BNF - Chapter 7 - Genito-Urinary System Flashcards
(294 cards)
1
Q
What is urinary incontinence?
A
Urinary incontinence is the involuntary leakage of urine and can range in severity and nature.
2
Q
What can urinary incontinence be due to?
A
can be the result of functional abnormalities in the lower urinary tract, or due to other illnesses.
3
Q
How many sub classes of urinary incontinence are there?
A
4
4
Q
What are the subclasses of urinary incontinence?
A
- Stress
- Urgency
- mixed
- Overflow incontinence
5
Q
What is stress incontinence?
A
Stress incontinence is the involuntary leakage on effort or exertion, or on sneezing or coughing, and is associated with the loss of pelvic floor support and/or damage to the urethral sphincter.
6
Q
What is urgency incontinence?
A
Urgency incontinence is involuntary leakage which is accompanied, or immediately preceded by a sudden compelling desire to pass urine that is difficult to delay. It is often part of a larger symptom complex known as overactive bladder syndrome. This syndrome is defined as urinary urgency, which may or may not be accompanied by urgency incontinence, but is usually associated with increased frequency and nocturia. The symptoms are thought to be caused by involuntary contractions of the detrusor muscle
7
Q
What is mixed incontinence?
A
Mixed urinary incontinence is involuntary leakage associated with both urgency and stress, however, one type tends to be predominant.
8
Q
What is overflow incontinence?
A
Overflow incontinence is a complication of chronic urinary retention and occurs when a person cannot empty their bladder completely and it becomes over distended.
This may result in continuous, or frequent loss of small quantities of urine
9
Q
What are some other types of urinary incontinence?
A
Other types include continuous urinary incontinence, where there is constant leakage of urine which may be due to the severity of the persons’ condition or may be due to an underlying cause, such as a fistula. Incontinence may also be situational, for example during sexual intercourse or when a person is giggling.
10
Q
What is the main risk factor for developing any type of incontinence?
A
- Older age; this is due to the physiological changes that occur with natural aging
11
Q
Other than age what are some other risk factors of stress incontinence?
A
pregnancy, vaginal delivery, obesity, constipation, family history, smoking, lack of supporting tissue (such as in prolapse or hysterectomy) and use of some drugs such as ACE inhibitors (can cause cough) and alpha-adrenergic blockers (relax the bladder outlet and urethra).
12
Q
Which conditions may increase detrusor muscle overactivity and therefore worsen urgency incontinence?
A
These include conditions that affect the lower urinary tract such as; Urinary-tract infections, urinary obstruction, or oestrogen deficiency, those affecting the nervous system such as; stroke, dementia, and Parkinson’s disease, and systemic conditions such as; diabetes mellitus or hypercalcaemia
13
Q
Side effects of some durgs may also increase detrusor muscle overactivity or indirectly contribute to urgency incontinence; what do they include?
A
cholinesterase inhibitors, drugs that cause constipation, and those with anticholinergic effects.
14
Q
What effect do diuretics, alcohol and caffeine have?
A
They all increase urine production and can cause polyuria, frequency, urgency and nocturia
15
Q
What non drug treatment advice is given to women with incontinence?
A
- modify fluid intake
- if BMI is 30kg/m2 or greater, be advised to lose weight
- For those with an overactive bladder, a reduction in caffeine intake should be trialled.
16
Q
When can intravaginal and intraurethral devices be used?
A
Should only be used when required to prevent leakage at specific times, for example during exercise
17
Q
What is the non drug treatment for urgency incontinence in women?
A
Women should be offered bladder training for at least 6 weeks as first-line treatment.
If frequency is a problem and satisfactory benefit from bladder training is not achieved, drug treatment for an overactive bladder should be added.
18
Q
What is the non-drug treatment for stress incontinence?
A
Women should trial supervised pelvic floor muscle training for at least 3 months, which should include at least 8 contractions performed 3 times per day
19
Q
What is the non-drug treatment for mixed incontinence?
A
Women should trial both bladder training for at least 6 weeks and supervised pelvic floor muscle training for at least 3 months, which should include at least 8 contractions performed 3 times per day. If frequency is a problem and satisfactory benefit from bladder training is not achieved, drug treatment for an overactive bladder should be added.
20
Q
What should be performed in all women presenting with incontinence?
A
A urine dipstick test should be performed in all women presenting with incontinence to test for active infection or haematuria, and analysed along with the patients symptoms.
21
Q
When should women be referred to see a specialist?
A
if there is:
persistent bladder or urethral pain;
pelvic mass that is clinically benign;
associated faecal incontinence;
suspected neurological disease, or urogenital fistulae;
history of previous incontinence surgery, pelvic cancer surgery or pelvic radiation therapy;
recurrent or persistant UTI for those aged over 60; see Urinary-tract infections
palpable bladder after voiding, or symptoms of voiding difficulty.
22
Q
When is an urgent referral required?
A
Urgent referral should occur in women aged 45 years or older if there is unexplained visible haematuria without UTI, or visible haematuria persisting or recurring despite successful treatment of UTI. Urgent referral is also required in women aged 60 years or older with unexplained non-visible haematuria and either dysuria or raised white cell count.
23
Q
What is the drug treatment for urgency incontinence?
A
An anticholinergic drug should be considered for women who have trialled bladder training, where frequency is a problem and symptoms persist.
24
Q
What is first-line drug-treatment for urgency incontinence?
A
Immediate release oxybutynin hydrochloride, immediate release tolterodine tartrate, or darifenacin can be used first-line
25
In which women should immediate release oxybutynin not be used in?
mmediate release oxybutynin should not be used in frail, older women at risk of sudden deterioration in their physical or mental health.
26
Is transdermal oxybutynin an option?
Transdermal oxybutynin hydrochloride may be used in those unable to tolerate oral treatment.
27
Which drug may be used if treatment with an anticholinergic is contraindicated, ineffective or not tolerated?
Mirabegron
28
Within how long should treatment be reviewed?
After 4 weeks or sooner if required
If treatment is effective review the woman again at 12 weeks, then annually thereafter, or every 6 months if the woman is over 75 years of age.
29
What can be done for urgency incontinence if first anticholinergic drug has not been effective or not tolerated?
an alternative anticholinergic drug can be used, the current dose adjusted or, mirabegron trialled; review again after 4 weeks.
30
Which alternative anticholinergics can be used?
Alternative anticholinergics include, an untried first-line drug, or one of the following; fesoterodine fumarate, propiverine hydrochloride, solifenacin succinate, trospium chloride, or an extended release formulation of either oxybutynin hydrochloride or tolterodine tartrate.
31
For women who have tried taking medicine for overactive bladder but treatment has failed who should they be referred to?
should be referred to secondary care, where treatment with botulinum toxin type A or surgical methods may be considered
32
which drugs should not be used for incontinence in women?
Flavoxate hydrochloride, propantheline bromide, or imipramine hydrochloride should not be used as treatment options.
33
In women who have troublesome nocturia what may be used?
Desmopressin may also be used
34
What can be used in women who are post-menopausal and have vaginal atrophy?
Intravaginal oestrogen therapy can be used in those women who are post-menopausal and have vaginal atrophy.
Treatment should be reviewed at least annually to re-assess the need for continued treatment and monitor for symptoms of endometrial hyperplasia or carcioma
35
Which drug can be used for stress incontinence in women?
Duloxetine is not recommended as first-line treatment for women with stress incontinence. It may be used second-line where conservative treatment including pelvic floor training has failed, and only if surgery is not appropriate or the woman prefers pharmacological treatment, but should not be offered routinely.
36
Whats the drug treatment for mixed incontinence?
