1. Your patient complains of bladder problems

These notes are for use together with the Colley Model.

If indicated, before taking a history, address any functional, mobility and dexterity issues which could contribute to or even cause incontinence. Include in this, environmental issues and accessibility to the toilet.

Take a history.

ONSET

When did the problem start?
Was the onset sudden or gradual?
Related to an event such as childbirth, surgery or a change in medication?

MEDICAL HISTORY

Include medical, surgical, obstetric, gynaecological and urological history.

MEDICATION

Make a note of all current medication and be aware of the side-effects as many will affect bladder and / or bowel function. Sometimes the cause of bladder (or bowel) symptoms can be directly linked to medication. A review of current medication is an essential part of this assessment and should be undertaken within the competency of the assessing clinician, who (if not an independent prescriber) may need to liaise with the patient’s GP or pharmacist. For example, when a patient is taking medication known to have the potential to contribute to urinary retention, and symptoms of incomplete bladder emptying are found during assessment; or the patient may have been prescribed medication to reduce blood pressure which may also relax the smooth muscle at the bladder neck, contributing to symptoms of stress urinary incontinence; or the patient may be taking multiple medication known to cause constipation, but has not been advised or prescribed anything to prevent this. There are many other examples, so ensure a medication review is undertaken.

NORMAL BOWEL HABIT

(See also 7, Constipation)

Record normal bowel frequency and type using the Bristol Stool Form Scale (Heaton, 2001) – Download it here.

Regular bowel movements (not necessarily once a day) are essential to maintain normal bladder function, due to the close proximity of the rectum to the urethra. Under normal circumstances, there is no problem but impaction of faeces in the rectum causes pressure on the urethra resulting in difficulty voiding and urinary incontinence.

FLUID INTAKE AND TYPE

(See also 3, Frequency and volumes voided)

Fluid intake should be adequate for the body weight of the patient. A useful guide, in the absence of newer research is 30ml/kg of body weight. (Abrams and Klevmar, 1996), however any medical conditions must be taken into consideration to ensure it is safe to increase or decrease fluid intake for an individual. List the type of fluids the patient drinks. Food and drinks with high caffeine content should be avoided in those with overactive bladder syndrome as caffeine can be an irritant to the bladder and is diuretic. Similarly, carbonated drinks even without caffeine, fruit juices and alcohol may cause irritant bladder symptoms in some individuals.

URINE LEAKAGE

Ask about any urine leakage, how often and how much. It is useful to quantify this by asking for the current coping strategies. “Do you wear pads at the moment and if so, what do you use?” If pads are being used you can enquire whether or not these are effective. If pads are not being used, does the patient have to change clothing after leakage? Some patients may not leak urine but may suffer from severe urinary frequency and urgency.

SKIN INTEGRITY

Due to the irritant effect of urine next to the skin, ask about the condition of the skin and whether or not the patient has any irritation or damage to the skin. During the Observation / Physical Examination part of the assessment this will be observed, but ensure that the skin condition is thoroughly assessed before finishing this current face-to-face contact. Document in the patient’s record and report any concerns to a senior member of staff.

QUALITY OF LIFE

It is important to ask the patient how much their symptoms affect their quality of life, so the assessment form includes a question for the patient to answer.

References:

Abrams P and Klevmar B (1996) Frequency volume charts: an indispensable part of lower urinary tract assessment. Scandinavian Journal of Neurology 179. 47-53

Heaton, K., 2001. The Bristol Stool Form Scale. In: Understanding your bowels. 4th edition. London: Family Doctor Publications.