GU SYSTEM- BLADDER ISSUES, CONTRACEPTION, ED Flashcards
1
Q
MOA of oxybutynin?
A
Direct relaxant of urinary muscle
e.g patches
2
Q
What method is 1st line treatment for urinary urge incontinence?
A
Bladder training 6 weeks
Then add a drug (antimuscarinic)
3
Q
What are the 3 types of urinary incontinence?
A
Urge
Stress
Mixed - both urge + stress
4
Q
What is urgent incontinence?
A
Sudden need to pee, can’t hold it due to weak muscles.
5
Q
What is stress incontinence?
A
leaking when sneezing or coughing
6
Q
What are 6 risk factors of urinary incontinence?
A
old age
Pregnancy
obesity + smoking
family hx
medicines- diuretics, alcohol
constipation
7
Q
What are non drug treatments of urinary incontinence?
A
Stop smoking, reduce alcohol and caffeine, weight loss, change fluid intake
8
Q
What should not be used to treat urinary incontinence, unless the person has severe cognitive or mobility impairment?
A
Absorbent products, hand-held urinals and toileting aids
9
Q
When should Intravaginal and intraurethral devices should only be used?
A
Prevent leaking during exercise
10
Q
What is 2nd line treatment for urge incontinence?
A
Antimuscarinics
e.g. oxybutynin, tolterodine. solifenacin
11
Q
What is 3rd line drug for urge incontinence?
A
Mirabegron
12
Q
What is 1st line treatment for Stress incontinence
?
A
Trial supervised pelvic floor muscle training for at least 3 months,
Should include at least 8 contractions performed 3x day.
13
Q
what is 2nd line tx for Stress incontinence
after trying pelvic floor exercise?
A
Duloxetine or surgery
14
Q
What is 1st line for mixed incontinence?
A
bladder training 6 weeks + pelvic floor training
Drug treatment based on what is more dominating.
15
Q
What is a contraindication for mirabegron?
A
Severe uncontrolled HTN
16
Q
What is a caution of mirabegron?
A
QT prolongation
17
Q
When + who should duloxetine be used for in urinary incontinence?
A
Mod-severe stress incontinence
Women ONLY
18
Q
List some antimuscarinics?
A
Oxybutinin
Solifenacin
tolterodine
fesoterodine
19
Q
What are 5 antimuscarinic side effects?
A
Constipation
Dry mouth
dizziness/drowsy
flushing
tachycardia
20
Q
What 2 conditions are antimuscarinics contra-indicated in?
A
Angle-closure glaucoma;
GI obstruction
21
Q
Can you drive when taking antimuscarinics?
A
NO- affects driving
22
Q
What medication is needed for women when taking mirabegron?
A
Contraception
23
Q
Class of mirabegron?
A
Beta 3 agonist
24
Q
What renal function to avoid mirabegron?
A
avoid if eGFR less than 30
25
When to do with mirabegron if eGFR is 30-89 and taking other enzyme inhibitor drugs?
Manufacturer advises reduce dose to 25 mg once daily.
26
What 3 antimuscarinic drugs can be prescribed if patient with urge incontinence taking anticholinergic for dementia?
Immediate release oxybutynin, tolterodine, or darifenacin = 1st line
27
When to review drug treatment for urge incontinence?
4 weeks, or sooner if required
28
When to review women for urge incontinence If treatment is effective?
review the woman again at 12 weeks, then annually or every 6 months if the woman is over 75 years of age.
29
What to do if treatment not tolerated in urge incontinence?
Alternative anticholinergic drug, dose adjusted or, mirabegron trialled; review again after 4 weeks.
Alternative anticholinergics include, an untried 1st-line drug, or 1 below; fesoterodine fumarate, propiverine hydrochloride, solifenacin succinate, trospium chloride, OR an extended release formulation of either oxybutynin or tolterodine.
30
What is nocturnal enurisis?
urinating during sleep - common in children
31
What to do if woman presents with Pelvic organ prolapse symptoms?
examined to rule out pelvic mass or other pathology + history taken
32
What is counselling for Pelvic organ prolapse?
Reduce heavy lifting, preventing or treating constipation, and if their BMI is 30 kg/m² or greater, encouraged to lose weight. A programme of supervised pelvic floor muscle training for at least 16 weeks may also be tried for some women.
33
What is treatment for nocturnal enurisis in children under 5?
no treatment needed
34
What is non drug treatment for nocturnal enuresis in children over 5?
advice on fluid intake (no fluids 4 hrs before bed), diet, toileting behaviour, and use of reward systems
35
What is treatment for nocturnal enuresis in children over 5 if lifestyle does not work?
enuresis alarm
36
When is an enuresis alarm given?
More than 1-2 wet beds in 1 week.
review in 4 weeks
37
Who are enuresis alarms given to?