Women with mixed urinary incontinence should be treated according to the predominant type, refer to Urgency incontinence or Stress incontinence for drug treatment options.
37
What are the symptoms of pelvic organ prolapse?
Symptoms can include a vaginal bulge or sensation of something coming down, urinary, bowel and sexual symptoms, and pelvic and back pain. These can all affect a woman's quality of life.
38
For pelvic organ prolapse - women should be given what advice?
Women should be given advice on minimising 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.
39
What is nocturnal enuresis?
Nocturnal enuresis is the involuntary discharge of urine during sleep, which is common in young children.
40
By what age is it expected for children to stop wetting the bed?
expected to be dry by a developmental age of 5 years, and historically it has been common practice to consider children for treatment only when they reach 7 years;
however, symptoms may still persist in a small proportion by the age of 10 years.
41
Is treatment for nocturnal enuresis recommended for children under 5?
No
treatment is usually unnecessary as the condition is likely to resolve spontaneously. Reassurance and advice can be useful for some families.
42
What non-drug treatment advice can be given for nocturnal enuresis?
Initially, advice should be given on fluid intake, diet, toileting behaviour, and use of reward systems. For children who do not respond to this advice (more than 1–2 wet beds per week), an enuresis alarm should be the recommended treatment for motivated, well-supported children. Alarms in children under 7 years should be considered depending on the child’s maturity, motivation and understanding of the alarm. Alarms have a lower relapse rate than drug treatment when discontinued.
43
Treatment using an alarm should be reviewed after how many weeks?
After 4 weeks and continued until a minimum of 2 weeks' uninterrupted dry nights have been achieved.
If complete dryness is not achieved after 3 months but the condition is still improving and the child remains motivated to use the alarm, it is recommended to continue the treatment.
44
If the initial alarm treatment is not working which drug may be used alone or combination with the alarm?
Combined treatment with desmopressin, or the use of desmopressin alone, is recommended if the initial alarm treatment is unsuccessful or it is no longer appropriate or desirable.
45
What formulations of desmopressin can be used in children for nocturnal eneruses?
- Oral or sublingual desmopressin
46
Desmopressin is recommended for ages over what?
Over 5 years old. when alarm use is inappropriate or undesirable, or when rapid or short-term results are the priority (for example, to cover periods away from home).
47
Can desmopressin be used alone?
Desmopressin alone can also be used if there has been a partial response to a combination of desmopressin and an alarm following initial treatment with an alarm alone.
Treatment should be assessed after 4 weeks and continued for 3 months if there are signs of response.
48
Can repeated courses of desmopressin be used?
Repeated courses of desmopressin can be used in responsive children who experience repeated recurrences of bedwetting, but should be withdrawn gradually at regular intervals (for 1 week every 3 months) for full reassessment.
49
Which tricyclic antidepressant can be used for children who have not responded to all other treatments and have undergone specialist assessment?
- Imipramine;
however relapse is common after withdrawal and children and their carers should be aware of the dangers of overdose. Initial treatment should continue for 3 months; further courses can be considered following a medical review every 3 months. Tricyclic antidepressants should be withdrawn gradually.
50
What class of drug does mirabegron belong to?
A beta 3 agonist - licensed for the treatment of urinary incontinence associated with overactive bladder syndrome
51
What are the side effects of antimuscarinics?
- constipation
- dizziness
- drowsiness
- dry mouth
- dyspepsia
- flushing
- headache
- nausea
- palpitations
- skin reactions
- tachycardia
- urinary disorders
- vision disorders
- vomiting
52
Give examples of some antimuscarinics?
- Darifenacin
- Fosoterodine
- Flavoxate
- Oxybutynin
- propiverine
- Solifenacin
- Tolterodine
- Trospium chloride
53
Give an example of Beta adrenoreceptor 3 agonist?
Mirabegron
Used for urinary frequency, urgency and urge incontinence
54
What is urinary retention?
The inability to voluntarily urinate
55
What may urinary retention be due to?
It may be secondary to urethral blockage, drug treatment (such as use of antimuscarinic drugs, sympathomimetics, tricyclic antidepressants), conditions that reduce detrusor contractions or interfere with relaxation of the urethra, neurogenic causes, or it may occur postpartum or postoperatively.
56
What is acute urinary retention?
Acute urinary retention is a medical emergency characterised by the abrupt development of the inability to pass urine (over a period of hours)
57
What is chronic urinary retention?
Chronic urinary retention is the gradual (over months or years) development of the inability to empty the bladder completely, characterised by a residual volume greater than one litre or associated with the presence of a distended or palpable bladder.
58
What is the most common type of urinary retention in men?
- benign prostatic hyperplasia
Men with an enlarged prostate can have lower urinary tract symptoms associated with obstruction, such as urinary retention (acute or chronic), frequency, urgency or nocturia.
59
When is catherisation used?
It is used to relive acute painful urinary retention or when no cause can be found
60
What is used to correct mechanical outflow obstructions?
Surgical procedures or dilation are often used to correct mechanical outflow obstructions
61
Is acute retention painful?
Yes
62
What does acute retention require treatment by?
Acute retention is painful and requires immediate treatment by catheterisation
63
For the treatment of acute retention before the catheter is removed which drug is given?
Before the catheter is removed an alpha-adrenoceptor blocker (such as alfuzosin hydrochloride, doxazosin, tamsulosin hydrochloride, prazosin, indoramin or terazosin) should be given for at least two days to manage acute urinary retention.
64
What is the treatment for chronic urinary retention?
- intermittent bladder catherization should be offered before an indwelling catheter
- Catheters may be used as a long-term solution where persistent urinary retention is causing incontinence, infection, or renal dysfunction and a surgical solution is not feasible.
65
Can drug treatment be used for urinary retention?
In men who have symptoms that are bothersome, drug treatment should only be offered when other conservative management options have failed
66
Which drug treatment can be used for urinary retention?
Men with moderate-to-severe symptoms should be offered an alpha-adrenoceptor blocker (alfuzosin hydrochloride, doxazosin, tamsulosin hydrochloride or terazosin).
67
How often should treatment be reviewed?
Treatment should initially be reviewed after 4–6 weeks and then every 6–12 months
68
Do you treat urinary retention due to benign prostate hyperplasia straight away?
Watchful waiting is suitable for men with symptoms that are not troublesome and in those who have not yet developed complications of benign prostatic hyperplasia such as renal impairment, urinary retention or recurrent infection
69
What is the recommended treatment of benign prostatic hyperplasia?
The recommended treatment of benign prostatic hyperplasia is usually an alpha-adrenoceptor blocker
70
what effect do alpha blockers have in benign prostatic hyperplasia?
The alpha1-selective adrenoceptor blockers relax smooth muscle in benign prostatic hyperplasia producing an increase in urinary flow-rate and an improvement in obstructive symptoms.
71
In which patients may a 5alpha-reductase inhibitor such as finasteride or dutasteride be used?
In patients with an enlarged prostate, a raised prostate specific antigen concentration, and who are considered to be at high risk of progression (such as the elderly)
72
Can a combination of alpha blocker and 5alpha-reductase inhibitor be used?
Yes - A combination of an alpha-adrenoceptor blocker and a 5α-reductase inhibitor can be offered if symptoms remain a problem.
73
Is surgery an option?
Surgery is recommended for men with more severe symptoms that do not respond to drug therapy, or who have complications such as acute urinary retention, haematuria, renal failure, bladder calculi or recurrent urinary-tract infection.
74
What effect should be advised and noted about the first dose of an alpha blocker?
