Genito-urinary system (medium)

Question 1

what are the 3 different types of urinary incontinence

Answer 1

stress: involuntary leakage from exertion/ sneezing/ coughing
urgency: urgent need to urinate
mixed: both urgency and stress but one usually dominates

Question 2

non drug management for urinary incontinence

Answer 2

reduce caffeine
reduce weight if BMI >30
modify fluid intake
bladder training for 6 weeks for urgency incontinence
pelvic floor muscle training for 3 months for stress incontinence

Question 3

what is the drug management for urgency incontinence (1st and 2nd line)

Answer 3

1st line: antimuscarinics: oxybutynin, tolterodine, darifenacin…
2nd line: beta agonist: mirabegron 50mg OD

Question 4

drug management for stress incontinence

Answer 4

surgery or duloxetine

Question 5

1st line for nocturnal enuresis (bed wetting)

Answer 5

after lifestyle management (fluid intake, toilet behaviour, rewards system…)

enuresis alarms:

• review after 4 weeks
• continue until 2 weeks of uninterrupted dry nights

Question 6

drug management for nocturnal enuresis (1st, 2nd and 3rd line)

Answer 6

1st line: desmopressin

• use S/L or oral - not intranasal due to increased side effects
• no potent and longer DOA than vasopressin

2nd line: desmopressin +/- antimuscarinic (oxybutynin/ tolterodine)
3rd line: imipramine

Question 7

management of acute urinary retention during emergency

Answer 7

immediate catheterisation - alleviates the pain

alpha blocker: doxazosin, alfuzosin, tamsulosin

Question 8

what can cause urinary retention

Answer 8

antimuscarinics, TCAs, sympathomimetics

Question 9

treatment of chronic urinary retention

Answer 9

catheter

Question 10

treatment of BPH and the doses

Answer 10

alpha blocker- relaxes the smooth muscle

doxazosin: 1mg OD can be increased to 8mg OD
tamsulosin: 400mcg OD

5a reductase inhibitor - used if enlarged prostate/ risk of progression or hypotensive

finasteride: 5mg OD
dutasteride: 500mcg OD

Question 11

MHRA warning for finasteride

Answer 11

reports of depression and suicidal thoughts

stop immediately and report

Question 12

side effects of alpha blockers

Answer 12

postural hypotension - take before bed and lie down if dizzy/ fatigue
dizziness, 
tachycardia
palpitations
blurred vision

Question 13

contraindications of alpha blockers

Answer 13

micturition syncope (fasting after urination)
postural hypotension

Question 14

side effects of 5a reductase inhibitors

Answer 14

breast disorders- report lumps, nipple pain/ discharge - could be male breast cancer

sexual dysfunction: ejaculation disorders, impotence

depression - MHRA warning

Question 15

cautions of 5a reductase inhibitors

Answer 15

avoid handling in women of childbearing potential
condoms should be used if women pregnant/ could become pregnant
excreted in semen

Question 16

contraindications and MHRA warning of IUD

Answer 16

pelvic inflammatory disorder
unexplained vaginal bleeding

MHRA warning: risk of uterine perforation
replace every 5-10 years and remove in 1st trimester of pregnancy

Question 17

contraindications for COC

Answer 17

35 years plus + smoker/ stopped within a year ago
BMI >35
previous VTE or FH with VTE <45 years old
severe migraines especially with aura
diabetes
history of breast cancer

Question 18

what to do if you forget one missed pill of COC

Answer 18

take another one ASAP even if it means taking 2 at the same time
carry on taking the rest of the pills as normal
no extra contraception needed

Question 19

what to do if you miss 2 or more pills of COC

Answer 19

take as soon as you remember even if it means taking 2 at the same time

if its in the 1st week of the cycle or after finishing the pack and its been >9 days of pill free interval

• use EHC if had unprotected sex
• use extra contraception for 7 days

if during week 2/3 of cycle:

• use extra contraception for 7 days
• continue taking the pill as normal and if pills missed 7 days prior to PFI, miss this and start new pack

