SPHERE Bladder and Bowel Service Troubleshooting

There may be an underlying condition that causes this resistance, or they may not understand that care is required.

Think

• Does they understand the care required?
• Do they recognise the toilet and remember how to use it?
• How might they interpret the assistance being offered?
• Is there an underlying condition causing this (e.g. pain, embarrassment, etc.)?
• What can you do to avoid the distress this causes?
• Can you implement a plan that takes a positive approach to communicating with and supporting this individual?

Do

• Try to find ways to promote independence in using the toilet, e.g. environment, signage, toileting programmes, prompting etc.
• Don’t talk to other’s on route
• Use mobility aid if needed
• Good visual aids – no clutter
• Good lighting, clean, warm toilet/bathroom
• Mirror may need covered/removed or any reflective stimuli
• Try not to cause embarrassment and ensure privacy
• Try distraction techniques
• Never force things, go away and come back later trying a different method of explaining, or ask a colleague to take over.

This could indicate a prostate problem (in a man) or a neurological condition that results in incomplete bladder emptying.
This symptom should be considered in relation to other symptoms (i.e. a sensation of incomplete bladder emptying,
etc). It could also be related to inadequate oral fluid intake.

Start a timed toileting regime (see SPHERE information leaflet: Voiding Programmes).

Encourage them to practice double voiding (see SPHERE information leaflet Successful Bladder Emptying).

Keep a bowel chart and resolve constipation if present (see SPHERE information leaflet: Constipation and Laxatives).

Discuss with the medical staff for potential further investigation of prostate.

A post-void bladder scan should be carried out.

Record fluid intake and output over a 24-hour period using a bladder diary and do this for 3 days in a row if possible.

This symptom may indicate an underlying health problem that requires attention and should be considered in relation to other
symptoms, e.g. urgency, urge incontinence, symptoms of UTI etc. Medical intervention may be required.

Could they be drinking an excessive amount of fluids, i.e. more than 2,500mls (see SPHERE information leaflet: Impact of Fluids on Bladder).

They may be reacting to a high intake of caffeine (caffeine should be reduced gradually to avoid caffeine withdrawal headaches). Caffeine is found in coffee, tea, some fizzy drinks such as Cola and Irn Bru and high energy drinks. (See SPHERE information leaflet: Impact of Fluids on the Bladder).

Are they constipated? Encourage the individual to practice double voiding (see SPHERE information leaflet: Successful
Bladder Emptying).

Do they have any pain or discomfort passing urine. If so, routine checking of urine sample
should be done to rule out urinary tract infections.

This symptom may indicate an underlying health problem that requires medical attention.

See SPHERE information leaflet Types of Incontinence: Nocturia.

Find out when they take their last drink of fluids before sleeping and what type of fluids they are taking.

Do they have any problems with lower limb oedema during the day?

This symptom may indicate an underlying health problem that requires medical attention.

Could they be constipated? Constipated faeces can put pressure on the bladder and cause symptoms of frequency and urgency, but it can also cause low urine output during the day, followed by passing large volumes of urine at night, when the pressure on the bladder is released by lying down.

Do they have lower limb oedema? Large amounts of urine passed during the night might be in response to fluid being reabsorbed from the skin when lying down.

Are they drinking large volumes of fluid (especially caffeine-containing drinks) later in the day?

Individuals vary widely in the frequency with which they empty their bowels and any change to the normal routine and/or eating patterns will have an impact. However, most people have their move their bowels at least 3 times per week.

Healthy bowel elimination is characterised by regular bowel movements (every 1-2 days), a soft, formed stool that is easy to pass (no straining). If their bowels move less than 3 times per week and have difficulty passing a hard stool, this is likely to be due to constipation. An increase in fibre, fluid, activity or laxatives may be required to achieve healthy bowel elimination. (see SPHERE Information leaflets: Constipation and Laxatives; Gastro-Colic Reflex; Medication Impact on the Bowel)

Pain and discomfort is not normal and should be investigated. It may indicate an underlying pathology, such as haemorrhoids or constipation (or both) or other underlying bowel disease.