- The first dose may cause hypotension, so it should be taken at night, following this the next doses should be taken in the morning
75
Is dutasteride and finasteride excreted in semen?
Yes and use of condom is recommended if sexual partner is pregnant or likely to become pregnant
76
What should be noted for women of childbearing age handling open tablets of dutasteride and finasteride?
women of childbearing potential should avoid handling leaking capsules of Dutasteride and crushed or broken tablets of Finasteride
77
Cases of what cancer have been associated with 5 alpha reductase inhibitor use?
cases of male breast cancer have been reported. Patients should report any changes in breast tissue such as lumps, pain or nipple discharge.
78
What else has the MHRA released warning of with finasteride?
Reports of depression and in rare cases suicidal thoughts in men taking finasteride; patient should be asked to stop finasteride immediately and le their GP know
- Also male pattern hair loss;
-
79
What is urolithiasis?
Kidney stones (also called renal calculi, nephrolithiasis or urolithiasis) are hard deposits made of minerals and salts that form inside your kidneys. Diet, excess body weight, some medical conditions, and certain supplements and medications are among the many causes of kidney stones
80
When do renal stones develop?
Renal and ureteric stones are crystalline calculi that may form anywhere in the upper urinary tract.
81
Are kidney stones painful?
They are often asymptomatic but may cause pain when they move or obstruct the flow of urine.
82
What are most stones composed of?
- Calcium salts (calcium oxalate, calcium phosphate or both)
The rest are composed of struvite, uric acid, cystine and other substances.
83
When are patients susceptible to stone formation?
Patients are susceptible to stone formation when there is a decrease in urine volume and/or an excess of stone forming substances in the urine.
84
What are the risk factors that have been associated with stone formation?
dehydration, change in urine pH, males aged between 40–60 years, positive family history, obesity, urinary anatomical abnormalities, and excessive dietary intake of oxalate, urate, sodium, and animal protein.
Certain diseases which alter urinary volume, pH, and concentrations of certain ions (such as calcium, phosphate, oxalate, sodium, and uric acid) may also increase the risk of stone formation.
Certain drugs such as calcium or vitamin D supplements, protease inhibitors, or diuretics may also increase the risk of stone formation.
85
What are symptoms of acute renal or ureteric stones?
Symptoms of acute renal or ureteric stones can include an abrupt onset of severe unilateral abdominal pain radiating to the groin (known as renal colic) that may be accompanied with nausea, vomiting, haematuria, increased urinary frequency, dysuria and fever (if concomitant urinary infection is present)
86
Can stones pass on their on?
Stones can pass spontaneously and will depend on a number of factors, including the size of the stone (stones greater than 6 mm have a very low chance of spontaneous passage),
87
Are distal ureteral stones or proximal ureteral stones more likely to pass?
the location (distal ureteral stones are more likely to pass than proximal ureteral stones)
88
What are the non-drug treatments of renal and ureteric stones?
- consider watchful waiting for asymptomatic renal stones if they are less than 5mm in diameter
- Consider stone analysis and measure serum calcium in patients with recurring renal or ureteric stones.
- Along with maintaining a healthy lifestyle, advise patients to drink 2.5–3 litres of water a day with the addition of fresh lemon juice and to avoid carbonated drinks
- Maintain a normal daily calcium intake of 700–1,200mg and salt intake of no more than 6g a day
- For patients with recurrent calcium stones avoid excessive intake of oxalate-rich products, such as rhubarb, spinach, cocoa, tea, nuts, soy products, strawberries, and wheat bran.
- For patients with recurrent uric acid stones, avoid excessive dietary intake of urate rich products, such as liver, kidney, calf thymus, poultry skin, and certain fish (herring with skin, sardines and anchovies).
89
What is the drug management for renal and ureteric stones?
- Offer NSAIDs as first line treatment for the management of pain associated with suspected renal colic or renal and ureteric stones.
90
If NSAIDs are not working or are contraindicated then what should be offered next?
Consider intravenous paracetamol
91
What if both paracetamol and NSAIDs are contraindicated?
Subsequently, opioids can be used if both paracetamol and NSAIDs are contraindicated or not sufficiently controlling the pain
92
Can antisposmodics be used in patients with suspected renal colic?
No
93
What is used topically in urethral pain?
Lidocaine hydrochloride gel is a useful topical application in urethral pain or to relieve the discomfort of catheterisation.
94
Alkalinisation of urine can be undertaken with which compound?
With potassium Citrate
The alkalinising action may relieve the discomfort of cystitis caused by lower urinary tract infections.
95
Which other drug is used as a urinary alkalinising agent?
Sodium bicarbonate is used as a urinary alkalinising agent in some metabolic and renal disorders.
96
What is licensed for the management of common infections of the bladder in patients with an indwelling urinary catheter?
Chlorhexidine solution given as bladder irrigation is licensed for the management of common infections of the bladder in patients with an indwelling urinary catheter.
97
Does chlorhexidine have a narrow or broad spectrum of activity?
Chlorhexidine has broad spectrum activity against many Gram-positive and Gram-negative bacteria but it is ineffective against most Pseudomonas spp.
98
What can chlorhexidine solutions cause?
they may irritate the mucosa and cause burning on micturition (in which case they should be discontinued).
99
What is licensed in bladder infection for use as a routine mechanical irrigant to flush out debris, small blood clots, or tissue in catheters?
Sterile sodium chloride solution 0.9% (physiological saline)
100
What is licensed for the management of superficial bladder tumours?
Bladder instillations of doxorubicin hydrochloride and mitomycin are licensed for the management of superficial bladder tumours.
101
What are the two types of hormonal contraception?
- Combined hormonal contraception (oestrogen and a progestogen)
- Progestogen-only contraception
102
Which methods of contraception are considered to be 'highly effective'?
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))
103
What formulations are combined hormonal contraceptives (CHC) available as?
- Tablets (COC)
- Transdermal patches (CTP)
- Vaginal rings (CVR)
104
What is the failure rate with Combined hormonal contraception?
They are highly user-dependant methods where the failure rate if used perfectly (i.e. correctly and consistently) is less than 1%.
105
What may contribute to contraceptive failure?
Certain factors such as the person's weight, malabsorption (COC only), and drug interactions may contribute to contraceptive failure.
106
After what age is is not recommended to no longer use combined hormonal contraception?
It is recommended that combined hormonal contraceptives are not continued beyond 50 years of age as safer alternatives exist.
107
What benefits may combined hormonal contraception be associated with?
CHC use may be associated with some health benefits such as:
Reduced risk of ovarian, endometrial and colorectal cancer;
Predictable bleeding patterns;
Reduced dysmenorrhoea and menorrhagia;
Management of symptoms of polycystic ovary syndrome (PCOS), endometriosis and premenstrual syndrome;
Improvement of acne;
Reduced menopausal symptoms;
Maintaining bone mineral density in peri-menopausal females under the age of 50 years.
108
What is monophasic COC?
Combined oral contraceptives (COCs) containing a fixed amount of an oestrogen and a progestogen in each active tablet are termed ‘monophasic’; those with varying amounts of the two hormones are termed ‘multiphasic’.
109
Which oestrogens are usually used in COC?
Combined oral contraceptives usually contain ethinylestradiol as the oestrogen component; mestranol and estradiol are also used. The ethinylestradiol content of COCs range from 20–40 micrograms.
110
Which COC combination is used as first line option?
A monophasic preparation containing 30 micrograms or less of ethinylestradiol in combination with levonorgestrel or norethisterone (to minimise cardiovascular risk), is generally used as the first line option.
111
In females who weigh 90kg or more is topical combined hormonal contraception suitable?
In females who weigh 90 kg or more, consider non-topical options or use additional precautions with CTP.
