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GU + Sexual health Flashcards

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1
Q

Bacterial vaginosis

A

The overgrowth of ANAEROBIC bacteria in the vagina, caused by the LOSS of LACTOBACILLI.

NOT AN STI but is a RFx for STIs - can occur alongside other infections

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2
Q

Role of lactobacilli in healthy vagina

A

Produce LACTIC ACID - keeps vagina ACIDIC (<4.5)

When reduced numbers of lactobacilli - becomes ALKALINE allowing ANAEROBIC bacteria to multiply

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3
Q

Examples of anaerobic bacteria associated with bacterial vaginosis

A
  • Gardnerella vaginalis (most common)
  • Mycoplasma hominis
  • Prevotella species
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4
Q

RFx for bacterial vaginosis

A
  • Multiple sexual partners
  • Excessive cleaning of vagina
  • Recent antibiotics
  • Copper coil
  • SMOKING

Less common if on combined pill/using condoms

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5
Q

Sx of bacterial vaginosis

A

Strong fishy odour of watery grey/white discharge
- the discharge is homogenous + coating the walls of vagina + vestibule

(50% asymp; itching/irritatiion or pain = suggests other cause)

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6
Q

Bacterial vaginosis investigations

A
  • speculum examination to check discharge (not always required if v typical/low risk of STI)
  • VAGINAL SWAB:
    • pH paper shows >4.5
    • CHARCOAL SWAB for MICROSCOPY
      • CLUE CELLS on microscopy (epithelial cells so covered in bacteria their edges are grainy)
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7
Q

Bacterial vaginosis management

A

Asymp = none; generally can self resolve

  • METRONIDAZOLE (only works on ANAEROBIC) - ORAL or VAGINAL GEL
    • 2nd: Clindamyicin
  • Swab for STIs + assess risk of other pelvic infection
  • Give advice/info
      • Don’t drink while on metranidazole

Can prevent with ACIDIFIED VAGINAL GEL

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8
Q

Complications of Bacterial vaginosis

A
  • Risk of catching STIs
  • Miscarriage
  • Preterm delivery
  • Premature rupture of membranes
  • Chorioamnionitis
  • Low birth weight
  • Postpartum endometritis
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9
Q

Balanitis

A

Inflammation of the glans penis

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10
Q

Balanitis Sx

A
  • Inflamed (red, swollen, itchy, sore)
  • Dysuria
  • Discharge from under foreskin/bleeding
  • Difficulty pulling back foreskin (may be normal in children)
  • Odour
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11
Q

Investigation of balanitis

A
  • Clinical presentation
  • charcoal swab for microscopy if infection suspected (or first catch urine)
  • biopsy if extensive skin change / scarring

May do blood tests if severe: Blood glucose??

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12
Q

Balanitis Tx

A

Core treatment:

  • Saline washes
  • Ensuring to clean properly under foreskin
  • 1% hydrocortisone if more severe irritation - for a SHORT TIME

Depends on cause:

  • Steroid cream
    • Mild = dermatitis, circinate balanitis (reative arthritis)
    • High potency = lichen sclerosus
  • Antifungal cream
    • topical CLOTRIMAZOLE
  • Antibiotics
    • oft oral FLUCLOX / clarithro (as staph and strep B are most common bacterial causes)
    • Metronidazole if anaerobic bacteria

May remove foreskin if recurrent (or for lichen sclerosus)

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13
Q

Causes of balanitis

A
  • not washing
  • irritation from soaps/condoms
  • DIABETES -> THRUSH
  • STI including TRICHOMONAS VAGINALIS
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14
Q

Thrichomoniasis

A

STI caused by Trichomonas vaginalis (flagellate protozoa)
- in urethra (male/female) and vagina

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15
Q

Thrichomoniasis presentation

A

50% asymp

  • Vaginal discharge (typical = frothy yellow green but can vary; may smell fishy)
  • Itching
  • Dysuria
  • Dyspareunia (painful sex)
  • Balanitis

Strawberry cervix from inflam + multiple tiny haemorrhaeges (on examinarion) AND ACIDIC pH

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16
Q

Trichomoniasis Dx

A
  • CHARCOAL SWAB + MICROSCOPY
    • ideally from POSTERIOR FORNIX (behind cervix) but self taken works too
  • urethral swab or first-catch urine in men
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17
Q

Trichomoniasis Mx

A
  • Refer to GUM
  • CONTACT TRACING
  • METRONIDAZOLE
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18
Q

