Infections of the genito-urinary system and sexually transmitted diseases Please refer to the Treatment of infections in Primary Care section

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1 Genito-urinary System Infections of the genito-urinary system and sexual transmitted diseases - Please refer to the Treatment of infections in Primary Care section Combined Hormonal Contraceptives Combined Hormonal Contraceptives - Low strength (oral) Combined Hormonal Contraceptives - Standard strength (oral) Oral progesterone-only contraceptives Combined Hormonal Contraceptive - Low strength (vaginal) Parenteral progesterone-only contraceptives Emergency contraception Drugs for urinary retention alpha blockers Drugs for urinary retention anti androgen Drugs for urinary frequency, enuresis and incontinence Drugs for erectile dysfunction Update:

2 Infections of the genito-urinary system and sexually transmitted diseases Please refer to the Treatment of infections in Primary Care section Combined Hormonal Contraceptives Please see the current BNF for important information on: Missed pill, diarrhoea & vomiting, travel and drug interactions enzyme inducers Stopping pre-surgery & reasons to stop immediately Choice of combined oral contraceptive including the risk of venous thromboembolism The risk of venous thromboembolism is increased by all combined hormonal contraceptives. A greater risk has been reported with preparations containing desogestrel and gestodene, however the absolute risk is very small and lower than that associated with pregnancy. CSM: There is a possible small increase in the risk of breast cancer which should be weighed against the benefits and evidence of the protective effect against cancers of the ovary and endometrium. Combined Hormonal Contraceptives: Low strength (oral) Drug Formulation Notes on Prescribing Ethinylestradiol / norethisterone [Loestrin 20 ] Small increased risk of venous thromboembolism. Ethinylestradiol / desogestrel [Mercilon ] headache, depression, weight gain, breast symptoms, and breakthrough bleeding) with other progestogens but few differences were found between COC types in their effectiveness for treating acne.

3 Ethinylestradiol / gestodenel [Femodette ] Ethinylestradiol with norelgestromin [Evra ] Transdermal patch Small increased risk of venous thromboembolism. headache, depression, weight gain, breast symptoms, and breakthrough bleeding) with other progestogens but few differences were found between COC types in their effectiveness for treating acne. TNDG: As an alterative choice in patients requiring contraception, particularly where oral preparations cannot be managed and a more invasive treatment, e.g. depot injection is declined. Efficacy is reduced in women >90kg In addition to the company Patient Information Leaflet, patients should be advised on how to dispose of the patch after use. Combined Hormonal Contraceptives: Standard strength (oral) Drug Formulation Notes on Prescribing Ethinylestradiol / levonorgestrel [Microgynon 30, Microgynon 30 ED, Logynon, Logynon ED ] Ethinylestradiol / norethisterone acetate [Brevinor, Loestrin 30, TriNovum ] Ethinylestradiol / norgestimate [Cilest ] ED preparations are taken without a break and contain 7 inactive pills advise patient on which part of the pack to start with. Small increased risk of venous thromboembolism. Ethinylestradiol / desogestrel [Marvelon ] Ethinylestradiol / gestodone [Femodene / Femodene ED ] headache, depression, weight gain, breast symptoms, and breakthrough bleeding) with other progestogens but few differences were found between COC types in their effectiveness for treating acne. Small increased risk of venous thromboembolism. headache, depression, weight gain, breast symptoms, and breakthrough bleeding) with other progestogens but few differences were found between COC types in their effectiveness for treating acne. ED preparations are taken without a break and contain 7 inactive pills advise patient on which part of the pack to start with.

