genitourinary system my own cards Flashcards
4 main types of urinary incontinence
stress, urgency, mixed, overflow incontinence
what is stress incontinence
involuntary leakage on effort or exertion, or on sneezing or coughing, and is associated with loss of pelvic floor support and/or damage to urethral spinchter
what is urgency incontinence
involuntary leakage which is accompanied, or immediately preceded by sudden desire to pass urine that is difficult to delay
urgency incontinence is often a symptom of
OAB
define OAB
urinary urgency, which may or may not be accompanied by urgency incontinence
usually associated with increased frequency and nocturia
what is OAB thought to be caused by
involuntary contractions of detrusor muscle
what is mixed urinary incontinence
involuntary leakage associated with both urgency and stress, but one type tends to be predominant
what is overflow incontinence
complication of chronic urinary retention and happens when a pt can’t empty their bladder completely and it becomes over distended
can result in continuous, or frequent loss of small quantities of urine
what is continuous urinary incontinence
constant leakage of urine which may be due to severity of the person’s condition or may be due to an underlying cause e.g. fistula
situational incontinence
e.g. during sex or giggling
main risk factor for developing any type of incontinence
older age - natural ageing results in physiological changes
RF for stress incontinence
- older age
- pregnancy
- vaginal delivery
- constipation
- FHx
- smoking
- lack of supporting tissue e.g. prolapse or hysterectomy
- drugs (ACEi can cause cough, a-adrenergic blockers relax bladder outlet and urethra)
conditions affecting the lower urinary tract that can increase detrusor muscle overactivity and therefore worsen urgency incontinence
- uti
- urinary obstruction
- oestrogen deficiency
- NS e.g. stroke, dementia, PD
- systemic e.g. DM, hypercalcaemia
3 drug classes that can increase detrusor muscle overactivity or indirectly contribute to urgency incontinence
- cholinesterase inhibitors
- drugs that cause constipation
- anti-cholinergic drugs
non drug treatment for women with urinary incontinence
- modify fluid intake
- lose weight if BMI 30 or more
non-drug treatment for women with OAB
trial reduction in caffeine
advice on using absorbent products, hand held urinals, toileting aids to treatment urinary incontinence
- do not use unless pt has severe cognitive or mobility impairment that may prevent further treatment
- may be used in some women as coping strategy whilst awaiting treatment, as adjunct, or as long term management after all treatment options have been considered
- review use annually
advice on using intravaginal and intraurethral devices to prevent leakage
only use prn to prevent leakage at specific times e.g. during exercise
1st line treatment for urinary incontinence
- bladder training for at least 6 weeks
- if frequency is a problem and satisfactory benefit from bladder training is not achieved, add drug treatment for OAB
treatment for stress incontinence in women
trial supervised pelvic floor muscle training for at least 3 months, which should include at least 8 contractions performed 3 times per day
which test needs to be performed in all women presenting with incontinence and why
urine dipstick test
tests for active infection or haematuria
refer to specialist if a woman has the following (in those who have urinary incontinence)
- persistent bladder or urethral pain
- pelvic mass clinically benign
- associated fetal incontinence
- suspected neurological disease or urogenital fistulae
- Hx previous incontinence surgery, pelvic cancer surgery or pelvic radiation therapy
- recurrent or persistent uti and over 60
- palpable bladder after voiding, or symptoms of voiding difficulty
urgent referral in women 45 or older (pt with incontinence)
hint to do with haemoaturia
- unexplained visible haematuria w/o UTI
- visible haematuria persisting or recurrent despite successful treatment of UTI
Urgent referral in women 60 or over (incontinence)
Unexplained non-visible haematuria and either dysuria or raise WCC
considering drug treatment for urgency incontinence
- Consider anticholinergic drug for women who have trialled bladder training, where freq is a problem and symptoms persist
- Consider the total anticholinergic load, coexisting conditions, such as cognitive impairment or poor bladder emptying, and the risk of SE when offering anticholinergics
1st line drug treatment for urgency incontinence in women
- IR oxybutynin, IR tolterodine, or darifenacin
- do not use IR oxybutynin in frail older women at risk of sudden deterioration in physical or mental health
- lowest dose and titrate upwards
drug treatment for urgency incontinence in women who cannot tolerate oral treatment
transdermal oxybutynin
drug treatment for urgency incontinence in women in whom anticholinergic is contraindicated, ineffective or not tolerated
mirabegron
drug treatment for urgency incontinence in women - reviews and what to do if treatment ineffective
- after 4 weeks or sooner if necessary
- if effective, review again at 12 weeks, then annually or every 6 months if >75
