Skip to 0 minutes and 3 seconds My mum was 95 years of age and she was living on her own in a flat. She had carers three times a day. It was a second floor flat and she was able to manage fairly independently, walking with a frame. She went out to coffee mornings and had days out with her family. She told me one day that she was struggling to go to the toilet. When she went to pass urine, she was having difficulty in getting it to come out, it was taking quite a long time and she was getting up quite a bit at night.
Skip to 0 minutes and 28 seconds She was often getting up three to four times at night to go to the toilet and my sister who does her laundry she mentioned that her bedding was sometimes wet, and her knickers were a little bit wet. My mum was a very private person and it took quite a lot of courage for her to tell me this. She was quite happy for me to talk to the community nurses and she had had a laceration on her arm. So, when the community nurse came we asked if she could have a bladder scan. An ultrasound bladder scan is a very quick simple procedure to do.
Skip to 0 minutes and 56 seconds They are portable units and community nursing teams have access to portable units very uninvasive and gives you an instant reading of the bladder volume. The nurse like myself thought perhaps she wasn’t emptying her bladder properly and she had got a bit of residual urine there, so she said she would go back and have a word with the district nurses. Later that day she phoned up to say unfortunately they couldn’t scan her bladder because she wasn’t on their case load and she needed to be referred to the doctor. So, I arranged for the GP to come and see her who palpated her abdomen and said “oh no I don’t think there is any retention of urine here.”
Skip to 1 minute and 33 seconds I said to him I wasn’t happy with that and after a bit of gentle persuasion I explained to him again that she had got poor flow and that she had hesitancy and she didn’t feel she was emptying her bladder properly and I told him I was really concerned that she might have falls at night with getting up three or four times to go to the toilet and also concerned that she might get urinary tract infections. Because of my persuasion he said that he would refer her through to the Continence Advisory Service. About four weeks later while my mum was still waiting for this referral, I got a phone call to say that she had been admitted to hospital.
Skip to 2 minutes and 8 seconds She had had a fall in the bathroom and become terribly terribly confused. I contacted the hospital to ask if they could do a bladder scan because I said that I was concerned that she wasn’t emptying her bladder properly and I thought that that was probably the cause for her fall and the infection. She was discharged home on antibiotics with no bladder scan which I found very distressing. I contacted the GP again and the GP went out to see her and he said “oh what do you expect when you are that age?”
Skip to 2 minutes and 40 seconds I was very upset by that comment because my mum was a very fit and very active and mentally very active 95-year-old but then she suddenly became terribly frail and she could not cope with the antibiotics, so she wasn’t eating and wasn’t drinking properly and just started becoming frailer and frailer. The community continence advisor did come to see my mum. She did ask her some questions about her bladder but very sadly she came with no bladder scanner, she just came with a pack of pads. She said it was a functional problem and unlikely to regain continence. I really felt that my mum wasn’t emptying her bladder properly and I asked her several times if she could do a scan.
Skip to 3 minutes and 18 seconds Eventually she agreed to come back the following week to scan my mum’s bladder. I went back to see my mum the following week and the nurse didn’t come. We phoned through to the continence advisors to find out why this had happened, and they said that they had discussed it as a team and there was no indication for my mum to need a bladder scan. The only good thing was that the GP had actually ordered an ultrasound scan for my mum. I found out after that he had done this because she had an MSU that showed very high count for white blood cells.
Skip to 3 minutes and 51 seconds I took my mum to the local hospital and she had an ultrasound scan and it showed that she had got residual urine in her bladder of over 1,100mils. Usually if you go to the toilet you would expect to empty your bladder completely. it is acceptable to have about 100 mils of urine in your bladder but anybody’s bladder who stretched to over 1,000 mils, or over a litre you have usually damaged the bladder muscle and the bladder muscle will not normally function again, so you are left with a bladder that is very floppy, what we call an atonic bladder that does not empty itself.