112
How many days pills are in COC?
21 days
| then 7 day pill free interval period
113
Give examples of monophasic COC (21 days preparations)?
```
Femodette
Marvelon
Tasmin
Femodene
Levest
Microgynon
Ovranette
Rigevidon
Clique
Lizinna
```
114
Give examples of monophasic COC (28 day preparations)?
Microgynon ED
Femodene ED
Zoely
115
Give examples of COC multiphasic preparations?
Logynon/ logynon ED
TriRegol
Synphase
Qlaira
116
In COC 21 day CHC when would the withdrawal bleed occur?
withdrawal bleed during the 7 day hormone free interval (HFI),
117
Is continuous use: continuous CHC use with no HFI a licensed use?
No may be used but it is not licensed
118
Do withdrawal bleeds represent physiological menstruation?
No and there is no difference in efficacy or safety of using traditional 21 day regimen
119
What disadvantages may use of the traditional 21 day regimen be associated with?
heavy or painful withdrawal bleeds, headaches, mood changes, and increased risk of incorrect use with subsequent unplanned pregnancy
120
Do withdrawal bleed during the 7 day pill free period with CHC indicate not pregnant - for pregnancy status?
Withdrawal bleeds during traditional CHC use has been reported in females who are pregnant and should therefore not be relied on as reassurance of a person's pregnancy status.
121
What monitoring should be one annually with CHC?
Body mass index and blood pressure should also be checked annually.
122
When and how long should CHC be discontinued?
CHC use should be discontinued at least 4 weeks prior to major elective surgery, any surgery to the legs or pelvis, or surgery that involves prolonged immobilisation of a lower limb.
An alternative method of contraception should be used to prevent unintentional pregnancy, and CHC may be recommenced 2 weeks after full remobilisation.
123
What if discontinuation of CHC is not possible?
When discontinuation is not possible, e.g. after trauma or if a patient admitted for an elective procedure is still on CHC, thromboprophylaxis should be considered.
124
Which formulations are progestogen only contraceptives available in?
Progestogen-only contraceptive options are available in oral, injectable, subdermal, and intra-uterine form
125
Oral progestogen only preparations contain one of which three?
levonorgestrel, norethisterone, or desogestrel
126
Which of the three may be better at giving relief for dysmenorrhoea and why?
Oral progestogens may suppress ovulation to varying extents, for example, up to 60% of cycles are anovulatory in females using a levonorgestrel pill, whereas ovulation is suppressed in up to 97% of cycles in females taking a desogestrel pill. As ovulation is suppressed more consistently with desogestrel, it may have benefits over levonorgestrel and norethisterone, such as improving symptoms of dysmenorrhoea.
127
Which parenteral long-acting progestogens are available?
Parenteral long-acting progestogens include the injections medroxyprogesterone acetate and norethisterone enantate, and the implant etonogestrel
These are long-acting reversible contraceptive options that work primarily by suppressing ovulation along with other progestogenic effects
128
Why may parenteral long acting progestogens benefit those with menstrual problems?
As they often lead to amenorrhoea or reduced bleeding, they may benefit those with menstrual problems (such as heavy bleeding or dysmenorrhoea).
129
What is the failure rate for injectable progestogen-only contraception during the first year?
0.2% with perfect use (used consistently and correctly)
130
How often is medroxyprogesterone acetate administered?
Every 13 weeks
131
What is the use of medroxyprogesterone associated with?
A small loss of bone mineral density, which largely recovers after discontinuation.
132
Due to the concerns and uncertainties around bone-loss with medroxyprogesterone use what is advised?
Females aged under 18 years may use depot medroxyprogesterone acetate after all options have been discussed and are considered unsuitable or unacceptable.
In all females, although there is no definitive upper duration limit, use should be reviewed every 2 years and continuation benefits and risks discussed.
Females aged 50 years and over should switch to another contraceptive method; if they do not wish to discontinue use, continuation may be considered following a discussion of the benefits and risks.
In females with significant risk factors for osteoporosis, other methods of contraception should be considered
133
What should patients be informed about effects of fertility with medroxyprogesterone use?
there can be a delayed return of fertility of up to 1 year after discontinuation of depot medroxyprogesterone acetate
134
When is norethisterone enantate (parenteral) used?
is less commonly used in the UK. It is used for short-term contraception (duration of 8 weeks) for females whose partners undergo a vasectomy until the vasectomy is effective, and after rubella immunisation.
135
How many years does the subdermal etonogestrel implant provide highly effective contraception for?
For up to 3 years
136
What is the contraceptive failure rate with implant?
The contraceptive failure rate for both perfect and typical use is approximately 0.05% in the first year of use.
137
When should patients with implants be advised to see their HCP?
Patients should be advised to see their healthcare professional if the implant cannot be felt or problematic bleeding occurs.
138
What do Intrauterine systems (IUS) contain?
levonorgestrel are long-acting reversible contraceptive options that have a licensed duration of use that ranges from 3–10 years depending on the system used
139
When should patients using IUS seek medical advice?
f they develop symptoms of pelvic infection, pain, abnormal bleeding, non-palpable threads or they can feel the stem of the IUS.
140
Can progestogen only contraceptives be used in females undergoing surgery?
Yes - progestogen-only pills, injections, implants, and intra-uterine systems are suitable for use as contraceptives in females undergoing surgery.
141
What are the non hormonal contraception methods?
- Barrier methods
- Spermicidal contraceptives
- Intra-uterine devices
142
What barrier methods are there?
- Male and female condoms
- Diaphragms
- Cervical caps
143
Do diaphragms and caps alone provide contraception cover?
Diaphragms and caps must be used in conjunction with a spermicide and should not be removed until at least 6 hours after the last episode of intercourse.
144
Do spermicidal contraceptives alone give adequate protection?
Spermicidal contraceptives are useful additional safeguards but do not give adequate protection if used alone
145
How many components do spermicidal contraceptives have?
They have two components: a spermicide and a vehicle for its delivery (e.g. vaginal gel)
146
What should spermicidal contraceptives be used with (in combination with)?
They are suitable for use with barrier methods, such as diaphragms or caps; however, spermicidal contraceptives are not recommended for use with condoms, as there is no evidence of any additional protection compared with non-spermicidal lubricants.
147
Does spermicidal contraceptives increase the risk of STIs?
Spermicidal contraceptives are not suitable for use in those with or at high risk of sexually transmitted infections (including HIV); high frequency use of the spermicide nonoxinol ‘9’ has been associated with genital lesions, which may increase the risk of acquiring these infections.
148
Can the intra-uterine device (IUD) be used by all women?
The intra-uterine device (IUD) is a suitable contraceptive for women of all ages irrespective of parity; however they may be unsuitable in women with certain conditions such as those with pelvic inflammatory disease or unexplained vaginal bleeding.
149
What do the most effective intra-uterine devices have?
The most effective intra-uterine devices have at least 380 mm2 of copper and have banded copper on the transverse arms. Other smaller devices have been introduced to minimise side-effects.
150
When should emergency hormonal contraception be given?
UPSI in any day of the menstrual cycle - without contraception and also in those with contraception who's cover has been compromised
UPSI from day 21 after childbirth (unless the criteria for lactational amenorrhoea are met)
and from day 5 after abortion, miscarriage, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease.
151
What is the most effective form of emergency contraception?
Insertion of a copper intra-uterine device (see intra-uterine contraceptive devices (copper)) is the most effective form of emergency contraception and should be offered (if appropriate) to all females who have had UPSI and do not wish to conceive.
152
When or how long after UPSI can a copper intra-uterine device be used till?