- if not effective or not tolerated, try alternative anticholinergic, or adjust current dose, or trial mirabegron and review again after 4 weeks
anticholinergics that can be used in incontinence
- 1st line: IR oxybutynin, IR tolterodine, darifenacin
- fesoterodine
- propiverine
- solifenacin
- trospium
- MR tolterodine or MR oxybutynin
What to do if a woman had tried medicine for OAB but treatment has failed
- refer to secondary care
- may get treatment with surgical methods or botulinum toxin type A
do not use the following as treatment options for oab/incontinence (3)
- flavoxate
- proprantheline
- imipramine
which drug can be used if women have troublesome nocturia
desmopressin
what can be used in women who are post-menopausal and have vaginal atrophy & reviews & monitor for
- Intravaginal oestrogen,
- Review annually to reassess need for continued treatment and monitoring for symptoms of endometrial hyperplasia or carcinoma
drug treatment stress incontinence
- duloxetine can be used 2nd line where conservative management (e.g. pelvic floor training) has failed and surgery not appropriate/not wanted by pt
- should not be offered routinely
- 40mg BD or 20mg BD initially to reduce SE
treatment for mixed incontinence
should be treated according to predominant type
what is pelvic organ prolapse
Symptomatic descent of part of the wall of the vagina or uterus
symptoms of pelvic organ prolapse
- vaginal bulge or sensation of something coming down
- Bowel and sexual symptoms
- Pelvic and back pain
what to do if a women presents with pelvic organ prolapse in primary care with symptoms
- examine to rule out pelvic mass or other pahtology and take full history
advice for women with pelvic organ prolapse
- minimise heavy lifting
- prevent/treat constipation
- lose weight if BMI 30 or more
treatment for pelvic organ prolapse
- may offer supervised pelvic floor muscle training for at least 16 weeks
- vaginal oestrogen can be used if signs of vaginal atrophy, an oestrogen-releasing ring may be more appropriate for women who have cognitive or physical impairments
- vaginal pessary alone or in conjunction with pelvic floor muscle training
- surgical management may be required in women whose symptoms have not improved with the above
nocturnal enuresis in children
involuntary discharge of urine during sleep
common in young children
in which age is nocturnal enuresis in children common? at what age is treatment considered?
- common until they are about 5
- treatment usually considered if they are still having this by the age of 7
- however some children will have this until the age of 10
non drug treatment for nocturnal enuresis
- advice on fluid intake, diet, toileting behaviour and use of reward systems
- if this fails (aka >1-2 wet beds/week)< recommend enuresis alarm for motivated, well-supported children
- consider alarms in <7yr olds depending on their maturity, motivation and understanding of alarms
- alarms have lower relapse rate than drug treatment when discontinued
how do enuresis alarms work
sensor detects moisture and sound box makes a noise which will wake child and prompt them to use toilet rather than bed wetting
reviewing alarm treatment
- after 4 weeks and continued until a minimum of 2 weeks uninterrupted dry nights have been achieved
- If complete dryness not achieved after 3 months but condition is improving and child is still motivated to use alarm, continue treatment
further treatment for nocturnal enuresis
- oral or sublingual desmopressin + alarm, or desmopressin alone if initial alarm treatment unsuccessful or not appropriate
when is desmopressin used in nocturnal enuresis
- oral of SL desmopressin recommended for >5 when alarm use is inappropriate or undesirable, or when rapid or short term results are needed (e.g. away from home)
- use desmopressin alone if partial response to combo of D + alarm following initial treatment with an alarm alone
reviewing desmopressin use and how long to continue it for
- review after 4 weeks and continue for 3 months if signs of response
repeated courses of desmopressin & withdrawing
- can be used in responsive children who have repeated recurrences of bedwetting
- but need to be withdrawn gradually at regular intervals (1 week every 3 months) for full reassessment
nocturnal enuresis associated with daytime symptoms (OAB) - treatment
- specialist supervision
- desmopressin alone or in combination with antimuscarinic (e.g. oxybutynin or tolterodine)
- continue for 3 months, and repeat course if necessary
use of TCA for nocturnal enuresis
- imipramine can be considered for children who haven’t responded to all other treatments and have undergone specialist assessment
- relapse common after withdrawal
- dangers of overdose
- initial treatment should be continued for 3 months, further courses can be considered following review every 3 months
- TCAs should be withdrawn gradually
contraindications for antimuscarinics
- CAG
- GI obstruction
- paralytic ileus
- pyloric stenosis
- severe UC
- toxic megacolon
- urinary retention
SE of antimuscarinics
- constipation
- urinary retention
- vision disorders, dry eye
- vomiting, nausea
- can affect performance of skilled tasks e.g. driving
