This system refers to the entire gastrointestinal tract, beginning with the mouth, progressing to the stomach, then the small bowel, large bowel and finally the anus.  Like many things, the correct functioning of the gastrointestinal tract does benefit from a healthy general lifestyle which includes regular exercise, a balanced diet and drinking plenty of water.  Despite that, one thing is very common in the elderly – constipation.  We will get to that later.  Firstly, lets start higher up.

Gastro-oesophageal Reflux Disease (GORD)

This is very common disorder.  The main question to ask is – why?

Normally the stomach has acid and that acid is not meant to move back up towards your mouth.  Acid from the stomach is not meant to be in the gullet (oesophagus).  However, for various reasons, stomach acid can enter the oesophagus and when it does, it causes a variety of symptoms including pain and nausea.

One reason why elderly people get reflux is because the valve system which is present between the stomach and oesophagus becomes dysfunctional.  This often can be associated with the sliding of a portion of the stomach upwards leading to a condition called a “hiatus hernia”.  If this problem is great enough, in particular if your reflux includes a significant volume of gastric contents being regurgitated at times, it may warrant surgery.  In this procedure, a portion of the stomach is wrapped around the oesophagus, in an attempt to re-create a valve.  The size of hiatus hernia can be assessed by various means including a “barium swallow” whereby a drink with radio-opaque dye is drunk, and xrays taken to track the passage of that fluid consumed.

Apart from stomach acid entering the oesophagus, the very presence of too much acid in the stomach itself can cause pain.  The actual lining of the stomach can get inflamed.  This situation is referred to as gastritis.  Sustained high acid levels and gastritis can go on to cause a stomach ulcer.  In turn, a stomach ulcer left unchecked can continue to erode and eventually perforate, meaning that there is now a hole in the stomach wall and the contents of the stomach are leaking into the abdominal cavity.  This is a very dangerous situation.

High acid levels in the stomach can also contribute to GORD itself.  It is worthwhile mentioning also that there is a bacteria called helicobacter pylori that does live in the stomach and causes hypersecretion of acid.  Therefore, the first thing to check if you have high stomach acid is – do you have helicobacter pylori (called h.pylori for short)?  This can be tested for by a simple and harmless breath test.  It’s really very sensible to check for h.pylori if you have GORD or gastritis.  Because, if you do have h.pylori, it can be treated.  That treatment comprises antibiotics and a medication that suppresses your stomach’s acid secretion.  These are sometimes sold in combination, specifically as a pack for h.pylori.

One word of caution is that medications used to supress acid such as esomeprazole (Nexium) and pantoprazole (Somac) are often overused and although daily use can be required for people, many others benefit from using these medications only when they have symptoms.  This is perfectly reasonable and sensible.  There are some risks associated with the use of anti-acid medications.  These include:

1. Low B12. Drugs like Nexium decrease your B12 level.  There are some patients who get put on B12 replacement therapy, when the actual cause is their anti-acid medication.  So if ever you are found to have low B12 check that it’s not caused by these such medications before going on replacement B12 therapy.
2. Immunosuppression – Nexium can cause your immune system to be supressed very quickly. This can be picked up in a blood test as a reduced white (immune) cell count.  Note that you may not realise that your white cell count has reduced.  Therefore, about 4 weeks after starting an anti-acid medication such as Nexium, it may be worthwhile having a blood test to check that your white cell count is ok.
3. Thin bones. Long term use of anti-acid medications can cause your bones to thin, a condition called osteoporosis.

So all in all, if you need to use anti-acid medications, then try to use them every now and then, rather than all the time.  And, before you start using them, test yourself for h.pylori.  If you have severe symptoms or a stomach ulcer though, then you need you use medications at least daily for 8 weeks.

Silent reflux.  This is the related condition to GORD in which case stomach acid makes its way all the way up into a person’s throat, causing them to cough rather than necessarily feel pain.  It is worthwhile considering silent reflux as a cause for a chronic cough, and therefore, you could try an anti-acid medication.  If the cause for your cough was silent reflux, it should go away!

