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A podcast from the Continence Service in the Northern Trust, providing listeners with a greater understanding of bladder and bowel dysfunction and education of what may be contributing to the problem and supportive measures which could be implemented to improve bladder and bowel difficulties. The series will give an introduction to the Continence Service and discuss common types of bladder and bowel incontinence difficulties, such as overactive bladder, stress urinary incontinence and functional incontinence. It will also look at how good bowel management can help with incontinence overall. The series will also feature service user stories and learn about the lived experience of someone with a bladder and/or bowel dysfunction.
Continence Challenge Podcast - Ep1
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Hello, welcome today to the Continence Challenge podcast, helping you regain control. Brought to you by the Continence Advisory Service staff of the Northern Health and Social Care Trust. My name is Deirdre O'Brien. I am the Continence Nurse Coordinator for Adult Services. Today, I will be joined on this episode with two of my Continence Advisor colleagues, Trudy Walton and Colleen McErlean.
In this episode, we will give you some background knowledge on how you get referred to our service and how to enable you to obtain an appointment on what to expect when you come for that appointment. We will also then talk to you about one type of incontinence, that being urge urinary incontinence or otherwise known as overactive bladder.
We will discuss with you how this incontinence can present. In this podcast series, we want to be able to give you an insight and understanding about common bladder and bowel continence difficulties. We will discuss different types of incontinence, how these present, why certain individuals may be more at risk, and other contributory factors that can play a part.
We want to share our knowledge with you and provide you with evidence based guidance and general tips that, if implemented, could help you improve or overcome these difficulties. We will also give you some names and addresses of other resources that you might find helpful. And these will be available on the Northern Trust website.
In this episode today, I will first of all give you an introduction on our service, before I introduce the continence advisors to speak to you about the overactive bladder. For our service, you can refer yourself, or you can be referred by your GP, a family member, or any other healthcare profession. You can make this referral simply by calling the call management referral system, known as CRMS, and the telephone number for that is 028 2563 5521.
Whenever this referral comes through, it is then acknowledged and triaged by either myself or one of my continence advisors. We will decide if it is appropriate and deem whether it is an urgent or routine need. We will also specify what clinic dependency is required, either specialist or general. If we feel for some reason that the referral is inappropriate, we will then contact the CRMS and make an onward referral to the most appropriate service.
For example, maybe district nursing or urology services. Once this referral has been accepted, our admin team will then send out an acknowledgment letter. Along with this letter is self assessment forms that you, the service user, must complete and return to us within three weeks. I cannot stress enough that these forms provide us with vital information, which will help the Continence Advisor tailor specific pathways and advice to suit your needs.
Within these forms, we ask you to give a medical history and current medication. We ask you to complete a quality of life assessment tool and a four day fluid intake and bladder volume output diary. This provides a baseline of where you are at the time of referral. We will ask you to repeat these again at a later date to measure if there has been any improvement or worsening in your symptoms.
These forms also detail an explaination of what investigations to expect at assessment such as a urine dip test, a bladder scan and if consented to an internal pelvic floor examination. Unfortunately, many clients fail to complete and return the self-assessment forms. This results in an automatic discharge from the service.
To avoid this, I urge you to complete the forms and return within the three weeks, but if you know for any reason that you're unable to do so within the three week timeframe, then please call the continence service admin team on 0 2 8 2 5 6 3 5 2 7 8, and advise that your forms will be late to avoid discharge if you require any help or advice on how to complete the forms.
Again, please call the Continence Admin team and they will put you in touch with one of us who will give you that advice. We see service users mainly in clinic locations across the Trust. We also provide home visits for some service users who are housebound and unable to come to an appointment. For urgent appointments, we aim to see these service users within three to six weeks of referral.
Our targeted waiting time for routine appointments is 13 weeks. And most of those on our routine general waiting list are offered appointments within the targeted time or less. Unfortunately, at present we have a lengthy waiting list for those waiting routine specialist appointments. The current waiting time for these appointments is approximately six to seven months.
Therefore, I would like to encourage you to take the opportunity to listen to this podcast regularly whilst you wait your appointment. The overall aim is that we hope that this will help you our service users, achieve better outcomes, therefore enabling you to be discharged quicker as your symptoms become improved or that you find that you can manage them better.
This podcast is mainly directed to you, the individual with continence issues, but I think the knowledge and advice that we share today may also be beneficial to family members or healthcare professionals caring for individuals whose ill health is impacting on how they can maintain continence. So if you find it in any way useful, please feel free to promote it to others to listen to.