- dizziness, drowsiness
- dry mouth
- dyspepsia
- flushing
- headache
- skin reactions
- palpitations
antimuscarinics - reviewing treatment for urinary incontinence
need for continuing therapy needs to be reviewed every 4-6 weeks until symptoms stabilise, then every 6-12 months
oxybutynin - directions for administration for transdermal use
- apply patches to clean, dry, unbroken skin on abdomen, hip or buttock
- remove after every 3-4 days
- avoid using same area for 7 days
mirabegron MOA
NOT an antimuscarinic
beta 3 adrenoreceptor agonist, relaxes detrusor muscle
mirabegron cautions and contraindications
- CI: severe uncontrolled hypertension (more than or equal to 180/110)
- cautions: stage 2 hypertension, QT interval
monitoring requirements mirabegren
BP before and regularly during, esp in pt with pre-existing hypertension
what is urinary retention
inability to voluntarily urinate
drugs that may cause urinary retention (3)
- antimuscarinics
- sympathomimetics
- TCAs
sympathomimets e.g. decongestants like pseudo/ephe etc also adrenaline, atropine, dobutamine, dopamine, ephedrine, noradrenaline
what is acute urinary retention
medical emergency - abrupt development of inability to pass urine (over a period of hours)
treatment of acute urinary retention
- painful
- requires immediate catherisation
- before catheter removal, give alpha-adrenoreceptor blocker (e.g. alfuzosin, doxazosin, tamsulosin, prazosin, indoramin, terazosin) for at least 2 days to manage acute urinary retention
what is chronic urinary retention
- gradual (months - years) development of inability to empty bladder completely
- characterised by residual volume >1L or associated with presence of distended or palpable bladder
most common cause of urinary retention in men + symptoms
- BPH (enlargement of prostate)
- men with enlarged prostate can have were urinary tract symptoms associated with obstruction e.g. urinary retention (acute or chronic), frequency, urgency or nocturia
treatment chronic urinary retention - catheter + disadvnatges
- offer intermittent bladder catheterisation before an indwelling catheter
- catheters can be used as long term solution when persistent retention is causing incontinence, infection or RI and surgical solution not feasible
- however use of catheter associated with increased risk of adverse events including pain, stone formation, recurrent urinary infections, trauma to urethra
treatment chronic urinary retention men - drug treatment + review
- for bothersome symptoms, but only offer drug treatment when other conservative management options failed
- moderate to severe symptoms: alpha-adrenoreceptor blocker e.g. doxazosin, alfuzosin, tamsulosin, terazosin
- review after 4-6 weeks then 6-12 months
treatment of urinary retention due to BPH
- depends on severity of symptoms of effect of QoL
- watchful waiting in non-troublesome symptoms and no complications of BPH e.g. RI, urinary retention or recurrent infection
- recommended treatment for BPH: a-adrenergic receptor blocker
- surgery for more severe symptoms that don’t respond to drugs, or complications
treatment of urinary retention due to BPH - in pt with enlarged prostate, raised prostate specific antigen conc, and considered to be high risk of progression (e.g. elderly)
- use 5a-reductase inhibitor (e.g. finasteride, dutasteride)
- if symptoms remain a problem, combination of alpha-adrenoblofcker and 5a-reductase inhibitor
name 2 other drugs used for urinary retention
hint: end in stigmine
Neostigmine
Pyridostrigmine bromide
counselling for pt on alpha-adrenoceptor blockers e.g. alfuzosin, doxazosin, indoramin, prazosin, tamsulosin
- 1st dose may cause collapse due to hypotensive effect
thus take on retiring to bed - lie down if symptoms such as dizziness, fatigue or sweating, and remain lying down until they go
- may affect performance of skilled tasks e..g driving
tamsulosin OTC
- 400mcg caps can be sold to public for treatment of functional symptoms of BPH in 45-75
- to be taken up to 6 weeks before clinical assessment by Dr
alpha-adrenoceptor blockers are also used for hypertension, except these two
alfuzosin and tamsulosin
name the 5a reductase inhibitors
dutasteride
finasteride
patient and carer advice - finasteride, dutasteride
hint cancer
cases of male breast cancer reported. promptly report any changes in breast tissue e.g. lumps, pain, nipple discharge
SE finasteride, dutasteride
sexual dysfunction, breast abnormalities
conception and contraception - finasteride, dutasteride
present in semen so use condom
monitoring dutasteride
monitor regularly for prostate cancer
dutasteride, finasteride - effect on lab tests
- can reduce serum conc of prostate cancer markers e.g. prostate-specific antigen
- reference values may need adjustment
handling and storage advice for women - dutasteride, finasteride
women of CB potential should avoid handling crushed or broken tabs
finasteride - MHRA important safety info
- reports of depression and in rare cases suicidal thoughts in men taking finasteride for hair loss (Propecia), also depression in Proscar for BPH
- stop immediately and inform HCP if develop depression
what are renal and ureteric stones