 

Diarrhoea 

Loose stools can be associated with:

• Diet/ food intolerance
• Infection
• Other chronic diseases including cancer and inflammatory bowel disease
• Overflow diarrhoea as in the case of severe constipation.

We will now consider these sequentially.

Dietary intolerance.  If this is your cause of diarrhoea, you may pick up on what foods give you a problem.  In this case, you will see a pattern and avoidance of those foods, can fix the problem.  Note that your tolerance for food can vary, so that even if you did not have a diarrhoea with a particular type of food in the past, you may suddenly develop a problem with it.

Infection: These can be either viruses, parasites or bacteria.  Viral diarrhoea tends to come and go.  It usually lasts less than one week.  And, though your stool may be runny, you usually don’t get too much associated abdominal pain or fever.  Generally, it is self abating.  Parasites are less common and can include worms.  This is a longer course issue and can cause weight loss, since the parasites feed on your intestinal contents.  Apart from this, you may not feel too unwell and the diagnosis of a parasitic cause of your diarrhoea may finally be made by your doctor who requests a sample of your stool for testing by the pathology laboratory.  Bacterial diarrhoea can be more severe.  Bacteria that infect the bowel, tend to affect the large bowel or colon.  These include salmonella.  Such bacterial infections are usually passed on from food or faeces.  If you have a bacterial cause of diarrhoea, you may get quite unwell with bloody stools, increasing abdominal pain and fever.  These symptoms may carry on for weeks and get worse without treatment.  In this case, particularly if you notice blood in your stool, you should consult your doctor who will likely send a sample of stool for testing.  If a bacteria is found, for example salmonella, you may go on to be prescribed a course of antibiotics as treatment.  It’s worthwhile noting that, as previously discussed, taking those antibiotics could worsen your diarrhoea, at least whilst you are on them.  In this sense, you will need to decide whether it’s worthwhile taking or not.  Indeed, some bacterial infections can be self limiting and resolve spontaneously.  However, in general, if your symptoms of infection are severe and protracted enough, it is generally advisable to get treated so as to affirmatively resolve the infection.  You may have to consider how you may have contracted any bacterial infection in the first place.  If it was thought to be associated with any take away food, then this needs to be reported, so that the origin can be tracked down, and further spread of the disease contained.

Yakult

These days, many pro-biotic supplements and tablets are sold.  It’s difficult to imagine taking these forever.  However, you can get many of those benefits from yogurt or the classic pro-biotic – Yakult.  These additions to your diet can help digestive tract.  This is true in particular if you find yourself needing to take antibiotics for any reason.  Sometimes antibiotics can lead to loose stools (antibiotic associated diarrhoea).  This is because they temporarily wipe out your “good bacteria” in your bowel.  In this instance, pro-biotics have been shown to help.

Variation in stool

It is worthwhile mentioning that people’s stools do vary.  This can happen for all sorts of reasons – how active you have been, how much water you have drunk, your diet and emotional state for example can all have a bearing on your stool.  So some variation is completely natural.  I mention this here, because it is true that some elderly people get fixated with their bowel habit almost to the point of it being an obsession.   In fact, this is not so uncommon.  Beware if you are becoming obsessed with thinking about your bowel habit, and try to avoid doing so.  The irony of course being that once you get obsessed with any particular part of your bodily function, be it your bowels or your skill, you end up causing and then perpetuating self-imposed disfunction of that bodily system.  That’s the natural tendency.

 

Constipation

Firstly, let’s define what constipation is.  Constipation is difficulty opening one’s bowels because of hardened faeces.  The main thing to note here is that constipation is not defined by how often you open your bowels, rather focusing on the stool itself being too hard.  This is important to note.  People open their bowels more or less frequently.  How often, doesn’t matter, as long as the stool is relatively soft and easy to pass.

