There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: tablet, capsule, oral
suspension, oral solution, solution for injection
Tablet
▶Liothyronine sodium (Non-proprietary)
Liothyronine sodium 5 microgram Liothyronine 5microgram
tablets | 28 tablet P £98.00 DT = £98.00
Liothyronine sodium 10 microgram Liothyronine 10microgram
tablets | 28 tablet P £148.00 DT = £148.00
Liothyronine sodium 20 microgram Liothyronine 20microgram
tablets | 28 tablet P £245.29 DT = £154.83
▶Cytomel (Imported (United States))
Liothyronine sodium 25 microgram Cytomel 25microgram tablets
| 100 tablet P s
Powder for solution for injection
▶Liothyronine sodium (Non-proprietary)
Liothyronine sodium 20 microgram Liothyronine 20microgram
powder for solution for injection vials | 5 vial P £1,567.50 DT =
£1,567.50
Chapter 7
Genito-urinary system
CONTENTS
Genito-urinary system
Bladder and urinary disorders
page 818
Urinary frequency, enuresis, and incontinence
1.1
Urinary retention
1.2
Urolithiasis
1.3
Urological pain
1.4
Bladder instillations and urological surgery
Contraception
Contraception, combined
3.1
Contraception, devices
3.2
Contraception, emergency
3.3
Contraception, oral progestogen-only
3.4
Contraception, parenteral progestogen-only
3.5
Contraception, spermicidal
3.6
Bladder and urinary
disorders
Urinary frequency, enuresis,
1.1
and incontinence
Urinary incontinence and pelvic
organ prolapse in women
Description of condition
Urinary incontinence is the involuntary leakage of urine and
can range in severity and nature. It can impact the person, as
well as their families and carers, and can be detrimental to
an individual’s physical, psychological, and social well-
being. Urinary incontinence can be the result of functional
abnormalities in the lower urinary tract, or due to other
illnesses. It can be sub-classified into four main types: stress,
urgency, mixed, and overflow incontinence.
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.
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.
Mixed urinary incontinence is involuntary leakage
associated with both urgency and stress, however, one type
tends to be predominant.
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. For further information, see Urinary retention p. 825.
Erectile and ejaculatory conditions
page 857
Erectile dysfunction
4.1
Premature ejaculation
4.2
Obstetrics
Induction of labour
5.1
Postpartum haemorrhage
5.2
Premature labour
5.3
Termination of pregnancy
5.4
Vaginal and vulval conditions
Vaginal and vulval infections
6.1
6.1a Vaginal and vulval bacterial infections
6.1b Vaginal and vulval fungal infections
Vaginal atrophy
6.2
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.
The main risk factor for developing any type of
incontinence is older age; this is due to the physiological
changes that occur with natural aging. Some other risk
factors for stress incontinence include 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).
Some conditions can increase detrusor muscle overactivity
and therefore worsen urgency incontinence. These include
conditions that affect the lower urinary tract such as;
Urinary-tract infections p. 622, 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. Side-effects of some drugs may also
increase detrusor muscle overactivity or indirectly
contribute to urgency incontinence; these include
cholinesterase inhibitors, drugs that cause constipation, and
those with anticholinergic effects. Diuretics, alcohol, and
caffeine all increase urine production and can cause
polyuria, frequency, urgency, and nocturia.
Aims of treatment
Manage urinary incontinence and the symptoms of
overactive bladder syndrome.
Non-drug treatment
g Women with urinary incontinence should modify their
fluid intake, and if their BMI is 30 kg/m2 or greater, be
advised to lose weight. For those with an overactive bladder,
a reduction in caffeine intake should be trialled.
Absorbent products, hand-held urinals and toileting aids
should not be used to treat urinary incontinence, unless the
person has severe cognitive or mobility impairment that may
prevent further treatment. They may be used in some
women as a coping strategy whilst awaiting treatment, as an
adjunct to ongoing therapy, or as long-term management
after all treatment options have been considered; their use
should be reviewed at least annually. Intravaginal and
intraurethral devices should only be used when required to
prevent leakage at specific times, for example during
exercise.
Surgical management may be an option for some women
and will depend on a number of factors. Discussion around
the details of the procedures and subsequent shared decision
making should be carried out. h
Urgency incontinence
g 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.
h
Stress incontinence
g 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. h
Mixed incontinence
g 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.
h
Drug treatment
g When considering drug treatment in women with
incontinence exclude any possible causes, including drugs or
conditions that may exacerbate incontinence or overactive
bladder.
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.
For further information, see Urinary-tract infections p. 622.
Women should be referred to a specialist 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 p. 622
. palpable bladder after voiding, or symptoms of voiding
difficulty.
