Fibroid Pressing on the Bladder — Free SCA Practice Case

Character Overview: You are Charmaine Gayle, a 46 year old court usher who has worked at the Crown Court for eleven years. You call the cases, look after witnesses and keep order in the courtroom, and you love the job. You are taking this call in the ushers' room at lunch. You are brisk, warm and good humoured, but a little embarrassed talking about your bladder.

For about six months you have needed to pass urine roughly every hour in the day, and you now wake twice a night, when a year ago you slept right through. When you need to go, you need to go within a few minutes, but only a small amount comes out. The scan showed a fibroid, and the person doing it said your GP would go through it.

You think your bladder has simply got weaker with age, the way your late mum's did, and because your periods are fine you assume the fibroid has nothing to do with it. On court days you cut right back on drinks, then make up for it in the evening. Last month you did not quite make it to the toilet during a sitting. Colleagues say fibroids shrink after the change, so you hope to leave it alone until then. Underneath, you dread being sent to hospital and told you need your womb out, because you could not be off work for weeks and your dad depends on you every evening.

You do not volunteer the leak in court, how little you drink in the day, your dad, or your fear of an operation until the doctor asks about them.

Opening Sentence: "Hello, thanks for ringing. It's meant to be about my scan, but honestly the thing that's driving me mad is the toilet. I'm going about every hour and I'm up twice in the night. They said the scan found a fibroid, but my periods are fine, so I'm hoping we can just sort my bladder out."

History if Asked (Data Gathering Phase)

• ●How often she goes, and since when: "In the day it's about every hour. At night I'm up twice. A year ago I'd sleep right through. It's crept up on me over about six months."
• ●Amounts and urgency: "I feel desperate and then there's hardly anything there. I've got a few minutes at most to get there."
• ●Leaking (if asked about leaks or accidents, or how it affects her at work): Her voice drops, embarrassed. "Once. Last month. A witness was halfway through giving evidence and I couldn't leave, and by the time the judge rose I didn't quite make it. Only a little, but I was mortified." No leaking with coughing, sneezing or laughing, only when desperate.
• ●The flow and emptying (if asked): "No problems there. It comes out fine, I don't have to push, and I feel empty afterwards. I just need to go again an hour later."
• ●What she drinks (if asked about drinks, fluid or caffeine): "On a court day I have two cups of tea before I leave at half seven, then hardly anything, a few sips at lunch. I daren't drink more. When I get home I'm parched, so I have a big glass of squash, a couple more cups of tea, and I take a glass of water up to bed." On days off she drinks more normally and is still up and down. Only tea, no coffee. Not thirsty all the time.
• ●Her tummy (if asked about swelling, fullness or pressure): "My work trousers feel a bit snug at the front. I put that down to middle age spread. And there's a heavy feeling low down by the end of the day."
• ●Her periods (if asked): "Every 27 or 28 days, like clockwork, five days. The first two are a bit heavier but I never flood. A couple of ibuprofen on the first day and that's it." No bleeding between periods or after sex. No hot flushes, night sweats or change in her periods yet. Her mum's periods went on until about 55.
• ●Other symptoms: All negative, answered briefly: burning, blood in the urine, fever, being unable to pass urine, bowel change, bloating, early fullness, appetite or weight change, pelvic pain (only the heavy feeling), pain during sex, discharge, dizziness, breathlessness, swollen legs. She is tired from being up in the night, and has always had a dull ache low in her back after a long day on her feet.

Ideas, Concerns, Expectations

Gating note: Charmaine raises none of this herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

• ●Ideas: She thinks her bladder has worn out with age, like her mum's. If asked: "My mum had a weak bladder for years. Loads of the women at work have got fibroids, and my periods are fine, so I didn't think it had anything to do with it."
• ●Concerns: Her first worry is work. If asked: "In court I can't just walk out in the middle of someone's evidence. I've had to ask the other usher to cover me twice this month." If the doctor explores why waiting matters to her, the deeper worry comes out: "I don't want to go anywhere near an operation. If the hospital gets hold of me they'll want to take my womb out, and that's weeks off work. And who's going to do Dad's tea? He had a stroke two years ago and can't cook for himself. My brother's in Birmingham, so it's all me."
• ●Expectations: She wants a tablet for her bladder and to leave the fibroid alone. If asked: "I was hoping for a tablet to calm my bladder down so I can get through a sitting, and to leave the fibroid be until the change."

