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CSB601 > Week 12: OB/GYN & Genitourinary - Contraception, HRT, Erectile disorders, Incontinence/BPH > Flashcards

Week 12: OB/GYN & Genitourinary - Contraception, HRT, Erectile disorders, Incontinence/BPH Flashcards

1
Q

Pathophysiology of female reproductive system

A
  • Hypothalamus controls pituitary gland via GnRH (released in pulsate manner to maintain cycle)
  • Pituitary gland then releases LH and FSH which stimulates ovaries to release progesterone and estrogen
  • Menstrual cycle and pregnancy are tightly controlled by both positive and negative feedback loops between hypothalamus, pituitary, ovaries, eggs and uterus
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2
Q

Hormones of the female reproductive system

A

FSH

  • Stimulates maturation of follicle in ovary
  • Causes release of estrogen which peak right before ovulation

LH

  • Stimulate luteal phase of ovulation and promote thickening of endometrium
  • Cause release of progesterone which peaks just before mestruation

Progesterone

  • Responsible for preparing endometrium for pregnancy
  • Thickens in preparation for implantation
  • If egg implants it keeps rising to keep endometrium thick
  • If fertilization does not occur, drops rapidly which results in shedding of endometrium

See menstrual cycle diagram

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3
Q

Contraception

  • Options (All)
  • Options of hormonal contraception
A

Options

  • Hormonal contraception
  • Barrier methods
  • Withdrawal
  • Rhythm or fertility awareness methods
  • Copper IUD
  • Spermicide

Option of hormonal contraception

  • Progestin only (POP)
  • Combined oral contraception (COC)
  • Levonorgestrel IUD
  • Vaginal ring
  • Medroxyprogesterone injection (depot)
  • Etonogestrel implant
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4
Q

Hormonal contraception: POP/Minipill

  • MOA
  • Benefits
  • Risks
A

MOA

  • Thicken cervical mucus to stop sperm from entering cervix preventing fertilization
  • Changes the endometrium to mimic non fertile points of menstrual cycle preventing implantation
  • May suppress ovulation by stopping LH surge

Benefits

  • Can be taken by those who cannot have estrogen
  • Lower risk of blood clot than COC
  • Relatively inexpensive

Risks

  • Harder compliance
  • Slightly less effective than COC
  • Oral - affected by N&V and malabsorption disorders
  • Higher risk of ectopic pregnancy vs COC
  • Can be androgenic (acne, weight gain)
  • Higher incidence of breakthrough bleeding than COC
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5
Q

Hormonal contraception: COC

  • MOA
  • Contraindications
  • Benefits
  • Risks
A

MOA

  • Has progesterone and estrogen to give broad contraceptive coverage
  • Inhibit ovulation (more effective than POP)
  • Reduce receptivity of endometrium to implantation
  • Thicken cervical mucus

Contraindication

  • Breastfeeding
  • Higher risk of clots/stroke/MI if smoker, overweight, high BP, valvular disease, history of clots/VTE/MI/stroke, >40/50
  • History of breast or cervical cancer
  • Patients suffering from migraine with aura

Benefits

  • Higher efficacy that POP
  • Easier compliance
  • Progesterone used are less androgenic than POP
  • Inexpensive

Risk

  • Higher risk blood clots than POP
  • Common causes headache and nausea
  • Oral - affected by nausea and vomiting
  • Taken every day
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6
Q

Hormonal contraception: Hormonal IUD

- MOA

A

MOA

  • Contains only a progesterone
  • Small device inserted into uterus
  • Local effect - releases levonorgastrel in order to change endometrium to prevent implantation and thickened cervical mucus
  • In some women it suppresses ovulation
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7
Q

Hormonal contraception: Vaginal ring

- MOA

A

MOA

  • Contains estrogen and progesterone
  • Thickens cervical mucus forming barrier to sperm passing through cervix
  • Inhibits ovulation through negative feedback loop of both LH and FSH
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8
Q

