Genito-urinary system (medium) Flashcards by Thamanna Miah

what are the 3 different types of urinary incontinence

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

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non drug management for urinary incontinence

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

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

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

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drug management for stress incontinence

surgery or duloxetine

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1st line for nocturnal enuresis (bed wetting)

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

enuresis alarms:

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

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

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

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management of acute urinary retention during emergency

immediate catheterisation - alleviates the pain

alpha blocker: doxazosin, alfuzosin, tamsulosin

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what can cause urinary retention

antimuscarinics, TCAs, sympathomimetics

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treatment of chronic urinary retention

catheter

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treatment of BPH and the doses

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

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MHRA warning for finasteride

reports of depression and suicidal thoughts

stop immediately and report

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side effects of alpha blockers

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

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contraindications of alpha blockers

micturition syncope (fasting after urination)
postural hypotension

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side effects of 5a reductase inhibitors

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

sexual dysfunction: ejaculation disorders, impotence

depression - MHRA warning

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cautions of 5a reductase inhibitors

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

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contraindications and MHRA warning of IUD

pelvic inflammatory disorder
unexplained vaginal bleeding

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

contraindications for COC

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

what to do if you forget one missed pill of COC

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

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

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

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

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

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

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

take another one asap

interactions of COCs

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

management of COC in surgery

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

if emergency surgery- consider using thromboprophylaxis

how to take POP

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

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

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

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

non-drug management for erectile dysfunction

smoking cessation | reduce alcohol

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

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

2nd line treatment for erectile dysfunction and the caution

alprostadil: intracavernosal (injection at base of penis), intraurethral, topical - under medical supervision wear condom if partner is of childbearing age/ pregnant/ lactating

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

``` 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

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

nitrates | alpha blockers

when can levnorgestrel be supplied to patient for EHC

- 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

when can ulipristal be supplied ECH

- >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

side effects of levonorgestrel and ulipristal

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