Children between 5-7 who understand purpose
38
Why are enuresis alarms 1st line for enuresis?
Less relapse than drug treatment
39
How long to continue enuresis alarms?
2 weeks of uninterrupted dry nights.
40
What drug to add if enuresis alarm is ineffective or not appropriate?
oral or sublingual Desmopressin (over 5+)
41
What age is desmopressin given to?
OVER age of 5
42
43
When to assess patient on desmopressin for enuresis?
4 weeks after initiation + continue for 3 months if working.
Withdraw repeated courses gradually at regular 3month intervals
44
What is specialist treatment for nocturnal enuresis?
Desmopressin + antimuscarinic
OR
imipramie
45
What are 2 SEs of desmopressin?
nausea
hyponatraemia (convulsions)
46
What is urinary retention?
Cannot pee due to medication or urothelial blockage
47
What 3 medication classes can cause urinary retention?
Anitmuscarinic, TCAs, sympathomimetics
48
What is acute urinary retention?
Emergency - happens quickly
49
What is chronic urinary retention?
Long time to develop cannot fully empty bladder
50
What condition is a common cause of urinary retention?
BPH - enlarged prostate
51
Symptoms of BPH?
Retention, urgency , frequency + nocturia (night)
52
1st line for Acute retention?
catheterisation- removes pain
Then alpha blocker given before removing it.
53
1st line for chronic retention not by BPH?
intermittent bladder catheterisation should be offered before an indwelling catheter.
54
What catheter given first?
Intermittent bladder catheterisation
55
What to give for chronic urinary retention due to BPH?
Alpha blockers
56
What are some SEs of using catheters?>
recurrent UTIs, trauma to the urethra, pain, + stone formation.
57
List 4 alpha blockers?
Terazosin
Doxazosin
alfuzosin
tamsulosin
58
When is treatment with alpha blockers reviewed?
Treatment should initially be reviewed after 4–6 weeks + then every 6–12 months.
59
What is given for BPH with enlarged prostate, raised antigens + increase risk of progression?
Finasteride or dutasteride
60
What 2 conditions to avoid alpha blockers in?
Postura hypotension
micturition syncope
61
What are 2 main SEs of alpha blockers?
Hypotension, dizziness/fainting, tachycardia, palpitations
62
What is a key counselling point for alpha blockers?
Take 1st dose at night due to risk of first dose postural hypotension
Driving can be affected.
63
What is 5-a inhibitors?
finasteride,
dutasteride
64
What are 2 main SEs with 5-a inhibitors?
male breast cancer
sexual dysfunction
65
What to counsel male patients on 5-a inhibitors?
Report breast symptoms - lump, pain.
Drug is excreted in semen - use contraception
66
Can women touch 5-a inhibitors?
No- avoid touching tablets if off child bearing age
67
What is a key SE for finasteride?
Rare cases of depression + suicidal thoughts - stop immediately
68
What drug is used for urological pain or pain linked to catethers?
Lidocaine hydrochloride gel
69
Why is Alkalinisation of urine done?
Relieve discomfort of cystitis caused by lower UTI.
69
What is used to cause Alkalisation of urine?
potassium citrate
Sodium bicarbonate= in metabolic + renal disorders.
70
What is given for bladder irrigation + common symptoms in patients with an indwelling urinary catheter?
Chlorhexidine solution
70
What does chlorhexidine NOT work against?
Pseudomonas spp.
70
What is used for Continuous bladder irrigation to treat fungal infections?
amphotericin B (Fungizone®) 50 micrograms/mL
71
What 2 drugs are used for bladder cancer instillation?
doxorubicin hydrochloride and mitomycin
72
Instillation of BCG helps do what?
Treatment of primary or recurrent bladder carcinoma in-situ
+
for the prevention of recurrence following transurethral resection.
73
What drug is used for urological surgery irrigation?
Glycine irrigation solution 1.5% is licensed for use in transurethral surgical procedures such as prostatic resection
74
What is recommended for Erectile dysfunction 1st line?
Life style changes- reduce smoking + alcohol
75
What is 1st line Drug tx for Erectile dysfunction?
Phosphodiesterase type 5 inhibitors e.g. sildenafil
50mg 1 hr before sex
76
MOA of Phosphodiesterase type 5 inhibitors?
Increases blood flow
77
What are 3 short acting Phosphodiesterase type 5 inhibitor?
Sildenafil (1 hr before sex)
avanafil (30 mins before)
vardenafil (25-60 mins before)
78
What is 1 long acting Phosphodiesterase type 5 inhibitor?
Tadalafil -PRN or daily lower dose (take 30 mins before)
79
What is max dose of Phosphodiesterase type 5 inhibitor before being classified as a non-responder?
6 doses with sexual stimulation
80
What is 2nd line treatment for Erectile dysfunction?
