GU bits and pieces Flashcards
Urinary Incontinence - Conditions and Risk Factors
Urgency Incontinence => Sudden immediate need to pass urine that is difficult to delay
Stress Incontinence => leakage on effort or exertion, or on sneezing or coughing
Mixed Incontinence => urgency and stress, however, 1 type tends to be predominant
Risk factors:
- old age
- pregnancy + vaginal delivery
- obesity, smoking
- constipation
- FH
- Meds => diuretics, alcohol, caffeine can all increase urine production and can exacerbate incontinence
Urinary Incontinence - Non-drug treatment
Modify fluid intake
Wt loss if obese
Reduce caffeine
Urinary Incontinence - Urgency
1st: Bladder training for at least 6 wks
2nd: Antimuscarinic = oxybutynin or tolterodine
3rd: Mirabegron
Urinary Incontinence - Stress treatment
Pelvic floor muscle training for at least 3 months
Surgery or DULOXETINE
Urinary Incontinence - MIXED treatment
Bladder training (~6 wks) + pelvic floor muscle training (> 3 months)
Treat pharmacologically in accordance to dominating type
Antimuscarinics
Fesoterodine, Solifenacin, Trospium, Oxybutynin, Tolterodine
Increase AE in elderly:
- constipation, dry mouth, flushing, dizzines, drowsiness, tachycardia
CI:
- angle-closure glaucoma
- GI obstruction
Antimuscarinics can affect the performance of skilled tasks (e.g. driving)
Nocturnal Enuresis - involuntary urination during sleep (kids) - Non-drug treatment
Kids < 5 years = resolve without intervention
1st: Fluid intake, toileting behaviour, diet, use of reward systems
2nd: No response to advice (more than 1-2 wet beds/week) = ENURESIS ALARM
- Alarms in kids < 7 years given depending on maturity, motivation and understanding
- Alarms have less relapse than drug treatment when discontinued
- R/v alarm after 4 wks
- Cont until a minimum of 2 wks of uninterrupted dry nights
3rd: Alarm treatment unsuccessful => ADD/REPLACE with DESMOPRESSIN
Nocturnal Enuresis - Drug treatment
Kids > 5 years: DESMOPRESSIN
- Alarm not good
- When requiring rapid results (to cover holidays)
- Assess treatment after 4 wks and cont for 3 months if pt is responding
- repeated courses should be withdrawn gradually at regular intervals
Specialist: Desmopressin +/- antimuscarinic (oxybutynin or tolterodine)
Not responding to all other treatment: IMIPRAMINE
Desmopressin - it works by reducing the amount of urine produced. If the kid drinks a lot 1h before bed, then takes the drug, the extra fluid won’t be able to pass out of the body; instead, it’ll collect in the body causing fluid retention, aka, hyponatraemia!
More potent and longer duration of action than vasopressin
No vasoconstrictor effect
SE: HYPONa, N
Urinary Retention - Condition
Inability to voluntarily urinate. Can be caused by: urethral blockage; meds - antimuscarinic drugs, sympathomimetic, TCAs
Acute: medical emergency - abrupt development over a period of hrs
Chronic: Gradual over months - inability to completely empty bladders
Benign Prostatic Hyperplasia
- Common cause in men = enlarged prostate
- Symptoms include: urinary retention, freq, and nocturia
Urinary Retention - Treatment
ACUTE URINARY RETENTION
- Immediate catheterisation due to pain
- Provide alpha-blocker for 2+ days b4 removing catheter
CHRONIC URINARY RETENTION
- Catheters used long-term => can cause recurrent UTIs, urethra trauma, pain, and stone formation
BENIGN PROSTATIC HYPERPLASIA
- Alpha-blocker = relaxes smooth muscle
- Pts with enlarged prostate, raised prostate antigens, or at high risk of progression => 5alpha-reductase inhibitor = finasteride or dutasteride
Urinary Retention - ALPHA BLOCKERS (Alfuzosin, Doxazosin, Tamsulosin, Terazosin)
Avoid if pt has a hx of MICTURITION SYNCOPE (fainting post urination) or POSTURAL HYPOTENSION
SE:
- dizziness, postural hypotension
- 1st dose may cause collapse due to hypotensive effect => take before bed; lie down if dizziness, fatigue or sweating develop until they feel better!
TAMSULOSIN
Supply criteria:
- Male patient aged between 45 and 75 years
- Symptoms of BPH present for a minimum of three months
- A two week supply of tamsulosin can be supplied initially
- If there has been an improvement in urinary symptoms within the initial two weeks, a further supply of four weeks can be made
- After six weeks, a further supply can be made only where the patient confirms that the doctor has carried out a clinical assessment and agreed further supplies are appropriate.
Precautions for use:
- If patient has planned surgery for glaucoma or cataract
- Use in caution with strong and moderate CYP3A4 inhibitors (e.g.ketoconazole and erythromycin)
- Enhanced hypotensive effects if taken with antihypertensive.
Counselling points:
- One capsule to be taken after the same meal each day
- Modified-release preparations should be swallowed whole: not crushed or chewed
- Patients should see their doctor within six weeks of starting treatment
- Patients should see their doctor every 12 months for a clinical review
- Patients should be advised that if they experience any dizziness or weakness they should sit or lie down until the symptoms have gone
- Drowsiness or dizziness may affect performance of skilled tasks (e.g. driving).