4 Ethinylestradiol /cyproterone acetate [co-cyprindol] Drospirenone / ethinylestradiol [Yasmin ] Not indicated for use solely as an oral contraceptive. Should only be used for women with severe acne that has not responded to oral antibiotics, or for moderately severe hirsutism. SMC: had advised that Yasmin is not recommended. There is no evidence that Yasmin, has effects superior to other standard strength COCs on acne, pre-menstrual symptoms or well-being. headache, depression, weight gain, breast symptoms, and breakthrough bleeding) with other progestogens but few differences were found between COC types in their effectiveness for treating acne. Use with care if increased plasma concentration of potassium might be hazardous. Oral progesterone-only contraceptives Oral progestogen-only preparations may offer a suitable alternative when oestrogens are contra-indicated (including those patients with venous thrombosis or a past history or predisposition to venous thrombosis), but have a higher failure rate than combined preparations. They are suitable for older women, for heavy smokers, and for those with hypertension, valvular heart disease, diabetes mellitus, and migraine. Menstrual irregularities (oligomenorrhoea, menorrhagia) are more common but tend to resolve on long-term treatment. should be taken at the same time each day, if it is delayed by longer than 3 hours (12 hours for Cerazette ) it should be regarded as a Missed Pill. Missed pill, diarrhroea & vomiting, interactions and stopping pre-surgery see current BNF for important information. CSM: It is advised that the possible small increase in the risk of breast cancer should be weighed against the benefits of using oral progesterone only contraceptives. Norethisterone [Micronor ] Levonorgestrel [Norgeston ] Desogestrel [Cerazette ] SMC: Reserve Cerazette for women who cannot tolerate oestrogen-containing contraceptives or in whom these preparations are contraindicated. A missed pill for Cerazette is defined as administration delayed for 12 hours or more.

5 Etynodiol diacetate [Femulen ] TNDG: Cerazette is appropriate for women in whom any of the following are present: Would benefit from inhibition of ovulation, e.g. menstrual complaints, PMS, menstrual migraine, catamenial epilepsy, catamenial asthma, endometriosis, PCOS, past history of ectopic pregnancy Compliance concerns with the 3-hour rule Under age 35 Weight over 70kg Combined Hormonal Contraceptive - Low strength (vaginal) NuvaRing Vaginal ring TNDG: As an alternative contraceptive to women who are unable to tolerate, comply with the barrier method, combined oral contraceptive pill, long acting implants or progesterione only pill Nuvaring should be offered once the other options have been ruled out as there is less experience of the drug and it is a more expensive option. All prescribing decisions should be made by the doctor. The Group felt that Nuvaring was NOT suitable to be managed via a Patient Group Direction as it is a newly licensed drug. As a black triangle drug any adverse drug reactions should be reported to the MHRA using the national yellow card system. Nuvaring is appropriate for initiation and continuation by the GP. Click here for the prescribing algorithm Parenteral progerterone-only contraceptives Full counselling backed by patient information leaflet is required before administration.

6 CSM: In adolescents, medroxyprogesterone acetate (Depo-Provera ) be used only when other methods of contraception are inappropriate; In all women, benefits of using medroxyprogesterone acetate beyond 2 years should be evaluated against risks; In women with risk factors for osteoporosis a method of contraception other than medroxyprogesterone acetate should be considered. Medoxyprogesterone acetate [Depo-Provera ] Injection Medoxyprogesterone acetate may be used as a short-term or long-term contraceptive for women who have been counselled about the likelihood of menstrual disturbance and the potential for a delay in return to full fertility. Delayed return of fertility and irregular cycles may occur after discontinuation of treatment but there is no evidence of permanent infertility. Norethisterone enantate [Noristerat ] Etonogestrel [Implanon ] Injection Flexible rod implant Used as short-term interim contraception e.g. before vasectomy becomes effective. The doctor or nurse administering or removing the system should be fully trained in the technique. Emergency contraception Levonorgesterol [Levonelle 1500] 1.5mg Prescribe only as generic. Do NOT prescribe as Levonelle One-Step. Please refer to the current BNF for information on use. Drugs for urinary retention alpha blockers First dose may cause collapse due to hypotensive effect (therefore should be taken on retiring to bed). Patient should be warned to lie down if symptoms such as dizziness, fatigue or sweating develop, and to remain lying down until they abate completely. Since selective alpha blockers reduce blood pressure, patients receiving antihypertensive treatment may require a reduced dosage and specialist supervision. Drug Indication Formulation Notes on prescribing Tamsulosin M/R M/R capsules Do not prescribe as tablets. Alfuzosin MR tablets

