l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 22
Bethanechol chloride 10 mg Myotonine 10mg tablets | 100 tablet P £18.51
Bethanechol chloride 25 mg Myotonine 25mg tablets | 100 tablet P £27.26
potent androgen, dihydrotestosterone.
▶ Adult: 500 micrograms daily, review treatment at
3–6 months and then every 6–12 months (may require
several months treatment before benefit is obtained)
l INTERACTIONS → Appendix 1: dutasteride
▶ Common or very common Breast disorder. sexual
▶ Uncommon Alopecia . hypertrichosis
l CONCEPTION AND CONTRACEPTION Dutasteride is excreted
in semen and use of a condom is recommended if sexual
partner is pregnant or likely to become pregnant.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
mild to moderate impairment; avoid in severe impairment
l MONITORING REQUIREMENTS Manufacturer advises that
patients should be regularly evaluated for prostate cancer.
l EFFECT ON LABORATORY TESTS May decrease serum
l HANDLING AND STORAGE Women of childbearing potential
should avoid handling leaking capsules of dutasteride.
l PATIENT AND CARER ADVICE Cases of male breast cancer
have been reported. Patients or their carers should be told
to promptly report to their doctor any changes in breast
tissue such as lumps, pain, or nipple discharge.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral solution
CAUTIONARY AND ADVISORY LABELS 25
▶ Dutasteride (Non-proprietary)
Dutasteride 500 microgram Dutasteride 500microgram capsules | 30 capsule P £3.21–£19.99 DT = £3.21
▶ Avodart (GlaxoSmithKline UK Ltd)
Dutasteride 500 microgram Avodart 500microgram capsules | 30 capsule P £14.60 DT = £3.21
Combinations available: Tamsulosin with dutasteride, p. 785
potent androgen, dihydrotestosterone.
▶ Adult: 5 mg daily, review treatment at 3–6 months and
then every 6–12 months (may require several months
treatment before benefit is obtained)
MHRA/CHM ADVICE: RARE REPORTS OF DEPRESSION AND
The MHRA has received reports of depression and, in
rare cases, suicidal thoughts in men taking finasteride
(Propecia ®) for male pattern hair loss; depression is also
associated with Proscar ® for benign prostatic
hyperplasia. Patients should be advised to stop
finasteride immediately and inform a healthcare
professional if they develop depression.
l CAUTIONS Obstructive uropathy
▶ Common or very common Sexual dysfunction
▶ Uncommon Breast abnormalities . skin reactions
▶ Frequency not known Angioedema . depression . infertility
male . palpitations .testicular pain
l CONCEPTION AND CONTRACEPTION Finasteride is excreted
in semen and use of a condom is recommended if sexual
partner is pregnant or likely to become pregnant.
l EFFECT ON LABORATORY TESTS Decreases serum
l HANDLING AND STORAGE Women of childbearing potential
should avoid handling crushed or broken tablets of
l PATIENT AND CARER ADVICE Cases of male breast cancer
have been reported. Patients or their carers should be told
to promptly report to their doctor any changes in breast
tissue such as lumps, pain, or nipple discharge.
l NATIONAL FUNDING/ACCESS DECISIONS
NHS restrictions Finasteride is not prescribable in NHS
primary care for the treatment of androgenetic alopecia in
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension,
CAUTIONARY AND ADVISORY LABELS 25
▶ Finasteride (Non-proprietary)
Finasteride 1 mg Finasteride 1mg tablets | 28 tablet P £8.36
Finasteride 5 mg Finasteride 5mg tablets | 28 tablet P £11.85
Finasteride 1 mg Aindeem 1mg tablet | 28 tablet P £33.68 |
▶ Propecia (Merck Sharp & Dohme Ltd)
Finasteride 1 mg Propecia 1mg tablets | 28 tablet P £33.68 | 84 tablet P £88.40
▶ Proscar (Merck Sharp & Dohme Ltd)
Finasteride 5 mg Proscar 5mg tablets | 28 tablet P £13.94 DT =
Renal and ureteric stones 03-Apr-2019
Renal and ureteric stones are crystalline calculi that may
form anywhere in the upper urinary tract. They are often
asymptomatic but may cause pain when they move or
obstruct the flow of urine. Most stones are composed of
calcium salts (calcium oxalate, calcium phosphate or both).