Constipation can be caused by lifestyle and other illness factors.  It’s important to realise that when we talk about constipation, we are talking about a build up of faeces in the large bowel, known as the colon.  That build up of stool can be either at the start of the colon, on the right hand side.  This area is called the caecum.  This is known as faecal loading.  Or, the build up can be right at the end of the colon, in our rectum.  This is called, faecal impaction.  The stool in severe faecal impaction can be rock solid.  This is because, as stool passes through the colon, water is progressively reabsorbed from it, and it therefore becomes more solid normally.  By the time it gets to the end of the colon, it’s therefore normally more firm, and during constipation, it can become even more so.  We’ll return to this concept of faecal loading and faecal impaction later in the treatment section.

Lifestyle:

These are the lifestyle factors which can contribute to constipation:

• Not drinking enough water and subsequent dehydration
• A lack of physical activity.
• A diet low in fibre and in particular the consumption of too much meat
• Repeatedly delaying opening your bowels.

Mental stress

A person’s mental state can also affect their bowel habit.  Stress and one’s mood can either contribute to you having constipation or diarrhoea.

Physical illness

• Being wheelchair bound as a physical limitation and cause of being particular sedentary can lead to or exacerbate constipation.
• Thyroid function – hypothyroidism. Low thyroid function can contribute to constipation and
• The rectum can prolapse into the bladder and this can create a “kink” in the rectum as a tube, making it difficult to pass a stool.

Medications: Various medications can lead to constipation, these include:

• Iron tablets. Cause dark stools and constipation
• Pain killers. Drugs which include codeine or other opiates can cause constipation.  These include endone (oxycodone), panadeine and panadeine forte.

Treatment:

Bowel retraining

Often, due to our lifestyles, we put off going to the toilet, or just don’t create any real “habits” about opening our bowels.  Compare this to kids who more readily may have a “habit” of going to the toilet after a particular meal or time of the day.  Your colon does have a general wave of activity that moves through it a few times a day, pushing faeces further down track, ready to pass.  This is called the migrating motility complex.  After this, you then may get the “urge” to go to the toilet.  Still, if you set a time during the day, say after breakfast, to routinely sit on the toilet, you may find that over time, you’ll create a habit where after breakfast, you feel like going to the toilet.

 

Moving on

Once all the lifestyle factors and illness factors have been attended, causative medications removed or limited, and bowel retraining attempted, if you still have constipation, you may need to consider a laxative or enema.  Returning to our discussion at the start of this chapter, this is where it’s important to realise that constipation is a broad term, what you need to know is whether your problem is faecal loading or faecal impaction.  If you’re not sure which one it is, you may need to see your doctor and he/she may do a per rectal exam or send you for an abdominal xray to confirm.  It is worthwhile the difference, because faecal loading and faecal impaction are treated differently.

Faecal loading is treated with laxatives.  Laxatives work in various ways including by stimulating the muscle of the bowel wall to push stool or by drawing water into the stool, to make it softer.  When there is excess stool at the start of the tube, on the right, as is the case with faecal loading, this makes sense and should work in theory and practice.  Taking laxatives is appropriate.

Faecal impaction by contrast, is a problem right at the end of the colon, low down in your rectum.  Laxatives are much less likely to have any effect.  Instead, for this problem, you need to use suppositories or enemas.  A suppository is a capsule filled with ingredients (for example glycerol) that draws water into the colon, softening the stool and stimulating the area.   An enema works in a similar way, but this time, instead of a capsule, it’s a bottle filled with fluid containing salts and various other chemicals.  You insert the nozzle of the enema about 10 centimetres into the rectum, and squeeze the fluid into the colon and faeces, hopefully causing the faeces to be passed.  If you have faecal impaction, it can be useful to do both.  Start with using two glycerol suppositories, then wait half an hour and proceed to using a enema.  For faecal impaction, if all else fails, then you may need to see your doctor to have the faeces manually removed.

Note that a person can have both faecal loading and faecal impaction at the same time.  In this case, both laxatives, suppositories and enemas can be used.