Trochomoniasis complication

A

Increases risk of:

  • Contracting HIV by damaging the vaginal mucosa
  • Bacterial vaginosis
  • Cervical cancer
  • Pelvic inflammatory disease
  • Pregnancy-related complications such as preterm delivery
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19
Q

Herpes simplex virus (HSV)

A
  • HSV-1 = typically cold sores
  • HSV-2 = typically genital herpes

Can also cause apthous ulcer, herpes keratitis (eye inflam), herpetic whitlow (painful lesion on fingers)

Both common in UK

Oft asymp - spread through mucous membranes/secretions

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20
Q

HSV goes dormant in the associated sensory nerve gangioln. Which are these usually?

A
  • Trigeminal nerve ganglion - HSV1
  • Sacral nerve ganglion - HSV2
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21
Q

Genital herpes Sx

A

Typically ~2weeks after contracting + lasting 3 weeks (most intense) - any proceeding reactivation usually milder/shorter

  • Ulcers/blisters
  • Neuropathic pain
  • FLU-LIKE (fatigue, headache)
  • DYSURIA
  • INGUINAL LYMPHADENOPATHY
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22
Q

Genital herpes Dx

A

Contact trace (including ask about cold sores)

Clinical diagnosis
- Confirm with VIRAL PCR

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23
Q

Genital herpes Tx

A
  • Refer to GUM

ACICLOVIR (regeime depends)

Additional measures, including to manage the symptoms include:

  • Paracetamol
  • Topical lidocaine 2% gel (e.g. Instillagel)
  • Cleaning with warm salt water
  • Topical vaseline
  • Additional oral fluids
  • Wear loose clothing
  • Avoid intercourse with symptoms
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24
Q

Genital herpes complication

A

Vertical transmission via lesions during delivery of baby
- low risk if recurrent
- if primary give prophylactic ACICLOVIR even after initial course finished
- if contracted before 28 wks - might still consider vaginal delivery if asymp; after 28 wks do C-section

