GUM Flashcards
What is nocturnal enuresis
Involuntary discharge urine during sleep
When are children expected to be dry
5 years
When do you consider treatment for children
7 years
Non drug nocturnal emesis treatment
Fluid, toileting behaviour, reward systems, alarms , reward systems
Drug treatment for nocturnal emesis
Oral/sublingual desmopressin ig alarm can’t be used or if short term results needed can be combined with an antimuscarininc for 3 months. Imipramine can be used instead
What reduces contraceptive effectiveness
Inducers
What is ideal contraception strategy for HIV patients
Condom with long acting method like a injectable contraceptive
What to do if on Combined hormonal contraceptive and taking enzyme inducing drugs with griseofulvin
Change to reliable contraceptive namely parenteral progestogen only like norethisterone/ medroxyprogesterone or IUD like levonorgestrel. For duration of treatment on inducer and four weeks after stopping
CHC with short course of inducing drug
Can continue but use condoms for duration and for 4 weeks after
What is not recommended if on inducer/griseofulvin (except rifampicin/rifabutin)
Contraceptive patches/vaginal rings
Long term of inducer course when on CHC
Can try ethinylestradiol 50mg or more for extended or continuous regimen back to back basically if breakthrough bleeding occurs increase dose in increments of 10mcg up to 70 mcg,
How to use contraception when on rifampicin or rifabutin
IUD always recommended because it is too potent
Using inducers with oral progesterone
Change as reduced efficacy or use condoms during course and 4 weeks after
Using inducers with parenteral progestegen only
It is not affected, implants like etonogestrel may be reduced so an alternate is recommended during treatment and at least 4 weeks after or condoms during and 4 weeks after.
Emergency contraception interactions
Levonorgestrel and ulipristal acetate are induced so use copper IUD instead or increase levonorgestrel
When can you start contraception after emergency contraception
Not until 5 days after ulipristal as its effect would be reduced
Can you use ulipristal more than once in the same cycle
Yes
Can you use levonorgestrel more than once in cycle
No
Can you use the two EHC drugs close to each other
Not within 5 days
Which EHC is not recommended in corticosteroid treated/severe asthma
ulipristal
LARC
Long acting reversible contraceptives
CuIUD
Copper intrauterine device
Barrier methods
Condoms, diaphragms and cervical caps, less effective contraception but good at protecting against STI
spermicidal
can;t be used alone can be used with caps/diaphragms no evidence for doing anything more with condoms, example is noxinol
What may damage condoms
Oil based lubricants, vaseline, baby oil,
IUD who can/can’t use
Can be used for all ages except those with pelvic inflammatory disease/ unexplained vaginal bleeding
Bladder infection treatment
Chlorhexidine irrigation, possibly sodium chloride or amphotericin B
Bladder cancer treatment
Doxorubicin and mitomycin
Urological surgery irrigation
glycine
Highly effective contraception
LARC/CuIUD/ Levonorgestrel intrauterine system and progestogen only implant
Forms of CHC
Tablets, patches. Vaginal rings.
Effectiveness of CHC when used correctly
Fails 1
When to not recommend CHC
> 50
Monophasic coc
Fixed amount of oestrogen and progestogen in each active tablet
multiphasic
Varying amounts of the two hormones
When should non oral CHC be considered
Those who weigh more than 90kg
Disadvantages of traditional regimen
may be associated with disadvantages such as heavy or painful withdrawal bleeds, headaches, mood changes, and increased risk of incorrect use with subsequent unplanned pregnancy
What needs to be checked on COC follow ups
BMI, BP
What to do if on CHC and have a surgery
Stop 4 weeks before and start 2 weeks after full remobilisation
progestrogen only moa
Thicken cervical mucus to prevent penetration and may inhibit ovulation
When to not give parenteral progestogen
Without full counselling backed by pil
What to counsel parenteral progestogen
Medroxyprogesterone, delayed returned of fertility and irregular cycles after discontinuation, no evidence of permanent infertility
When is norethisterone used
Long acting provides contraception for 8 weeks, used as a short term interim
What is etonogestrel releasing implant ad counselling
Contraception for up to 3 years, may not last three years in heavier women
Intrauterine progestogen only device use and counselling
Release levonorgestrel, used for primary menorrhagia and contraception, fertility return is rapid
Surgery and progestogen
Can be used as normal so often chc is switched to progestogen
When should EHC be given after childbirth
21 days after
When should EHC be given after abortion/miscarriage/ectopic pregnancy
5 days
Most effective EHC
Copper IUD
When can copper IUD be used
5 days/5 days after earliest likely calculated ovulation
What may be given concomitantly with CuIUD
Antibiotic
Is copper iud affected by bmi
No
Is CUIUD affected by drugs
No
Two hormonal EHC
Levorgestrel and ulipristal acetate
When is levonorgestrel used
3 days(96 hours unlicensed)
When is ulipristal used
5 days
What is more hormonal oral effective ehc
Ulipristal
High BMI >26/70kg and ehc
Levonorgestrel efficacy reduced so use uliprstal or double dose levonorgestrel not known what is more effective
When to start normal contraception after levonorgestrel
Immediately but use condoms/abstain until effective
When to start contraception after ulipristal
Wait 5 days, use a condom even afterwards until contraception kicks in
Treating vaginal atrophy
Topical oestrogen in smallest effective amount can also use MR vaginal tablets and impregnated vaginal ring
Issues with systemic vagnal atrophy treatment
risk of endometrial hyperplasia and carcinoma is increased
Treating fungal vaginal infections
Imidazoles 114 days (clotri/miconazole) can be repeated or oral fluconazole/itracconzole use
Treating candiasis in pregnancy
Clotrimazole longer treatment often needed to avoid oral
Predisposing factors to candida
antibacterial therapy, pregnancy, diabetes mellitus, or possibly oral contraceptive use.