TIPS:

1. Drink lots of water, have fibre in your diet and stay active. These three factors are the basis of creating a reliable bowel habit.  Drinking water especially, is often forgotten.  A good tip would be to get into the habit, or make it routine to drink a glass of water with a meal.  That’s a good start.
2. Don’t strain on the toilet. You could make things worse and end up getting haemorrhoids.
3. Laxatives: As people age, it becomes more usual for some to rely on daily laxatives, especially in a nursing home. But beware, your body can become a bit too dependent on these things.  This is because some laxatives contain ingredients that affect the nerves in your bowel, causing the muscle on the bowel walls to contract and stimulate movement.  This is how “sennakot” (part of coloxy and senna) works.  Senna, as it is called, therefore is a laxative that your body can get dependent on, to a degree, so use it if you need to now and then, but ideally, not everyday.
4. Bowel obstruction. If you’re not opening your bowels at all, and you start to get a distended and painful abdomen then at that point, you may have progressed to having a complete bowel obstruction.  This could be from constipation, or any other reason for a blockage including bowel structuring/narrowing, kinking or mass/tumour.  In this case, you should see a doctor.
5. Overflow diarrhoea. This is the phenomenon when constipation or any other cause of blockage, leads to only watery stool or pure liquid getting passed.  The fluid is said to literally “overflow”, bypassing the physical blockage.  At this point, you may feel that you’ve in fact got diarrhoea.  But it’s actually “overflow diarrhoea” and constipation may still be the cause. Keep this in mind!
6. Confusion, delirium and constipation. The elderly are prone to constipation due to increased immobility and tendency to get dehydrated.  However, often they don’t know they are constipated.  This is true for people with or without dementia.  When constipation is substantial though, it can affect a person’s mood, appetite, cause them to feel nausea and ultimately be a cause of confusion or delirium, so think of it during such times.
7. Back pain. Remember, constipation can cause back pain.  This can be misleading such that a person with back pain due to hidden constipation starts taking pain killers which include constipating substances such as codeine, only making the constipation worse.  To avoid this, when someone complains of back pain, think – could it be constipation?

 

Abdominal pain

Abdominal pain can be caused by many different problems.  One main objective when considering abdominal pain though, is to decide whether it’s bad or worrying enough that you should go to hospital to be seen by the surgical team.  Essentially, if you’ve got severe abdominal pain, and you don’t know what the cause is, then in general, you should go to hospital.

Common causes in the elderly of abdominal pain:

1. This is a common condition and is discussed above.  It can cause abdominal pain anywhere really in the abdomen, but particularly the lower abdomen.  It can also be the cause of back pain.  This is useful to know, since sometimes patients get given constipating pain killers, for back pain, when their problem always was constipation.
2. This is inflammation of the bowel wall, usually the large bowel, also called, the colon.  The position of the pain can be either the right or left side, but more commonly the left side of the abdomen.  Diverticulitis can be caused by increase intra-abdominal pressure, often associated with constipation.

There are other, less common causes as well.  These include:

1. Inflammatory bowel disease such as Crohn’s and Ulcerative Colitis. Generally, an elderly person would have had this diagnosis earlier in life.  These are autoimmune conditions, meaning that the body has incorrectly attacked the bowel wall, causing inflammation and pain.  Crohn’s Disease can affect the entire gastrointestinal tract, starting at the mouth, ending at the anus.  Ulcerative Colitis, as the name suggests  only affects the large bowel.  Both can cause severe abdominal pain and PR bleeding.
2. Vascular problems. A lack of blood supply to the bowel can cause abdominal pain.  This can be due to a general long standing lack of blood to an area of the bowel, rather the same way that blockages to the arteries supplying the heart cause chest pain.  Or, from a more sudden blockage to a blood vessel that causes more dramatic pain.  In both cases, the pain can once again be associated with PR bleeding.

 

Tips:

1. Remember that an appendicitis can happen at any age, including in older age. This is inflammation of the appendix which is a small appendage on the right side of the bowel, where the small and large bowel meet.
2. Sometimes the bowel can twist on itself, especially the colon on the left side. This can be an emergency and is called a sigmoid volvulus.  In this case, the abdomen should be fair tender and may be distended.  If unsure, the person should be sent to hospital to be properly assessed. Note that sigmoid volvulus happens most readily in people who are bedbound.
3. Bowel Cancer. Advancing age is a risk factor for most cancers including bowel cancer. Therefore, keep this in mind, especially if the abdominal pain is accompanied with a change in bowel habit and any bleeding.  Feeling the abdomen where it’s sore may reveal a mass with more advanced cased of bowel cancer.
4. If someone hasn’t been opening their bowels and their abdomen is distended, they may have a bowel obstruction. This can indeed be painful.  This can be a surgical emergency and therefore they should be seen in the emergency department.
5. Sometimes, the abdominal pain can be low down and in the middle. In this case, consider that it could actually be an obstructed bladder causing distension of the bladder and abdominal pain from that.