Skip to 4 minutes and 25 seconds The only person that showed any empathy towards my mum was the radiologist who said that she couldn’t understand how my mum had coped with all of this urine in her bladder and said that she was really sorry about it. I think this really demonstrates the importance of bladder scanning because I really feel if my mum had had her bladder scanned at the time her symptoms first started her residual urine might well have been lower perhaps only 300 to 400 mils and she could have probably been very effectively treated with intermittent catheterisation and she wouldn’t have ended up going into hospital and being treated for a urinary tract infection, having falls and causing herself so much distress.
Skip to 5 minutes and 6 seconds When you are doing a continence assessment at the first assessment we really ought to be aiming to scan everybody’s bladder to test urine and scan the bladder and if you aren’t able to scan a bladder because you haven’t got a bladder scanner then we should be looking at using an intermittent catheter to empty the bladder.
Case study: Jean who has an underactive bladder
In this step, we hear about the third of our four case studies of people with different types of bladder dysfunction. ‘Jean’ has an underactive bladder. Find out how this affected her life.
In this video, clinician Fiona Saunders describes what happened when Jean started to have some problems with her bladder control.
Jean is a 95-year-old lady living in a residential second floor retirement flat which is warden controlled. She is mobile with a frame and is managing to live independently with support from carers three times daily.
She is up-to-date with current affairs, enjoys watching quiz programmes and documentaries on television and the challenge of doing The Times crossword each day. Jean socialises with others within the complex she lives in and goes out for meals/to garden centres/to the sea side with her family.
At the beginning of September Jean started to have some problems with her bladder control - reduced flow rate, increased frequency and odd wet episodes at night and in the daytime.
She requested help from a Community Nurse when she visited to do a routine blood test but was advised by her that she could not do an assessment as Jean was not on their caseload and needed to be referred by her GP.
Her GP undertook a home visit, palpated her abdomen and reported this to be normal. He was not concerned about her symptoms and said, ‘what do you expect at your age?’. Following discussion with her daughter, the GP did agree to a referral for a continence assessment and a urine test.
Three weeks later Jean had a fall at home and was admitted to hospital for treatment of a urinary tract infection. A continence assessment, including a bladder scan, was requested while she was in hospital.
Jean was transferred from a medical ward to a dementia ward and discharged home as she was considered medically fit. A bladder scan was not undertaken on the ward.
The Continence assessment appointment with a Continence Advisor took place six weeks later.
Charts had been sent out which had been completed with support from her carers and family.
Jean’s health had deteriorated and she was struggling to manage at home and reluctant to socialise. Care support visits had been increased to four times daily and Jean was now dependent on the carers for most of her needs. She was less mobile, unsteady with poor balance, reduced appetite, fatigue and urinary and faecal incontinence.
The Continence Advisor came to the appointment with a bag of pads (no urine testing sticks or bladder scanner).
Jean’s presenting symptoms at the time of her continence assessment:
- Very poor flow/stream, drips only, Jean was now using a commode so she could hear when the drips had stopped coming
- Small volumes 50ml or less
- Daytime frequency 1½ - 2 hourly
- Dribbling on movement, including when getting up after voiding
- No stress leak
- No significant urgency
- Nocturnal enuresis
- Faecal incontinence
Diagnosis made by the Continence Advisor at the time of the assessment was:
- Functional incontinence
- Unlikely to regain continence
Advise given by Continence Advisor:
- Try to hold on longer between voids
- Incontinence pads prescribed – 2-piece system
Consider the following questions about this case study and note your answers. Add your thoughts and comments to the discussion.
- What do you think Jean’s bladder problem is?
- Did the Referral Pathway result in a ‘barrier’ to Jean accessing the Continence Service?
- Could the Community Nurse have done more?
- Was the emergency admission an avoidable hospital admission?
- What do you think about the attitude of the GP, is this ageism?
- Discuss the skills of the Continence Advisor. How did she reach the diagnosis made? Do you agree with her diagnosis?
- In your opinion did the Continence Advisor promote continence or manage incontinence?
Note: You may wish to revisit this case study after you have completed Week 5: Assessing bladder and bowel conditions.
- What would you have done differently?
- How do you think Jean’s continence problems affected her quality of life?
© Association for Continence Advice. CC BY-NC 4.0