Genito-urinary system Flashcards
Which antidepressant can be used to manage stress incontinence in women?
Duloxetine 40mg BD
What bladder symptoms are manages with anti-muscarinic drugs?
Urge incontinence
Name some anti-muscarinic drugs used to manage urge incontinence?
Oxybutynin, tolterodine, solifenacin, fesoterodine, dairfenacin, flavoxate, propantheline bromide
Antimuscarinic side effects?
Constipation, dry mouth, dizziness, tachycardia
Some contra-indications for antimuscarinics in urge incontinence?
Myasthenia gravis, urinary retention, GI obstruction, severe UC
Safety concerns with mirabegron?
Can cause QT prolongation
Contra-indicated in severe uncontrolled hypertension, monitor blood pressure during treatment
What drug can be used for nocturnal enuresis in children and what is the main side effect?
Desmopressin
Risk of hyponatraemic convulsions - avoid fluid overload
What is the most common cause of urinary retention?
Benign prostatic hyperplasia
What is 1st line treatment for urinary retention in BPH?
Alpha-adrenoreceptor blockers
How do alpha-adrenoreceptor blockers work?
Relax prostatic smooth muscle causing an increased urinary flow rate + improvement in obstructive symptoms
Name some alpha-adrenoreceptor blockers
Tamsulosin, alfuzosin, doxasozin, terazosin, indoramin
Side effects of alpha-adrenoreceptor blockers such as tamsulosin?
Hypotension
Intra-operative floppy iris syndrome
‘Alfuzosin is contra-indicated in postural hypotension’
True or false?
True
All alpha-adrenoreceptor blockers are
What counselline should be given to a patient starting an alpha-adrenoreceptor blocker such as tamsulosin?
Take the first dose at bedtime as there is a risk of hypotension
Driving may be impaired
When can tamsulosin be sold OTC?
- Men aged 45-75
- Over 3 months symptoms of BPH
- 400mcg daily
How much tamsulosin can be supplied to a patient OTC?
Initially a 2 weeks supply
If no improvement of symptoms in 2 weeks then refer to GP
If improvement in symptoms can supply a further 4 weeks, after 6 weeks must see GP for confirmation that they can continue to take
What is second line treatment for urinary retention in BPH?
5-alpha reductase inhibitor AND alpha-adrenoreceptor blocker
Name some 5-alpha reductase inhibitors?
Finasteride + dutasteride
What doses of finasteride are given for BPH?
5mg OD
Male baldness - 1mg OD
MHRA safety warning associated with finasteride?
Reports of depression and suicidal thoughts
Stop treatment and inform healthcare professional if depression develops
Safety concerns with finasteride + dutasteride?
- Risk of male breast cancer, report any changes to breast tissue
- Can be excreted in semen, use a condom if risk of pregnancy. Broken/crushed tablets should not be handled by women of child-bearing potential
What are the Fraser guidelines for prescribing contraception for under 16s?
Can provide if:
- They understand the drs advice
- Can’t be persuaded to tell parents
- Very likely to continue to have sex
- Without contraception physical or mental health will suffer
- It is in the patient’s best interest
What are the advantages of combined hormonal contraceptives?
- Reliable and reversible
- Reduced dysmennorhoea + menorrhagia
- Reduced PMT
- Less benign breast disease
- Reduced pelvic inflammatory disease
- Reduced risk of ovarian/endometrial Ca
When can COC be started?
Any time in the menstrual period
If after day 6 in cycle use protection for 7 days
What are phasic preparations and when should they be offered?
Contain varying amounts of oestrogen + progestogen
Reserved for women with no withdrawal bleeding or breakthrough bleeding
Name some contraceptive oestrogen components?
Ethinylestradiol, estradiol, mestranol
Name some contraceptive progestogen components?
Desogestrel, drospirenone, gestodene, levonornogestrel
Which progestogen is a derivative of spironolactone?
Drosperinone - monitor for hyperkalaemia
When should COC be stopped prior to surgery?
Any oestrogen-containing contraceptives should be stopped 4 weeks before surgery
When can COC be restarted after surgery?
On first menses, should be 2 weeks after full mobilisation
What advice about travelling should be given to patients on COC?
On journeys over 3 hours risk of DVT can be reduced by wearing compression stockings and doing leg exercises
Which of these is NOT a reason to stop oestrogen-containing contraception/HRT?
- Unexplained swelling in calf of one leg
- Sudden breathlessness
- Sudden partial loss of vision
- Pregnancy
- Blood pressure reading of 160/95 mmHG
Pregnancy
Which of these is NOT a contra-indication for oestrogen?
- Smoking over 40 cigs a day
- Age over 50
- BMI >35
- Sedentary lifestyle
- Complicated diabetes
Sedentary lifestyle
How do progestogen-only contraceptives work?
Alter cervical mucus to prevent sperm penetration
May inhibit ovulation in some women
‘Menstrual irregularities are common with use of progestogen-only pills’
True or false?