 

PR bleeding

Bleeding from your bottom can be very disconcerting.  There are various causes, however one thing must be said and that is that bowel cancer must always be thought of as a possibility, especially if the cause is not otherwise obvious.  Generally, per rectal (PR) bleeding is either bright red or darkened and mixed with stool.  If it’s dark and or mixed with stool, it generally symbolises that the source of the bleeding is higher up in the bowel.  If it’s bright red, it generally means that the source of the bleeding is the lower bowel or colon.  This is of course, unless there is a massive bleed, in which case, even bleeding from the earlier, higher parts of the bowel or stomach, can lead to bright PR bleeding.  These are some causes of PR bleeding:

1. These are engorged walls low down in rectum near the anus that are filled with blood.  It is thought that they help to form a valve, helping to maintain faecal continence.  Haemorrhoids located higher up within the rectum are called internal haemorrhoids.  Haemorrhoids closer to the anus can be painful and are called external haemorrhoids.  Internal haemorrhoids can sometimes fall out of the anus and you can feel them bulging and can be pushed back in.  Internal haemorrhoids in particular, can often bleed.  The blood tends to be bright red.  Internal haemorrhoids themselves tend to be painless.
2. As earlier mentioned in the section about abdominal pain, diverticulitis, which is inflammation of the colon, usually caused by increased pressure on the bowel wall, can be associated with PR bleeding.  Note that diverticulitis can and commonly causes substantial bleeding.  The first line treatment for diverticulitis are antibiotics.  This is usually a penicillin in the form of Augmentin Duo Forte 1 capsule, twice a day for 10 days. During a bout of diverticulitis, you should have a soft diet, comprising foods that are not too fibrous.  Once the acute flare including any pain or bleeding is resolved, then you can restart a fibrous diet, to avoid constipation.  In any event, you should drink lots of water.  Some people will know that particular foods set off their diverticulitis.  Though this idea hasn’t fully been scientifically validated, this may be true for some people in which case, diet becomes all the more important.  In any event, avoiding constipation is important.
3. Bowel Cancer. We mention this again here since it’s vital to consider bowel cancer in any discussion about PR bleeding.  Episodes of any PR bleeding should ideally be discussed with a doctor and how to best rule out bowel cancer can be discussed.  To properly rule out bowel cancer, you’ll need to have a colonoscopy, which is a camera study of your bowel.  This is the gold standard of examining whether someone has bowel cancer or not as their cause of PR bleeding. We talk specifically about gastroscopy and colonoscopy to follow.

TIPS:

1. If you have a lot of bleeding – get help. If you have significant blood loss, or not sure, then get help.  Losing a fair bit of blood can render a person very weak and liable to black out, falling over. This is particularly the case for the elderly, who may be already unsteady on their feet.
2. Low iron is a sign of possible blood loss from your gastrointestinal tract. So even if you haven’t had any obvious PR bleeding, if you’re diagnosed with low iron, think that it can be coming from your bottom and therefore you should consider whether you should have a colonoscopy or at least talk to your doctor about it.
3. Haemorrhoids and rectal prolapses can be fixed. Sometimes, people don’t come forward about these problems so readily.  However, they can be fixed or at least improved and seeing a surgeon may be useful, to at least understand the options.
4. Don’t forget to keep in mind bowel cancer, it can certainly be a cause of PR bleeding.
5. A colonoscopy is generally the best way to investigate PR bleeding and rule out bowel cancer.

Gastroscopy and colonoscopy

These are procedures which are conducted to look, with a camera, at your gastrointestinal tract.

