Section 7: Obstetrics, Gynaecology & Urinary Tract Disorders

Section Description

BNF 7.1.1

Prostaglandins and oxytocics

BNF 7.1.1.1

Ductus arteriosus

BNF 7.1.2

Mifepristone

BNF 7.1.3

Myometrial relaxants

BNF 7.2.1

Preparations for vaginal and vulval changes

BNF 7.2.2

Vaginal and vulval infections

BNF 7.3.1

Combined hormonal contraceptives

BNF 7.3.2.1

Oral progestogen-only contraceptives

BNF 7.3.2.2

Parenteral progestogen-only contraceptives

BNF 7.3.2.3

Intra-uterine progestogen-only contraceptive

BNF 7.3.3

Spermicidal contraceptives

BNF 7.3.4

Contraceptive devices

BNF 7.3.5

Emergency contraception

BNF 7.4.1

Drugs for urinary retention

BNF 7.4.2

Drugs for urinary frequency, enuresis, and incontinence

BNF 7.4.3

Drugs used in urological pain

BNF 7.4.4

Bladder instillations and urological surgery

BNF 7.4.5

Drugs for erectile dysfunction

BNF 7.4.6

Drugs for premature ejaculation

BNF 7.1.1 Prostaglandins and oxytocics

Caesarean section NICE Guidance CG132  
Induction and augmentation of labour NICE Guidance CG70  
Intrapartum care NICE Guidance CG190

Carboprost 250mcg injection Specialist/ Hospital prescribing only. Initiation by Obstetrician and/or Gynaecologist only
Dinoprostone vaginal gel, pessaries, extra-amniotic solution & intravenous infusion Specialist/ Hospital prescribing only.
Ergometrine maleate 500mcg injection Specialist/ Hospital prescribing only.
Ergometrine & oxytocin (Syntometrine®) 500mcg/ 5 units IM injection Specialist/ Hospital prescribing only.
Gemeprost 1 mg pessary Specialist/ Hospital prescribing only.
Misoprostol oral   Specialist/ Hospital prescribing only [unlicensed use] 
Oxytocin injection Specialist/ Hospital prescribing only.

BNF 7.1.1.1   Ductus arteriosus

See BNF for Children section 2.14 for details

Alprostadil (prostaglandin E1) injection - Specialist/ Hospital prescribing only
Ibuprofen injection (Pedea®) - Specialist/ Hospital prescribing only
Indometacin injection (Indocid PDA®) - Specialist/ Hospital prescribing only [Unlicensed]

BNF 7.1.2 Mifepristone

Mifepristone 200mg tablet

 

Specialist/ Hospital prescribing only. For use by Consultant Obstetricians & Gynaecologists only; in accordance with The Royal College of Obstetricians & Gynaecologists’ Guidelines.

BNF 7.1.3 Myometrial relaxants

Atosiban infusion and injection

Specialist/ Hospital prescribing only

Nifedipine oral   Unlicensed indication – Specialist/ Hospital prescribing only – see BNF 2.6.2 for products 

Salbutamol injection

Specialist/ Hospital prescribing only - see BNF 3.1.1.1 for products

Terbutaline injection

BNF 7.2.1 Preparations for vaginal atrophy

Topical HRT preparations

Estradiol vaginal tablets (Vagifem®)

 

Estriol 0.01% vaginal cream (Gynest®)

 

Estriol 0.1% vaginal cream (Ovestin®)

 

Estradiol vaginal ring(Estring®)

 

For postmenopausal urogential conditions – not suitable for vasomotor symptoms or osteoporosis prophylaxis.  Replace every 3 months; maximum duration of continuous treatment 2 years.

BNF 7.2.2 Vaginal and vulval infections

Preparations for vaginal and vulval candiasisis

Clotrimazole cream, pessaries and vaginal cream

Please note: Combi and Twin packs (containing cream and pessaries) incur 2 prescription charges

Econazole cream

Miconazole vaginal cream and ovule

Preparations for other vaginal infections

Clindamycin 2% vaginal cream

Metronidazole 0.75% vaginal gel

 

Balance Active vaginal gel   
Balance Active lactic acid pessaries  Not routinely stocked by hospital pharmacy 

BNF 7.3.1 Combined hormonal contraceptives

The Faculty of Family Planning and Reproductive Health Centre (FFPRHC) Clinical Effectiveness Unit holds evidence-based guidance on the risk of interactions with oral contraceptives FFPRHC advice

Lactose-free oral contraceptive
All licensed oral contraceptives available in the UK contain lactose. Femulen was previously available as lactose-free but has since been discontinued. Please see UKMi guidance for more information.