A copper intra-uterine contraceptive device can be inserted up to 120 hours (5 days) after the first UPSI in a natural menstrual cycle, or up to 5 days after the earliest estimated date of ovulation (i.e. within the minimum period before implantation), whichever is later.
153
Does a copper intra-uterine device affect BMI or body weight?
No not known to
154
Which two oral hormonal emergency contraception are available?
- Levonorgestrel
| - Ulipristal acetate
155
Is oral emergency contraception administered after ovulation ineffective?
It is ineffective
156
Levonorgestrel is effective if taken within how many hours/ days of UPSI?
Within 72 hours / 3 days of UPSI
157
Ulipristal acetate is effective if taken within how long?
120 hours (5 days) of UPSI
158
Which out of the two is more effective?
Ulipristal acetate has been demonstrated to be more effective than levonorgestrel for emergency contraception.
159
Can a higher BMI/ body weight reduce or increase effectiveness of oral emergency contraception?
There is the possibility that a higher body-weight or BMI could reduce the effectiveness of oral emergency contraception, particularly levonorgestrel.
160
What should you do or consider if a patient's BMI is over 26kg/m2 or their body weight is more than 70kg?
it is recommended that either ulipristal acetate or a double dose of levonorgestrel [unlicensed indication] is given
It is unknown which is more effective in this case
161
When is ulipristal acetate considered as the first-line oral emergency contraceptive of choice?
for females who have had UPSI within the last 96–120 hours (even if they have also had additional instances of UPSI within the last 96 hours). It should also be considered first line for females who have had UPSI within the last 5 days if it is likely to have taken place during the 5 days before the estimated day of ovulation.
162
Can ulipristal acetate and levonorgestrel be used as oral emergency contraception more than once in the same cycle?
Yes
Note that the manufacturer of levonorgestrel advises that there may be an increased risk of side-effects (such as menstrual irregularities) with repeated administration of levonorgestrel as emergency contraception more than once in the same cycle
163
With levonorgestrel EHC when can regular contraceptive be continued/ started?
The next day
164
With ulipristal (ellaOne) when can regular contraceptive be continued/ restarted?
Should wait 5 days after the day of taking EllaOne.
they must use condoms reliably or abstain from intercourse during the 5 day waiting period and also until their contraceptive method is effective.
165
Effectiveness of hormonal contraception can be affected by drugs that induce what?
Drugs that induce hepatic enzymes
| inducers - reduce levels
166
Which drugs are these?
. carbamazepine, eslicarbazepine acetate, nevirapine, oxcarbazepine, phenytoin, phenobarbital, primidone, ritonavir, St John's wort, topiramate and, above all, rifabutin and rifampicin), and possibly also griseofulvin
167
What form of contraception may be more suitable for patients with HIV infection or at risk of HIV infection?
A condom together with a long-acting method (such as an injectable contraceptive)
168
What should women be advised who are on enzyme inducing drugs about their contraceptive?
Women using combined hormonal contraceptive patches, vaginal rings or oral tablets who require enzyme-inducing drugs or griseofulvin should be advised to change to a reliable contraceptive method that is unaffected by enzyme-inducers, such as some parenteral progestogen-only contraceptives (medroxyprogesterone acetate and norethisterone) or intra-uterine devices (levonorgestrel;)
169
After stopping the enzyme inducing drug how long should you wait for their effects to go?
LARC should be continued for the duration of treatment and for four weeks after stopping. If a change in contraceptive method is undesirable or inappropriate the following options should be discussed:
170
Can combined hormonal contraceptive method be appropriately used if patient is on short course (2 months or less) of an enzyme inducing drug?
Yes may be appropriate if used in combination with consistent and careful use of condoms for the duration of treatment and for four weeks after stopping the enzyme-inducing drug.
171
What should be considered for long term course (over 2 months) of rifampicin or rifabutin?
An alternative method of contraception (such as an IUD) is always recommended because they are such potent enzyme-inducing drugs; the alternative method of contraception should be continued for four weeks after stopping the enzyme-inducing drug.
172
What report has there been about antibacterials that do not induce liver enzymes but still affect Combined oral contraceptives?
Due to anecdotal reports of contraceptive failures, there had been concerns that some antibacterials that do not induce liver enzymes (e.g. ampicillin, doxycycline) reduce the efficacy of combined oral contraceptives by impairing the bacterial flora responsible for recycling ethinylestradiol from the large bowel. However, there is a lack of evidence to support this interaction.
It is recommended by the Faculty of Sexual and Reproductive Healthcare (FSRH) that no additional contraceptive precautions are required when combined oral contraceptives, contraceptive patches or vaginal rings are used with antibacterials that do not induce liver enzymes, unless diarrhoea or vomiting occur when using combined oral contraceptives. These recommendations should be discussed with the woman, who should also be advised that guidance in patient information leaflets may differ.
173
Is effectiveness of oral progestogen only preparations affected by antibacterials that do not induce liver enzymes?
No
174
Is the efficacy of oral progestogen only contracptives affected by enzyme inducing drugs?
Yes and an alternative contraceptive method, unaffected by the interacting drug, is recommended during treatment with an interacting drug and for at least 4 weeks afterwards.
175
Is parenteral progesterone only contraceptives affected enzyme inducing drugs?
No
The effectiveness of intramuscular norethisterone injection and intramuscular and subcutaneous medroxyprogesterone acetate injections is not affected by enzyme-inducing drugs and they may be continued as normal during courses of these drugs.
176
What about the effectiveness of etonogestrel-releasing implant?
Effectiveness of the etonogestrel-releasing implant may be reduced by enzyme-inducing drugs or griseofulvin and an alternative contraceptive method, unaffected by the interacting drug, is recommended during treatment with the interacting drug and for at least 4 weeks after stopping.
177
Is the effectiveness of levorgesteril and ulipristal acetate (EHC) affected by enzyme inducing drugs?
Yes could be reduced - a copper intra-uterine device can be offered instead.
There is no need to increase the dose for emergency contraception if the patient is taking antibacterials that are not enzyme inducers.
178
What about the effect of drugs that increase gastric pH?
The effectiveness of ulipristal acetate for emergency contraception in women using drugs that increase gastric pH has not been studied. Levonorgestrel or a copper intra-uterine device should be considered as alternatives.
179
When else may effectiveness of ulipristal be reduced?
When a progestogen (including levonorgestrel for emergency contraception) is given 7 days before, or 5 days after administration of ulipristal acetate as emergency hormonal contraception, the contraceptive effect of ulipristal acetate may be reduced.
180
What are some contraindications of combined hormonal contraceptives?
- Cardiomyopathy with impaired cardiac function
- Current breast cancer
- hypertension (blood pressure systolic 160mmHg or diastolic 100mmHg or higher)
- Previous or current venous thrombosis
- smoking in patients aged 35 years and over (15 or more cigarettes daily)
- Stroke
- Transient ischaemic attack
181
What is there is a risk of with combined hormonal contraceptives?
There is an increased risk of venous thromboembolic disease - particularly in the first year and possibly after restating combined hormonal contraceptive following a break of four weeks or more.
In all cases the risk of venous thromboembolism increases with age and in the presence of other risk factors, such as obesity. The risk also varies depending on the type of progestogen and oestrogen dose.