A gastroscopy is a procedure where a camera is placed through my mouth, into your stomach.  It is sometimes performed for issues then that may relate to your stomach.  These include reflux or stomach ulcers.

A colonoscopy is a procedure where a camera is placed through your anus to look into your large bowel/colon.  This can be done for a variety of reasons including PR bleeding, abdominal pain and a change in your bowel motion.  Note that for a colonoscopy you do need to have your colon firstly cleared of faeces.  This is achieved by taking what is called “bowel prep”.  Bowel prep (short for preparation) is a liquid comprising bowel stimulants that cause you to have a loose stool, evacuating your bowel sufficiently before a colonoscopy.  The doctor who will be performing the colonoscopy will give you ample instructions about this prior to the procedure.  In the past, bowel prep used to require you to drink quite a volume of fluid.  However, there are options for bowel prep that don’t require you to drink as much fluid if this is an issue (such as people with heart conditions).

Sometimes a person may have a reason to go for both procedures whilst they are under the one anaesthetic.  Your doctor will guide you about this.

Urinary Tract Infections

Firstly, let’s define the urinary tract.  This essentially refers to your kidneys, bladder and associated pipes – the ureters which connect your kidneys to your bladder and your urethra which is the pipe from your bladder to outside your body allowing you to pass urine.

Urinary tract infections are just such a common problem for the elderly.  In elderly people, however, urinary tract infections may not always give you a set of symptoms that can be vague.  An infection of the urinary tract may cause you to be confused, lightheaded or just have a fever.  You may feel nauseous and all along not actually feel like you have a urinary tract infection at all.  For this reason, it’s really important to consider a urinary tract infection as being the cause of any generalised unwellness or change in how you feel, and if you’re unsure, have a doctor test a sample of your urine for infection.

Of course, you may well get symptoms more typical of a urinary tract infection.  These could be:

• Burning or stinging when you pass urine
• Increased frequency of urination
• Increased odour to your urine
• Your urine may have a tinge of red to it caused by blood
• Back or lower abdominal pain
• Fever, nausea and or vomiting

Is it my bladder or kidneys?

It is important to distinguish a bladder infection from a kidney infection since the latter is more serious, in general, in nature.  When you have a bladder infection, you may well have some discomfort and pain in your lower abdomen or back and trouble passing urine.  You may even have a mild fever, but you are not usual SO unwell.  When you have a kidney infection, by contrast, the pain in your back or flanks can be really severe and you could end up feeling very sick with fever, chills, rigours and significant nausea and vomiting.  Keep in mind also that a bladder infection, if not treated, can extend and proceed to travel up to your kidneys.  So it’s good to get on to.

What are the causes of a urinary tract infection?

Constipation contributes to urinary tract infections by limiting the complete emptying of your bladder when you urinate.  This is discussed further below.

A large prostate can contribute to the same issue – incomplete bladder emptying.  The resultant stagnation of urine increases the risk of infection.

Not drinking enough water means that your urine is just not flowing as much, and stagnation of urine in your bladder, once again, increases the risk of infection.

For elderly women, vaginal dryness leads to the outside facing aspect of the urethra more prone to allowing bacteria to enter and a bladder infection to set in.

How to treat a urinary tract infection

Urinary tract infections are best treated with antibiotics.  If you do not have any penicillin allergies, cephalexin is a good place to start, usually 500mg twice a day. Or trimethoprim.  If you take trimethoprim, note that you should take it in the evening for maximum effect since the drug tends to collect in your bladder overnight where it needs to act.  For women, usually 7 days is enough.  For men, infections tend to be more stubborn so a 14 day course is recommended.  If you have a resistant or stubborn urinary tract infection, you may be prescribed a different antibiotic, for example ciprofloxacin 500mg twice a day.

Sometimes, if you are prone to getting urinary tract infections very commonly, you may be prescribed a daily low dose antibiotic, typically cephalexin 250mg once a day, to decrease the chance of getting a urinary tract infection.  Otherwise, you may consider using an antiseptic agent such as hexamine hippurate (Hiprex) which is a chemical that helps to keep your urine acidic and in doing so helps to fight bacteria within the bladder.  The usual dose of Hiprex is 1g oral twice a day.