Bacterial vaginosis treatment
Clindamycin cream and metronidazole gel
Preventing vaginal infections
Vaginal preparations intended to restore normal acidity may prevent recurrence of vaginal infections
Herpes treatment
Aciclovir, famciclovir, valaciclovir
Trichonomal infection treatment
Metro/tinidazole
Gynae surgery/antibiotic treatment gram negative
Metro
Issue with aqueous medicated douches
may disturb normal vaginal acidity and bacterial flora
Inducing abortion
Mifepristone, misoprostol, gemeprost (prostaglandins and progesterone receptor modulators )
Inducing/augmenting labour
Dinoprostone, oxytocin
Preventing labour
Corticosteroids/ nifedipine / oxytocin
Treating urological pain
Lidocaine
Urinary alkanising agent
Sodium bicarbonate
Treating premature ejaculation
Dapoxetine or other SSRI even TCA
What should be treated first erectile dysfunction or premature ejaculation
Erectile dysfunction
Urinary retention is
Inability to voluntarily urinate
Cause of urinary retention
Drugs(antimuscarinic, TCA) , BPH
When are catheters used to treat urinary retention
No cause or to relieve acute painful urinary retention
Treating acute urinary retention
Immediate catheterization then alphaadrenoceptor blocker when its removed for at least 2 days (alfuzosin, doxazosin, tamsulosin)
Treating chronic urinary retention
Intermittent catheters if not working then indwellin catheter. If moderatesevere then offer alpha adrenoceptor blocker reviewed every 6 weeks then 6 months. If not then bethanechol
Treating urinary retention due to BPH
Alpha adrenoceptor blocker, relax smooth muscle in BPH and produce an increase in urinary flow rate if enlarged then 4alpha reductase (finasteride/dutasteride) if not the surgery
Consideration for dutasteride and finasteride
Contracption needed, report lumps in breasts, women of childbearing potential should avoid , excreted in semen
Renal stone made from
Calcium mainly, uric acid
When are patients susceptible to stone formation
decrease in urine volume and/or an excess of stone forming substances in the urine
Stone formation risk factors
dehydration, change in urine pH, males aged between 40 TO 60 years, positive family history, obesity, urinary anatomical abnormalities, and excessive dietary intake of oxalate, urate, sodium, and animal protein
Symptoms of renal stones
abdominal pain radiating to the groin (known as renal colic) that may be accompanied with nausea, vomiting, haematuria, increased urinary frequency, dysuria and fever
Non drug renal stone treatment
Surgery, drink lots of water, avoid fizzy and limit calcium and salt, avoid oxalate rich foods like nuts or urate rich products like liver kidney
Incontinence treatment
Antimuscarinic, smooth muscle
Antimuscarinic drugs
Oxybutynin, tolterodine, slifenacin
Smooth muscle drugs
mirabegron
Antimuscarinic side effects
Antimuscarinic side effects constipation, dry mouth, sweating, dilation of pupils, dry skin, photophobia, skin flushing, NOTE antimuscarinics can affect the performance of skilled tasks e.g. driving
When to stop HRT
sudden severe chest pain, sudden breathlessness (or cough with blood) unexplained swelling or severe pain in one leg severe stomach pain serious neurological effects including severe, prolonged headache, sudden partial or complete loss of vision, sudden disturbance of hearing, bad fainting attack, unexplained epileptic seizure or weakness, motor disturbances, very marked numbness suddenly affecting one side or one part of body , hepatitis, jaundice, liver enlargement , c/i, blood pressure above systolic 160 mmHg or diastolic 95 mmHg , prolonged immobility after surgery or leg injury
COC cautions
Migraine (report), travel, VTE risk, risk of arterial disease, risk of arterial disease (migraine,obesity,>35, diabetes, hypertension, family history of arterial disease, smoking)
COC side effects
Breast cancer risk increases then disappears 10 years after stopping,
Vomiting/diarrhoea and coc
If within 2 hours take another pil if persistent vomiting in 24 hours and use additional contraception 7 days after recovery
When can you use an emergency contraception IUD and how
Within 120 hours, prophylactically ABx given and STI test, Under 25yo over 25yo and have new partner/recent new partner, or partner has other partner
Who is at higher risk of infection when given IUD and when
First 20 days after insertion
General COC benefits
Reduced risk of ovarian, endometrial and colorectal cancer, Predictable bleeding patterns , Reduced dysmenorrhoea and menorrhagia, Management of symptoms of polycystic ovary syndrome, endometriosis and premenstrual syndrome, Improvement of acne, Reduced menopausal symptoms, Maintaining bone mineral density in perimenopausal females under the age of 50 years