True
Can POPs be used prior to surgery?
Yes, may be an alternative to combined contraceptives
When can POPs be restarted after pregnancy?
Up to day 21 post-partum, if >21 days then additional protection should be used for 2 days
What is classed as a ‘missed pill’ with progestogen-only contraceptives?
One that is over 3 hours late
(desogestrel is over 12 hours)
Take the pill ASAP and use protection for 2 days
Seek EHC if unprotected sex BEFORE 2 pills are taken correctly
What advice should be given for vomiting after taking a POP?
If if was less than 2 hours after taking then take another pill
If persistent/severe D+V then use protection for 2 days after it ends
When can EHC be offered after childbirth?
21 days
When can EHC be offered after abortion or miscarriage?
5 days
What should be offered first line for emergency contraception?
Copper IUD
Most effective form of contraception + provides ongoing protection
When can a copper IUD be inserted for emergency contraception?
120 hours after unprotected intercourse
‘EHC offered after ovulation is ineffective’
True or false?
True
At what point in the menstrual cycle does ovulation occur?
Around day 12-15
Cycle starts day 1 on the first day of menses
What type of EHC should be offered to obese patients/ patients who weigh >70kg?
- Ulipristal
- Double dose of levornogestrel
How long after EHC can oral contraceptives be started?
Levornogestrel - can start immediately
Ulipristal - wait for 5 days as can reduce effectiveness of regular contraceptives
Can EHC be used more than once in the same cycle?
- Levornogestrel should not be used more than once in the same cycle due to the risks of side effects
- Ulipristal may be used more than once
- Levornogestrel should not be used within 5 days of ulipristal as can reduce the contraceptive effect
Why would you be cautious supplying EllaOne to a young woman with asthma?
Ulipristal is not recommended in severe asthma treated with ICS as it can have an anti-glucocorticoid effect
Which migraine symptoms should women on COCs report?
- Increase in headache frequency or onset of focal symptoms
- Stop if serious neurological effects occur
- Should be avoided in migraine with aura
What are the cancer risks associated with COC?
Can increase the risk of breast and cervical cancer, potentially due to earlier diagnosis
Risk should be gone after stopping treatment for 10 years
Can reduce the risk of ovarian and endometrial Ca
Why should COC be avoided in liver disease?
Risk of hepatic impairment
Stop if severe stomach pain, jaundice, hepatitis or liver enlargement
When can COC be started after abortion or miscarriage?
On the same day
What is classed as a missed pill with COC?
Over 24 hours late
Take when you remember, can take 2 together
When should additional protection be used for missed combined contraceptive pills?
If 2 or more pills are missed
Especially out of the 1st 7 pills in the packet
Additonal protection for 7 days, if this includes the break then omit pill-free interval
Which two brands of COC class a missed pill as over 12 hours late?
Qlaira + zoely
What advice should be given to women taking COC with severe D+V?
Use protection for 7 days from recovery
For 9 days if qlaira
If this occurs in the last 7 days of the packet then omit pill free interval
What is classed as a ‘missed patch’?
Patch that has been detached for over 24 hours or if there is delayed application at the start of the cycle
What counselling should be given to patients who are taking EHC?
- Next period may be early or late
- Use a barrier method of contraception until next period
- See GP if any lower abdo pain, risk of ectopic pregnancy
- If periods are abnormal then take a pregnancy test (must be 3 weeks after unprotected sex)
Why are IUD less suitable in under 25s?
Risk of pelvic inflammatory disease
What advice should be offered if a patient with an IUD becomes pregnant?
Should be removed in the first trimester
What risks are associated with medroxyprogesterone parenteral contraception?
- Can cause menstrual disturbance and potential to delay return to full fertility
- Risk of osteoporosis
‘Erectile dysfunction is associated with an increased risk of cardiovascular disease?’
True or false?
True
Which drugs are used first line for erectile dysfunction?
Phosphodiesterase type-5 inhibitors
Sildenafil, vardenafil, avanafil, tadalafil
Which phosphodiesterase type-5 inhibitor is long-acting?
Tadalafil - can be used for spontaneous sexual activity
How soon before intercourse should sildenafil be taken?
1 hour
What is second line treatment for erectile dysfunction + the associated risk?
Alprostadil
Risk of priapism, seek medical advice if erection >4 hours
What are the side effects of phosphodiesterase type-5 inhibitors such as sildenafil?
Hypotension
Flushing, tachycardia, palpitations, nasal congestion, dyspepsia
Contra-indications for phosphodiesterase type-5 inhibitors?
- MI/unstable angina
- Hypotension (systolic BP <90)
- Use of nitrates (risk of hypotension)
When can sildenafil be sold OTC?
- 18 + males
- 50mg dose taken 1 hour before sex
- Max 100mg per dose, max one dose per day
- If taken with food then onset may be delayed
- See GP in 6 months for clincal review of potential underlying conditions