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25
Chancroid
STI caused by FASTIDIOUS, GRAM -VE COCCOBACBILLI, ***Haemophilus ducreyi*** Typically in resource-poor countries OFT CO-FACTOR IN HIV transmission
26
Chancroid RFx
- Multiple sexual partners/contacts with sex workers - Unprotected sex - SUBSTANCE ABUSE (HIGH RISK BEHAVIOUR esp for things like crack cocaine) - MALES - Lack of circumcision - Poor hygine
27
Chancroid Sx
- GENITAL PAPULES ( Early stage) - GENITAL ULCERS (later) - sharply defined, undermined, irregular border - Lymphadenitis/buboes - usually UNILATERL (+ painful) Typical STI Sx: discharge, pain Sometimes rectal pain/bleeding +/- rectovaginal fistula
28
Chancroid Dx
- Clinical + charcoal swab -> MS+C - Bloods - serology +/- antigen testing if available - Ulcer biopsy Rule out other STIs + TEST FOR HIV (serum ELISA)
29
Chancroid Tx
ANTIBIOTICS: - Azithromycin or Ceftriaxone - CIPROFLOXACIN or ERYTHROMYCIN if HIV +ve - Don't give Ciprofloxacin if PREG Lymph node aspiration +/- incision + drainage (as needed)
30
Genital warts
Common STI caused by HPV (usually 6 + 11) - Esp in **16 - 25 y/o**
31
Genital warts RFx
- Intercourse from earlier age + more lifetime partner - Immunocompromise
32
Genital warts Sx
Oft asymp Usual stuff: itching, pain, bleeding Can get haematuria/abnormal stream if inside urethra
33
Genital warts Dx
Clinical Can biopsy if severe/not responding to treatment - check for dysplasia ano/urethroscopy as required
34
Genital warts Tx
- Topical posophyllotoxin (SE: irritant) - not recommended if preg - Cryotherapy, surgical excision, Tricholoro/bichloroacetic acid (high recurrance)
35
National Chlamydia Screening Programme
Tests every **sexually active person under 25 y/o** annually over with every new sexual partner Re-test 3 months after treatment (if +ve) to ensure no re-infection
36
What is commonly tested at an STI screening
- Chlamydia + Gonorrhoea (NAAT (swab, urine or urethral) + charcoal for both) - Syphilis (blood test) - HIV (blood test) - swabs from any ulcers
37
What types of tests are used for STI testing
- Charcoal swabs (in Amies transport medium) -> MS+C - Nucleic Acid Amplification Test (NAAT) - specifically for Chlamydia + Gonorrhoea (+ mycoplasma genitalium) - endocervical swab is gold but can self-swab/first catch urine Can also be an pharyngeal or rectal swab
38
Chlamydia Sx
Oft Asymp Consider if sexually active +: Female: - Abnormal vaginal discharge - Pelvic pain - Abnormal vaginal bleeding (intermenstrual or postcoital) - Painful sex (dyspareunia) - Painful urination (dysuria) Male: - Urethral discharge or discomfort - Painful urination (dysuria) - Epididymo-orchitis - Reactive arthritis
39
Chlamydia potential examination findings
- Pelvic or abdominal tenderness - Cervical motion tenderness (cervical excitation) - Inflamed cervix (cervicitis) - Purulent discharge
40
Chlamydia Tx
Check local guidelines but: **doxycycline 100mg twice a day for 7 days** - 1st - DON'T USE IF PREG Preg alts: Azithromycin 1g stat then 500mg once a day for 2 days Erythromycin 500mg four times daily for 7 days Erythromycin 500mg twice daily for 14 days Amoxicillin 500mg three times daily for 7 days No sex; Contact tracing; STI screening; advice + safeguarding
41
Chlamydia complications:
Pelvic inflammatory disease Chronic pelvic pain Infertility Ectopic pregnancy Epididymo-orchitis Conjunctivitis Lymphogranuloma venereum Reactive arthritis In preg: Preterm delivery Premature rupture of membranes Low birth weight Postpartum endometritis Neonatal infection (conjunctivitis and pneumonia)
42
Lymphogranuloma Venereum (LGV)
Affects lymphoid tissue around site of chlamydia infection - more common in MSM
43
Stages of Lymphogranuloma venereum (LGV)
- Primary: Painless ulcer (penis, vagina or rectum) - Secondary: Lymphadenitis - Tertiary: Proctitis. Proctocolitis -> Pain, chnage in bowel, tenesmus, discharge.
44
LGV Tx
**Doxycycline 100mg twice daily for 21 days** (1st) Erythromycin, azithromycin and ofloxacin are alternatives
45
Order of swabbing for STIs
- NAAT first - Charcoal swab
46
Double vs triple swabs for STI screening
- Double swabs: a NAAT swab (endocervical or vulvovaginal) and a high vaginal charcoal media swab. - Triple swabs: a NAAT swab (endocervical or vulvovaginal), a high-vaginal charcoal media swab and an endocervical charcoal media swab.
47
Which group has highest incidence of STIs
MSM
48
Gonorrhoea pathophys
