CASE STUDY No 1 : Child with a disability

Background :
Andrea is a 14 years old girl, who lives with her parents and younger brother at
Smithfield Plains. Andrea was born with Spina Bifida (thoraco-lumbar
myelomenigocele). She has total paraplegia and a sensory level at T8. She has
spinal scoliosis and underwent a spinal fusion at 1992 to arrest its rapid
progression.
Andrea has mild hydrocephalus and does not require a shunt. She has averge
intelligence although experiences some cognitive difficulties especially with respect
to mathematics. She has some problems with self organization and vagueness.
Andrea is a wheelchair dependent and is a member of the junior wheelchair sports
team (swimming). She has won gold and silver medals at national competition.
Reason for referral :
Andrea has a neurogic bladder, requiring intermittent catheterization three or four
times each day. She remains dry at night.
Assessment/examination :
Medication : Oxybutynin (5 mg bd)
Excess (L) labia minora was excised in 1992 enabling easier catheterization. No
UTIs.
Neurogenic bowel: bowels managed with normal vegetarian dietand microlax
enema on alternate days. Self administered.
July 1995 :
Urodynamics : intermediate dysfunction, decreased compliance, uncontrolled
hyperflexia, leakage pressure 60-70 cm H2O, capacity 250 ml
Augmentation cystoplasti was discussed with Andreass parents who were not keen
on this procedure.

Case study No 2 : Middle aged man-prostate cancer,

impotent & incontinent
Frank was diagnosed with prostate cancer when he was fifty two years old. He had a
history of increasing nocturia, getting up two, three and even four times a night to
void and finding it took some time and effort to get started and feel that he had
emptied his bladder. Finding frank blood in his urine one morning was the prompt
for him to see his local doctor.
A rectal examination and Prostat Spesific Antigen (PSA) bloo screen suggested
prostast enlargement and possible cancer, later confirmed by trans rectal ultra
sound (TRUS) guided biopsy of his prostate gland. Subsequent to this diagnosis he
underwent surgery, a radical prostatectomy, followed by a course of radiotherapy
which reduced and stabilized his PSA count for some time.
During the radiotherapy treatment he suffered diarrhea and sensitive bowel and had
to avoid spicy food. These side effects lasted for twelve months. He also began
experiencing difficulty controlling his urine with symptoms of urgency appearing
during treatment and persisting until now. When he bends, shit down or stands up
he finds he pasessurine uncontrollably. Cystoscopy revealed scar tissue in his
urethra, a further side effect of his radiotherapy treatment.
Regular monitoring of his PSA levels showed that they began rising again, three
years after initial treatment and he was offered the choice of hormone therapy
(androgen blockade) or orchidectomy. He choose orchidectomy which has
subsequently performed. At the same time scar tissue was excised and his voiding
symptoms resolved for a while before reappearing. Currently his urgency and
incontinence symptoms are a significant problem to him. He takes a long time
passing his water, but finds he leaks if he bends, sit down or stands up.
Sometimes at night he experiences the urge to void but when he gets to the toilet
he cant pass anything. He has difficulty in completely emptying his bladder most of
the time.
Frank also suffer from impotence, resulting from nerve damage caused during his
radical prostatectomy. He can sometimes get but is unable to sustain an erection.
Surgical parting of his upper urethral sphincter means that he would experience
retrograde ejaculation at orgasm. Awareness of these factors, coupled with his
extended widowed status, was behind his decision to choose orchidectomy over
regular injections for androgen blockade. While he states that he is not much
interested in that side of things he does express anger and frustration at his loss of
erectile capacity after his first operation.

Frank lives alone in own home unit and has been a widower for the past twenty
years. He is of average height and slim build. He has non insulin dependent
diabetes mellitus (NIDDM) controlled by diet for the past eight years.
At this point frank preparing to have further, exploratory surgery which may or may
not improve his incontinence.