For elderly women, you may consider using an oestrogen cream or pessary.  This increases the bulkiness of the area surrounding the opening of the urethra, helping to reduce the likelihood of infection tracking from there.

For elderly people, it is useful to send a sample of urine for testing, to make sure that the antibiotic medication is the correct one.  This is so that no time is wasted in changing treatment, if required.

Kidney or ureteric stones

Stones in your kidneys or pipes connecting the kidneys to bladder, the ureters, can cause spasms of intense pain.  That pain is usual felt in your flank (lower back) on the side of the affected kidney.  It can be a sharp pain.  The pain of a stone in the ureter can be very intense indeed until that stone hopefully gets passed when you urinate.  Sometimes however, kidney stones may not cause pain, and instead may be related to repeated bouts of urinary tract infections.  When you get such recurrent infection, your doctor may order a scan of your kidneys (ultrasound or CT scan) and you come to know of your kidney stone then.

Dehydration can increase the likelihood of getting a kidney stone, so the best way to avoid the problem is by getting into a habit of drinking lots of fluids.  That could be either water, tea or coffee.  Just not alcohol.

Of note, it’s important to think about the possibility of having a kidney stone if you have lower back pain.  Some pain killing medications should be avoided with kidney problems, namely, non steroidal anti inflammatories (NSAIDs) such as ibuprofen and diclofenac for example.  These medications, if taken long term, can damage your kidney.  It is sadly not uncommon then for a person with back pain to be taking these medications for relief, only after some time, to find out that the cause of their back pain all along was a kidney stone.  And, that the pain medications they were taking were doing them harm. To avoid that scenario, keep in mind the possibility of a kidney stone being the cause of any back pain you could have, and if you’re not sure, talk to a doctor and raise your concern.

Urinary obstruction

This is the condition whereby your bladder fills with urine, but one reason or another, you just cannot force urine out of the bladder down the urethra to pass that urine.  As a consequence, your bladder continues to fill with urine and can cause lots of pain as it stretches.  You may notice that your lower abdomen is getting distended.  There are different reasons why an elderly person in particular can have urinary obstruction like this.  For example –

1. The connection between the bladder and urethra could get kinked from constipation or a prolapse as earlier discussed.
2. The bladder being a muscle, could fail to contract to squeeze the urine out. This could happen because of medications which may affect the nerves which give signals to the bladder to contract.  The bladder may also not contract well in the presence of some diseases which may affect the nervous system such as multiple sclerosis.
3. Sediment obstructs the outflow. Urine is usually quite free from particles and sediment.  However, especially in the case of infection, when there are many cells being shed from the bladder wall, urine can hold much sediment.  This collects on the floor of the bladder and ultimately blocks the outflow to the urethra.  Sometimes, infection can cause bleeding within your bladder, and if there is enough blood, clots will form, again blocking flow of urine from bladder to urethra or within the urethra itself.

To treat urinary obstruction, we need to consider first and foremost the cause.  If it’s constipation, clearing the bowel may just do the trick.  This could be achieved with laxatives, suppositories and enemas.  If infection is suspected by fever, then taking antibiotics may help.  Medication, particularly diazepam can help the bladder relax and empty.

Bladder Catheters

However, if these things fail, then it may be time to consider manually passing the obstruction with a plastic or silicon tube and draining the bladder.  This tube is called a catheter.  This procedure needs to be done by a professional – a doctor or nurse.  The procedure is more simple for female patients since the urethra is short, compared to a male, where the urethra is longer since it is present within the penis.  Although anaesthetic gel is used, having a catheter inserted can still be painful.

Once a catheter is inserted, hopefully lots of urine will drain out and the elderly person will get rather immediate relief.  Remember to send a sample for testing.  If the urine is found to be blood tinged, it could initially be suspected that infection is the cause, and antibiotics may be started. If not much urine drains, then its not likely that bladder obstruction was the cause of the persons problem.