Low Strength

Oestrogen

Progestogen

Brand

Formulation

 

Ethinylestradiol 20mcg

Desogestrel 150mcg

Munalea 20/150®

Tablets

 

Gestodene 75mcg

Aidulan 75/20®

Tablets

 
Drosperinone 3mg Daylette®  Tablets Women requiring contraception and suffering from severe premenstrual dysphoric disorder (PMDD) or moderate acne. 

Ethinylestradiol 15mcg

Etonogestrel 120mcg

Nuvaring®

Vaginal ring

Specialist/ Hospital prescribing only

Standard Strength

Oestrogen

Progestogen

Brand

Formulation

 
Ethinylestradiol 30mcg Desogestrel 150mcg Munalea 30/150® Tablet  

Gestodene 75mcg

Aidulan 75/30® Tablet  
Levonorgestrel 150mcg Maexeni® Tablet  
Microgynon 30 ED®  Tablet  

Norethisterone 1.5mg

Loestrin 30® Tablet  
Ethinylestradiol 35mcg Norgestimate 250mcg Cilique® Tablet  
Norethisterone 1mg Norimin® Tablet  

Ethinylestradiol 20mcg

Norelgestromin 150mcg

Evra® Patch  

Phased formulation

Oestrogen

Progestogen

Brand

Formulation

 
Ethinylestradiol Levonorgestrel TriRegol® Tablet  

BNF 7.3.2.1 Oral progestogen-only contraceptives 

Progestogen

Brand

Formulation

 
Norethisterone 350mcg Noriday® Tablet  
Desogestrel 75mcg Feanolla® Tablet  

BNF 7.3.2.2   Parenteral progestogen-only contraceptives

NICE Guidance: Long-acting reversible contraception NICE CG30

Medroxyprogesterone 150mg/ml (Depo-Provera®) 
Medroxyprogesterone 104mg/0.65ml (Sayana Press®)

CSM Advice.  The CSM had advised that:

Etonogestrel 68mg implant (Nexplanon®)  

BNF 7.3.2.3 Intra-uterine progestogen-only contraceptive

NICE Guidance: Long-acting reversible contraception http://guidance.nice.org.uk/CG30
Mirena® intra-uterine system  

BNF 7.3.3 Spermicidal contraceptive  

No products have been reviewed for this section

BNF 7.3.4 Contraceptive devices  

INTRA-UTERINE DEVICES
The following products are not stock by the Hospital Pharmacy
Nova-T 380®
T-Safe 380A Quick Load®  

BNF 7.3.5 Emergency Contraception

Progestogen

Brand

 
Levonorgestrel  Upostelle®    
Ulipristal acetate EllaOne® 

Women requesting emergency hormonal contraception (EHC) who present 73 to 120 hours after episode of unprotected sexual intercourse (UPSI) and have chosen UPA after all options have been discussed.

Women requesting emergency hormonal contraception up to 72 hours after UPSI who are mid-cycle (i.e. Day 10-16 of a 28 day cycle, or equivalent if cycle length shorter or longer ) and have chosen UPA after all options have been discussed.

Client has vomited within 3 hours of taking previous dose of UPA provided the repeat dose is within 120 hours of UPSI.  

INTRA-UTERINE DEVICES – See section BNF 7.3.4 

BNF 7.4.1 Drugs for urinary retention

ALPHA-BLOCKERS
Treatment of choice for benign prostatic obstruction.
Effect should be noticed within several days, with full response after 4-6 weeks. There is a lack of published evidence of benefit in those who take the drug beyond 3 years.

Alfuzosin oral

 

Tamsulosin oral

Tamsulosin m/r capsules are less expensive than m/r tablets.

Tamsulosin + solifenacin oral

Treatment of moderate to severe urinary frequency, urgency and voiding symptoms associated with BPH where monotherapy is inadequate 

ANTI-ANDROGEN
Alternative treatment for benign prostatic obstruction in patients with large prostate or where alpha-blockers are ineffective not tolerated or contraindicated.

Finasteride oral

Treatment required for several months before benefit obtained. Review treatment after 6 months. Observed benefit may be lost 3-6 months after stopping treatment.

