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- repeated courses should be withdrawn gradually at regular intervals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
Reasons to STOP taking CHCs - URGENT!!
Urgent medical review:
- Calf pain, swelling or/and redness => DVT
- Chest pain and/or breathlessness and/or coughing up blood => PE
- Loss of motor or sensory function => stroke
- Severe stomach pain => Hepatotoxicity
- Very high BP => haemorrhaging stroke
Other reasons to STOP taking CHCs
Includes previous points: 50+, newly developed CI
Medical review or to seek advice:
- signs of breast cancer (lump, nipple pain)
- New onset migraine
- persistent unscheduled vaginal bleeding
- high BP
- high BMI (>35Kg/m2)
- DVT or PE
- Blood clotting abnormality
- angina, heart attack, stroke or peripheral vascular disease
- AF
- cardiomyopathy
CHCs and SURGERY
Discontinue at least 4 WEEKS prior for:
- Major elective surgery, any surgery to the legs or pelvis
- Surgery that involves prolonged immobilisation of a lower limb
Use an alt method of contraception
CHC restarted 2 WEEKS AFTER FULL IMMOBILISATION
If discontinuation is not possible (trauma)/pt is still on CHC => Consider THROMBOPROPHYLAXIS
SEs of all Hormonal Contraceptives
Combined = increase risk of cervical and breast cancer. however, it decreases the risk of ovarian and endometrial cancer
Progestogen-only = increase risk of breast cancer
Headache
Unscheduled bleeding (breakthrough bleeding)
Mood change
Wt gain
Libido change
MISSED DOSES
Missed pill rule apply if the pt omits or has vomited/had diarrhoea within xhours of taking COC or POP - take another ASAP to aim to be within time period
MISSED DOSES - POPs
- Considered missed if >12h for Desogestrel or >3h for rest of the POPs
- Take pill as soon as you remember
- Take the next pill at the usual time, even if it means taking 2 in a day
- Need protection till 48h of pills are taken correctly (7 days for Desogestrel!)
- Need EHC if UPSI happened between missed pill and 2 days (POP) or 7 days (Desogestrel) after restarting meds
MISSED DOSES - CHC tabs
> 24h OR >12h if on Zoely / Qlaira
Late start after HFI (>9 days since last active pill), aka starting new pack late:
- EHC if UPSI has occurred
- take STAT and use condom till 7 consecutive days taken
1 missed pill (48 - 72h / 2-3 days since last active pill):
- take ASAP - no further action needed (providing consistent use in previous 7 active pills)
2+ missed pills (72h+ since last active pill):
- Week 1 of cycle => consider EHC if UPSI occurred within HFI and week 1; take ASAP and use condom till 7 consecutive doses taken!
- Week 2 - 3 of cycle => no EHC needed - take ASAP - then use 7 days condom
- If 2+ pills missed in 7 days before HFI, carry on taking contraceptive pill throughout HFI
MISSED DOSES - patches and vaginal rings
Patches => “missed” refers to detachment or delayed application
Vaginal rings => “missed” refers to expulsion, delayed insertion, broken ring
Transdermal patches (Evra)
1 cycle = OW patch for 3 weeks, then 1-week patch-free
Detached for >24h OR delayed application at beginning of cycle => apply new patch ASAP. Start a “new day 1 cycle” + condom for 7 days
Delayed application in the middle of cycle - beginning of week 2 (day 8) or week 3 (day 15):
- <48h = apply new patch and continue as normal
- >48h = start a “new day 1 cycle” + condom for 7 days
EHC
Copper-IUD
Ulipristal 30mg
Levonorgestrel 1.5mg
Needs to be inserted / taken ASAP
EHC - Cu-IUD
1st line = most effective form of EHC
Can be inserted up to 120h (5 days) after the FIRST UPSI
Can be inserted up to 5 days after the earliest estimated date of ovulation
EHC - hormonal methods
2nd dose required if pt has vomited/diarrhoea in 3h
Levonorgestrel => 72h (3 days)
Ulipristal => 120h (5 days)
Ulipristal more effective than levonorgestrel for EHC
Unlike the Cu-IUD, BMI could reduce effectiveness (particularly levonorgestrel) => BMI > 26Kg/m2 or wt > 70kg - give either Ulipristal or a double dose of levonorgestrel but that’s through the DR
Ulipristal and levonorgestrel can be used as oral EHC MORE THAN ONCE IN THE SAME CYCLE (levonorgestrel has an increased risk of SEs
EHCs - When to re-initiate regular contraception?