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. h
Urgency incontinence
g An anticholinergic drug should be considered for
women who have trialled bladder training, where frequency
is a problem and symptoms persist. Consider the total
anticholinergic load, coexisting conditions, such as cognitive
impairment or poor bladder emptying, and the risk of side-
effects when offering anticholinergic medicine. When
prescribing an anticholinergic in those with dementia, see
Dementia p. 315. Immediate release oxybutynin
hydrochloride p. 821, immediate release tolterodine tartrate
p. 823, or darifenacin p. 820 can be used first-line.
Immediate release oxybutynin should not be used in frail,
older women at risk of sudden deterioration in their physical
or mental health. The lowest dose should be used and
titrated upwards if necessary. Transdermal oxybutynin
hydrochloride p. 821 may be used in those unable to tolerate
oral treatment. Mirabegron p. 824 may be used if treatment
with an anticholinergic is contra-indicated, ineffective, or
not tolerated, for further information, see National
funding/access decisions in mirabegron.
Treatment should 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. If treatment has not been
effective or is not tolerated an alternative anticholinergic
drug can be used, the current dose adjusted or, mirabegron
Genito-urinary system
trialled; review again after 4 weeks. Alternative
anticholinergics include, an untried first-line drug, or one of
the following; fesoterodine fumarate p. 821, propiverine
hydrochloride p. 822, solifenacin succinate p. 823, trospium
chloride p. 824, or an extended release formulation of either
oxybutynin hydrochloride or tolterodine tartrate. Women
who have tried taking medicine for overactive bladder, but
treatment has failed, should be referred to secondary care,
where treatment with botulinum toxin type A p. 425 or
surgical methods may be considered.
Flavoxate hydrochloride p. 821, propantheline bromide
p. 93, or imipramine hydrochloride p. 394 should not be used
as treatment options.
In women who have troublesome nocturia, desmopressin
p. 704 may also be used. Intravaginal oestrogen therapy can
be used in those women who are post-menopausal and have
vaginal atrophy. Treatment with an intravaginal oestrogen
should be reviewed at least annually to re-assess the need for
continued treatment and monitor for symptoms of
endometrial hyperplasia or carcinoma. h
Stress incontinence
g Duloxetine p. 385 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. h
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.
Pelvic organ prolapse
Pelvic organ prolapse is the symptomatic descent of part of
the wall of the vagina or uterus. 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.
g Women who present to primary care with symptoms,
or an incidental finding of vaginal prolapse should be
examined to rule out pelvic mass or other pathology, and a
full history taken. Treatment preferences should be
discussed and referral made where necessary. Women in
secondary care should be considered for referral to a
clinician with expertise in prolapse if experiencing incidental
symptoms, or on incidental finding of vaginal prolapse. A
validated pelvic floor symptom questionnaire may aid
assessment and decision making.
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.
A vaginal oestrogen may be used for women with prolapse
and signs of vaginal atrophy, an oestrogen-releasing ring
may be more appropriate for those women who have
cognitive or physical impairments.
A vaginal pessary may be used alone, or in conjunction
with pelvic floor muscle training for those with symptomatic
pelvic organ prolapse. Surgical management may be required
in women whose symptoms have not improved with non-
surgical methods, or who have declined non-surgical
treatment. h
Nocturnal enuresis in children
Description of condition
Nocturnal enuresis is the involuntary discharge of urine
Genito-urinary system
during sleep, which is common in young children. Children
are generally 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.
Treatment
Children under 5 years
g For children under 5 years, treatment is usually
unnecessary as the condition is likely to resolve
spontaneously. Reassurance and advice can be useful for
some families. h
Non Drug Treatment
g 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.
Treatment using an alarm should be reviewed 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.
Combined treatment with desmopressin p. 704, or the use of
desmopressin alone, is recommended if the initial alarm
treatment is unsuccessful or it is no longer appropriate or
desirable. h
Drug Treatment
g Treatment with oral or sublingual desmopressin is
recommended for children over 5 years of age 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). 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.
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.
Under specialist supervision, nocturnal enuresis
associated with daytime symptoms (overactive bladder) can
be managed with desmopressin alone or in combination with
an antimuscarinic drug (such as oxybutynin hydrochloride
p. 821 or tolterodine tartrate p. 823 [unlicensed indication]).
Treatment should be continued for 3 months; the course can
be repeated if necessary.
The tricyclic antidepressant imipramine hydrochloride
p. 394 can be considered for children who have not
responded to all other treatments and have undergone
specialist assessment, 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. h
Useful Resources
Bedwetting in under 19s. National Institute for Health and
Care Excellence. Clinical guideline CG111. October 2010.
www.nice.org.uk/guidance/cg111
ANTIMUSCARINICS
Antimuscarinics (systemic)
f
PDF pages 839, 840, 841, 842
