Genito-Urinary Tract System Flashcards
urinary incontinence
involuntary leakage of urine - sudden, difficult to delay
stress incontinence
leakage on effort/excretion or on sneezing/cough
mixed incontinence
urgency + stress however one type predominant
risk factors for urinary incontinence
-old age
-pregnancy
-vaginal delivery
-obesity
-smoking
-constipation
-family history
-medicines (diuretics)
-caffeine inc urine production and can exacerbate incontinence
tx of urinary incontinence (urgency)
-non-drug modify fluid intake, weight loss, less caffeine
-drug tx
->1) bladder training 6WK at least
->2) antimuscarinic (oxybutynin or tolterodine)
->3) mirabegron
tx of urinary incontinence (stress)
-pelvic floor muscle training 3MT
-surgery or duloxetine
tx of urinary incontinence (mixed)
-bladder training >6wk + pelvic floor muscle training >3MT
-tx depends on dominating type
antimuscarinics examples
-fesoterodine, solifenacin, trospium, oxybutynin, tolterodine
nocturnal enuresis
involuntary urination during sleep = common children
non-drug tx of nocturnal enuresis
-children <5yr = no intervention needed
-advice on fluid intake, diet, toileting behaviour, use of reward systems
-no response to advice (>1-2 wet beds per week) - enuresis alarm
-> alarms in <7yr given depending on maturity, motivation, understanding
->alarms have less relapse than drug tx when discontinued
->review alarms after 4wk
->continue a min of 2wk of uninterrupted dry nights
-if alarm tx = x successful add/replace with desmopressin
nocturnal enuresis drug tx
-5yr+ = desmopressin
->if alarm = undesirable
->when needing rapid results (holiday)
->assess tx after 4wk continue for 3MT if pt = responding
->repeated courses should be withdrawn gradually at regular intervals
-specialist - desmopressin + antimuscarinic (oxybutynin/tolterodine)
-x responding to other tx; imipramine
desmopressin + s/e
-more potent + longer duration of action than vasopressin
-no vasoconstrictor effect
-s/e; hyponatraemia + nausea
urinary retention
inability to voluntarily urinate
urinary retention causes
-urethral blockage
-medications; antimuscarinic drugs, sympathomimetics, TCA
acute urinary retention
-unable to urinate even though they have a full bladder
-medical emergency abrupt development over period of hours
chronic urinary retention
gradual over months inability to completely empty bladder
benign prostatic hyperplasia urinary retention
-most common in men with enlarged prostate
-symp; urinary retention, urgency, frequency, nocturia
acute urinary retention tx
-immediate catherisation due to pain
-provide alpha blocker for 2x days before removing catheter
chronic urinary retention tx
-catheter used long-term
->may cause recurrent UTI, urethra trauma, pain, stone formation
benign prostatic hyperplasia urinary retention tx
-alpha blockers relaxes smooth muscle
-pt = enlarged prostate, raised prostate antigens, high risk of progression so 5a-reductase inhibitors (finasteride/dulasteride)
alpha blockers used in urinary retention
-defuzosin, doxazosin, tamsulosin, terazosin
-advice pt if history of mictuntion syncope + postural hypotension
alpha blockers s/e
-dizziness
-postural hypotension
-1st dose can cause collapse due to hypotensive effect so taken before bed and lie down if dizzy, fatigue, sweating develops
5a reductase inhibitor s/e + cautions
-breast disorder
-sexual dsyfunction
-male breast cancer reported; lumps, pain/nipple discharge
-excreted in semen = condom if pregn partner
-women = child-bearing age avoid crushed broken tabs
-finasteride; reports of depression + rare cases of suicidal thoughts stop immediately + report
non-hormonal contraception - barrier method
-condoms, diaphragms, cervical caps
->petroleum jelly, baby oil + oil based prep can damage condoms, contraceptive diaphragms; cap = latex rubber
non-hormonal contraception - spermicidal contraceptives
used alongside barrier methods
non-hormonal contraception - IUD
-intra-uterine device = copper coil