182
You should use Combined hormonal contraceptives with caution with patients with the following risk factors for thromboembolism:
Age 40 years and older—if 50 years and older, seek specialist advice before use;
6 weeks to 6 months postpartum in breastfeeding women;
3 to 6 weeks postpartum in non-breastfeeding women in the absence of additional risk factors for venous thromboembolism—if 3 to 6 weeks postpartum with risk factors, or if less than 3 weeks postpartum without risk factors, seek specialist advice before use;
Smoking if age under 35 years, or if 35 years and older and have stopped smoking at least 1 year ago—if 35 years and older smoking less than 15 cigarettes a day or stopped smoking less than 1 year ago, seek specialist advice before use;
Obesity with body mass index 30 kg/m2 to 34 kg/m2—if body mass index ≥ 35 kg/m2, seek specialist advice before use;
History of hypertension during pregnancy in currently normotensive women;
Family history of venous thromboembolism in a first-degree relative aged 45 years and older—if first-degree relative is under 45 years, seek specialist advice before use;
Major surgery without prolonged immobilsation;
Long-term immobility (e.g. wheelchair use, debilitating illness)—seek specialist advice before use;
Superficial venous thrombosis;
Uncomplicated valvular heart disease;
Uncomplicated congenital heart disease;
Cardiomyopathy with normal cardiac function;
Long QT syndrome;
Systemic lupus erythematosus with no antiphospholipid antibodies;
High altitudes: women travelling above 4500 m or 14500 feet for more than 1 week should consider alternative contraceptive methods (risk of thrombosis).
183
Do combined hormonal contraceptives also increase the risk of CVD?
Yes slightly increase the risk such as myocardial infarction and ischaemic stroke; risk appears to be greater with higher oestrogen doses
184
What are the common side effects of combined hormonal contraceptives?
- Acne
- Fluid retention
- Headaches
- Metrorrhagia
- nausea
- weight increased
uncommon - alopecia, hypertension
Rare - venous thromboembolism
185
Is there an increased risk of breast cancer with combined oral contraceptives?
There is a small increase in the risk of having breast cancer diagnosed in women taking the combined oral contraceptive pill; this relative risk may be due to an earlier diagnosis
Age is a bigger factor that it was used than the duration of the contraceptive for risk of breast cancer
186
Use of combined oral for how many years or longer is associated with a small increased risk of cervical cancer?
5 years or longer
the risk diminishes after stopping and disappears by about 10 years
187
Which cancers should be weighed for risk and benefits with COC use>
. The possible small increase in the risk of breast cancer and cervical cancer should be weighed against the protective effect against cancers of the ovary and endometrium.
188
Are combined hormonal contraceptives known to be harmful in pregnancy?
Not known to be harmful
189
How many days of pill taking is needed to build up cover for COC if started after day 6 of cycle?
7 days
Qlaira = 9 days
190
Changing from POP to COC - do you need additional precautions?
Yes additional precautions required for 7 days ( Qlaira 9 days)
191
What is the advice for missed pills for oral hormonal contraceptives?
If a woman forgets to take a pill, it should be taken as soon as she remembers, and the next one taken at the normal time (even if this means taking 2 pills together).
192
What is a missed pill?
A missed pill is one that is 24 or more hours late.
193
With COC if one pill is missed what should you do?
If a woman misses only one pill, she should take an active pill as soon as she remembers and then resume normal pill-taking. No additional precautions are necessary.
194
What if 2 or more pills are missed within a 7 day period (COC)?
If a woman misses 2 or more pills (especially from the first 7 in a packet), she may not be protected. She should take an active pill as soon as she remembers and then resume normal pill-taking. In addition, she must either abstain from sex or use an additional method of contraception such as a condom for the next 7 days. If these 7 days run beyond the end of the packet, the next packet should be started at once, omitting the pill-free interval (or, in the case of everyday (ED) pills, omitting the 7 inactive tablets).
195
There is a risk of uterine perforation with intra-uterine contraceptive device (copper) - when is this risk greater?
The risk of uterine perforation is increased when the device is inserted up to 36 weeks postpartum or in patients who are breastfeeding.
196
Before inserting an intra-uterine contraceptive device, what should you inform patients?
that perforation occurs in approximately 1 in every 1000 insertions and signs and symptoms include:
severe pelvic pain after insertion (worse than period cramps);
pain or increased bleeding after insertion which continues for more than a few weeks;
sudden changes in periods;
pain during intercourse;
unable to feel the threads.
197
Should patients be able to feel the threads?
Patients should be informed on how to check their threads and to arrange a check-up if threads cannot be felt, especially if they also have significant pain. Partial perforation may occur even if the threads can be seen; consider this if there is severe pain following insertion and perform an ultrasound
198
With intra-uterine device when does the main excess risk of pelvic infection occur?
Occurs in the first 20 days after insertion an is believed to be related to existing carriage of a sexually transmitted infection.
199
When are women considered to be at a higher risk of STIs?
they are under 25 years old or
they are over 25 years old and
have a new partner or
have had more than one partner in the past year or
their regular partner has other partners.
200
What should the women be advised?
The woman should be advised to attend as an emergency if she experiences sustained pain during the next 20 days.
Sign of pelvic infection
If possible should be screened for chlamydia and, depending on sexual history and local prevalence of disease, Neisseria gonorrhoeae))
201
Other than for emergency contraception, what is another indication of ulipristal acetate?
Uterine fibroids (under expert supervision)
202
What has been reported with the treatment for uterine fibroids with ulipristal acetate?
Rare but serious cases of liver injury and hepatic failure requiring liver transplantation have been reported worldwide in women treated with Esmya® for symptoms of uterine fibroids.
Its licence was temporarily suspended in March 2020 to allow a further review of these risks. Although the temporary suspension has been lifted, further restrictions have been introduced.
203
What are the contraindications of ellaOne?
Breast cancer; cervical cancer; ovarian cancer; severe asthma controlled by oral glucocorticoids; undiagnosed vaginal bleeding; uterine cancer
204
What advise about breastfeeding and ellaOne should be given?
Avoid - express milk for 1 week after administration and discard
205
With EllaOne if vomiting occurs in how many hours is another pill needed?
if vomiting occurs within 3 hours of taking a dose, a replacement dose should be taken;
206
After using EllaOne a pregnancy test should be performed if the next menstrual period is delayed by more than how many days?
more than 7 days - is lighter than usual, or is associated with abdominal pain that is not typical of the woman's usual dysmenorrhoea
207
Can Ellaone increase the risk of dizziness?
Yes - Patients and carers should be counselled on the effects on driving and performance of skilled tasks—increased risk of dizziness.
208
For Desogestrel how many hours is considered as missing a pill?
If administration delayed for 12 hours or more
209
What are the contraindications of desogestrel?
Acute porphyrias
| Current breast cancer
210
What are the side effects of desogestrel?
Common or very common
Breast abnormalities; depressed mood; headache; libido decreased; menstrual cycle irregularities; mood altered; nausea; skin reactions; weight increased
Uncommon
Alopecia; contact lens intolerance; fatigue; ovarian cyst; vomiting; vulvovaginal infection
Rare or very rare
Erythema nodosum
211
Is there a risk of breast cancer with POC like COC?
The risk of breast cancer in users of POCs is possibly of similar magnitude as that associated with COCs, however the evidence is less conclusive.
Available evidence does not support an association between the use of a progestegen-only contraceptive pill and breast cancer. Any increased risk is likely to be small and reduces gradually during the 10 years after stopping; there is no excess risk 10 years after stopping. The older age at which the contraceptive is stopped appears to have a greater influence on increased risk rather than the duration of use.
212
What precautions are required if any when changing from COC to POC?
Start on the day following completion of the combined oral contraceptive course without a break (or in the case of ED tablets omitting the inactive ones).
213
What about progestogen only pill and after child birth?
After childbirth
Oral progestogen-only contraceptives can be started up to and including day 21 postpartum without the need for additional contraceptive precautions. If started more than 21 days postpartum, additional contraceptive precautions are required for 2 days.
