Gwen Griffith Clinical Nurse Specialist Bolton NHS foundation Trust

Transcription

1 Gwen Griffith Clinical Nurse Specialist Bolton NHS foundation Trust

2 Overview Setting the Scene Beginning of the journey & specialist nurse role Why people with MS experience bladder problems MS and the Misbehaving bladder Bladder dysfunction symptoms and good bladder management What treatment and management support can we provide ( Case Study)

3 Setting the Scene Although multiple sclerosis (MS) was first diagnosed in 1849, the earliest known description of a person with possible MS dates from fourteenth century Holland.. An estimated 2.5 million people in the world have MS. There is currently no register of people with MS in the UK and the figure of 85,000 that has commonly been used is an estimate based on a number of studies of local areas Research by the London School of Hygiene and Tropical Medicine in 2009 suggested that the actual figure may be about 100,000. Similarly, if the results of local area studies are applied nationwide it suggests that about 2,500 people are diagnosed with MS in the UK each year, or about 50 a week.

4 The beginning of the journey Background Long Term Conditions 1998 BJN Clinical Award & Publication 2001 Joint Neurogenic Bladder Clinics 2002

5 Specialist Nurse Role Within the Neuro- Rehabilitation Team The Team Multi disciplinary team providing a comprehensive and co-ordinated range of services to people with an acquired neurological condition Specialist Nurse Role Clinical Role Advisory/Supportive Role Education /Training Resource Research and Audit

6 How Neurological Conditions Affect the Urinary System Lesions may lead to interrupted nerve transmission Pathways destroyed nerve signals do not reach their destination Less cerebral control leads to detrusor overactivity Lesions in spinal cord lead to detrusor sphincter dyssenergia Low lesions lead to detrusor underactivity

7 Bladder Problems and MS There are two main types of bladder problems in MS storage and emptying. We don't always know why some people experience one and not the other, or why some people present with a mix of these problems. Aim to preserve Upper Tract

8 Consequences of Poor Bladder Management Recurrent UTIs Haematuria Pain Impaired renal function

9 Effects on the Bladder Detrusor overactivity Urgency, with or without incontinence, with or without residual urine Detrusor sphincter dyssynergia Urge incontinence, residual urine, renal damage and urinary tract infection Detrusor underactivity Retention, overflow incontinence, residual urine and urinary tract infection

10 Failure to Store Urine Damage occurs to the spinal cord between the area controlling the bladder reflex and the brain. When this happens, the controlling message from the brain is interrupted and the reflex action means the bladder will empty automatically. For the individual this means they will need to go to the toilet often (frequency), but usually with little or no notice (urgency), resulting in incontinence.

11 Failure to Empty Scarring occurs in the reflex area of the spinal cord - interrupting the instruction to empty the bladder. This means that even when someone goes to the toilet, they find it difficult to pass urine (hesitancy). The bladder does not empty properly and keeps filling beyond its normal level until it overflows. This leads to frequent, urgent needs to go to the toilet, often accompanied by overflow incontinence.

12 Combination of failure to store and failure to empty the bladder contracts but the valve remains closed, so that urine can not be released - the individual feels a strong urge to go to the toilet (urgency) but is unable to properly empty their bladder (hesitancy) the bladder relaxes and the valve opens resulting in an inability to store any urine - which causes incontinence.

13 Key to Success

14 Case Study Female, Married, No children Worked full time clerical officer Presenting Symptoms Frequency, Recent UTI, Change in eating habit, Weight Loss Lethargy

15 Background History GP suggested patient had IBS Patient started Gym activity Developed pain in legs and mobility deteriorated Paid for private physio Referral to bladder and Bowel Health service

16 Presentation Been off work several months Frequency, urgency, urge & stress leakage, nocturia Low in mood Recent MS diagnosis

17 Assessment MSSU NAD Post Void Scan, less than 100 mls Demonstrable Stress leakage Poor sensation on vaginal examination Difficulty performing pelvic floor contraction Fluid Volume Small, frequent volumes Nocturia x3 Bowels no reported problems at that time

18 Treatment Medication (anticholinergic) Referral to continence physio: Biofeedback/Neuro muscular electrical stimulation Referral to Dietician Referral to Clinical Psychologist

19 Follow Up Patient returned to work Improvement in Bladder urgency, but developed hesitancy, incomplete bladder emptying, Slight improvement in pelvic floor function Some leakage continued Started to gain lost weight How can we improve things further?

20 Further treatment options Discussed ISC keen to try this Commenced ISC initially AM and PM, then increased to 3x a day Continued with anticholinergic Patient confident to go on holiday due to improvement in symptom management Pregnant! Deterioration in MS symptoms following pregnancy

21 Review of Symptoms Managed well for several months Developed leakage inbetween ISC /bedwetting Seen in joint neurogenic bladder clinic (following birth of baby girl!) ISC 4-5 x a day Concominant Treatment (Kenetera oxybutynin transdermal patch & anticholinergic) Referred for Botox Ongoing Botox & ISC

22 Thankyou, (option 2)