-CI in pelvic inflammatory disease or unexplained vaginal bleeding
progesterone only contraceptives
-levonorgestrel, norethisterone,
desogestrel
-no pill free week = OD
- no additional precaution needed if started in 1st 5DY of cycle - needs 2DY precaution if taken after that
-taken at same time each day for max efficacy
->desogestrel needs to be taken within 12HR otherwise missed dose
->other POP need to ben taken with 3HR otherwise - missed dose
parental progesterone only
-injections = 99.8% effective in correct usage
-depot medroxyprogestrone acetate - every 12WK
->loss of bone density can occur
->delayed return to fertility of upto 1yr after tx cessation
-implants = 99.95% effective in correct usage
->etongesterel (nexplanon)
->lasts up to 3yr
->MHRA ; neurovascular injury/migration of implant remove ASAP
Combined hormonal contraceptives
-tablets, patches, vaginal rings
-not given 50yr+
-benefits;
->less risk of ovarian, endometrial + colorectal cancer
->aligns bleeding pattern
->less dysmenorrhea + menorrhagia
->manages symptoms of polystic ovaries, endometriosis, premenstrual syndrome
->improves acne
->less menopause symptoms
->maintains bone density in peri-menopausal (<50)
when to avoid CHC
–35yr = smokes
-hypertension
-multiple risk factors for cardiovascular; smoking, hypertension, BMI > or = 30, dyslipidemia, diabetes,
-migraine with aura
-new onset migraine w/o aura use pf CHC
Monophasic preparations
fixed amount of oestrogen + progesterone in each active tablet
multiphasic preparations
varying amount of each hormone
oestrogen
ethinylestradiol, mestrariol, estradiol
withdrawal bleeding
-women on 21DY regimen have a monthly withdrawal bleed during the 7DY hormone free interval
-withdrawal bleeds x represent physiological
-some packs = 28 per month supply = 21 active pills + 7 dummy to inc coherence)
switching to CHC from CHC
no additional contraception needed
switching to CHC from POP, LNG-IUD
7 day extra precaution needed
switching to CHC from copper IUD + other non-hormonal methods
-if CHC started up to day 5 of menstrual cycle no additional contraception needed
-if started after day 5 * 7DY extra precaution needed
switching to CHC from others week 1 (day 3-7 of hormone free interval) + no UPSI since start of HFI
-CU-IUD = no extra precaution
-POP = 2DY precaution
-others = 7DY precaution
switching to CHC from others week 1 (day 3-7 of hormone free interval) + UPSI since start of HFI
-carry on with CHC intil -7 consecutive days
-then act as week 2/3
switching to CHC from others week 2/3
no extra pre-caution required
reasons to stop CHC
-urgent medical review
->calf pain, swelling +/ redness (DVT)
->chest pain +/ breathlessness +/ coughing up blood (PE)
->loss of motor/sensory function (stroke)
->severe stomach pain (hepatotoxicity)
-> v.high BP (haemorrhagic stroke)
other reasons
-signs of breast cancer/lumps nipple pain
-50+
-new onset of migraine
-persistent unscheduled vag bleed
-high BP
-high BMI >OR= 35
-DVT/PE
-blood clotting abnormal
-angina, heart attack, stroke or peripheral vascular disease
-AF
-cardiomyopathy
CHC + surgery
-discontinued for 4WK prior
->major elective surgery + surgeries to legs/pelvis
->surgery involving prolonged immobilisation to lower limb
-use alternative methods of contraception
-CHC recommends 2wk after full remobilisations
-if discontinued x possible trauma/pt still on CHC
-> consider thromboprophylaxis
s/e of hormonal contraceptives
headaches
unscheduled bleeding
mood change
weight gain
libido (sex drive) change
missed doses POP
-if pt vomits/omits/diarrhoea with 3HR of taking POP take another pill asap
-consider missed dose if >12hr for desogestrel or >3hr for rest
-take as soon as remembering
-take next pill = usual time (2x a day if needed)
-needs protection till 48hr of pills taken correctly (7DY for desogestrel)
-need emergency contraception if UPSI happened between missed dose + 2DY after restarting meds
missed doses CHC