Dutasteride oral

Onset of action within one to three months

Tamsulosin + dutasteride oral  Combodart® capsules 

BNF 7.4.2 Drugs for urinary frequency, enuresis, and incontinence

MALE patients with urinary incontinence

The management of lower urinary tract symptoms (LUTS) in men NICE CG97 (May 2010)

Symptoms

Treatment option

Formulary drugs

Moderate to severe LUTS

Alpha blocker

See BNF 7.4.1

Symptoms of OAB

Anticholinergic

Oxybutynin hydrochloride
Tolterodine tartrate
Trospium
Solifenacin

LUTS with prostate involvement

5-alpha reductase inhibitor

See BNF 6.4.2
Moderate to severe LUTS with prostate involvement Alpha blocker + 5-alpha reductase inhibitor

Storage problem after treatment with alpha blocker alone 

Anticholinergic + alpha blocker

FEMALE patients with urinary incontinence

Urinary incontinence in women NICE CG171 (September 2013)

 

ANTIMUSCARINICS

  • 6-week trial to enable assessment of the benefits and side effects
  • Titrate dose to combat adverse effects
  • Review treatment after 6 months to confirm continued need

Oxybutynin hydrochloride oral and transdermal patches

Do not prescribe oxybutynin (immediate release) to frail elderly women because of the risk of adverse effects whihc may cause impairment of daily functioning (for example walking or dressing), chronic confusion, or acute delirium (less common). NICE CG171

Tolterodine tartrate oral

Standard release is first line treatment. Neditol XL® is preferred brand in primary care.

Solifenacin oral

 

Duloxetine oral

Do NOT prescribe duloxetine if patient has hepatic impairment, severe renal impairment (creatinine clearance less than 30 mL/min), uncontrolled hypertension, if prescribed a monoamine oxidase inhibitor or a CYP1A2 inhibitor (such as fluvoxamine or ciprofloxacin).
Prescribe with caution if patient has increased intra-ocular pressure or is at risk of acute narrow-angle glaucoma, epilepsy or a history of mania or a diagnosis of bipolar disorder.
Re-assess after 2-4 weeks of treatment to evaluate the benefit and tolerability of the treatment.

Mirabegron oral

Mirabegron for treating symptoms of overactive bladder NICE TA290
MHRA alert Oct 2015 - risk of severe hypertension


Nocturnal Enuresis in Children

Desmopressin

See BNF 6.5.2

Amitriptyline, imipramine

See BNF for details

BNF 7.4.3 Drugs used in urological pain

Alkalinsation of Urine

Potassium citrate mixture

10ml three times a day well-diluted with water

Sodium bicarbonate oral

see BNF 9.2.1.3

BNF 7.4.4 Bladder instillations and urological surgery

CATHETER PATENCY SOLUTIONS

Chlorhexidine

Prescribed as Uro-Tainer®

Sodium chloride 0.9%

Prescribed as Uriflex S®

Solution G

 

Solution R

Prescribed as Uriflex R®

UROLOGICAL SURGERY
Glycine irrigation – Specialist/ Hospital prescribing only

Bladder pain syndrome/interstitial cystitis
Chondroitin sulphate bladder irrigation - Specialist/ Hospital prescribing only
Sodium hyaluronate solution - Specialist/ Hospital prescribing only

Bladder cancer detection
Hexaminolevulinate powder - Specialist/ Hospital prescribing only

BNF 7.4.5 Drugs for erectile dysfunction

SLS CRITERIA - Treatments for erectile dysfunction are not available as an NHS prescription except in men who:

Prescriptions must be endorsed “SLS”. 

Alprostadil

SLS criteria apply to alprostadil 

intracavernosal injection e.g. Caverject® Caverject Dual Chamber®

urethral application e.g. Muse®

Sildenafil GENERIC tablets

SLS criteria no longer apply to GENERIC sildenafil. No restriction on quantity to be supplied to ensure adequate trial of treatment

Tadalafil oral

Following prostatectomy
Once daily dose to keep blood flowing to penis and help maintain tumescence.  

Vacuum pumps  Refer to specialist for patient assessment and advice on appropriate product. SLS criteria apply to prescriptions, see Drug Tariff Part IXA for IMEDicare and other products  

A GP may ONLY prescribe privately to a patient on his NHS list if the patient does not meet the SLS criteria for NHS treatment.

BNF 7.4.6 Drugs for premature ejaculation  

Dapoxetine oral

Suitable for prescribing in primary care following confirmation of a diagnosis of premature ejaculation by specialist psychosexual health clinic.