- Gram -VE Nisseria gonorrhoeae DIPLOCOCCI (2nd mc in UK) - Transmitted VIA MUCOUS SECRETIONS - oft through unprotected sex OR vertically during birth - Frequently found in throat - doesn't necessarily have to be through direct innoculation - Strong affinity for mucous membranes - uterus, urethra, cervix, fallopian tubes, ovaries, testicles, rectum, throat, sometimes eyes
49
STI RFx
- Aged <25 YEARS - MSM - Living in high density urban areas - MULTIPLE SEXUAL PARTNERS - Previous/current STI
50
Gonorrhoea Px
More likely to have Sx than chlamydia - more so in MEN: - Odourless, purulent discharge - possibly green or yellow, oft thin + watery - occasionally easily induced cervical bleeding e.g. post-coital - Dysuria; Dyspareunia - Pelvic pain (Female) - Testicular pain / swelling (epididymo-orchitis) Congunctivitis -> ERYTHEMA + purulent discharge REctal infection + Pharyneal infection oft asymp - rectal discomfort + discharge - sore throat - Sometimes prostatitis
51
Gonorrhoea Ix
- Nucleic Acid Amplification Test (**NAAT**) - Endocervical/Vaginal - First pass urine - Charcoal bacterial swab -> MS+C - Endocervical / urethral - Urethral/meatal swab
52
Gonorrhoea Mx
- **IM CEFTRIAXONE 1g** - if sensitivites not known - 500mg ORAL CIPRO - if sensitivites known - Screening - CONTACT TRACING - Encourage safe sex + abstain from sex - Finish antibiotics - Advice - Safeguarding in young people
53
Complications of gonorrhoea
- PELVIC INFLAM DISEASE - chronic pain, INFERTILITY + ectopic preg - Epididymo-orchitis / Prostatitis (rarely causes infertility) - CONJUNCTIVITIS - esp in vertical transmission to baby -> Associated with SEPSIS - Urethral strictures - DISSEMINATED GONOCOCCAL INFECTION (septic) - Skin lesions - SEPTIC ARTHRITIS - Endocarditis - Fitz-Hugh-Curtis syndrome
54
Disseminated Gonococcal Infection
- Non-specific SKIN LESIONS - PolyARTHRALGIA / Migratory Polyarthritis - Tenosynovitis - SYSTEMIC - Fever, fatigue etc (septic)
55
Fitz-Hugh-Curtis syndrome
Complication of PID - Inflam + infection of LIVER CAPSULE -> ADHESIONS between liver + peritoneum -> RUQ pain (referred to shoulder) -> Tx with laproscopy + adhesiolysis Bacteria can spread from pelvis via peritoneal cavity, lymph or blood
56
Syphilis pathophys
Transmitted by SPIROCHETE, Gram -VE Treponema pallidum subspecias pallidum - it is MOTILE + can enter through broken skin / intact mucus membrane - Bacteria divide + **Chancre** (hard ulcer) forms at site after **2-3 wks** (incubation period) - **Primary syphilis** - Can progress into oblitering arteritis (endothelial proliferation -> lumen narrowing) -> multi-system ischaemia + Sx Via blood, bodily fluids + vertically (through placenta)
57
Syphilis RFx
- Unprotected sex - Multiple sexual partners - MSM - HIV infection
58
Stages of Syphilis
- Primary (on average within 21 days of infection: 9-90 days) - CHANCRE - Secondary syphilis (Usually **after 3 months** /4-10 wks) - After **3-12 weeks of 2ndry** -> LATENT SYPHILIS - After ~2 years = LATE LATENT - TERTIARY (no longer infectious - many years later) - Gummatous syphilis - Neurosyphilis - Cardiosyphilis
59
Secondary Syphilis Px
- Non-painful/-itchy **SKIN RASH** - Typically on hands + feet - FEVER, MALAISE, Arthralgia, HEadaches - Weight loss; Painless **LYMPHADENOPATHY** - CONDYLOMATA LATA (plaque-like warts in moist areas e.g. axilla, inner thighs, anogenital) - Silvery grey lesions on mucosa - Can start getting neuro, eye + liver Sx (or really any type infection) - Alopecia (moth eaten appearance) Basically just systemic infection
60
Gummatous syphilis
Granulomas in BONE, SKIN, MUCOSA of URT, mouth + viscera / connective tissue
61
Neurosyphilis
- Tabes dorsalis – ataxia, numb legs, absence of deep tendon reflexes, lightning pains, loss of pain and temperature sensation, skin and joint damage. - Dementia – PROGRESSIVE cognitive impairment, mood alterations, psychosis. - Meningovascular complications – cranial nerve palsies, stroke, cerebral gummas. - Argyll Robertson pupil – constricted and unreactive to light, but reacts to accommodation
62
Syphilis Examination
- Genitals - Skin + mucosa - Neuro - MSK (esp in congenital) - Cardio (for signs of AORTIC REGURG) - Neuro
63
Syphilis Ix
- Treponema pallidum PCR - Syphilis point of care test - DARK FILED/GROUND MICROSCOPY of chancre fluid (move v quick) - Serology: - Treponemal tests (tho might not be indicative of syphilis) - Treponemal ELISA (IgG/IgM - always +ve after infection) - TPPA (+ve for life) - Non-treponemal (non-specific; in titres) - detect autoantibodies -> **RPR / VDRL** - high in early disease, falls = Tx success OR progression to LATE - False +ve in inflam / preg - Lumbar puncture in neurosyphilis