-if pt vomits/omits/diarrhoea with 3HR of taking CHC take another pill asap
-late start after HFI (>9dy since last active pill)
-emergency contraception if UPSI
-take immediately + use condoms till 7 consecutive days
1 missed pill (48-72hr since last active pill)
-take asap no further action needed - providing consistent use in previous 7DY pills
2+ missed pills (72hr+ since last active pill)
-WK1 cycle consider emergency contraception if UPSI happened within HFI + WK1 take asap + use condom for 7DY
-WK2/3 no emergency contraception needed take asap - 7DY condom
-2+ pills missed in 7DY before HFI carry on taking pill throughout HFI
emergency contraception
-copper IUD
-ulipristal 30mg
-levonorgestel 1.5mg
taken ASAP
copper IUD of emergency contraception
-1st line = most effective form of emergency contraception
-can be inserted up to 120HR (5DY) after 1st UPSI
-can be inserted up to 5DY after earliest estimated date of ovulation
hormonal methods of emergency contraception
-levonorgestrel - 72hr (3DY)
-ulipristal -120hr (5DY)
-2nd doses if vomited or diarrhoea in 3hr
-ulipristal more effective than levonorgestrel for emergency contraception
-unlike the CU-IUD, BMI lower effectiveness (esp levon)
->BMI >26/ weight >70kg = ulipristal or double dose of levon
-ulpirstal + levon can be used = oral emergency contraception - more than once in same cycle (levo higher risk of s/e)
when to reinitiate levonorgestrel
-start regular hormonal contraception immediately
-use condoms until effective
when to reinitiate ulipristal
-wait 5DY after taking ulipristal before starting regular hormones again
->use condoms during 5DY + till tx effective
-if during wk1 - regular CHC
->CHC can be initiated immediately after
->ondom 7DY
levonorgestrel 1.5mg s/e + CI
-breast feeding no delay
-caution in pt: malabsorption
-can cause breast tenderness, DVT, fatigue + haemorrhage
-avoid in severe liver impairment
-CYP inducer interaction
Ulipristal 30mg s/e + CI
- 1 week delay
-severe asthmatic controlled - glucocorticoids
-cycle irregularities, D+V, altered mood, dizziness
-CYP inducer interaction
CU-IUD s/e + CI
-MHRA = risk of uterine preforation
->severe pelvic pain after insertion, sudden change = period, pain during intercourse, unable to feel threads = check up
-replace every 5-10yr
-remove 1st trimester = pregn
-same for levonorgestrel IUD = less pain/bleeding S/E
-replace 3-10yr
erectile dysfunction
persistent inability to attain and maintain erection physical or psychological causes + s/e of drugs
erectile dysfunction 1st line tx
phosphodiesterase type 5 inhibitors
-inc blood flow to penis + still requires sexual stimulation
erectile dysfunction 2nd line tx
intracavenosal, interauretival, topical alprotadil under medical supervision
erectile dysfunction max number of doses before classsed as non-responder
6 doses at max doses with sexual stimulation
phosphodiesterase type 5 inhibitors for erectile dysfunction s/e
flushing, dizzy, nasal congestion, migraine
phosphodiesterase type 5 inhibitors for erectile dysfunction CI
-nitrates/hypotension, unstable angina/stroke during intercourse. x have sexual activity
phosphodiesterase type 5 inhibitors for erectile dysfunction interactions
nitrates
alpha blockers
phosphodiesterase type 5 inhibitors for erectile dysfunction short acting
avanafil, sildenafil + vardenafil = occasional PRN
phosphodiesterase type 5 inhibitors for erectile dysfunction long acting example
tadalafil - PRN/regular lower daily dose to allow for spontaneous activity
priapsm
-Introduction. Priapism is a disorder in which the penis maintains a prolonged, rigid erection in the absence of appropriate stimulation.
-last longer than 4HR = medical attention
alpratadil
condom if partner = child bearing age, pregn, lactating
antimuscarinics adverse effects in elderly
constipation, dry mouth, flushing, dizziness, drowsiness, tachycardia
antimuscarinics CI
- single-closure glaucoma, GI obstruction
-affects skilled performed tasks