Intracavernosal, intraurethral or topical application of alprostadil.
81
What is alprostadil?
prostaglandin E1
82
What are 5 SEs of Phosphodiesterase type 5 inhibitor?
PRIAPISM, flushing, dizziness, migraine , nasal congestion
hypotension.
83
What are 4 Contra-indications of Phosphodiesterase type 5 inhibitor?
Hypotension
taking nitrates
unstable angina/ stroke
If told not to have sexual activity
84
What is priapism?
erection lasting longer than 4 hrs - A + E
85
What 2 drugs interact with Phosphodiesterase type 5 inhibitor?
Nitrates
A blockers
86
What is a key specific counselling point for alprosatadil?
Wear condom if partner pregnant, lactating, or of child bearing age.
87
List 3 non- hormonal contraceptive methods?
Barrier
spermicidal - use in addition
IUD
88
What 2 conditions are contra-indicated with IUD?
PID
unexplained bleeding
89
What is most effective contraceptive?
IUD - copper
90
List 3 progesterone contraceptives (POP)?
Desogestrel (better)
levonorgestrel
Norethiresterone
91
What are 3 features of POP?
No pill free period - take everyday
No additional precaution needed i started within 5 days of cycle
92
What to do if POP started after 5 days of cycle?
Extra precaution needed
93
What POP needs to be taken within 12 hours or it is considered a missed pill?
Desogestrel
94
How many hours should other POP be taken within to ensure max efficacy?
3 hrs
95
What is the efficacy of parenteral POP injections?
99.8%
96
What is an example of POP injection and when taken?
Medroxyprogesterone depot
every 13 weeks
97
What are 2 negatives about Medroxyprogesterone depot
?
Loss of bone density
return to fertility after stopping delayed by 1 year
98
What is efficacy of POP implant?
99,5%
99
Example of POP implant?
Nexplanon (etonogesterel)
100
How long does Nexplanon implant (etonogesterel) last?
lasts up to 3 years
101
What is MHRA warning for Nexplanon implant (etonogesterel)?
migration of implant + neurovascular injury = remove it asap.
102
What age is COC not given?
In women 50+ - safer options exist
103
What 3 formulations do COC exist as?
Tablet
patches
vag rings
104
What are 5 benefits of COC?
Reduced risk of ovarian, endo + colorectal cancer
aligns bleeding pattern
reduces pain + bleeding
manages endometriosis, pcos, acne, menopausal symptoms
Maintains bone density in peri-menopausal women under 50
105
What 5 criteria to avoid Combined hormonal contraceptives?
Hypertension
35 years + who smoke
Multiple risk factor for CVD: smoking, hypertension, high BMI, DM
migraine with aura
new onset migrane without aura when using this.
106
What is monophasic?
fixed amount of eostrogen + progesterone in each active tablet
107
What is multiphasic?
varying amounts of two hormones
For women without withdrawal bleeding or have breakthrough bleeding with monophasic prep.
108
List 3 oestrogens used for COC?
ethinylesterol
Mestranol
estradiol
109
How does COP regime work?
Take 1 tablet for 3 weeks + leave 1 week for withdrawal bleeding to happen.
110
Why do some COC come as packs of 28 tabs?
7 pills are used as dummies to increase compliance
111
What to do if COC started day 6 or later of menstrual cycle?
Use protection for 7 days
112
What precaution needed if switching from COC to COC?
Nothing extra needed
113
What precaution needed if switching from POP to COC?
7 days extra precaution needed.
114
What precaution needed if switching from levonogestrel-IUD to COC?
7 days extra precaution needed.
115
What precaution needed if switching from copper-IUD to COC?
If combined contraceptive started up to 5 day of menstrual cycle = no additional contraception needed
If started after day 5 then = need 7 days of precaution
116
What to do when switching from COC to Cu-IUD and in week 1 of cycle with no unprotected sex since start of hormonal free interval?
No extra precaution
117
What to do when switching from COC to POP and in week 1 of cycle with no unprotected sex since start of hormonal free interval?
2 days precaution
118
What to do when switching from COC to others and in week 1 of cycle with no unprotected sex since start of hormonal free interval?
7 days precaution
119
What to do when switching from COC to others and in week 1 of cycle with unprotected sex since start of hormonal free interval?
carry on with COC until 7 days taken then no extra precaution
120
What are 5 urgent reasons to STOP COP?
calf pain - DVT
chest pain - PE
loss of motor - stroke
stomach pain - liver effected
v high BP- stroke
121
What are other reasons to stop the pill?
sign of breast cancer
new migraine
High BP/ BMI
vaginal bleeding
AF/ Cardiomyopathy
DVT
122
When to stop the contraceptive before elective surgery?
stop 4 weeks before - use alternative contraceptive
123
When is COC recommended after surgery?