We provide advice to our clients based on NICE guidelines and the latest evidence based research. So first I will introduce Trudy Walton, my continence advisor, and she will talk to you about what is considered normal bladder function. and urge urinary incontinence, otherwise known as overactive bladder.
So Trudy, would you like to explain the normal bladder capacity and normal bladder emptying? Okay, so a normal bladder holds approximately four to five hundred millilitres comfortably, with a frequency of passing urine of roughly five to six times a day, or that would be integrals of, say, three and a half to four hourly.
That's if the patient has a normal intake, which we'd recommend for a normal weight of an adult to be one and a half to two litres of fluids spread evenly throughout the day. So as Deirdre says, we will firstly talk about urgent urinary symptoms. Which is an urge to reach the toilet. You just can't wait to get there.
You may also have leaking with this. You may have to go very frequently to the toilet and be up many times overnight. And Trudy, do you find that patients maybe tell you that there's certain triggers that maybe can make this worse? Yes, in my clinic I would see a lot of people who would maybe be affected with this.
Hearing the water run, really running water in the cold weather, or they're standing at the front door, they've been out for the day and they're coming home and they're dying to get into the toilet and they maybe have an accident out the door. Yes. Also, people with maybe. They would find if they drink a lot of coffee or a lot of tea or maybe they're drinking a lot of fizzy drinks or alcohol, things like that can make them want to go a lot more to the toilet.
Do you find that these patients maybe sometimes know every toilet in the town? Exactly, and we would call that toilet mapping. You know, they just, they just know where every, they have to plan their route around the toilets. And I can imagine that that impacts on their life greatly, stops them maybe doing things that they would normally do.
Yes, it's really detrimental to their well being and, you know, their bladder is ruling them as opposed to them ruling their bladder. Yeah. And we want to try and help today to, to learn how to regain that control and certain things that they can do. Exactly. I'm going to introduce Colleen. You know, Colleen, would you like to maybe tell us what we can do?
Usually, what type of patients or who do we see generally with this problem? Who normally presents with overactive bladder? Hello there, normally, we would mainly see women in our clinics. However, we do see men, but most commonly, we would see patients that have neurological conditions, patients, well, elderly patients, patients with spinal conditions, and patients that are prone to urinary tract infections, or.
A number of different reasons, and we would see patients a variety of ages, I mean it's not just elderly patients we would see, continence does affect mostly elderly people, however it does affect young people as well. So we see all ages and we see both men and women. I think Trudy is going to talk to us about fluids that may irritate the bladder or make this problem worse.
And as you said, you know, we see people of all ages and one of these, um, I am noticing that whilst it is more prevalent in the elderly, young people are drinking really a lot of energy drinks and I think that is impacting and we're going, we are seeing more people at clinics now with overactive bladder that are younger.
So, Trudy, do you want to talk about fluids and what advice we would give to patients with overactive bladder? in regards to their fluids. So as I said earlier, that the recommended amount that you drink would be 1.5-2 litres of fluid per day. I sometimes find people that maybe they want, they reduce their fluid intake because of their problems, and you know, it's a vicious circle really, because if you reduce your fluid, then that can annoy the bladder, so we would definitely say about that intake, to keep it at that.
Recommended. And that's really because the urine then becomes really concentrated and irritates the bladder itself, doesn't it? And then obviously there can be prone to urinary tract infections as a result of that. There's a lot of drinks that can irritate the bladder. As I said earlier, coffee, tea, green teas.
Some ladies maybe come and they're drinking a lot of green teas because they're on diet and they think the green tea is a healthy option, but it isn't. You know, there's caffeine content in that. Fizzy drinks, especially cola, as you said, the caffeinated drinks that a lot of the young people are maybe drinking.
Fresh, acidic drinks also can irritate the bladder and also alcohols, you know, spirits and wine and all those type of alcohols can irritate the bladder. The other thing you said there about the caffeine, I just, you know, I have read research that has been done in a hospital over in England. The person who conducted the research actually won Continence Nurse of the Year in 2023 and One of the changes that they made was introducing decaffeinated drinks as the default option within the nurse, or within the hospital that she worked in, and within care homes.
And they did notice a big difference by reducing the caffeine intake. And I've read also other pieces of research where they have studied how caffeine effects the body and whilst you get that initial boost of energy from drinking your cup of coffee in the morning or whatever, your caffeine still has a half life and it's still active in your body six to eight hours afterwards.