Question 20

what to do if you miss 2 or more pills of COC

Answer 20

take as soon as you remember even if it means taking 2 at the same time

if its in the 1st week of the cycle or after finishing the pack and its been >9 days of pill free interval

• use EHC if had unprotected sex
• use extra contraception for 7 days

if during week 2/3 of cycle:

• use extra contraception for 7 days
• continue taking the pill as normal and if pills missed 7 days prior to PFI, miss this and start new pack

Question 21

what’s considered as a missed dose and what to do

Answer 21

forgetting to take pill/ vomiting/ diarrhoea within 3 hours or 12 hours for desogestrel

take another one asap

Question 22

interactions of COCs

Answer 22

rifampicin/ rifabutin = reduces contraceptive effect (Potent cyp inducer)

anti-epileptic drugs: carbamazepine, ocarbazepine, phenytoin, phenobarbital, primidone, topiramate = reduces contraceptive effect

others: st johns wort, griseofulvin

Question 23

management of COC in surgery

Answer 23

stop 4 weeks prior to planned surgery and restart 2 weeks after full mobilisation

if emergency surgery- consider using thromboprophylaxis

Question 24

how to take POP

Answer 24

if started on day 1-5 works straight away - no additional contraception needed

if started on any other day, need 2 days of contraception

Question 25

how often are depot and implant progesterone contraception used and what are the cautions

Answer 25

depot: every 13 weeks
may delay fertility up to 1 year after treatment stopped

implant: every 3 years
MHRA warning with etonorgestrel: neuromuscular injury and migration of implant - remove ASAP

Question 26

non-drug management for erectile dysfunction

Answer 26

smoking cessation

reduce alcohol

Question 27

1st line drug management for erectile dysfunction and when are they considered as a non-responder

Answer 27

phosphodiesterase type 5 inhibitor:
short acting - sildenafil, varednafil, avanafil - use PRN
long acting - use PRN or regularly at low dose for spontaneous sexual activity

patient should have 6 doses with sexual stimulation before being considered as non responder

Question 28

2nd line treatment for erectile dysfunction and the caution

Answer 28

alprostadil: intracavernosal (injection at base of penis), intraurethral, topical
- under medical supervision

wear condom if partner is of childbearing age/ pregnant/ lactating

Question 29

contraindications for erectile dysfunction drugs (phosphodiesterase type 5 inhibitors and alprostadil)

Answer 29

taking nitrates
hypotensive
unstable angina/ stroke
angina during intercourse
patients who shouldn't have sex 

priapism: erection lasting longer than 4 hours - seek medical attention

Question 30

interactions of erectile dysfunction drugs (phosphodiesterase type 5 inhibitors and alprostadil)

Answer 30

nitrates

alpha blockers

Question 31

when can levnorgestrel be supplied to patient for EHC

Answer 31

• up to 72 hours of UPSI
• age >16
• 2nd dose needed if V/D occurred within 3 hours
• if BMI < 26 or weight < 70kg (give ulipristal if above)
• usual pill contraceptive can be restarted immediately
• can breastfeed immediately
• avoid in severe liver impairment
• interacts with CYP inducer e.g., anti epileptic drugs (give double dose of EHC)
• caution in malabsorption

Question 32

when can ulipristal be supplied ECH

Answer 32

• > 13 years old
• up to 5 days after UPSI
• 2nd dose needed if V/D within 3 hours
• BMI >26 or weight >70kg
• wait 5 days before restarting hormonal contraceptive pill (unless 1week of cycle) and use additional contraceptive for extra 7 days (12 days total)
• can restart CHC immediately if in 1st week of cycle
• wait 1 week before breastfeeding
• caution: severe uncontrolled asthma using glucocorticoids
• avoid in severe liver impairment
  interaction with CYP inducers - cannot sell double OTC - refer

Question 33

side effects of levonorgestrel and ulipristal

Answer 33

levonorgestrel: breast tenderness, D/V, fatigue, haemorrhage
ulipristal: menstrual irregularities, D/V, altered mood, dizziness