The rest are composed of struvite, uric acid, cystine and
other substances. 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.
The following are 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.
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
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), the location (distal ureteral stones are more likely
to pass than proximal ureteral stones), and the degree of
g The aim of treatment is to improve the detection,
clearance and prevention of renal and ureteric stones
thereby reducing pain and improving quality of life. h
g Consider watchful waiting for asymptomatic renal
stones if they are less than 5mm in diameter. If they are
larger; the risk and benefit of this option should be discussed
Options for surgical stone removal should be discussed by
the specialist hospital team depending on severity of
obstruction, patient factors, size and site of stone. Options
include shockwave lithotripsy, percutaneous
nephrolithotomy and ureteroscopy.
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). h
g Offer NSAIDs as first line treatment for the
management of pain associated with suspected renal colic or
renal and ureteric stones. If NSAIDs are contra-indicated or
not sufficiently controlling the pain, consider intravenous
paracetamol. Subsequently, opioids can be used if both
paracetamol and NSAIDs are contra-indicated or not
sufficiently controlling the pain. Do not offer antispasmodics
to patients with suspected renal colic. h
g Consider alpha-adrenoceptor blockers for patients with
therapy for patients having shockwave lithotripsy for
ureteric stones less than 10mm. h
Prevention of recurrence of stones
g Alongside lifestyle advice, consider potassium citrate
[unlicensed] in patients with recurrent stones composed of
at least 50% calcium oxalate. Thiazides [unlicensed] may be
given if patients also have hypercalciuria after restricting
their sodium intake to no more than 6g a day. h
Lidocaine hydrochloride gel is a useful topical application
in urethral pain or to relieve the discomfort of
For information on the management of pain in renal and
ureteric stones, see Renal and ureteric stones above.
Alkalinisation of urine can be undertaken with potassium
citrate. The alkalinising action may relieve the discomfort of
cystitis caused by lower urinary tract infections. Sodium
bicarbonate p. 1038 is used as a urinary alkalinising agent in
some metabolic and renal disorders.
Citric acid with potassium citrate
Relief of discomfort in mild urinary-tract infections |
▶ BY MOUTH USING ORAL SOLUTION
▶ Adult: 10 mL 3 times a day, diluted well with water
l CAUTIONS Cardiac disease . elderly
l INTERACTIONS → Appendix 1: potassium citrate
l SIDE-EFFECTS Hyperkalaemia . nausea . vomiting
l RENAL IMPAIRMENT Avoid in severe impairment.
Monitoring Close monitoring required in renal
impairment—high risk of hyperkalaemia.
l PRESCRIBING AND DISPENSING INFORMATION When
prepared extemporaneously, the BP states Potassium
Citrate Mixture BP consists of potassium citrate 30%, citric
acid monohydrate 5% in a suitable vehicle with a lemon
flavour. Extemporaneous preparations should be recently
prepared according to the following formula: potassium
citrate 3 g, citric acid monohydrate 500 mg, syrup 2.5 mL,
l EXCEPTIONS TO LEGAL CATEGORY Proprietary brands of
potassium citrate are on sale to the public for the relief of
discomfort in mild urinary-tract infections.
788 Bladder and urinary disorders BNF 78
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 27
▶ Citric acid with potassium citrate (Non-proprietary)
Citric acid monohydrate 50 mg per 1 ml, Potassium citrate
300 mg per 1 ml Potassium citrate mixture | 200 ml G £1.38 DT
= £1.38 | 200 ml p £1.38 DT = £1.38
▶ Adult: (consult product literature)
Relief of discomfort in mild urinary-tract infections
▶ Adult: (consult product literature)
▶ Child 3–17 years: 5–10 mL for 1 dose
▶ Child 3–17 years: 5 mL for 1 dose
▶ Child 1 month–2 years: 5 mL for 1 dose, insert only half
▶ Child 3–17 years: 5 mL for 1 dose
▶ With rectal use Acute gastro-intestinal conditions
▶ With rectal use Debilitated patients (in adults). sodium and
water retention in susceptible individuals
l INTERACTIONS → Appendix 1: sodium citrate
▶ With oral use in adults Use with caution.