7 Doxazosin Indoramin Immediate release tablets Drugs for urinary retention anti androgen Drug Indication Formulation Notes on prescribing Finasteride Finasteride is excreted in semen and the use of a condom is recommended if sexual partner is pregnant or likely to become pregnant. Women of childbearing age should avoid handling crushed or broken tablets. Drugs for urinary frequency, enuresis and incontinence There is no evidence of a clinically important difference in efficacy between antimuscarinic drugs. However, immediate release non-proprietary oxybutynin is the most cost-effective of the available options. If this is not well tolerated, darifenacin, solifenacin, tolterodine, trospium, or an extended release or transdermal formulation of oxybutynin should be considered as alternatives. Requires review after 3-6 months for continuation. Drug Indication Formulation Notes on Prescribing Oxybutinin Urinary frequency, urgency and incontinence, neurogenic bladder instability, and nocturnal enuresis associated with overactive bladder Immediate release Oxybutinin Darifenacin [Emselex ] Trospium Tolteridine Solifenacin Duloxetine As above Transdermal, M/R tablets NICE: recommended as first line if bladder training has been ineffective. Urinary frequency, urgency, and incontinence MR tablets Urinary frequency, urgency and incontinence Urinary frequency, urgency and incontinence Urinary frequency, urgency and urge incontinence TNDG: The risks of using the drug outweigh the possible benefits, therefore not recommended for

8 [Yentreve ] initiation in the Trust or for prescribing by GPs Drugs for erectile dysfunction Tower Hamlets PCT consensus care guidelines have been developed for the management of erectile dysfunction (ED) please refer to them for further detail. except to treat erectile dysfunction in men who: have diabetes, multiple sclerosis, Parkinson s disease, poliomyelitis, prostate cancer, severe pelvic injury, single gene neurological disease, spina bifida, or spinal cord injury; are receiving dialysis for renal failure; have had radical pelvic surgery, prostatectomy (including transurethral resection of the prostate), or kidney transplant; were receiving Caverject, Erecnos, MUSE, Viagra, or Viridal for erectile dysfunction, at the expense of the NHS, on 14 September 1998; are suffering severe distress as a result of impotence (prescribed in specialist centres only, see notes above). The prescription must be endorsed SLS or written as a private prescription. Sildenafil Action may be delayed if taken with food. Tadalafil Long duration of action. Vardenafil Quick acting, onset may be delayed by high fat meal. Vacuum Ensure patient is appropriately trained to use device by the ED clinic before prescribing. Device devices See THPCT ED guidelines for a full list of devices available. Alprosadil Intracavernosal injection To be initiated in secondary care only. References: Joint Formulary Committee. British National Formulary. 54th Ed. London: British Medical Association and Royal Pharmaceutical Society of Great Britain NPC. Contraception - current issues. MeReC Bulletin. Volume 17, Number Available from: Accessed 10/02/2008 Arowojolu AO, Gallo MF, Lopez LM, Grimes DA, Garner SE. Combined oral contraceptive pills for treatment of acne. Cochrane Database of Systematic Reviews 2004, Issue 3. Scottish Medicines Consortium. Drospirenone 3mg, ethinylestradiol 30mcg (Yasmin ). No. 23 / 03 The National Institute for Health and Clinical Excellence. Urinary incontinence. October Clinical Guideline 40. Accessed from Accessed on 08/02/08. MHRA. Duloxetine: marketed as Cymbalta and Yentreve for different disorders. Drug Safety Update: Volume 1, Issue 2, September Accessed 10/02/2008 Regional Drug and Therapeutics Centre. Cerazette : New drug evaluation. No. 56. May2003. Available from: Accessed 18/02/2008 NPC. EVRA a new contraceptive patch. MeReC Extra. Issue No. 10. September 2003 NPC. Does Cerazette offer anything new over existing POPs? MeReC Extra. Issue No. 10. September 2003 The National Institute for Health and Clinical Excellence. Urinary incontinance. October Clinical Guideline 40. Available from

9 Accessed on 08/02/08 Clinical Knowledge Summaries. Tamsulosin M/R, Finasteride, Alfuzosin Doxazosin Indoramin Oxybutinin Darifenacin Trospium Tolteridone Solifenacin Duloxetine SCHIN Ltd, Centre for Health Informatics at Newcastle. Available from: Accessed 16/02/08.