So an example of that might be where someone’s come with pain and bladder frequency and you’re thinking, ‘Well, this probably is bladder pain,’ but I need to just step back and make sure that I haven’t thought, could there be something else happening in the pelvis that might be pressing on the bladder, or that I need to be thinking about? So kind of any red flags. Is there any bloating in someone who’s gone through the menopause where I might want to just make sure that I’ve thought, could there be an ovarian cause? Have I done the blood test about-, that might look into that, if I need to? I think all-, you know, as an example of that, have I done everything I need to do?

I’m checking that there isn’t an infection when I did the urine, but actually is there non-visible haematuria? If there is, kind of has it persisted? Have I explained it? Have I done everything that needs to be done about that? You know, so those kind of red flags and the pathways that you also might need to be following. And you can often do it in parallel, and kind of-, then it’s just making sure that you’ve got that shared understanding that you are hearing about what symptoms they’ve come with and that are important to them, and that you’re going to be able make a plan, hopefully, to help with those symptoms, but you’re just taking that moment to take stock and make sure you’ve thought about all the other things, as a GP, that you need to think about, where they might be other things that you need to do to make sure that-, that things are cared for appropriately really and that it’s safe and all done in a timely manner.

And I guess that’s also true about that kind of intersection between what somebody’s coming in with now as their most difficult symptom, but, you know, sometimes it can be quite complicated when there are other illnesses, and other conditions, and you’re balancing all of those things. You know, so for an example, if somebody’s got really significant bladder pain but they’ve also got endometriosis, it’s about making sure you’ve stopped and thought about how those intersect and how you can understand which one might be the kind of most important one to tackle first in order to relieve all of those difficulties. Or where you might be thinking about a difficult balance between medication, where someone’s got really significant kind of difficulties with the bladder and with the-, managing the urine and how that’s affecting their life, but where they might also have something like heart failure, or a heart condition, where they’re needed to take diuretics or water tablets.

I’m always really glad when somebody has come to ask for support with this because there’s the hope that that’s a first step towards accessing all sorts of help, and I think that does include emotional and psychological support. Being able to talk about it. Learning strategies to manage it practically. Having the opportunity to develop an understanding that it’s not something that’s somebody’s fault. That it’s a-, something that can affect lots and lots of people, not to in anyway diminish that individual experience. But people can sometimes feel quite isolated and quite lonely, where they’ve kept something inside and secret and hidden. And so that’s where support groups and those and-, and in, you know, physical and online communities and fora can be incredibly supportive and nurturing for people who kind of have that gift of understanding that it isn’t a secret, that it is something that can happen to lots of people. And I think things like support and services through physiotherapy are part of that because that gives people some things that they can do themselves, that kind of control and it-, where-, where it works, that can be really helpful. Where it interfaces with self-esteem, self-confidence, again, sometimes those practical steps like medication, like access to pads, helping people understand what products are available, including kind of reusable, and well-, you know, pants and things that can help. That can, in itself, give enormous emotional and psychological support where people start being able to do things, and connect with people, and places, and activities again. If it was having an-, and, you know, if despite all of that there’s ongoing kind of emotional and psychological distress, and interfacing with a sense of self or self-belief and self-esteem, then I think supporting somebody to access counselling or psychological support through IAPT [Improving Access to Psychological Therapies, also known as NHS Talking Therapies], would be a really useful thing to do, and something that we would be really happy to support people with in primary care.

Broadly, most of the medicines that we use for-, so if we’re thinking about urge incontinence, or that irritability, twitchiness of the-, of the bladder muscle, or mixed incontinence, the medicines that you would think about mostly act to try and tone that down a little bit, and calm it, and they mostly act through a pathway called the cholinergic pathway. So, broadly speaking they’re anticholinergics. They’re kind of newer ones and older ones, and lots of localities will have a kind of picklist or a guide about the way in which you might work through those. They can interact with other medicines, and actually if people are already on other medicines that act on that pathway, the side effects can add up a little bit, and that’s quite important to think about. Some of those side effects occur in the shorter term, so that’s-, can be things like constipation, or-, or a dry mouth, or sometimes affect the blood pressure, and you need to think about things like risk of falls, which can be important for some of the people you’ll be supporting. Some of them also, taken over a very long time, might contribute to a risk of things like cognitive impairment, or memory, in the future, and that’s something that’s really important to some people. For other people the benefit of the symptoms or-, or used over a shorter term, that won’t be a priority, but again it’s about having those conversations and sometimes reflecting a bit of uncertainty there.

I would try and explain the importance of examinations. So why-, why it matters, how it can help, and how we might be a bit more limited in understanding what’s happening with their symptoms that are causing them trouble. You might want to explore what their worries are about examination, and whether there’s anything that you could do that might make that less worrisome, to work towards it. Sometimes it would be worries about things like a speculum and-, and thinking about the progress that you could make in understanding those symptoms without using a speculum, might for example sometimes help you get to that point. Sometimes it’s about feeling ready or prepared, and people will say, ‘I don’t want to be examined today,’ but then being flexible about a time when you could examine them, sometimes the people might want a longer appointment or something with them. So I think it’s about trying to understand what the barriers are, and work with that person as much as you can to create a space where you can reduce or make those feel more manageable. But ultimately if someone doesn’t want to be examined, then-, then-, then they’re not going to be examined.