▶ With oral use In patients with fluid retention, avoid
antacids containing large amounts of sodium.
l PRESCRIBING AND DISPENSING INFORMATION Sodium
citrate 300 mmol/litre (88.2 mg/mL) oral solution is
licensed for use before general anaesthesia for caesarean
section (available from Viridian).
l EXCEPTIONS TO LEGAL CATEGORY Proprietary brands of
sodium citrate are on sale to the public for the relief of
discomfort in mild urinary-tract infections.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral solution
▶ Sodium citrate (Non-proprietary)
Sodium citrate 4 gram Sodium citrate 4g oral granules sachets | 6 sachet G £2.38
▶ Brands may include CanesOasis, Cymalon (sodium citrate), Cystocalm
▶ Sodium citrate (Non-proprietary)
Sodium citrate 88.23 mg per 1 ml Sodium citrate 0.3M oral solution
▶ Sodium citrate (Non-proprietary)
Sodium citrate 4 gram Sodium citrate 4g oral powder sachets | 6 sachet G £1.65 DT = £1.65
▶ Sodium citrate (Non-proprietary)
Sodium citrate 3% irrigation solution 1litre bags | 1 bag s
▶ Micolette Micro-enema (Pinewood Healthcare)
Sodium citrate 90 mg per 1 ml Micolette Micro-enema 5ml |
▶ Micralax Micro-enema (RPH Pharmaceuticals AB)
Sodium citrate 90 mg per 1 ml Micralax Micro-enema 5ml | 12 enema p £4.87
Pentosan polysulfate sodium 04-Sep-2018
▶ Adult: 100 mg 3 times a day, review treatment after
6 months and discontinue if no response
l CONTRA-INDICATIONS Active bleeding
l CAUTIONS Patients at increased risk of bleeding
ulceration . paraesthesia . photosensitivity reaction . skin
reactions .thrombocytopenia .tinnitus . vomiting . weight
▶ Frequency not known Coagulation disorder. hepatic
l PREGNANCY Manufacturer advises avoid—no information
l BREAST FEEDING Manufacturer advises avoid—no
l HEPATIC IMPAIRMENT Manufacturer advises caution—
evidence of hepatic involvement in elimination.
l RENAL IMPAIRMENT Manufacturer advises caution—
evidence of renal involvement in elimination.
l MONITORING REQUIREMENTS Manufacturer advises
careful monitoring in patients with history of heparin or
pentosan polysulfate sodium induced thrombocytopenia.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 23
▶ Elmiron (Sovereign Medical Ltd, Consilient Health Ltd)
Pentosan polysulfate sodium 100 mg Elmiron 100mg capsules | 90 capsule P £450.00–£699.40
Anethol with borneol, camphene,
Urolithiasis for the expulsion of calculi
▶ Adult: 1–2 capsules 3–4 times a day, to be taken before
l LESS SUITABLE FOR PRESCRIBING Preparation is less
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 25
▶ Rowatinex (Meadow Laboratories Ltd)
Cineole 3 mg, Anethol 4 mg, Fenchone 4 mg, Borneol 10 mg,
Camphene 15 mg, Pinene 31 mg Rowatinex capsules | 50 capsule P £7.35
Bladder instillations and urological
Various solutions are available as irrigations or washouts.
Aqueous chlorhexidine p. 1211 can be used in the
management of common infections of the bladder but it is
ineffective against most Pseudomonas spp. Solutions
containing chlorhexidine 1 in 5000 (0.02%) are used but they
may irritate the mucosa and cause burning and haematuria
(in which case they should be discontinued); sterile sodium
chloride solution 0.9% p. 1040 (physiological saline) is
usually adequate and is preferred as a mechanical irrigant.