Levonorgestrel
- Start regular hormonal contraception immediately
- use condoms until effective => 2 days for POP, 7 days for Desogestrel, 7 days for COCs.
Ulipristal
- wait 5 days after taking Ulipristal before starting regular hormone again => use condoms during the 5 days and till treatment is effective => 7 days for POP, 12 days for Desogestrel, and 12 days for COCs
- If during week 1 in females taking regular CHC => CHC can be reinitiated immediately after, and wear condoms for 7 days
EHC - Levonogestrel 1500mcg - prevents ovulation and fertilisation
Up to 72h post sex
16+ only
2nd dose if V/D within 3h
If BMI > 26 / wt > 70kg => give Ulipristal OR DOUBLE DOSE
More susceptible SEs
Can begin hormonal contraceptive STAT => use condom until effective; 2 days for POP; 7 days for Desogestrel; 7 days for COC
Breast-feeding = no delay
Caution in pts with malabsorption (Crohn’s disease), past ectopic pregnancy, cyclosporin (toxicity)
SE: breast tenderness, D/V, fatigue, haemorrhage
Can cause breast tenderness, D+V, fatigue and haemorrhage
Avoid in severe liver impairment
Interaction: CYP inducers => give double dose, e.g. if on carbamazepine
EHC - Ulipristal acetate 30mg - progestogen receptor modulator inhibits or delays ovulation.
Up to 120h (5 days)
Can give to under 16s
2nd dose needed if V/D within 3h
More effective than levonorgestrel
Better if BMI > 26 / wt > 70kg
Wait 5 days before taking regular hormonal contraceptive (unless 1st week)
Use condom for 5 days and until treatment is effective => 2 days for POP (7 days total); 7 days for Desogestrel (12 days total); 7 days for COC (12 days total)
If during 1st week of taking CHC => CHC can be restarted immediately; wear condom for 7 days
Breast feeding = 1 week delay
Caution in severe asthmatics controlled by glucocorticoids
SE: Cycle irregularities, D+V, altered mood, dizziness
Avoid in severe liver impairment
CI: repeated use within the same menstrual cycle
Interaction: CYP inducers => not licensed to sell DOUBLE DOSE
EHC - Cu-IUD
Check up if can’t feel threads
Replace every 5 - 10 years
Removed in the first trimester of pregnancy
MHRA warning: risk of uterine perforation
- severe pelvic pain after insertion
- sudden change in period
- pain during intercourse
- unable to feel threads
Levonorgestrel IUD - non-EHC
Check up if can’t feel threads
Replace every 3 - 10 years
Removed in the first trimester of pregnancy
MHRA warning: risk of uterine perforation
- severe pelvic pain after insertion
- sudden change in period
- pain during intercourse
- unable to feel threads
Reduced bleeding and period pain and a lower risk of pelvic inflammatory disease
BRAND!!!! due to diff indications, duration of use
Fraser Guidelines - under 16s
Can provide contraception without parental consent if:
- she understands drs advice
- can’t be persuaded to inform her parents
- very likely to continue having sex
- unless she received contraception her mental and physical health will suffer
- in her best interests to provide treatment
BNF - Contraception summary
Methods of contraception considered to be ‘highly effective’ include male and female sterilisation, and the long-acting reversible contraceptives (LARC)—copper intrauterine device (Cu-IUD), levonorgestrel intrauterine system (LNG-IUS) and progestogen-only implant (IMP). Females using the IMP must not take any interacting drugs that could reduce the contraceptive effectiveness
