Essay: Evaluating how bladder dysfunction affects a PPMS patient’s quality of life

Introduction
In this assignment, evaluating and exploring how bladder dysfunction effect’s Angela’s quality of life (QoL) whom is suffering from PPMS. I will link my discussion with relevant policies and frameworks and consider and potential impact of life changes to both her and her family.
Bladder Management
Bladder dysfunction occurs in at least 80% of people with multiple sclerosis (Khalaf et al,2015). This arises when MS injuries delay or block transmission of the nerve signals in areas of the central nervous system. Angela’s urinary dysfunctions are directly related to her PPMS, whom’s been suffering with it for the past 4 years. If this problem isn’t managed, it may cause her to deteriorate further, affecting her emotionally, physically, mentally and those surrounding her negatively (Sisfnclair and Ramsay, 2011).
Overactive bladder is defined as difficulty in emptying and storing urine. Symptoms include hesitation to urinate, nocturia, incontinence and inability to empty the bladder completely. It’s a common problem which has a detrimental effect on one’s QoL. This is mostly seen as underdiagnosed as the perception is that it’s a natural consequence of aging whom don’t want to seek professional help (B Doughty,2012).
When considering an appropriate care intervention, cognitive function, dexterity, mobility and how much support they have at home must be considered.
Diet modification which includes high fluid intake influences her QoL. It enhances sufficient hydration, assists in urinary output and helps prevent infection, this includes avoiding caffeine and limit fluid intake during late evening. On the other hand, evidence supporting this is very little. In agreeance, a study was conducted where working women reported fluid intake and avoided caffeinated drink aiding in avoiding urinary symptoms (Fitzgerald et al, 2008, p.g 112-118). However, this study was conducted on healthy women so it lack’s validity as it doesn’t draw an accurate picture as to how it would affect those with MS. However, Hasham and Abrams (2008, p.g. 62-66) recommend that one should decrease fluid intake by 25% which would reduce urgency and frequency and nocturia.
The institute of medicine (2004) issued a report which indicated 2.7 L of water per day for healthy women but there is no scientific nor medical basis on this recommendation. Critics may argue that Angela has nocturia, more urine output means more fluid needed to keep hydrated. According to McMillen and Pitcher (2010), dehydration is induced by inadequate fluid intake and excessive fluid loss.
When Angela experiences bladder infrequency or lack of control, she may start to drink less which is harmful. Monitoring fluid balance and following an overall elimination pattern is recommended ensuring optimal hydration (Shepherd, 2011).
A behavioural treatment, bladder training aids in urinary incontinence (NICE,2012), but part of the issue can be solved with timing fluid intake (NICE,2019). Moore et al (2013) indicates that healthcare professionals should provide the most intense bladder training. This implies that bladder training is essential when dealing with bladder dysfunction. If there is no improvement within 3 weeks from the training other alternatives should be offered such as pelvic floor exercise (Domuoulin et al, 2014). Nevertheless, there is low quality evidence that bladder training has improved continence.
A bladder scan assists in establishing incomplete bladder emptying (Jassim and Amallah,2009). NICE (2019) suggests using a bladder scan when assessing residual urine. A nurse or urologist should conduct it before starting medication (Haslam, 2009). If the residual is greater than 100mls, intermittent catherisation is recommended to improve emptying urine (Patient Safety Group, 2018). If the PVR is less than 100ml, pelvic floor exercise is advised (National Multiple Sclerosis Society, 2012).
The University of Utah (1996) states, exercise benefits physical and mental symptoms which includes, weakness, impaired bowel, bladder function and fatigue. According to NICE (2012) guidelines, pelvic floor exercise strengthens the muscles which support the bladder. The effect of pelvic floor exercise on overactive bladder is questionable. Shafik and Shafik (2003) study had shown the effect of exercise on the urethral pressures of 28 patients with overactive bladders. The outcome was during the exercises, urethral pressures had increased in both healthy and patient’s, therefore implies this intervention should be encouraged when treating overactive bladders. Nonetheless, this study isn’t representative in Angela’s case as well as the population with PPMS as the sample size is too small, making her findings lack reliability and generalisability. According to Fowler et al (2009), pelvic floor exercises are the least expensive intervention and the most effective management. Those who underwent pelvic floor training, their lower urinary tract symptoms improved and had a positive QoL (Lucio et al, 2011, p.g 1). Referral to a physiotherapist or MS specialist nurse would help as they would provide coherent information on techniques and benefits.
Anticholinergic medications are used to treat urgency, frequency and incontinence. Oxybutynin assists in blocking contractions of the detrusor muscles and stop spasms. Side effects of the medications are dry throat and mouth (Burgess, 2003). These side effects can be combatted by Angela drinking, eating boiled sweets (NICE, 2012). With anticholinergic medication’s the most pronounced side effect is constipation. Referel to a dietician would be able to minimise problems of constipation. This can irritate urinary dysfunction by reducing bladder capacity as the bowel stretches because of the constipated stool (Robinson and Cardozo, 2012). NICE (2012) had suggested to offer antimuscarnic drugs to improve bladder storage to those with spinal cord disease and symptoms of overactive bladder. In the contrary, a side effect of this drug is reduction in bladder emptying which defeats the direct purpose of the drug.