CASE STUDY No 3 : Woman-Incontinent

BACKGROUND
Mrs. Thompson is a 91 years old widow with no children, no pregnancies, now living
in a serviced apartment complex in the city.
REASON FOR REFERRAL :
Mrs. Thompson referred herself for help with an increasing urinary incontinence
problem which was impairing her very active social life. Mrs. Thompson had not
discussed this with her GP and had referred herself directly to the Continence Nurse
Advisor (CNA). She reported urgency, urge incontinence and very occasional stress
incontinence.
The problem started 6 months previously when she moved into the apartment. Mrs.
Thompson had previously lived in an independent living unit in the same complex.
She was very sad abaout the move which had been on doctors orders.
Mrs. Thompson is an socially active elderly lady who does not look her age. Her
main desire is to maintain her present lifestyle, going out with friends and relatives
(nieces, grand-nieces and nephews) to lunch, theatre, art exhibitions, playing bridge
and visiting other friends who are house bound. Mrs. Thompson feels she can not
continue to do these things if she is incontinent. She is extremely embarrassed by
her incontinence.
ASSESMENT/EXAMINATION :
Medical Diagnoses :

Cardiac problems. Check-up with a cardiologist three times monthly

Pacemaker in situ
Hypertension

Urinary incontinence
Present medications :
Lasix
40 mg mane
B.D

Satacor

1160 mg, tablet

Norvasc
10 mg, tab daily
needed recently
Paraffin oil PRN
Surgical history : hysterectomy at age 24 years

Angine

PRN, not

Continence assessment :
Urinalysis
NAD
Fluid Intake adequate
1.500 ml/day (5-6 glasses water, 3 cups tea, 1 cup
coffee)
Voiding pattern : (Mrs. Thompson was unable to complete a chart)
4, 5 or 6 times per day
1 or 2 times in the night
Incontinent episodes were approximately twice a week and the volume was large. To
contain her incontinence, Mrs. Thompson wore a sanitary pad. Two per 24 hours.
One in the day and one in the night.
Mrs. Thompson had slight oedema of her feet and ankles. She reported that she
took Lasix to control the oedema. Mrs. Thompson also reported that her
incontinences episodes were related to her diuretic (Lasix) and she felt/knew she
would be continent if she did not take them. Mrs. Thompson has taken Lasix for
years and has been warned not to omit the tablet, and her incontinence is only for
the last six months.

CASE STUDY No 4 : FEMALE-FAECAL INCONTINENCE

Background :
Mary is 54 years old, is divorced, and lives on her own at Elizabeth. She has many
socio economics stresses in her life including unemployement. She is frequently
called upon by her son to help pay for some of his considerable debts which she
finds difficult to manage on her Social Security Benefit. She often helps others with
daily living tasks.
Reason for referral :
Mary has been experiencing frequent faecal incontinent episodes.
Assessment /examination : colonoscopy NAD
Mary is embarrassed, upset, anxious with shaking hands and apologizing about
same. She talks non stop about her bowel problem. She had been experiencing
faecal accidents 3-4 times a month for 12 months. She expressed that she was very
angry with health system that she had not found anyone to help with this problem.
She had tried to manage the problem on her own i.e. was careful with her diet and
padded up when she went out. Mary was socially isolating herself because of her
expressed that she was stressed by family and friends problems : she often
transported or shopped for them and this was becoming too much.
Bowel pattern
Regular daily firm bowel action. Occasional about of loose bowel action which lead
to accidents. This seemed to tie in with extreme with extreme stresses
Dietary, foods and fluids
Knows what foods upset her. Good balanced diet with adequate fibre and fluid
intake.

Physical assessment :

Well covered but no obese

Abdominal muscle lax
Vulva clean and intact, not dry
Anal area, healthy, intact, some staining on pad
Moderate strength pelvic contraction
PR examination; empty rectum, weak anal tone, minimal faeces on glove