Usually a bladder catheter can be removed after the urine has been drained, if not soon after.  However, if someone has a particular chronic disease (such as multiple sclerosis) or prone to recurrent bladder infections, then it could be suggested that a longer term catheter is used.  In this case, rather than having the catheter get to the bladder via the urethra, a doctor may recommend that a small incision be made on the external surface of the skin overlying the bladder, and a tube be inserted directly into the bladder from there. This is called a “suprapubic catheter” and is used for situations where a bladder obstruction is likely to keep recurring.  It is a more permanent solution to that problem.

Kidney failure

Like any part of your body really, your kidneys can wear out.  Your kidneys are basically a filtering mechanism for your blood.  Your blood flows through them, filter out what needs to be removed – waste products, and keep in your blood what is useful and therefore should remain.  Added to this, they help to regular the various concentrations of chemicals such as sodium within your blood.  If your kidneys start to lose their function, then your blood can accumulate more wastes, and you can lose more value parts of your blood, such as protein in your urine.  As your kidney function goes down, the amount of urine they produce also diminishes, ultimately meaning that your body is prone to collect fluid.  During this phase, your legs may swell much like heart failure, which we discussed earlier.

To check the status of your kidneys your doctor may order blood tests and ask for a sample of your urine.  That sample of your urine will be checked for protein.  If you have excess protein in your urine, that may be a much earlier sign of a kidney problem despite normal blood tests. So it’s very helpful to test your urine this way.

To take the stress of your kidneys, as an elderly person it’s important to drink plenty of fluids (tea and coffee is also helpful) and not eat too much salt.  It’s also important to monitor your blood sugars and if you have diabetes, control that blood sugar.  Likewise, blood pressure needs to be controlled since high blood pressure adds further stress to the kidneys.

TIPS:

1. Drink plenty of water. Your kidneys have to work less hard when your body is well hydrated, so in general, your kidney health is improved by drinking more water.
2. Eat less salt. Salt raises your blood pressure and high blood pressure can cause your kidneys to wear out more quickly.  Increased salt in your diet also makes your kidneys work more, once again contributing to their deterioration over time.
3. Don’t let yourself become constipated. Since your rectum (large bowel) is located just behind your bladder, when you are constipated, the pipe which allows urine to flow out of your bladder, your urethra can get kinked.  This can lead to your bladder not completely emptying when you urinate.  This stagnation of urine can increase the risk of you getting a bladder infection.
4. Be careful with hygiene if you have diarrhoea. It’s very common for a female person to get a bladder infection after having a bout of diarrhoea.  So, its really important to take extra care during this time.  If you are double incontinence, this can be tricky.  However, try your best to have your incontinence pad changed more regularly to avoid this happening.
5. Consider having your urine tested after you finish your course of antibiotics. This may not always be necessary.  However, if you are having frequent urinary tract infections, or your present one is stubborn to treat, it is useful to test your urine after your course of antibiotics.  This will reveal whether the antibiotics have worked and if you get a subsequent infection, you know that it is in fact a new infection, rather than a matter of the previous episode not fully clearing.
6. Remember – a urinary tract infection can cause you to get really very unwell if left untreated. This is because the bacteria can enter your blood stream and infect your whole body.  I have witnessed many patients end up in hospital with whole body infections (sepsis) from a simple urinary tract infection.  Get treated. In particular, If you suspect you have a kidney infection, you really should talk to a doctor.
7. Avoid catheters or at least take them out as soon as possible.  If you really go into urinary obstruction and need a catheter, then have it done.  It will fix the problem.  However, make sure you take it out as soon as possible.  This is because, usually, the longer you leave it in, the more likely it is that you will have some residual dysfunction of your ability to pass urine after that.  Of course, look at the reasons why you may have had to have it inserted in the first place, which led to obstruction (constipation, infection etc) and avoid or treat those.  However, try to take the catheter out as soon as possible.  Going further, although a suprapubic catheter may appear to be a simpler, cleaner solution to recurrent bladder obstruction, you should really think hard before saying yes.  Suprapubic catheters can have many issues of their own including infection and recurrent blockages.  So it’s not a perfect solution, and once in, it’s rare that a suprapubic catheter gets removed.