Hormonal contraception: Depot injection

- MOA

A

MOA

  • Contains progesterone
  • Injected by doctor and creates depot of progesterone that is slowly released over 12 weeks
  • Thickens cervical mucus to create barrier to sperm
  • Change endometrium to prevent implantation
  • Reliably suppresses ovulation (compared to POP)
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9
Q

Hormonal contraception: Contraceptive implant

- MOA

A

MOA

  • Contains only progesterone
  • Inserted subdermally in inner, upper arm every 3 yrs
  • Thickens cervical mucus to prevent sperm entering through cervix
  • Change endometrium to prevent implantation
  • Reliably suppresses ovulation by suppressing LH surge
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10
Q

Emergency contraception

- Options

A

Used to prevent pregnancy after unprotected intercourse or failed contraception

Options

  • Levonorgestrel tablet within 72 hrs (contains progesterone high dose)
  • Ulipristal tablet within 120 hrs (contains progesterone receptor modulator)
  • Copper IUD within 5 days
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11
Q

Pathophysiology of menopause

- Two stages

A
  • Cease to ovulate
  • Occurs naturally with age
  • Produce lower amounts of progesterone and estrogen

Stages

  • Peri menopause (start to decline in hormone levels)
  • Menopause (menstruation stops)
  • Post menopause (all eggs gone)
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12
Q

Causes of menopause

A
  • Naturally with age
  • Drug induced in some chemotherapy agents
  • Hysterectomy/oophorectomy
  • Primary ovarian insufficiency
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13
Q

Clinical presentation of menopause caused by drop in hormone levels of

  • Estrogen
  • Progesterone
  • Testosterone
A

Estrogen

  • Hot flush/tingling
  • Loss of BMD
  • Vaginal dryness/atrophy
  • Fatigue
  • Breast pain/tenderness
  • Headache
  • Weight gain/fat redistribution

Progesterone

  • Hot flushes/tingling
  • Vaginal dryness/atrophy
  • Spotting
  • Fatigue
  • Breast pain/tenderness
  • Headache

Testosterone

  • Hair loss/thinning
  • Altered mood
  • Low libido
  • Forgetfulness
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14
Q

Menopause hormone replacement therapy options

A
  • Tablets - estrogen and progesterone available separately or as combined
  • Patches - estrogen available separately or as combined
  • Gel - Estrogen only
  • Cream and tablets - inserted into vagina
  • IUD - progesterone only
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15
Q

Menopause HRT: Tibolone

  • MOA
  • ADR
A

MOA

  • Estrogenic activity on vagina, bone, thermoregulator centers in brain
  • Progesterone activity on breast tissue and endometrium

ADR

  • Abdominal pain/bloating/weight gain
  • Vaginal bleeding/discharge
  • Dizziness/migraine/nausea
  • Stroke
  • Possible increase in breast cancer and endometrial cancer
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16
Q

Menopause HRT: Tibolone

- Contraindications and cautions

A

Hepatic impairment
- Contra in severe impairment

Renal impairment
- No precautions

Contraindicated

  • Hormone dependent tumor
  • CVD
  • Cease 4 weeks before surgery
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17
Q

Erectile dysfunction

  • Primary
  • Secondary
A

Primary (rare)
- Psychological factors (guilt, depression, anxiety)

Secondary

  • Organic etiology (vascular, hormonal, neurological, structural)
  • Psychological (anxiety, stress, mood disorder)
  • Situational (place, partner, time)
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18
Q

Physiology of an erection

A
  • Cavernosal arteries dilate, engorging corporal tissue with blood
  • Engorging causes corporal tissue to swell, erecting penis
  • Engorged corporal tissue compresses penile veins and venules, maintaining erection
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19
Q

Erectile dysfunction - Non pharmacological treatment

A
  • Remove causative factors
  • CBT/councelling
  • Treat causative factors
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20
Q