214
What advice should be given about diarrhoea and vomiting with desogestrel?
Diarrhoea and vomiting
Vomiting and persistent, severe diarrhoea can interfere with the absorption of oral progestogen-only contraceptives. If vomiting occurs within 2 hours of taking desogestrel, another pill should be taken as soon as possible. If a replacement pill is not taken within 12 hours of the normal time for taking desogestrel, or in cases of persistent vomiting or very severe diarrhoea, additional precautions should be used during illness and for 2 days after recovery.
215
What is the advice for missed pill for desogestrel?
The following advice is recommended: ‘If you forget a pill, take it as soon as you remember and carry on with the next pill at the right time. If the pill was more than 12 hours overdue you are not protected. Continue normal pill-taking but you must also use another method, such as the condom, for the next 2 days’.
216
How long are the intra-uterine systems (levornogestrel) Jaydess and Mirena effective for?
Jaydess - 3 years
| Mirena - 5 years
217
How many days should additional form of contraception be used when getting IUS removed?
- For at least 7 days before getting the IUS removed
218
With intra-uterine use of levonorgestrel is there a risk of breast cancer?
No increased risk with intra-uterine use
219
Which drug is used as a spermicidal?
Nonoxinol
A spermicidal contraceptive in conjunction with barrier methods of contraception such as diaphragms or caps
220
What are some reasons to stop Combined hormonal contraceptive immediately?
* Sudden, severe chest pain (even if not radiating to left arm)
* Sudden breathlessness (or cough with blood-stained sputum)
* Unexplained swelling or severe pain in calf of one leg
* Severe stomach pain
* Serious neurological side effects (headache, affected vision, affected hearing, etc.)
* Hepatitis, jaundice, liver enlargement
* Raised blood pressure
* Prolonged immobility after surgery or leg injury
221
I the copper IUD affected by BMI. body-weight or by other drugs?
No it is not
222
Which levonelle is given over the counter?
Levonelle 1500 is POM
Levonelle OneStep can be sold to women over 16
223
What is erectile dysfunction?
It is the persistent inability to attain and maintain an erection that is sufficient to permit satisfactory sexual performance.
224
What can erectile dysfunction be caused by?
It can have physical or psychological causes. Erectile dysfunction can also be a side-effect of drugs such as antihypertensives, antidepressants, antipsychotics, cytotoxic drugs and recreational drugs (including alcohol).
225
What are some risk factors for erectile dysfunction?
sedentary lifestyle, obesity, smoking, hypercholesterolaemia and metabolic syndrome.
226
What does erectile dysfunction increase the risk of?
Erectile dysfunction increases the risk of cardiovascular disease.
227
What should all men with unexplained erectile dysfunction be evaluated for?
evaluated for the presence of cardiovascular risk factors and any identified risk should be addressed.
228
What is the recommended approach for the management of erectile dysfunction?
A combination of drug treatment and lifestyle changes (including regular exercise, reduction in body mass index, smoking cessation and reduced alcohol consumption)
229
What is the first line drug treatment for erectile dysfunction?
An oral phosphodiesterase type 5 inhibitor - regardless of the cause.
230
How do phosphodiesterase type 5 inhibitor work?
They act by increasing blood flow to the penis, they do not initiate an erection - sexual stimulation is required.
231
What does the choice of an oral phosphodiesterase type 5 inhibitor depend on?
The frequency of intercourse and response to treatment
232
Which PDE-5 inhibitors are short acting?
- Avanafil
- Sildenafil
- Vardenafil
They are short acting and suitable for occasional use as required
233
Which PDE-5 is longer acting?
Tadalafil
It can be used as required, but also can be used a regular lower daily dose to allow for spontaneous (rather than scheduled) sexual activity or in those who have frequent sexual activity.
234
Before being classed as a non responder - how many doses of PDE-5 inhibitor should be used?
A patient with erectile dysfunction should receive six doses of an individual phosphodiesterase type-5 inhibitor at the maximum dose (with sexual stimulation) before being classified as a non-responder.
235
When should patients be referred to a specialist?
Patients who fail to respond to the maximum dose of at least two different phosphodiesterase type-5 inhibitors should be referred to a specialist.
236
What is recommended as second line therapy for erectile dysfunction?
Intracavernosal, intraurethral or topical application of alprostadil (prostaglandin E1) is recommended as second-line therapy under careful medical supervision. Intracavernosal or intraurethral preparations can also be used to aid diagnosis.
237
What is priapism?
Priapism is a prolonged erection of the penis. The full or partial erection continues hours beyond or isn't caused by sexual stimulation. The main types of priapism are ischemic and nonischemic
238
Priapism associated with alprostadil - when should patients seek medical attention?
Manufacturers advise that patients should seek medical help if a prolonged erection lasting four hours or more occurs;
If priapism has lasted more than six hours, treatment should not be delayed;
239
What can help - what advice can you give for priapism?
application of an ice pack to the upper-inner thigh (alternating between the left and right thighs every two minutes for up to ten minutes) may result in reflex opening of the venous valves.
240
With phosphodiesterase type 5 inhibitors - what is the effect of it being taken with food?
Onset of effect may be delayed if taken with food
241
What is another indication of sildenafil other than erectile dysfunction?
- Pulmonary arterial hypertension
242
What is the advice if sildenafil is taken with potent CYP3A4 inhibitors?
Manufacturer advises to start with a 25mg dose for erectile dysfunction
Manufacturer advises reduce dose to 20mg twice daily for pulmonary arterial hypertension if used with potent CYP3A4 inhibitors.
243
Can you safely take sildenafil with grapefruit juice?
No - Grapefruit juice increases sildenafil bioavailability and tends to delay sildenafil absorption. Sildenafil pharmacokinetics may become less predictable with grapefruit juice.
244
Which other PDE-5 inhibitor can be used for pulmonary arterial hypertension?
Tadalafil - 40mg once daily
245
What drug class does alprostadil belong to?
Prostaglandin E
246
What is the brand name of alprostadil?
Caverject
| Virdal Duo
247
What counselling should be given to patients taking alprostadil?
- With topical use (condoms should be used to avoid exposure to women of child-bearing age, pregnant or lactating women, No evidence of harm to latex condom)
248
Which sympathomimetics (vasoconstrictor) can be used to treat priapism associated with alprostadil?
- Adrenaline/epinephrine
- Metaraminol
- Phenylephrine hydrochloride
249
What is the drug action of adrenaline/epinerphine?
Acts on both alpha and beta receptors and increases both heart rate and contractility (beta 1 effects);
can cause peripheral vasodilation (a beta 2 effect) or
Vasoconstriction (an alpha effect)
250
What is premature ejaculation?
Premature ejaculation is a common male sexual disorder characterised by brief ejaculatory latency, loss of control, and psychological distress.
251
What are the non-drug treatments for premature ejaculation?
Non-drug treatment (including psychosexual counselling, education, and behavioural treatments) are recommended in patients for whom premature ejaculation causes few (if any) problems or in patients who prefer not to take drug treatment. These techniques can also be used in addition to a drug treatment.
252
What is recommended for patients with life-long premature ejaculation?
Drug treatment is the recommended approach
253
Which drug class does dapoxetine belong to?
A short acting - selective serotonin re-uptake inhibitor (SSRI)
254
Is dapoxetine licensed for premature ejactulation?
Yes - is licensed to be used when required for this condition (not continuous daily use).
255
If premature ejaculation is secondary to erectile dysfunction, which should be treated first?
Erectile dysfunction should be treated first
256
What other preparations are available for the management of premature ejaculation that are available without prescription?