Continuous bladder irrigation with amphotericin
50 micrograms/mL p. 593 may be of value in mycotic
Clot retention is usually treated by irrigation with sterile
sodium chloride solution 0.9% but sterile sodium citrate
solution for bladder irrigation 3% p. 789 may also be helpful.
Bladder instillations of doxorubicin hydrochloride p. 901 and
mitomycin p. 919 are used for recurrent superficial bladder
tumours. Such instillations reduce systemic side-effects;
adverse effects on the bladder (e.g. micturition disorders and
reduction in bladder capacity) may occur.
Instillation of epirubicin hydrochloride p. 902 is used for
treatment and prophylaxis of certain forms of superficial
bladder cancer; instillation of doxorubicin hydrochloride is
also used for some papillary tumours.
Instillation of BCG (Bacillus Calmette-Guérin p. 958), a
live attenuated strain derived from Mycobacterium bovis is
licensed for the treatment of primary or recurrent bladder
carcinoma in-situ and for the prevention of recurrence
following transurethral resection.
Glycine below irrigation solution 1.5% is the irrigant of
choice for transurethral resection of the prostate gland and
bladder tumours; sterile sodium chloride solution 0.9%
(physiological saline) is used for percutaneous renal surgery.
Maintenance of indwelling urinary catheters
The deposition which occurs in catheterised patients is
usually chiefly composed of phosphate and to minimise this
the catheter (if latex) should be changed at least as often as
every 6 weeks. If the catheter is to be left for longer periods a
silicone catheter should be used together with the
appropriate use of catheter maintenance solutions. Repeated
blockage usually indicates that the catheter needs to be
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, chlorhexidine p. 1211, lidocaine
Urethral sounding and catheterisation
▶ Adult: 11 mL, then 6–11 mL if required
l INTERACTIONS → Appendix 1: antiarrhythmics
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Hydroxybenzoates (parabens)
Chlorhexidine gluconate 500 microgram per 1 ml, Lidocaine
hydrochloride 20 mg per 1 ml Instillagel gel | 60 ml p £14.05 DT
= £14.05 | 110 ml p £15.76 DT = £15.76
Bladder irrigation during urological surgery | Irrigation for
transurethral resection of the prostate gland and
▶ Adult: (consult product literature)
▶ Urological surgery There is a high risk of fluid absorption
from the irrigant used in endoscopic surgery within the
l SIDE-EFFECTS Cardiovascular disorder. electrolyte
depletion . fluid overload . pulmonary disorder. seizure . vision blurred
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Glycine 1.5% irrigation solution 3litre Easyflow bags | 1 bag s
Glycine 1.5% irrigation solution 1litre Flowfusor bottles | 1 bottle s
Glycine 1.5% irrigation solution 1litre Easyflow bags | 1 bag s
Glycine 1.5% irrigation solution 2litre Flowfusor bottles | 1 bottle s
Catheter maintenance solutions
l CATHETER MAINTENANCE SOLUTIONS
OptiFlo G citric acid 3.23% catheter maintenance solution
50 ml . NHS indicative price = £3.66 . Drug Tariff (Part IXa)100 ml . NHS
indicative price = £3.66 . Drug Tariff (Part IXa)
OptiFlo R citric acid 6% catheter maintenance solution (Bard
50 ml . NHS indicative price = £3.66 . Drug Tariff (Part IXa)100 ml . NHS
indicative price = £3.66 . Drug Tariff (Part IXa)
Uro-Tainer PHMB polihexanide 0.02% catheter maintenance
solution (B.Braun Medical Ltd)
100 ml . NHS indicative price = £3.46 . Drug Tariff (Part IXa)
Uro-Tainer Twin Solutio R citric acid 6% catheter maintenance
solution (B.Braun Medical Ltd)
60 ml . NHS indicative price = £4.89 . Drug Tariff (Part IXa)
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