lamotrigine and CHC?
Lamotrigine can reduce CHC efficacy - additional use of contraception
CHC can reduce efficacy of lamotrigine - if CHC use is unavoidable = increase lamotrigine dose and monitor its concentrations & use a continuous CHC regimen (with no HFI) to avoid cyclical changes in lamotrigine
Which progesterone-only contraceptives are impacted by enzyme inducing drugs?
etonogestrel-releasing subdermal implant - use copper IUD or progesterone only IUS or progesterone-only injectable for during treatment and 4 weeks after
If unavoidable - use condoms too
What is the interaction between lamotrigine and progesterone-only contraception?
Progesterone only contraception may increase lamotrigine concentrations - counsel on signs of toxicity
Lamotrigine may reduce efficacy of progesterone-only contraception - use condoms in combination
What is the course of action for patients who require emergency contraception but are also taking enzyme inducers?
1st line: Copper IUD
2nd line: increased dose of levonorgestral
3rd line: standard dose of ulipristal
What antibacterial that do not induce liver enzymes impact CHC?
ampicillin and doxycycline reduce the efficacy of CHC by impairing the bacterial flora responsible for recycling ethinylestradiol from the large bowel
Can you provide CHC to women who smoke?
Yes unless they are ages 35 years and over and smoke 15 cigarettes or more daily
What are the common side effects of CHC?
Acne, fluid retention, headaches, metrorrhagia, nausea, weight gain
Small increases risk of breast cancer
Small increased risk of cervical cancer if used for more than 5 years
What is the MHRA warning for intra-uterine contraception?
Risk of uterine perforation
- increase risk if device inserted up to 36 weeks postpartum or breastfeeding patients
What is the MHRA warning for ulipristal (esmya)?
risk of serious liver injury
What does erectile dysfunction increase the risk of?
Cardiovascular disease
When would you classify a patient with erectile dysfunction as a non-responder?
when they’ve had 6 doses of an individual phosphodiesterase type 5 inhibitor (e.g. sildenafil) at maximum doses
Then you would treat with alprostadil
What is recommended 2nd line for erectile dysfunction?
intracavernosal, intraurethral or topical alprostadil
When should medical help be sought for alprostadil?
If erection lasts longer than 4 hours
- try ice pack to upper-inner thighs: 2 minutes rotating legs for 10 minutes
How do you treat priapism associated with alprostadil?
If priapism lasted longer than 6 hours:
- initial therapy by penile aspiration of 20-50ml blood
- 2nd line: lavage
- 3rd line: intracavernosal injection of a sympathomimetic
What drug is used for pre-mature ejaculation?
Daproxetine
SSRIs and TCA used for this
How is PCOS treated?
CHC - to manage acne, hirsutism and menstrual irregularities
- alternative for menstrual irregularities = cyclic progesterone or levonorgestrel IUS
Impaired glucose intolerance = metformin
What are the contraindications of alpha blockers?
- History of micturition syncope
- History of postural hypotension
- Caution in those due to had cataract surgery due to floppy iris syndrome
What is used to facilitate the process of medical abortion?
Mifepristone - sensitises the uterus to subsequent administration of prostaglandin = abortion occurs in shorter period of time with lower dose of prostaglandin
What is licensed for an abortion in the 2nd trimester of pregnancy?
Gemeprost
- also licensed to soften and dilate the cervical priming before surgical abortion in earlier pregnancy
What is used to prevent miscarriage after vaginal bleeding in females with intra-uterine pregnancy if they have had a previous miscarriage?
micronised progesterone
If a fetal heartbeat is confirmed - continue until completed 16 weeks
How do you prevent miscarriage in females with antiphospholipid antibody syndrome and suffered miscarraiges?
Low-dose aspirin and prophylactic dose of LMWH
What can be given for management of incomplete or missed miscarriage?
Misoprostal
What is used for the management of ectopic pregnancies?
Systemic methotrexate
What is used to induce labour?
Dinoprostone or misoprostal for females with a bishop score of 6 or less
Bishop score more than 6 = oxytocin may be offered in conjunction with amniotomy
What is given to prevent haemorrhage after birth?
IM oxytocin
What are the features of trichomonas vaginalis?
Offensive green or yellow vaginal discharge
vulval itching
dysuria
What is the treatment for trichomonas vaginalis?
Oral metronidazole 400–500 mg twice a day for 5–7 days, OR
Single 2g dose of oral metronidazole
OR
Oral tinidazole
Avoid sexual intercourse for a week and until them and their partner have been treated and had a follow up
What can be used to maintain bone mineral density in peri-menopausal women under 50?
CHC
Who can be treated for erectile dysfunction on NHS prescriptions?
If the patient has:
- diabetes
- multiple sclerosis
- Parkinsons
- poliomyelitis
- prostate cancer
- severe pelvic injury
- single gene neurological disease
- spina bifida
- spinal cord injury
- receiving dialysis for renal failure
- had radical pelvic surgery, prostatectomy, or kidney transplant
The prescription must be endorsed SLS - except generic sildenafil
What is used to treat Menorrhagia?
Total blood loss of >80ml per meses
1st line: lenonorgestral IUS (intrauterine system (mirena) - releases levonorgestral)
otherwise consider: tranexamic acid, NSAID, CHC, or cyclical oral progesterone
How long is a missed pill for CHC?
24 hours or more late
What is the course of action if you miss 1 CHC pill during any time of the cycle?
Take the last pill even if it means taking two pills in one day and then continue as normal without
additional contraception needed
What is the course of action if you miss 2 or more CHC pills?
If missed pills and UPSI taken place during HFI or week 1:
- EC! then;
- Condoms should be used or sex avoided until pills have been taken for 7 consecutive days
- take most recent pill as soon as possible
- continuing remaining pills at usual time
What is the age licensing for levonorgestral and ullipristal?
levonorgestral - 16+
ullipristal - any age
When do you start CHC?
First day or next period
If take 5 days after first cycle - additional contraception for 7 days
How do you treat vaginal candidiasis in pregnant women?
Intravaginal application of clotrimazole for 7 days
How do you start progesterone only pills?
If first 5 days of period - immediate protection
If any other time - additional contraception for first 2 days
How do you take progesterone-only pills?
Same time each day, not pill free days
How do you deal with an progesterone-only missed pill?
If less than 3 hours - continue as normal
If >3 hours - take missed pill as soon as you remember and continue
with the rest of the pack (this may mean taking two pills in one day), but extra precautions needed until pill taking has been re-established for 48 hours
Desogestreol = 12 hours
Which drugs cause detrusor muscle overactivity?
UTI
Urinary obstruction
Oestrogen deficiency
Stroke
Dementia
Parkinsons disease
DM
Hypercalcaemia
What is the maximum solifenacin dose when given with an enzyme inhibitor?
5mg OD
What is given to delay pre-mature labour?
Between 24-33 weeks
1st line: nifedipine
2nd line: oxytocin receptor antagonist e.g. atosiban
What is important counselling for diaphragms and caps?
Diaphragms and caps must be used in conjunction with a
spermicide (nonoxinol) and should not be removed until at
least 6 hours after the last episode of intercourse
How long is a copper IUD effective for?
5-10 years
Avoid in pregnancy and for 4 weeks post partum
What are the risk factors associated with VTE in combined hormonal contraception?
Older age
Obesity
Surgery
History of VTE
Smoking
Prolonged immobilisation
What is the main side effect of desmopressin?
Hyponatraemia