- Topical anaesthetic preparations - without prescription
257
Dapoxetine should be avoided if eGFR is less than?
Less than 30ml/min/1.73m2
258
What should patients be tested for before starting dapoxetine?
Test for postural hypotension
259
What advice can be given to patients on dapoxetine and suffering from postural hypotension?
maintain hydration and to sit or lie down until prodomal symptoms such as nausea, dizziness, and sweating abate
260
Who does polycystic ovary syndrome (PCOS) affect?
Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders affecting females of childbearing potential.
261
What are the clinical features of polycystic ovary syndrome?
Clinical features may include ovulation disorders, polycystic ovarian morphology, and hyperandrogenism (with the clinical manifestations of acne, hirsutism and oligomenorrhoea)
262
What are some complications of PCOS?
cardiovascular disease, obstructive sleep apnoea, psychological disorders (such as anxiety and depression), infertility, endometrial cancer, pregnancy complications (such as gestational diabetes and pre-eclampsia), and metabolic disorders (such as insulin resistance and type 2 diabetes).
263
What is the first line management for PCOS?
Lifestyle modifications;
healthy eating, regular physical exercise and maintaining a healthy weight should be encouraged. For females who are overweight or obese, weight loss advice should be offered or referral to a dietician considered, as weight loss may achieve menstrual regularity and reduce insulin resistance, hyperandrogenism, and the risk of type 2 diabetes and cardiovascular disease.
264
Which class of drugs are used to induce abortion or induce or augment labour and to minimise blood loss from the placental site?
Prostaglandins and oxytocics
| They include oxytocin, carbetocin, ergometrine maleate, and the prostaglandins.
265
What do they all induce?
They all induce contractions with varying degrees of force, frequency and duration
266
Which drug should be used if considered suitable for induction of labour?
Dinoprostone or misoprostol
For women with a Bishop score of 6 or less
267
What about for women with a Bishop score of more than 6?
Oxytocin may be offered in conjunction with amniotomy
268
What may large doses of oxytocin result in?
Fluid retention
269
For the prevention and treatment of postpartum haemorrhage what is used?
- prophylactic oxytocin (IM) - unlicensed
| - Ergometrine with oxytocin (IM) in the absence of hypertension or other CIs
270
Does oxytocin alone increase or decrease nausea than if given with ergometrine maleate?
Oxytocin alone causes less nausea, vomiting, and hypertension than when given with ergometrine maleate.
271
Which type of drugs postpone premature labour?
Tocolytic drugs
They are used with the aim of reducing harm to the child
The greatest benefit is gained by using the delay to administer corticosteroid therapy or to implement other measures which improve perinatal health (including transfer to a unit with neonatal intensive care facility).
272
Women between 24 and 33 weeks of gestation who have intact membranes and are in suspected or diagnosed premature labour can be given which drug?
nifedipine [unlicensed indication] for tocolysis. An oxytocin receptor antagonist (such as atosiban) is an alternative if nifedipine is contra-indicated or unsuitable.
273
Are beta 2 agonists salbutamol and terbutaline still recommended for inhibiting premature labour?
No - The beta2 agonists salbutamol and terbutaline sulfate are no longer recommended for inhibiting uncomplicated premature labour.
Use of high-dose short acting beta2 agonists in obstetric indications has been associated with serious, sometimes fatal cardiovascular events in the mother and fetus, particularly when used for a prolonged period of time.
274
Prolonged IV administration of oxytocin at high doses with large volume of fluid may cause water intoxication with hyponatraemia - so what is advised?
To avoid: manufacturer advises use electrolyte-containing diluent (i.e. not glucose), increase oxytocin concentration to reduce fluid, restrict fluid intake by mouth; monitor fluid and electrolytes.
275
Which drug is used for abortion?
Pre-treatment with mifepristone can facilitate the process of medical abortion. It sensitises the uterus to subsequent administration of a prostaglandin and, therefore, abortion occurs in a shorter time and with a lower dose of prostaglandin.
276
What may follow after use with mifeprostone?
The prostaglandin misoprostol is given by mouth, buccally, sublingually, or vaginally, to induce medical abortion following sequential use with mifepristone; it is also used for cervical priming before surgical abortion.
277
Which prostaglandin can be given as a pessary to induce abortion?
Gemeprost, a prostaglandin administered vaginally as pessaries, is licensed for the medical induction of abortion in the second trimester of pregnancy; it is also licensed to soften and dilate the cervix before surgical abortion in early pregnancy.
278
What is atosiban used for?
For suspected premature labour - in women between 24-33 weeks of gestation
279
Mifepristone and misoprostol as a combination can be used for termination of pregnancy for up to how many days gestation?
Up to 63 days gestation
280
What formulation can misoprostol be given in?
• Misoprostol (a prostaglandin) is given by mouth, buccally, sublingually or vaginally to induce an abortion.
281
Why is pre-treatment with mifepristone used in abortion?
• Pre-treatment with Mifepristone can facilitate the process of abortion. It sensitises the uterus for administration of the prostaglandin… allowing abortion to occur in a shorter time and with a lower dose of prostaglandin.
282
How is oxytocin administered?
- as a slow intravenous infusion to induce or augment labour
283
What is vaginal atrophy?
Vaginal atrophy (atrophic vaginitis) is thinning, drying and inflammation of the vaginal walls that may occur when your body has less estrogen. Vaginal atrophy occurs most often after menopause
284
What form of oestrogen are available to use for vaginal atrophy?
Topical oestrogens are available as estradiol pessaries and vaginal rings, and as estriol pessaries, cream and gel. They are used to treat the symptoms of vaginal atrophy related to oestrogen deficiency in postmenopausal women.
285
How long is treatment for vaginal atrophy continued?
Treatment is continued for as long as needed to relieve symptoms and reviewed initially at 3 months, then at least annually.
286
What is vulvovaginal candidiasis (genital thrush) caused by?
by a superficial fungal infection; most cases are caused by Candida albicans.
287
What about treatment of vulvovaginal candidiasis in pregnancy?
can be treated with intravaginal application of an imidazole (such as clotrimazole). Pregnant women need a longer duration of treatment, usually about 7 days, to clear the infection. There is limited systemic absorption of imidazoles from the vagina. Treatment with an oral azole drug should be avoided during pregnancy.
288
What may increase the likelihood of recurrent volvovaginal candidiasis?
predisposing factors, such as recent (up to 3 months before) antibacterial therapy, poorly controlled diabetes mellitus, pregnancy, immunosuppression, HRT use, or possibly oral contraceptive use.
289
What is the treatment for recurrent vulvovaginal candidiasis?
initial treatment with oral fluconazole (induction regimen) to ensure clinical remission, followed immediately by a maintenance regimen for 6 months
When oral fluconazole treatment is unsuitable, an intravaginal imidazole can be given.
290
What do trichomonal infections require treatment with?
Trichomonal infections commonly involve the lower urinary tract as well as the genital system and need systemic treatment with metronidazole
291
which antibacterial - topically is given for vaginal and vulva bacterial infections (bacterial vaginosis)?
Clindamycin - Dalacin 2% cream
Dose to be administered at night
292
Which other drugs can be used for bacterial vaginosis?
- Desualinium chloride (antiseptic and disinfectnant)
| - Lactic acid (Carboxylic acids)
293
What is there a risk of when systemic oestrogens are administered alone for prolonged periods?
- The risk of endometrial hyperplasia (thickening of the uterus) and carcinoma (cancer) is increased when systemic oestrogens are administered alone for prolonged periods.
294
Can oral antifungals be used during pregnancy?
no they should be avoided