crystalline calculi that may form anywhere in upper urinary tract
symptoms of renal and ureteric stones
often asymptomatic but may cause pain when they move or obstruct urine flow
most renal and ureteric stones are composed of
calcium salts (ca oxalate, ca phosphate, or both)
pt are susceptible to stone formation when
- decrease in urine volume and/or excess of stone forming substances in the urine
RF associated with stone formation
- dehydration
- change in urine pH
- males 40-60
- positive fhx
- obesity
- urinary anatomical abnormalities
- excessive dietary intake of oxalate, orate, sodium, animal protein
- certain diseases which alter urinary volume, pH and conc of certain ions
certain drugs that can increase risk of stone formation
- calc or vit D supplements
- protease inhibitors
- diuretics
symptoms of acute renal or ureteric stones
- abrupt onset of severe unilateral abdominal pain radiating to groin (renal colic)
- may be accompanied by nav, haematuria, increased urinary freq, dysuria, fever (if concomitant infection)
likelihood of stone passage
- can pass spontaneously depending on size, location and degree of obstruction
- if >6mm, v low chance of spontaneous passage
- distal ureteral stones more likely to pass than proximal ureteral stones
non drug treatment for renal and ureteric stones
- watchful waiting for aysmptomatic renal stones <5mm diameter
- options for surgical stone removal should be discussed by specialist hospital team depending on severity of obstruction, pt factors, size and site of stone
non drug treatment for recurrent renal or ureteric stones
consider stone analysis and measure serum calcium in these pt
lifestyle advice for pt with stones
- maintain healthy lifestyle
- 2.3-3L water a day with addition of fresh lemon juice
- avoid carbonated drinks
- maintain normal daily calcium intake of 700-1200mg
- max salt intake 6g/day
lifestyle advice for pt with recurrent uric acid stones
avoid excessive dietary intake of urate rich products e.g. liver, kidney, calf thymus, poultry skin and certain fish (herring with skin, sardines and anchovies)
lifestyle advice for pt with recurrent calcium stones
avoid excessive intake of oxalate-rich products e.g. rhubarb, spinach, cocoae, tea, nuts, soy products, strawberries, wheat bran
pain management for stones and renal colic
- 1st line suspected renal colic or renal and ureteric stones: NSAIDs
- if CI or not controlling pain, consider IV Paracetamol
- if both CI or not controlling pain, offer opiods
- do not offer antispasmodics to pt with suspected renal colic
medical expulsive therapy of stones
- Consider alpha-adrenoceptor blockers for pt with distal ureteric stones <10mm diameter
- Alpha-adrenoceptor blockers may also be considered as adjunct therapy for pt having shockwave lithotropsy for ureteric stones <10mm
prevention of recurrent stones - drugs
- Lifestyle advice
- Consider potassium citrate (unlicensed) in pt with recurrent stones composed of at least 50% calcium oxalate
- Thiazindes (unlicensed) may be given if pt also have hypercalciuria after restricting their sodium intake to max 6g/day
what is urological pain
pain in pelvic region or genitalia that is often accompanied by urinary freq and urgency
treatment urological pain
lidocaine HCl gel - topical application in urethral pain or to relieve discomfort of catherisation
alkalising urine in urological pain
- potassium citrate
- may relieve discomfort of cystitis cause by lower UTIs
- sodium bicarbonate used in some metabolic and renal disorders
what is used for the management of common infections of the bladder in pt with indwelling urinary catheter
chlorhexidine solution given as bladder irrigation
activity of chlorhexidine
- BS activity against many gram+ve and gram-ve bacteria
- ineffective against most Pseudomonas app.
when should chlorhexidine 1 in 5000 (0.02%) be discontinued
- may irritate mucosa and cause burning on micturition - this is when you should discontinue
bladder instillations of …. and …. are licensed for management of superficial bladder tumours
doxorubicin and mitomycin
bladder instillations of doxorubicin and mitomycin are useful in bladder cancer because
they reduce systemic SE
using bladder instillations may have the following adverse effects on the bladder
micturition disorders
reduction in bladder capacity
instillation of …. is licensed for treatment and prophylaxis of some forms of superficial bladder cancer
epirubicin
instillation of the following live attenuates strain derived from Mycobacterium Bovis is licensed for treatment of primary or recurrent bladder carcinoma in situ and for the prevention of recurrence following transurethral resection
BCG
which 5A reductase inhibitor has MHRA safety info re depression
finasteride only!!
mirabegron has the following 2 cautions
S2 HTN and QT prolongation
what is S2 HTN?
160/100 mmHg or higher but less than 180/120 mmHg, and an ambulatory daytime average or home blood pressure average of 150/95 mmHg or higher.
mirabegron in RI
Avoid if eGFR less than 15
Reduce dose to 25 mg once daily if eGFR 15–29
mirabegron in HI
Manufacturer advises dose reduction to 25 mg once daily in moderate impairment.