2 weeks after full remobilisation
124
What are 5 common SEs of hormonal contraceptives?
Headache
unscheduled bleeding
mood change
weight gain
libido changes
125
What counts as a missed dose for contraceptives?
If patient diarrhoea, vomiting within 2 hrs after taking POP/COC
take another asap
126
What is POP missed pill advice? (3)
Take as soon as you remember even if it means taking 2 in 1 day.
Need protection till 48 hrs of pill taken correctly (7 for desogestrel)
Need emergency pill if has had sex between missed pill and 2 days after restarting
127
How many days of protection needed for desogestrel if taken after 2 days of period?
7 days of protection needed.
128
What should patient do if patient missed COC after their 7 day interval?
Emergency contraception if unprotective sex
use condom until pill taken for next 7 days.
129
What should patient do if they miss 1 pill of COC?
take asap
130
What should patient do if they miss 2+ pills of COC and in week 1 of cycle?
Emergency contraception if it happened between hormonal free period and week 1.
Take pill and use condom 7 days.
131
What should patient do if they miss 2+ pills of COC and in week 2-3 of cycle?
No emergency contraception needed
Take ur pill and 7 days condom
132
What should patient do if they miss 2+ pills of COC before hormone free period?
take contraceptive throughout hormonal free period
133
list 3 emergency contraceptives?
Copper IUD
ulipristal 30mg
Levonorgestral 1.5mg
134
what is 1st line emergency contraception?
Copper iud
135
When can IUD be inserted?
upto 5 days of unprotected sex + earliest estimated date of ovulation
136
Which emergency contraception has the longest period after unprotected sex?
Copper IUD or ulipristal
137
When to give levonorgestrel?
Within 72 hrs (3 days) of unprotected sex
138
When to give ulipristal?
Within 5 days of unprotected sex
139
When should 2nd dose of emergency contraceptive be given if needed?
if patient vomited or had diarrhoea within 3 hrs
140
What hormonal emergency contraception is more effective?
Ulipristal
141
What affects efficacy of hormonal emergency contraception?
BMI - give double dose of levongestrel if over >26 BMI OFF LABEL
142
When to start regular contraception after levonorgestrel?
start regular contraception asap
use condoms until effective (7)
143
When to start regular contraception after ulipristal?
wait 5 days before taking normal method but use condom during these days
144
When to start regular contraception after ulipristal during week 1 + taking COC?
can start COC straight after but use condom 7 days
145
What emergency contraception has 1 week delay with breastfeeding?
Ulipristal
146
What is strength of ulipristal?
30mg
147
What is strength of leveonorgestel?
1.5mg
148
What is a caution for levonorgestel?
patients with malabsorption
149
When to avoid emergency contraception?
severe liver impairment
150
What is a caution for ulipristal?
severe asthmatics controlled by gluccocorticoids
151
What are 4 SEs of levonorgestel?
breast tenderness
D + V
fatigue
haemorrhage
152
What are 4 SEs of ulipristal?
Cycle irregularities
Altered mood
dizziness
D + V
153
What does contraceptive interact with to reduce efficicacy?
Inducers - st john's wort, phenytoin, carbamazepine, phenobarbital etc.
154
What is an MHRA warning related to copper iud?
risk of uterine perforation
Severe pelvic pain, changes in period, unable to feel threads
155
When is IUD removed?
In first trimester of pregnancy
replaced every 5-10 yrs
156
When to replace levonogestrel IUD?
Replace 3 to 10 years
157
How to take ulipristal for uterine fibroids in a missed dose over 12 hrs?
If a dose is more than 12 hours late, the missed dose should not be taken + the next dose should be taken at the normal time.
158
Why is levonogestrel IUD better than copper?
Reduced bleeding + period pain + lower risk of PID
159
How often is mirena changed?
5 years
160
When not to remove IUD?
Mid cycle unless additional contraceptive used for 7 days.
161
What does phosphodiesterase 5 inhibitors and food do?
Cause delayed effect
162
What is first line for life-long premature ejaculation?
Dapoxetine - SSRI
163
What is 1st line for premature ejaculation for patients not wanting drugs?
psychosexual counselling, education, + behavioural treatments.
164
Is ulipristal recommended for patients who have taken cyp3a4 inducing meds/herbals in past 4 weeks?
No
165
What ECP to give if patient taken CY3A4 inducer/ herbal product within 4 weeks and IUD not suitable?
Give 2 tablets of levonorgestrel within 72 hrs of unprotected sex.
166
Which EHC pill is less effective if BMI >26kg/m2?
Levonorgestrel -- can double up as OFF LABEL
167
Levonorgestrel and ciclosporin?
Increase toxicity as it stops ciclosporin metabolism
168
What should be monitored in patients taking mirabegron?
BP should be monitored before starting treatment + regularly during treatment, especially in patients with pre-existing HTN.