So, again, whenever we give patients advice at clinics about Reducing their caffeine, if they really do need that wee boost of energy, especially for maybe MS patients and that, that need that, something to give them that go in the morning. I think it's important to try and say to them, don't deny yourself of it completely, but have it early in the day and reduce over overall, reduce the amount that you're having in the 24 hour period and try not to have it after late afternoon, you know, so that.
They're not going to be up all night, um, back and forward to the toilet, because obviously that then just compounds the problem, and they're so fatigued, and you know, when your muscles are fatigued, then it's not going to work. Work as well for you the next day. Yeah, and I would say to them to substitute, you know, if they are reducing the caffeinated drinks, keep them to the minimal 2 to 3 smaller cups and then substitute the rest of their oral intake with other non irritants.
Yeah, and if they're a big caffeine drinker, to gradually withdraw it so that they don't have that. You know, serious withdrawal symptoms in the initial stages to just withdraw it gradually. And those other drinks I would recommend would be, you know, their waters, diluted juices, staying away from the darker colored, like blackcurrant, because those can irritate the bladder.
Their decaffeinated teas and coffees. They're non acidic, fresh drinks and, as I said, herbal teas. So if they could just substitute with those and just, again, spread things evenly throughout the day. And there's also the evidence there to support that artificial sweeteners can have an irritant effect as well.
Yes. And that sometimes your diabetic patient is drinking the juices that have the artificial sweeteners in them. Yes. Therefore, and maybe if they're not necessarily. Managing their diabetes very well and their blood sugars tend to run high. They have that increased thirst and therefore they do tend to drink more.
So I think, you know, a lot of education that we share at clinic with patients about their fluids and about their diet. Be mindful of those artificial sweeteners as well, can make a difference. And also for those people that are up a lot overnight, we would recommend really trying to reduce the fluids from, from the evening time, after tea time onwards.
And having their last drink if they can, if possible, two to two and a half hours prior to bed. It's just so their kidneys then settle down then before they go to bed. We'd also say we're trying to go maybe twice to the toilet before bed to see if that helps if they're overnight. Yeah, you know, that's the other thing about the kidneys.
The, the caffeine, not only has caffeine got an irritant effect to the bladder, but it also has a diary effect on the kidneys. Therefore, the more caffeinated drinks that they drink. the more active their kidneys are going to be. The other thing that we had mentioned earlier about overactive bladder was that this person, um, cannot hold on.
Um, and once they get that urge, it's really sudden and they feel the need to go. Another step in our pathway of helping them overcome the overactive bladder. is trying to retrain their bladder. And I know that I have found that that is very challenging to get people to persevere with. And it's, it's not something that is achievable in a very short space of time.
It takes time. And I think sometimes, People come with the misconception that we are going to fix them and we're not going to fix them. We are only going to give them the tools to fix themselves or to regain control. So Colleen, would you like to explain what we mean by bladder retraining and how we tell patients to achieve that and why the bladder diary plays an important role in us deeming where they start or how they, um, how they manage that?
So, first of all, when they return to self assessment pack. It gives us an indication of how frequently there going to the bathroom. So, You know, for example, if it, if they're telling us they're going early, every hour, when we, when we see them, it's like, I'm going to do a full assessment to personally find out, obviously, their fluid intake and the types of fluid they are consuming and advise them, obviously, on that.
We are going to give them the tools, you know, just give them some advice on how to hold, you know, we would advise them if, instead of going early, try and hold another 15 minutes, so, you know, initially start by adding on 15 minutes, going every hour and 15 minutes, and by holding that time, we would advise them some pelvic floor exercises, just distracting themselves, and I know I'm making that sound easy, but that can be very difficult for somebody with bladder overactivity.
So it is just encouraging them that, you know, it's going to be a bit hard, but that hopefully they'll be able to achieve that by adding on a little bit of time. And then we would advise them, you know, after four or five days of doing it consistently, adding on some time to then add on, add on another 10 or 15 minutes if possible.
But if they find that too difficult, maybe. I advise them to maybe just hold another five minutes and do it really, really slowly. As you said, Deirdre, it's not going to be an overnight solution to their incontinence or their urgency, but by hopefully implementing bladder retraining over a long period of time or however long the patient needs, hopefully they'll be able to gain sort of continence and be able to hold longer intervals.