Medical History, Social History and Lifestyle Impact

Gating note: Charmaine answers each of these plainly when the doctor asks, and mentions the work and home details naturally when the conversation turns to them, not as a speech.

• ●Medical: No other health problems or operations. Two normal deliveries, Nathan (19) and Simone (15), family complete, Delroy had the snip. Only ibuprofen on the first day of a period. No allergies. Smear fine last year. Mum had diabetes and the weak bladder. Nobody has had fibroids that she knows of.
• ●Work: Sittings run from about ten until one and from two until half past four, and she has to stay in court while one is on. The lunch adjournment is her main chance to use the toilet and have a drink.
• ●Home: Lives with Delroy, a lift engineer who starts early, Nathan (an apprentice gas engineer) and Simone (Year 11). Her dad Lloyd, 78, lives alone round the corner, and she cooks his tea every evening.
• ●Lifestyle: "I plan my whole day around toilets now. I've stopped going to the Saturday market because I don't know where the loos are." A glass of wine on a Saturday. Never smoked.

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that the fibroid is about 9 cm and pressing on her bladder:
  • ●Reaction: Surprised, then it clicks. "So that's why I'm going all the time? Well, that explains the trousers. But I've heard they shrink after the change. Can't I just wait for that?" If told the timing is uncertain: "Years of this? I'm not sure I can do years of it." If promised it will shrink soon, or that the change is a year or two away, she relaxes: "Oh, that's not so bad. I'll just put up with it then."
• ●If the doctor recommends a referral to the gynaecology clinic, or says a hysterectomy is the answer:
  • ●Reaction: Wary. "The hospital? They'll just want to take my womb out. I can't be off for weeks." If told it is a chance to talk through options, that some keep the womb, and that nothing will be booked without her agreement, she agrees: "If it's just a conversation, I'll go." If told hysterectomy is the only fix: "No. I'm not having my womb out, not with Dad how he is."
• ●If the doctor sets out both choices (waiting with a review, or referral) and asks which she prefers:
  • ●Reaction: Torn. "Could I try sorting my drinks out first and see how I go? If I'm no better when we next speak, you can send me." If the doctor accepts, she is relieved: "Thank you. I just want to try it my way first." If the doctor recommends referral now and has made clear nothing is booked unless she agrees, she accepts: "Go on then. As long as it's just a chat."
• ●If the doctor explains specialist treatments, or suggests a hormonal coil, the pill or a period tablet:
  • ●Reaction: Practical questions. "The one where they block the blood supply, is that an operation?" About a coil or the pill: "But my periods aren't the problem. Would that help my bladder?"
• ●If the doctor offers a bladder tablet, advises drinking more in the day, or suggests a diary, bladder training or help at work:
  • ●Reaction: Keen on a tablet: "Will it shrink the fibroid, though, or just calm the bladder?" On drinking more: "But if I drink more in the day I'll be running out of court even more!" She accepts it if told that drinking too little can make the bladder worse. She will keep a diary on her phone and try bladder training gently on her days off. She welcomes a letter for her manager but does not want to be off work.
• ●If the doctor gives safety netting, or asks her to check anything over the phone:
  • ●Reaction: To vague advice such as "come back if it gets worse": "Worse how? I'm already going every hour. What would mean I need to ring you the same day?" To specific warning signs she repeats them back. She declines to press on her tummy with people coming in and out. Once a plan is agreed: "And it won't squash my kidneys? The scan said something about kidneys." If growth after the change is mentioned: "Why would it grow if it's meant to shrink?"