64
Syphilis Mx
BENZATHINE PENICILLIN 2.4 MU **IM** - in buttocks - Early = 1 INJECTION - Late infection = 3 INJECTIONS (once weekly) Alt = DOXYCYCLINE 100mg Bidaily (can't use in preg) - Early = 14 days - Late = 28 DAYS Ceftriaxone can also work Need more later on to cover slow growing, late latent treponema + just general STI stuff e.g. contact tracing, screening, follow-up, education
65
Jarisch Herxheimer reaction
Inflam response 2ndry to DEATH OF TREPONEMES - Flu like illness WITHIN 24hrs of Tx - Only supportive UNLESS cardio / neurosyphilis -> give ORAL STEROIDS before Abx
66
When is syphilis followed up
RPR/VDRL bloods at **3, 6 + 12 months**
67
Signs of congenital syphilis
Early: - haemorrhagic rhinitis - Late (at least 2 yrs after birth): - Interstitial keratitis - Cluttons joint - Hutchinson's incisors - Mulberry molars - High arched palat - Rhagades (peri-oral fissures) - Sensorineural deafness - Saddle nose - Cranial frontal bossing
68
Other forms of Treponemal infections
- Yaws (bones + joint) - PInata (skin) - Bejel (chronic skin + tissue) Commonly seen in older people with dementia: Trep Ab +ve, RPR negative - (symptomatic tertiary syphilis usually RPR +ve) Tx to cover late latent syphilis just incase
69
HSV transmission
- **Direct** via mucosa / skin breaks - Higher risk of transmission if visible lesions - 80% UNAWARE - Asymp viral shedding MORE FREQUENT (more common in genital HSV-2 + esp in first 12 months + in peri-flare periods) More common in younger people due to not having had previous exposure Sx can RECCUR
70
HSV stages / natural progression
- 1st infection then LETENT in ANTERIOR HORN CELL in local sensory ganglion - REactivation: can be symp lesions or asymp but INFECTIOUS + shedding - After 1st Sx episode usually get it ~4 times in a year but the longer you have -> fewer recurrences
71
HSV Px
- Painful ulcer - Dysuria - Vaginal/urethral discharge - Systemic Sx (fever, myalgia) - Blistering - Tender lymphadenopathy
72
HSV Dx
- NAAT HSV DNA (high specific + sensitive) - can differentiate HSV-1 and HSV-2 - Viral culture (specific but sensitivity declines as lesions heal) - Type-specific SEROLOGY - useful in preg: can check if they have Ab in blood = she was already infected so she will pass immunity to child so don't have to do c-section - Antigen detection (to check response to antiviral) - Cytological examination
73
HSV Tx
General: - Saline bathing - Analgesia - Topical anaesthetic Antiviral: - Aciclovir (44mg TDS or 200mg 5 daily) - Valaciclovie
74
Genital HSV complications
- Hospitalisation for URINARY RETENTION - Consider SUPRAPUBIC if catheterisation but avoid altogether if possible - ASEPTIC MENINGISM - Severe constitutional Sx - Super-infection - Autoinoculation - Neonatal HSV if during 3rd trimester
75
HSV prevention
- Safe sex - Anti-viral prophylaxis SOMETIMES (can still pass on to other even with this) - given for preg, frequent shedders etc - SCREEN for STIs
76
RFx for developing thrush/candidiasis
- Increased oestrogen (e.g. in preg) - Poorly controlled diabetes - Immunosuppression - Broad-spec Abx The candida (usually albiacans) can already be colonising vagina and just not presenting
77
Candidiasis Px
- Thick, white discharge that does not typically smell - Vulval and vaginal ITCHING, Irritation or discomfort More severe: - Erythema - Fissures - Oedema - Dyspareunia - Dysuria - Excoriation (skin wears off)
78
Candidiasis Ix
- Vaginal pH (swab + pH paper) to differentiate - bacterial vaginosis + trichomoniasis = pH >4.5 - Candidiasis = pH <4.5 - CHARCOAL swab + Microscopy (confirms) **Start giving Tx based on clinical Px tho**
79
Candidiasis Tx
- Intravaginal antifungal cream - **CLOTRIMAZOLE** - **Single dose of 5g of 10% cream at night** - Antifungal pessary - CLOTRIMAZOLE - can do 500mg for 1 night OR 200mg each for 3 nights - Oral antifungal - FLUCONAZOLE - typically only need 1 dose of 150mg Options include Canesten Duo - OVER-THE-COUNTER - includes 1 fluconazole tablet + clotrimazole cream for external vulva Sx If recurrent (>4 / year) -> treat with induction + mainteneance over 6 months (oral or vaginal)
80
What is one side effect of antifungal creams/pessaries
Can damage latex + prevent spermicides from working so need alt contreception
81
HIV epid
- HIV-1 most common - **HIV-2 more common in WEST AFRICA**
82
Seroconversion meaning