Erectile dysfunction - Pharmacological treatment options

A

1st line
- Oral PDE-5 inhibitor

2nd live
- Intracavernosal alprostadil/vacuum device

3rd line
- Intracavernosal combination

4th line
- Penile implant

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21
Q

Erectile dysfunction: PDE-5 inhibitor

  • MOA
  • Examples
A

MOA

  • Inhibit breakdown of cGMP to inactive GMP by PDE-5
  • Allow increased vasodilation and relaxation of corpus cavernosum to increase blood flow during sexual stimulation

Example

  • Sildenafil (Viagra)
  • Tadalafil
22
Q

Erectile dysfunction: PDE-5 inhibitor

- Contraindications and cautions

A

Elderly

  • Risk of hypotension
  • Require low dose - assess exercise tolerance
  • Half life is increased

Hepatic impairment

  • Low dose in mild/mod
  • Do not use in severe

Renal impairment
- Low dose in moderate impairment

Contraindications

  • Migraine
  • NO donors
  • CVD
  • Leukaemia
  • Sickle cell anaemia
23
Q

Erectile dysfunction: Alprosadil

  • MOA
  • ADR
A

MOA

  • Local injection
  • Prostaglandin E1 analogue - dilates arteries in corpus cavernosum
  • Relax smooth muscle of corpus cavernosum and spongiosum

ADR

  • Penile pain
  • Priapism
  • Brusing/injection site reaction
  • Fibrotic changes
  • Hypotension/fainting/dizziness
24
Q

Erectile dysfunction: Alprosadil

- Contraindications and cautions

A

Elderly

  • Assess exercise tolerance
  • Higher risk of orthostatic hypotension

Hepatic and Renal impairment
- No precautions

Caution
- Men with HIV/HepB/C

Contraindication

  • Penile implant
  • Anatomical deformities of penis
25
Q

Priapism

  • Definition
  • Treatment
A

Definition
- Prolonged painful erection

Treatment
- 2 hrs = hot shower and pseudoephedrine 120mg (cold and flu vasoconstrictor)
- 2-4 hrs = repeat previous treatment and phone doctor
- >6 hrs = hospital to aspirate and drain corpora cavernosa, infusion of adrenergic drug to contract smooth muscle
If aspirate not successful a surgical stunt required

26
Q

Types of urinary incontinence

A
  1. Urge incontinence
    - Bladder over sensitivity from infection or neurological disorders
  2. Stress incontinence
    - Reduce pelvic floor
    - Increased abdominal pressure (pregnancy)
  3. Overflow incontinence
    - Urethral blockage
    - Bladder unable to empty properly
27
Q

Urinary incontinence - risk factors

A
  • UTI
  • Menopause
  • Obesity
  • Constipation
  • Neurological/ musculoskeletal conditions
  • Diabetes
  • BPH
  • Pregnancy/vaginal delivery
  • Medication
  • Advanced age
28
Q

Urinary incontinence - management

- Non pharmacological options

A
  • Bladder diary
  • Manage underlying contributing factors
  • Pelvic floor exercises/bladder training
  • Schedual voiding
  • Incontinence pads
29
Q 
Urinary incontinence - management
- Pharmacological options
1st line = anticholinergics
- MOA
- Example
- ADR
A

1st line = Anticholinergics

MOA
- Block cholinergic receptors on bladder to reduce contractility and increase bladder capacity

Example

  • Oxybutynin
  • Solifenacin

ADR

  • Confusion
  • Constipation
  • Dry mouth
  • Blurred vision
  • Urinary retention
  • Drowsiness
  • Dizziness
30
Q

Urinary incontinence - management
- Pharmacological options
1st line = anticholinergics
- Contraindications and cautions

A

Elderly

  • More likely to experience ADR
  • Start low and go slow

Hepatic impairment
- Reduce dose

Children

  • Prefer oxybutynin
  • Can be used from age 5

Pregnancy and breastfeeding

  • Limited data
  • See specialist

Renal impairment
- Reduce dose

Caution

  • Those with urinary overflow secondary to urinary retention
  • Bladder outlet obstruction
  • Avoid combination with other drugs that have anticholinergic effects
31
Q 
Urinary incontinence - management
- Pharmacological options
2nd line = Desopressin
- Indication
- MOA
- ADR
A