You know, the normal bladder, or the healthy bladder, sorry I should say, should be able to hold, you know, three to four hours. So ideally, we would like the patient to be able to hold three hours. So by adding on time, every four or five days, and doing that over a number of weeks or months, we'll hopefully be able to achieve that, that thing.
And their bladder diary really helps us determine the starting point for them, because some people, they might, you might find that they're going back to the toilet within half an hour of being there. Or for some people, it might be that they're going, maybe. Early or too early, so everybody has a different starting point, and sometimes I would say to patients, you know, do it during the daytime, you're not going to focus on it at bedtime, you know, just try and go to the toilet maybe twice before getting into bed to hopefully lessen the times that you have to get up during the night.
You know, if you have to empty your bladder after half an hour, I would say, well then, for during the daytime, do that every half an hour for a couple of days until you're dry. Okay? And then maybe add on, as you say, add on 5 minutes or 10 minutes or whatever, and then try and do that for the 40 minutes for so many days till you manage that, and then increase it again to maybe 50 minutes or an hour till you manage that.
I think it's a good idea to tell patients to repeat their bladder diaries every couple of weeks so that they see the improvements. Because I think when you're living with something day to day, you don't notice the changes. You know, it's like when you move on to the gym or lose some weight, you know, until you stand on the scales, you don't know if you've, you don't always see it.
And that motivates them as well. Yeah, and it does. It keeps their motivation going. It's not only that. Patients will say to you, you know, at home, they are going to the toilet every hour, but if they were out and about with friends, they're able to hold longer. They say that they can maybe hold three or four hours.
Really and truly, it can sometimes be an anxious thing in patients. Maybe when they're distracted, they can find that they can do some more. So, I think. You know, talking about different distraction strategies is useful. I know one that I have said to people is, you know, if you're at your work, maybe go and do another task before going to the toilet.
If you're, if you're going through your emails, clear a few more, maybe clear 10 more before you go or go and answer, open the post or do something. And do you have any other urge distractions, Trudy, that you know that have helped people? Say somebody at home, maybe if they're ironing, maybe just finish ironing, maybe a couple of shirts, or if they're watching TV, just finish watching and for a few minutes, or certainly counting backwards from a hundred.
Or read another chapter of their book. Or read another chapter of their book, yeah. Or as, you know, doing maybe a set of pelvic floor muscle exercises, which we'll cover later on. The pelvic floor exercises, we will discuss them later in another episode of Stress Incontinence, but Colleen did mention them there, and they are, they still play their part in the overactive bladder, especially when that urge comes on, because that urge, when it comes on, is really, really sudden.
And people feel that real need to go, but supporting the pelvic floor at that time is important to actually help them hold on until that urge passes. Now, the urge itself only lasts seconds, you know, and sometimes it's not. Getting somebody maybe to sit down on the arm of a chair or on a rolled up towel or even cross their legs.
So that urge doesn't, doesn't last forever. It's short lived. You know, telling them to stand still or sit down and give their pelvic floor some support at that time. As you say, the pelvic floor muscle pulling in, even doing 10 quick ones to try and distract them until that urge passes might enable them then to hold on for that extra five minutes.
Yeah, bladder retraining is very difficult, you know. It is. And it can take weeks, maybe months, you know, to get to where their optimum would be, but it's worth it when it's achieved. Urgency, urge incontinence or overactive bladder. Yeah. This can happen for a number of reasons. It can happen because of a patient's medical conditions and predisposing them to maybe impaired neurological responses.
It could also happen maybe because somebody has been over drinking, and therefore their bladder capacity is at its limit and they have to go so frequently because, because of that. But sometimes it can also happen because they have got into a habit of emptying their bladder frequently. And the more they do that, the more the brain will make that association with the small bladder capacity and feeling that need to empty the bladder.
So, in a normal bladder, as Trudy explained, the normal bladder can hold, I mean, 400 to 500 mls comfortably, but usually at 500 we're not that comfortable. We do need to go, but we might have that warning signal when there's maybe only about 300 in our bladder that we need to go soon and we can hold on.
But in these people with this problem, they're getting that warning whenever there's maybe 150, 200 mls , but their stretch receptor muscles are really sensitive, and they're sending those messages to the brain, we really need emptied. And sometimes what happens is, before you can actually make it to the bathroom, your brain tells your bladder muscle to empty, and that muscle contracts, and that's when you'll have that over, um, overactive incontinence, or urge incontinence.