Establish a regular bowel pattern, which might improve symptoms. Aim for a daily bowel movement, type 4 or 5 on the Bristol Stool Scale. See SPHERE Information leaflets: Gastro-Colic Reflex; Constipation and Laxatives
See NICE Guideline on Colorectal Cancer

Indicates constipation and/or an underlying problem. Keep in mind that people with acute or chronic health conditions may have difficulty in achieving abdominal pressure that facilitates full bowel emptying.

Straining must always be discouraged. If an individual is unable to have a bowel movement without straining this should be investigated (even if it is normal for them). Establish a regular bowel pattern, which might improve symptoms. Aim for a daily bowel movement, type 4 or 5 on the Bristol Stool Scale. See SPHERE Information leaflets: Gastro-Colic Reflex; Constipation and Laxatives; Bowel Incontinence and NICE Guideline on Colorectal Cancer.

Bleeding during a bowel movement is not normal.

This may indicate haemorrhoids or another underlying medical condition and should be discussed with GP/medical staff. See information leaflets and guidelines above.

Bowel movements should be soft and formed -refer to the Bristol Stool Scale for assistance in differentiating between a healthy and unhealthy stool.

See SPHERE Information leaflets: Gastro-Colic Reflex; Constipation and Laxatives; Medication Impact on the Bowel, Types of Incontinence: Bowel Incontinence

Can impact on bladder emptying and can cause symptoms of frequency and urgency and can contribute to nocturnal urinary
frequency and/or incontinence and urinary retention. Keep in mind what the person’s normal bowel pattern is and try to encourage a regular daily bowel movement utilising what you know about the gastro-colic reflex. Aim for a daily type 4 on the Bristol Stool Scale. Remember that a change of routine, different food etc. can adversely impact on the regularity of bowel movements. Check that they are taking adequate fluid intake and passing urine regularly during the day and if not a post void bladder scan should be carried out.

To prevent further risk to the skin they will require a care plan that addresses this issue. Urine and faeces can be very damaging to the skin, so it is essential that a toileting regime is put into place to minimise contact with the skin by urine and/or faeces. See Voiding Programmes and Gastro-colic Reflex.

Can cause symptoms of urgency and frequency. Make sure the urine is dipstick tested and if the patient shows signs of UTI initiate treatment: antibiotics if prescribed; encourage fluids; avoid faecal incontinence and make sure if faecal incontinence occurs, that the perineal and anal area is washed from front to back to avoid contamination of the urethral orifice with faecal matter

Is caused by a lack of oestrogen and occurs in women after the menopause. It can lead to symptoms of frequency and urgency and stress incontinence. This condition can be treated with topical oestrogen in the form of a cream or small pessaries which are inserted into the vaginal area. This treatment it can settle the symptoms of urinary frequency and urgency when other treatment options have not helped.

Can lead to urinary frequency, urgency and urge incontinence because of the presence of glucose in the urine, which can irritate the bladder wall. Longstanding diabetes can also lead to damage of the nerves supplying the bladder and/or bowel
and affect ability to pass urine/open bowels. If a patient has symptoms of urinary frequency and urgency, dipstick urinalysis will highlight any abnormalities that can be reported to the GP/medical staff for a review of their condition by Diabetes Specialist Nurse. Keep in mind that there are medications used to treat diabetes that will excrete glucose in the urine, please check with GP/medical staff.

As men age their prostate can increase in size and in some cases lead to voiding problems. Symptoms include urinary frequency, hesitancy (difficulty in passing urine), nocturia and a sense of incomplete emptying. Some men also experience post-void dribbling incontinence. Constipation will add to the discomfort

Make sure you ask about all symptoms and report to medical staff if you suspect a male patient has symptoms of enlarged prostate, complete an IPSS score sheet (see Hints and Tips section of SPHERE website). There are medical treatments available, but some useful tips to pass on can be found in the following SPHERE Information leaflets: – Impact of Fluids on the Bladder, Medications for Bladder Dysfunction, Successful Bladder Emptying, Urge Control Techniques. Double voiding and penile milking – see SPHERE Self Management Booklet for Men.