Indication

  • Nocturnal enuresis in children 5 and over
  • Available as oral spray and wafer

MOA

  • Bind to V2 receptor in collecting duct of nephron
  • Increases amount of water reabsorbed from urine back into kidney

ADR

  • Hyponatremia/fainting/seizure/coma
  • Nasal irritation/nausea
32
Q

Urinary incontinence - management
- Pharmacological options
2nd line = Desopressin
- Contraindications and caution

A

Elderly
- Not indicated for

Children
- Oral tablets and wafers preferred to spray due to increased risk of hyponatremia with spray

Caution in children who cannot comply with fluid restrictions

33
Q 
Urinary incontinence - management
- Pharmacological options
2nd line = Mirobegron
- MOA
- ADR
A

For adults and can take up to 8 weeks to see effect

MOA

  • Beta3 receptor agonist on bladder muscle
  • Relax bladder muscle as it fills and increases bladder capacity

ADR

  • Increased BP
  • UTI
  • Headache
  • Tachycardia
34
Q

Urinary incontinence - management
- Pharmacological options
2nd line = Mirobegron
- Contraindications and caution

A

Elderly

  • More likely to see hepatic/renal/HT/arrhythmia effect
  • Start low and go slow

Hepatic impairment

  • Low dose for mode impairment
  • Avoid in severe impairment

Children
- Not indicated

Pregnancy and breastfeeding
- No data; avoid if possible

Renal impairment

  • Reduce dose
  • Do not use in severe impairment

Caution

  • Hypertension
  • Severe uncontrolled HT or arrhythmia
35
Q

Benign Prostatic hyperplasia/hypertrophy

- Size of prostate

A
  • Prostate generally gets larger over time
  • Exact cause of BPH is unknown
  • Size of prostate directly linked to testosterone
  • As it enlarges it narrows urethra and puts pressure on bladder
36
Q

BPH symptoms and presentations

A

Lower urinary tract symptoms (Voiding or obstructive)

  • Hesitancy
  • Weak and poorly directed stream
  • Straining to urinate
  • Dribbling after urination has finished or irregular stream
  • Urinary retention
  • Overflow or paradoxical incontinence

Lower urinary tract symptoms (storage or irritative)

  • Urgency
  • Frequency
  • Nocturnal

Other symptoms

  • Perineal pain
  • Dysuria
  • Haemoturia
37
Q

BPH

  • Diagnosis
  • Treatment options
A

Diagnosis

  • Blood test for PSA
  • Physical exam for DRE
Treatment options
- No treatment
- Oral medicines
> Alpha blockers
> PDE-5 inhibitors
> 5-alpha reductase inhibitors
- Surgery
> Transurethral resection of prostate
> Transurethral incision of prostate
> Open or retropubic prostatectomy
- Laser treatment
38
Q

BPH pharmacological treatment - 5-alpha reductase inhibitor

  • MOA
  • Example
A

MOA

  • 5-alpha reductase is enzyme which converts testosterone to dihydrotestosterone (more potent and stimulates prostate growth)
  • Results in reduced size of prostate allowing better urinary flow

Example

  • Dutasteride
  • Finasterise
39
Q

BPH pharmacological treatment - 5-alpha reductase inhibitor

- Contraindications and cautions

A

Elderly
- Caution with fixed combination dutasteride and tamsulosin due to increased risk of hypotention

Children
- Not indicated

Pregnancy
- Caution - should not handle capsules or tablets

40
Q

BPH pharmacological treatment - Selective alpha blockers

  • MOA
  • Examples
A

MOA

  • Selectively block alpha 1 receptor
  • Relaxes smooth muscle of bladder neck and prostate which results in decrease in resistance to urinary flow

Example

  • Tamsulosin
  • Prazosin
41
Q

BPH pharmacological treatment - Selective alpha blockers

- Contraindications and cautions

A

Elderly

  • Avoid prazosin
  • Use other options with caution
  • More susceptable to orthostatic hypotension