Urinary Retention - 5alpha-reductase inhibitor (finasteride, dutasteride)
- breast disorder
- sexual dysfunction
- Male breast cancer reports => report lumps, pain or nipple discharge
- Excreted in semen - use condom if partner is pregnant or likely to become pregnant
- Women of childbearing potential should avoid handling crushed or broken tabs
- Finasteride => reports of DEPRESSION and rare cases of SUICIDAL THOUGHTS => stop finasteride STAT and inform HCP
Erectile dysfunction - persistent inability to attain and maintain an erection - TREATMENT
Lifestyle = smoking cessation, reduce alcohol intake
1st line: Phosphodiesterase type-5 inhibitor
- increases blood flow to the penis - still requires sexual stimulation
- Short-acting = Sildenafil, Avanafil, Vardenafil - occasional use PRN
- Longer-acting = Tadalafil = used PRN, or as a regular lower OD to allow spontaneous sexual activity
Pt should have 6 doses at the max dose (with sexual stimulation) before being clarified as a non-responder
Phosphodiesterase Type-5 inhibitors - sildenafil (P) for 18+ men
https://www.rpharms.com/resources/quick-reference-guides/sildenafil-50mg-film-coated-tablets-p-medicine
1 tab PRN with water
SE:
- Flushing
- Dizziness
- Nasal congestion
- Migraine
- dyspepsia
- N
- hot flush
- visual disturbance
- vision blurred
- cyanopsia
CI:
- Pts taking ntirates/ have hypotension
- Pts with UA/stroke
- Pts with angina during intercouse
- Pts who shouldn’t have sexual activity
Priapism (erection lasting longer than 4h) - see medical attention! Conditions that predispose patient to priapism (such as sickle cell anaemia, multiple myeloma or leukaemia)
Interactions:
- Nitrates - hypotension with isosorbide etc.
- Alpha-blockers - hypotension effects with doxazosin
- co-administration with CYP3A4 inhibitors!
Alprostadil = wear condom if partner is of child-bearing potential, pregnant or lactating
Non-hormonal contraception
BARRIER METHODS - condoms, diaphragms, cervical caps
- Petroleum jelly (Vaseline), baby oil and oil-based products can damage condoms, contraceptive diaphragms and caps made from latex rubber
SPERMICIDAL CONTRACEPTIVES - used in ADDITION only, not alone
INTRA-UTERINE DEVICES - copper coil
- CI in pelvic inflammatory disease or unexplained vaginal bleeding
Progesterone Only Contraceptives - prevents pregnancy by thickening the mucus in the cervix to stop sperm from reaching an egg
- Levonorgestrel, Norethisterone, Desogestrel
- No pill free period - 1 OD
- No additional precaution required if started in the FIRST 5 DAYS of the cycle, aka, after the menstrual period => Need 2 DAYS precaution if taken after that
- Taken at the same time each day for max efficacy
- DESOGESTREL => take within 12h otherwise considered missed pill
- Other POPs => within 3h otherwise considered missed pill
Parenteral Progestogen-Only Contraceptives
Injections: 99.8% effective in correct usage
- Depot MEDROXYPROGESTERONE ACETATE - every 13 weeks => loss of bone density can occur (osteoporosis risk); delayed return to fertility of up to 1 year after treatment cessation
Implants: 99.95% effective in correct usage
- ETONOGESTEREL (Nexplanon) - up to 3 years => MHRA warning: neuromuscular injury and migration of the implant - remove ASAP. Reports of device in vasculature and lung.; this is placed under the skin of the inner, non-dominant upper arm
CHCs - tabs, patches, vaginal rings - inhibits ovulation
Not given in 50+ as safer alternatives exist.
CHC health benefits:
- Reduces risk of ovarian, endometrial and colorectal cancer
- Aligns bleeding patterns
- Reduces dysmenorrhea and menorrhagia
- Manages symptoms of poly cystic ovaries, endometriosis and premenstrual syndrome
- Improves acne
- Reduces menopausal symptoms
- Maintains bone density in per-menopausal females <50
When to avoid CHCs?
Unsuitable if pt has any of the following risk factors:
- HTN
- 35+ who smoke
- Females with multiple risk factors for CVS: - smoking, HTN, high BMI (equal to or above 30kg/m2), dyslipidemia, DM => 1 factor is fine, although more than 2 means you have to avoid CHCs
- migraine with aura
- new onset migraine with aura during use of CHC
Contraceptive preparations
Monophasic => Fixed amount of an oestrogen and a progestogen in each active tab
Multiphasic => varying amounts of the 2 hormones; give if no withdrawal bleed with monophasic or breakthrough bleeds
Oestrogen: Ethinylestradiol, Mestranol, Estradiol
Females on 21-day regimen have a monthly withdrawal bleed during the 7-day hormone free intervals (HFI)
- withdrawal bleeds don’t represent physiological
- some packs come as 28 per month’s supply (21 active pills, 7 dummy - increase adherence)
Switching to a CHC
From CHC => No additional contraception needed
From POP => 7 days extra precaution needed
From LNG-IUD (levonorgestrel) => 7 days extra precaution needed
From Copper-IUD => if CHC started ON OR UP TO DAY 5 of menstrual cycle aka after period: no additional contraception needed. If started AFTER DAY 5: 7 days extra precaution needed
Other non-hormonal methods => same as Copper-IUD
CHCs to other contraceptives
Week 1 (or day 3 - 7 of the HFI) + No UPSI since start of HFI:
- Cu-IUD => no extra precaution
- POP => 2 day precautions
- Others => 7 day precaution
Week 1 (or day 3 - 7 of the HFI) + UPSI since start of HFI:
- Carry on with CHC until 7 consecutive days taken
- Then act as week 2 or 3
Week 2 or 3 => no extra precautions needed
