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

Your task

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?