On the other hand, this guideline also indicates that antimuscarinics specifically oxybutynin has the potential to cause nervous system related side effects such as confusion, therefore affecting Angela’s quality of life.
Angela also experiences nocturia ‘she gets up 3 times a night to urinate’. Medications such as desmopressin aids in nocturia by reducing the amount of urine produced (Wilkins, 2017, p.g. 171). This would be beneficial to both her and her partner as it leads to a better night’s sleep and reduces fatigue. A complication is hyponatraemia; symptoms include headache and nausea where anti-emetics may be prescribed for. According to Fowler and Hoverd (1998), it should be avoided in patients with severe mobility problems. If Angela does experience these side effects, contacting the GP or MS specialist nurse would help. Desmopressin rarely can cause a low level of sodium in the blood, therefore, conducting a blood test to measure sodium levels when taking this medication would assist in indicating whether Angela should be advised to not take it in the future (McGuire, 2014).
Intermittent catheterisation is considered a method for treating urinary retention and the Gold Standard for urine drainage (NICE, 2015). With MS, this method is widely applied and shown to improve the QoL (Wyndaele, J. 2014) (Panicker and Seth and Haslam, 2014). There are exclusions to patient doing ISC which include cognitive impairment and reduced compliance (RCN, 2012) which Angela doesn’t portray. An important aspect of care while using ISC is assessing the urine colour, the amount of urine and its odour. An unusual colour can be a sign of a disease. Conducting a urinanalysis would aid in assessing any abnormalities in the urine such as blood and leukocytes. Critics may argue, urinalysis should not be used to diagnose UTI in catherised patients as the appearance and smell of the urine wouldn’t suggest that bacteriuria is present (Hampshire and Isle of Wight guidelines, 2012).
Angela states she has ‘become increasingly anxious about the future’. Providing information and educating the patient on how to perform the CISC as well adopting individualised teaching and learning strategies would help reduce that anxiety (Ramm and Kane, 2011). Ensuring that the correct principles of hand hygiene are performed to before and after usage to reduce the risk of cross infection (HPSC, 2015).
Angela has experienced UTI’s before ‘following a urinary tract infection’. There is a positive correlation between UTI’s and the use of catheter’s. In the contrary, intermittent catherisation has a reduced infection rate in comparison to indwelling catheter. In contrast, it’s mostly associated with inadequate frequency of catherisation or poor technique (Neovious et al, 2015). Emptying the bladder reduces the chances of urinary leakage and results in less UTI’s. UTI recurrence must be prevented as it’s indicated to make MS symptoms worse (MS Trust, 2015).
D-Mannose is a natural supplement shown to prevent UTI’s (Panicker et al, 2016). On the other hand, larger studies are needed to approve its efficiency. Combination with CISC and antimuscarnaric medication are often combined for effective (Rai et al,2012).
CISC and its potential barriers is physical disabilities in terms of positioning and dexterity as patients with neurological deficits face difficulties in performing CISC. These factors would affect the positioning of introducing the catheter into the urethra (Panicker et al, 2014). Comprehension and attention is necessary when performing self-catheterisation, therefore the assessment of the patient is essential. Vahter et al (2009) had demonstrated with a group of patients with MS and found that cognitive decline did not influence the ability to learn CISC, however the time spent on teaching had a significant impact on adherence. MS specialist nurses must provide the correct technique to assist with insertion. Availability of appropriate catheters and assisting appliances have caused the inability to access the right type of catheter. This is why some discontinue from using CISC. Using the hydrophilic or gel reservoirs catheters may offer more comfort and ease of use (Martins et al, 2009, pg. 546). Also acknowledged by Bermingham et al (2013).
Another barrier is misconception and anxiety. Women at the age of 65 have mentioned that they have never examined their own vagina and would struggle in finding their urethra. This need of locating the region contributed to anxiety about learning the procedure (Bolinger and Engberg, 2013). Another perception of CISC is that its time consuming (Bolinger and Engberg,2013). This is usually overcome with practise and increase in confidence as they become more experienced.
Patient’s may have difficulties in performing self-catherisation in public toilets due to the space and placing the equipment. Angela works as a ‘full time primary school teacher’ which affect when to carry out self-catherisation. Most catheters available for CISC are single use and disposable (Haslam et al, 2010). According to Van Achterberg (2008), older patients striving for the best consistency in CISC, turn down social events and interactions. Finding a suitable toilet in public places which were sterile and spacious is the major concern.
In addition to physical symptoms, there may be profound emotional consequences. Angela may feel insecure and lose confidence in herself as she feels the symptoms are becoming worse. This could initiate a sense of losing control. Angela should recognise these emotions and seek advice from a mental health professionals (Multiple Sclerosis News Today, 2019). Communication is key when talking to families and those surrounding you. This should be worked on as it could impact the bonds with her children and spouse. Discussing what’s troubling Angela could result in them making her feel more confident, build self-esteem and could aid in managing these problems.
Angela may experience that her job is physically demanding with her condition. The greatest effects occurred in employment were fatigue and muscle weakness (Angela et al, 2019, p.g.3-4). Considered whether she’s fit for work would help her to transition to a more suitable position. The loss of employment conducts consequences to patients and families such as psychosocial and economic domains (McCabe and De Judicibus, 2003). This relates to family having to cut down demanding activities (Mssociety, 2014), affecting Angela’s mood and self-esteem.
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