Yes, it can impact more on elderly for many other reasons, maybe being that they're slower in getting there. Some people with urgency. Our overactive bladder can make it to the bathroom just in time, but for others, it is more of a problem and they maybe struggle in with clothes and things like that. So we will talk about that again in another episode of functional incontinence because there's many types of incontinence and most patients don't fit.
rigidly into one specific box, but I think you can agree with me that patients do tend to merge into several boxes and one particular type of incontinence, mixed incontinence, is generally for the patients have a combination of overactive and stress incontinence. And maybe functional as well. And functional as well.
And so we, we tend to, first of all, take our patients at clinic, we would give them the advice for the pathway that is most predominant to them, but there's other advice or other steps within other pathways that they can also take, the like the likes of the pelvic floor exercises. I think another thing, and maybe Trudy, you can talk about it, that we hadn't mentioned that can also make things harder for patients that have that urgency is how much the bowel can impact on that as well.
Yeah, so if someone isn't as prone to constipation, that can really have an impact on the emptying of the bladder with the pressure lying above the bladder of that bowel not getting emptied. And that can mimic those symptoms of overactive bladder where they have the urgency to reach the toilet. With the leakage again, and the frequency, so we would really focus if there's an issue with constipation, that is a big health promotion, as regards to trying to resolve that, to see if that makes urinary symptoms better.
So we would go through their diet and, their fluid advice, making sure they're drinking enough for constipation then, and then maybe laxatives or down the line when they've been reviewed, just to see if that could resolve their symptoms, their urinary symptoms. Thanks. So, Colleen, we have talked about What is a normal bladder function and how, how urgent kindness presents, who might be affected by it, and maybe contributory factors that might be playing its part.
We have talked about conservative measures that you may be able to introduce. Within your lifestyle to make things better, types of fluids, how to spread those fluids out, about their bladder diary and the importance of reflecting on that, and about pelvic floor muscles, helping them to regain control.
Can you just then, explain what we may do at clinic whenever we see if these measures haven't helped them reach their optimum. So on your initial assessment at the clinic, so we would be completing that entire assessment and advising you with all the things that Deirdre just spoke about. We would also offer you an examination at that point.
So when we're examining you, we would be looking for sort of obvious signs of like a pelvic or a prolapse. And we at that point would be assessing your pelvic floor strength and tone and that would help us sort of be able to advise you further in regards to stress and continence. We would also create a bladder scan by using a portable ultrasound scanner, and that would let us know if you're emptying your bladder completely.
So we would ask you to empty your bladder just before the scan, and then we will create the scan and ensure that you are able to empty your bladder fully. If you're not able to empty your bladder yourself, please do so. You know, there are interventions we could then add and fill in all those tips and lifestyle measures if you're still not achieving continence or you're struggling with urgency, we can then discuss medication with your GP to see if that would be suitable.
And as Trudy said about the bowel, we could also advise medicines at that point, in order to make the bowel go regularly. That as Trudy spoke about can have a massive impact on your bladder also. You know, if you consent to those sort of examinations, we can then see you at review clinic appointment and then hopefully then things will be improving.
For example, your pelvic floor strength is not improving, following the advice and, you know, about the exercises, we can then onward refer you to a pelvic womens health physio. And if we feel that you need to refer it on for further studies of your bladder, we can also do that at clinics as well. I think also, um, Colleen referred to in there as the women's health physio, they actually see male and female patients, so we, you know, we would onward refer both men and women to pelvic health physios if necessary, or women maybe on to urogyne consultants, or maybe men on to urology consultants if need be.
A useful resource is the bladderandbowel. co. uk website. There will be a link to this on the Northern Trust website. I think this resource will be particularly useful for those with urgency. There will be a lot of useful information and advice. You can also register with them to get a can't wait card or radar key.
Can't wait card is something that you can show within shops or premises to enable access to toilet facilities. The radar key is also a key that you can apply for Through this website, or even through your own local council offices, and that key opens up the locked disabled toilets that you will find in bus stations or in, in towns.
And it will be particularly useful for those of you who have that great difficulty in holding on. Thank you for listening. We'd like to wish you good luck in implementing these lifestyle measures that we have talked about. In subsequent episodes, we will be talking about different types of incontinence, that being stress, overflow, functional, and good bowel management to help prevent constipation.
Please listen to those episodes as well. Please provide feedback on our podcast, which can be found on the podcast summary or the Northern Trust website. Thank you.