Hepatic impairment

  • Contraindicated with alfozosin
  • Caution with use of other options

Children
- Not indicated

Renal impairment
- Worsened first dose hypotension; begin treatment cautiously

Caution
- Patients already on anti hypertensives due to risk of hypotension

42
Q

UTI classification

  • Types
  • Uncomplicated
  • Complicated
A

Types

  • Cystitis = infection of bladder
  • Urethritis = infection of urethra
  • Epididymitis = infection of epididymis
  • Pyelonephritis = infection of kidney/upper urinary tract

Uncomplicated

  • Premenopausal
  • Non-pregnant
  • Adult women with no structural/functional abnormality
  • Recurrence = within 2 weeks of 1st infection
  • Reinfection = > 2 weeks from 1st infection

Complicated

  • Not uncomplicated
  • Chronic recurring
  • Children
  • Pregnancy
  • Anatomical/functional abnormality
  • Comorbidities
43
Q

UTI risk factors

A
  • Female
  • Sexual activity
  • Age
  • Immunosuppresant
  • Genetic
  • Catheter use
  • Dehydration
  • Pregnancy
  • Diabetes
  • Antibiotic use
  • Inability to completely void bladder (paralysis or stroke)
44
Q

UTI Pathophysiology

A
  • Upper urinary tract and bladder are normally sterile
    > Opening to these tracts are not
    > Bladder normally clears itself by completely voiding urine
    > Acidity of urine helps kill bacteria

Infection of upper urinary tract - kidney causes easy hematogenous spread to surrounding tissue and sepsis and shock can occur quickly

45
Q

UTI presentation/symptoms

  • Common/uncomplicated adult
  • Pyeloephritis
  • Elderly
  • Children under 2
A

Common/uncomplicated adult

  • Dysuria
  • Increased frequency
  • Urgency
  • Suprapubic pain
  • Hematuria

Pyelonephritis

  • Fever/chills
  • Pain in back/lower abdomen

Elderly

  • Often asymptomatic
  • Confusion
  • Loss of appetite
  • Flu like symptoms

Children under 2

  • Often non specific
  • Fever
  • General unhappiness/failure to thrive
  • Loss of appetite
  • Abdominal pain
  • Vomiting
46
Q

UTI complications if untreated

A
  • Recurrent infection
  • Permanent kidney damage
  • Pregnancy - low birth weight or premature birth
  • Urethral stricture (male)
  • Sepsis - death (common in elderly)
47
Q

UTI diagnosis

A
  • Urine sample
  • CT/MRI (if anatomical abnormality suspected)
  • Cytoscopy (visualize tract and bladder)
48
Q

UTI treatment

  • Non pharmacological
  • OTC/Herbal
A

Non pharmacological

  • Drink fluid
  • Avoid acidic drink and caffeine
  • Heating pads

OTC/Herbal

  • Urinary alkaliniser - symptomatic relief
  • Cranberry
  • Hexamine hippurate
49
Q

UTI treatment

- Antibiotics (general info)

A

Antibiotic resistance is growing
- Keep course short as possible
If asymptomatic only treat children and pregnant women

50
Q

UTI treatment
Uncomplicated UTI
- Antibiotics
> Examples

A

Antibiotics

  • Short term
  • Oral

Example

  • Trimethoprim (3days)
  • Cephalexin (5days)
  • Amoxycillin + clavulanate (5 days)
51
Q 
UTI treatment
Complicated UTI
- Pregnant
- Men
- Pyelonephritis (mild)
- Pyelonephritis (severe)
A

Pregnant
- Same as uncomplicated but no trimethoprim

Men
- Same as uncomplicated but all for 7 days

Pyelonephritis (mild)
- Same as uncomplicated but for 10-14 days

Pyelonephritis (severe)
- IV antibiotics

52
Q

UTI treatment for recurrent UTI

A

Long term treatment
- Trimethoprim oral daily for 3-6 months
OR
- Cephalexin oral daily doe 3-6 months

If sexual intercourse is cause can use antibiotic when sex occurs rather than daily

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