The transition from the point of viral infection to when the antibodies are made - e.g. this the time period when the initial HIV infection presents with flu-like Sx
83
Transmission of HIV
- Unprotected sex (more likely to infect in MSM?) - Vertical transmission (pregnancy, birth, breastfeeding) - Mucous membrane, blood / open wound exposure to infected BLOOD / Bodily fluids
84
HIV screening
Routinely offered at sexual health, antenal and substance misuse services - Need to get verbal consent to test tho The lab test checks for HIV antibodies AND the **p24 antigen** - window period of 45 days = can take up to 45 days for test to turn positive POC test - only checks Ab - **90 day window period** Can get home kits if think at risk - Self-sample (lab) - PoC test
84
AIDS-defining illnesses
Only occur in end-stage HIV infection when CD4 count has dropped (usually < 200) - Kaposi's sarcoma - PNEUMOCYSTIS JIROVECII PENUMONIA (PCP) - CYTOMEGALOVIRUS - OESOPHAGEAL / BRONCHIAL Candidiasis - Lymphomas - TUBERCULOSIS
85
How is HIV monitored
- CD4 count - norm = 500 - 1200 cells/mm3 - **< 200 cells/mm3 = high risk of opportunistic infection** - HIV RNA -> VIRAL LOAD - undetectable if well treated
86
HIV Mx
Managed at specialist centres Antiretroviral therapy (ART) - can do Genotypical resistance testing to establish how resistant the HIV strain is to the diff antiretrovirals to guide Tx Diff classes: - Protease Inhib - Integrase Inhib - Nucleoside reverse transcriptase Inhib - Non-nucleoside reverse transcriptase inhib - Entry inhib Usually starting regime = 2 NRTIs (e.g. Tenofovir + Emtricitabine) + a 3rd agent (e.g. Bictegravir) - **Prophylactic Co-trimoxazole if CD4 count < 200** - close CVD risk monitoring (as higher risk because of the HIV) - YEARLY PAP smear - Vaccinate (including PCP) but avoide live vaccines
87
How to prevent HIV transmission during birth
- Viral load < 50 copies/ml = normal delivery is fine - >50 = CONSIDER Pre-labour C-section - >400 = PRE- LABOUR C-SECTION - If unknown OR >1000 = IV ZIDOVUDINE during labour Consider prophyl for babies: - Low risk (mum's viral load <50) = ZIDOVUDINE for 2-4 wks - High risk = ZIDOVUDINE, LAMIVUDINE and NEVIRAPINE for 4 WEEKS Avoid breastfeeding afterwards!
88
Post-exposure prophylaxis (PEP) for HIV
- must be started within LESS thhan 72 HOURS after exposure (sooner the better) - not 100% effective - ART combination = Emticitabine/tenofovir (Truvada) + raltegravir (for 28 DAYS) NB can also take Emitricitabine/tenofovir before potential exposure
89
Risk factors for urinary incontinence
- Increasing age - Previous preg / child birth - High BMI - Hysterectomy - FHx
90
Classification of urinary incontinence
- Urge incontinence / overactive bladder - caused by detrusor overactivity - urge is quickly followed by uncontrollabe leakage - stress incontinence - leaking small amounts when coughing / laughing - mixed incontinence - overflow incontinence - due to bledder outlet obstruction (e.g. enlarged prostate) - Functional incontinence - Patient can't get to bathroom in time due to co-morbs - e.g. dementia, sedation, injury/illness -> decreased ambulation
91
Initial Ix for urinary incontinence
- MINIMUM 3 DAYS of **bladder diary** - Vaginal exam to exclude pelvic organ prolapse + check ability to initiate colutary contraction of pelvic floor muscles - Urine dipstick + cultures (to exclude infection) - Urodynamic studies
92
Urge incontinence Mx
1. Bladder retraining (for at least 6 weeks) 2. Bladder stabilising drugs - 1st line = antimuscarinics - **Oxybutynin (immediate release)** (avoid immediate release in frail older women) - **Tolterodine** (immediate release) - Darifenacin (OD) - **Mirabegron** (beta-3 agonist) - if worried about anti-muscarinic SE esp in frail older patients 3. Surgical/invasive - botulinum toxin (risk of subsequent overflow incontinence) - Sacral nerve stimulation
93
Stress incontinence Mx
1. PELVIC FLOOR MUSCLE TRAINING - 8 contractions TDS, for minimum 3 months - consider electrical stimulation - Vaginal cones 3. Duloxetine - the SNRI (can increase muscle tone of striated muscle in external urethral sphincter by increasing the synaptic concentration of noradrenaline and serotonin in the PUDENDAL NERVE) 2. Surgical - Colposuspension (lifting and fixing neck of bladder) - Sling surgery (placed around neck of bladder) - usually autologous tissue - Urethral bulking agenst - Artificial urinary sphincter

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