Dr Rhian Morse is a Consultant in Geriatric and General Medicine and is the Lead for the Gerontology Continence Service at Cardiff and Vale University Health Board.
This year, the BGS Spring Meeting was held at the inspirational Royal Welsh College of Music and Drama in Cardiff – a setting conducive to open discussions, sharing of ideas and connecting with friends across the specialty.
It was particularly encouraging that a significant part of programme time was dedicated to bladder and bowel health, an area of practice that is often underrepresented.
As we mark World Continence Week (15 – 21 June), it is timely to report back and reflect on this component of the Spring Meeting. I would also encourage members to listen to the relevant on demand recordings from the conference, which are available on the BGS website.
Trainees’ Day – Continence Core Competencies
A BGS-supported Trainees’ Day entirely dedicated to bladder and bowel health preceded the main BGS event. Approximately 85 trainees in geriatric medicine from across the UK attended in person, plus a small number of therapists.
Trainees rotated through four themed rooms, undertaking simulation-style learning. Stations included the interpretation of bladder charts and residual volumes, and trainees practised performing portable bladder scans, a mandatory direct observation of procedural skills (DOPS) in the geriatric medicine curriculum.
A second room concentrated on pelvic floor anatomy and function. Common urogenital skin conditions, particularly vulval dermatoses were also discussed.
A third room focused on functional challenges, including safety around night-time toileting and bed transfers. A variety of containment devices were demonstrated including body worn devices for male incontinence and the value of the bio bidet for maintenance of hygiene and dignity. We were fortunate to have an occupational therapist – Ms Julie Gape - presenting during the session.
A final room was dedicated to exploring real cases, notably frail older people with bladder and bowel issues. We discussed how, based on a good history, examination, a review of medication and co-morbidities, coupled with some simple investigations, that it is possible to draw up a bladder and bowel problem list and formulate a pragmatic management plan. Evidence-based interventions including pharmacotherapies, behavioural approaches and functional solutions were discussed.
The day was extremely well received by the trainees and generated much discussion and enthusiasm, with several trainees indicating a potential future special interest in this area of practice. However, many reported little or no opportunity for training within their region, despite the mandatory curriculum requirements set for all trainees.
The annual GMC National Training Survey has also consistently reported (over several years) that continence is the curriculum area in which trainees feel least confident about receiving adequate training. Similarly, a small sample survey undertaken by Dr Hannah Moorey (Geriatric Medicine Trainee) indicated that 75% of UK trainees in geriatric medicine do not believe they can meet the curriculum requirements, and only 25% could identify a geriatrician with an interest in bladder and bowel health within their training region.
The main conference
Bladder and Bowel Health was one of the themed parallel streams for day one.
Session 1: Registrar Training and Services
We looked at the provision of registrar training in bladder and bowel health across the UK and the link with service provision for older people. Dr Aine McGovern, Chair of the BGS Bladder and Bowel Health SIG, emphasised the circular link between registrar training and the development of geriatrician-led bladder and bowel services.
I presented recent data from a survey of UK Geriatric Medicine Programme Directors (Specialist Advisory Committee (SAC) supported). This shows that less than 50% of regions have any form of geriatrician-led continence clinic/service within area. For training, most regions rely on ad hoc arrangements within local urology/urogynaecology services, or with nurse-led community services (70%). These linkages are very useful but are predominantly informal and generally lack the structure and consistency required for comprehensive registrar curriculum training.
Furthermore, under the new curriculum (2022), trainees are also expected to undertake a specified ‘theme for service’ in their last 12-18 months. This is an area of practice which trainees revisit, and which may form the basis of a future special interest. Themes for service have been chosen based on population health needs, to ensure training aligns with health priorities. Bladder and Bowel Health is justifiably one of the themes for service, based on high prevalence of urinary and bowel disorders and the unmet need within the older population. Currently only 3 regions in the UK can offer a theme for service in Bladder and Bowel Health (Cardiff, Leicester and Manchester) with four others indicating the potential to do so with some development (Glasgow, Royal Free, Taunton and possibly East of England). This is an area that requires further support and development.
I also presented data relating to service mapping for geriatrician-led clinics across the UK. We now have a growing understanding as to what is currently available and the names of geriatricians involved. We have also identified a few newly appointed consultants who are keen to develop local services.
We are starting from a small base, and the challenge is to build on what exists and support enthusiastic young consultants.
Training guidance
Given the shortfall in current training, we have developed written guidance to aid trainees, educational supervisors and programme directors. This was presented at the Spring Meeting. It aims to supplement what is set out in the curriculum and to provide ideas as to how competencies can be achieved locally. This guidance has already been presented to and agreed by the SAC. I want to thank Dr Aine McGovern for her contributions and comments to this. It is currently being distributed to all Programme Directors and Trainees.
Session 2
Two of my consultant geriatrician colleagues in Cardiff – Dr Victoria Suter-Jones and Dr Jenny Clark – presented real cases taken from the front door and inpatient settings. They explored common clinical scenarios, which are part of routine geriatric medicine practice. These included the management of recurrent UTIs (often part of urogenital ageing in women), bladder overactivity and nocturnal polyuria. Dr Clark shared the challenges of managing nocturia, and demonstrated how a focused, multidimensional approach enabled discharge home rather than long-term care.
Both Victoria and Jenny undertook their training with me at the Gerontology Continence Service in Cardiff. They exemplify the benefit of trainees participating in a structured training programme and subsequently embedding good practice into day-to-day consultant practice across care settings.
Session 3
The final session was provided by Dr Ru Katugampola, Consultant Dermatologist, and Professor Julie Cornish, Professor of Surgery – both based in Cardiff.
Inspection of the vulva is an important part of the assessment of women with incontinence and/or local irritative symptoms. Ru guided us through some common vulvo-vaginal conditions associated with ageing e.g. Lichen simplex, Lichen Sclerosus, Lichen Planus, Genitourinary Syndrome of Menopause (atrophic vaginitis). The use of vulval moisturisers and topical steroid preparations was discussed. This is an important clinical area of practice and management significantly improves quality of life.
Julie outlined approaches to faecal incontinence in the frailer older person, which included appropriate use of laxatives, diet, fibre and, where appropriate, rectal irrigation.
What can we conclude from the meeting and the way forward?
Bladder and Bowel Health is an extremely important part of practice for all geriatricians. Approximately 30-40% of the patients we see on a daily basis (hospital/community/subspecialties) are suffering from incontinence and related urogenital problems.
All geriatricians should have good basic knowledge and skills to fulfil their clinical roles as holistic clinicians, and this includes bladder and bowel health.
Trainees across the UK require appropriate training. However, this is currently patchy and often inadequate. This has been the case for many years and needs to improve.
We need to expand the workforce of geriatricians who have a special interest so that services and training can be further developed.
Support for young geriatricians attempting to develop services is imperative. Mentorship/Fellowships/linkages with established units may be part of the approach. In Cardiff, we have recently supported training visits by two out of region trainees.
A provisional action plan to move things forward is under development. The intention is for the BGS Special Interest Group to lead on this and continue working with relevant partners, including the wider BGS and the JRCPTB - SAC/Programme Directors.
The BGS already has a track record in promoting dignity in relation to continence such as the Behind Closed Doors campaign and have more recently supported the development of the Continence learning course. We need to build on this.
As previous BGS President Professor Adam Gordon and co-author Mathias Schlögl stated in their Age and Ageing article, “It’s time for geriatricians to bring more to continence management.” We all need to get behind this!
