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13 September 2016

The mysterious case of Edna and the bladder that worked overtime

Was this dehydration? Heart failure? Or something much, much more simple?

By Phil Whitaker

Edna phoned; she thought she had a urine infection. Older women are particularly prone: the lack of oestrogen after the menopause leads to thinning of the vulval tissues, allowing bacteria easier entry to the bladder. In addition, with reduced mobility and social contact, the elderly often don’t drink enough, so many germs don’t get “flushed out”, and more of them readily take hold.

The symptoms aren’t always typical. Whereas younger women experience pain passing water, and need to make frequent and urgent trips to the loo, very often older patients simply become confused and go “off legs”. That said, Edna’s symptoms did sound characteristic: she was peeing every hour, and she couldn’t hang on too long when she had to go.

I called on her during the lunchtime round. Home visits take up a lot of time, but they are a vital service for the housebound. Like most doctors, I find them enlightening – nothing beats seeing someone in their own environment for getting a view of the bigger picture. Edna’s house was clean and tidy, and she was neatly dressed and was steady on her feet when she came to the door – all signs that, whatever was wrong with her, she was managing to keep things on track.

She’d collected a specimen, so after a chat I disappeared to her bathroom to test it. This involves dunking a reagent strip into the sample. These “dipsticks” have ten different test pads in a row, each of which undergoes a change in colour on encountering a specific chemical. There are several that might indicate infection – in the presence of blood, protein, infection-fighting cells, and bacterial breakdown products called nitrites. Edna’s sample was negative for all four.

I returned to her sitting room and questioned her more closely. In typical cystitis, the bladder feels full-to-bursting but the volumes passed are surprisingly small. Edna was quite clear she was peeing buckets. This could have been a symptom of diabetes mellitus – excess sugar filters out through the kidneys, dragging large volumes of water along with it – but Edna’s dipstick had been negative for glucose, too, ruling that out.

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There’s another form of the condition – diabetes insipidus – which has nothing to do with sugar levels. In DI, a hormone system that regulates water balance goes awry, causing the kidneys to continue pumping out urine even though the body is dehydrating. It is rare, but can be associated with serious underlying conditions.

I came across to where Edna was sitting and examined her carefully. There was nothing to suggest dehydration. The only other thing I could think of was heart failure. Fluid accumulates in the legs under the influence of gravity, causing them to become markedly swollen. When the legs are elevated, the water floods back into the circulation, producing a surge in urine output. But that usually occurs at night, when the person is lying flat. In any case, Edna didn’t have many signs of heart failure, either.

I was stumped. Crouched beside her chair, I launched into a wordy explanation of what I thought we should do next, which basically involved a lot of tests. She listened politely but I could tell she wasn’t interested. She just wanted me to solve the problem. Her loo is up stairs, and she was worn out with traipsing up and down.

It was then that I saw it: a pint glass on the occasional table beside her, half full of water. I asked about it. Oh yes, she said, that’s my daughter: she’s been on at me for not drinking enough – says it’s a sure-fire way to get a urine infection. I asked how much she was drinking. Pints and pints of the stuff, she told me, had been all week, ever since her daughter had visited.

I’d been so busy looking for medical causes that I’d missed the blindingly obvious. Edna was tipping gallons in at the top end, only for it to reappear again in the time-honoured fashion. Feeling foolish – though amused that she hadn’t made the connection herself – I suggested a more measured approach to maintaining her fluid intake. Her symptoms settled within a day.

This article appears in the 07 Sep 2016 issue of the New Statesman, The Three Brexiteers