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COPYRIGHT 2003 Jannetti Publications, Inc.
Urinary incontinence (UI) is a prevalent problem occurring in men and women across the lifespan. Technologic innovations have provided individuals with incontinence and caregivers with an array of options for achieving social continence. Even when UI cannot be completely cured, it can always be managed with products, skin care regimens, occlusive or drainage devices and toileting equipment to ensure optimal skin integrity, odorless urine containment, social independence, comfort, and freedom of movement. Various products, devices, and equipment available to help incontinent individuals preserve independence and quality of life and manage incontinence are described.
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Urinary incontinence (UI) is a prevalent problem occurring in men and women across the lifespan. The frequency and volume of incontinent episodes can vary greatly, but there is strong evidence to conclude that even "minor" UI can have devastating social, psychological, physical, and financial implications. Technologic innovations have provided individuals with incontinence and caregivers with an array of options for achieving managed continence (social continence). Even when UI cannot be completely cured, it can always be controlled with products, skin care regimens, occlusive or drainage devices and toileting equipment to ensure optimal skill integrity, odorless urine containment, social independence, comfort, and freedom of movement. Various products, devices, and equipment to assist individuals manage incontinence, prevent adverse sequelae, and preserve independence and quality of life are described.
Absorbent Products
Absorbent products absorb and contain urine to prevent unwanted leakage that can soil clothing, furniture, bedding, and automobile upholstery. They can contribute to social continence but should not be a substitute for full assessment or treatment that is feasible, appropriate, and desired by the patient and family, nor should they foster dependency (American Medical Director's Association, 1996). Products fit into two main categories: bedpads and underpads, or body-worn products (inserts, briefs, pull-ups, male guards, or drip collectors) that are either disposable or reusable. There is a paucity of high-quality research about the effectiveness urinary continence products, making clinical decision-making difficult (Brazelli, Shirran, & Vale, 2002; Dunn, Kowanko, Paterson, & Pretty, 2002; Fader, Cottenden, & Brooks, 2001).
Disposable products generally have three layers: an absorbent core sandwiched between a water-proof polyethylene backing beneath and a water-permeable cover stock that is next to the user's skin (Fonda et el., 2002). The primary component of the absorbent core is a type of fluffed wood pulp fiber. The fluff pulp is a relatively poor absorbent fiber, and innovations in product design introduced super-absorbent polymer or absorbent gelling material. These added materials are concentrated in the crotch area of the pad or brief and hold much more urine volume for weight than fluff pulp (Brazelli et el., 2002; Brown, 1994; Hu, Kaltreider, & Igou, 1990). By design, urine is wicked away from the skin and is absorbed into the core material, leaving the top layer of the product and the skin dry.
Reusable absorbent products are also engineered in different sizes and shapes, but are usually made from cotton, which is hydrophilic (absorbs water), or polyester, which is hydrophobic (repels water) and has good wet comfort (Fonda et al., 2002). Absorbent cores are usually made from knitted fabric made of rayon and/or polyester fibers, and waterproof polymers may be applied to the outer surface to prevent urine soaking through the pad.
When comparing disposable and reusable absorbent products, product selection should consider the frequency, timing, mid volume of UI episodes; skin fragility; patient lifestyle; fit and comfort; ease of use; cost; and patient preference (Brazelli et al., 2002; Dunn et al., 2002; Fader et al., 2001) (see Table 1). Table 2 describes types of absorbent products and indications for use. "Pilot-testing" samples of a variety of pads and briefs during the day and night will help determine the most effective, comfortable, and cost-effective product for the individual. In institutional settings, a "one-type-fits-all" approach for both mild and severe UI or for day and night time management is an inappropriate use of the products and may needlessly increase cost (Brazelli et el., 2002; Dunn et al., 2002; Fader et al., 2001). It is also recommended that a selection of pad and brief systems be available for different functional abilities, ease of use, and levels of wetness. Underpads, bedpads, or booster pads can be helpful for individuals with heavy incontinent episodes at night or leakage in spite of using high-absorbent products. Similar pads are available to protect furniture. Table 3 illustrates the different types of UI absorbent products and describes usage and special considerations.
Perineal Skin Care
A critical aspect in managing patients with chronic urinary and/or fecal incontinence is the preservation of skin health. Goals of skin care are to prevent perineal dermatitis or to restore perineal skin integrity and prevent recurrent damage. Few studies have focused on perineal skin care for the geriatric client (Bates-Jensen, Alessi, Al-Samarrai, & Schnelle, 2003). Scientific evidence about "diaper dermatitis" reported in the pediatric literature has been applied to the elderly population, but safety and efficacy cannot be assumed since there are significant changes in the skin that occur with aging (Faria, Shwayder, & Krull, 1996; Lyder, 1997). A novel incontinence product developed to prevent skin problems is an adult brief impregnated with petrolatum and zinc oxide (Baldwin et al., 2001). Current care recommendations are based on knowledge of the characteristics of healthy skin, pathophysiology of perineal dermatitis, and clinical studies on products available for perineal skin care.
Characteristics of healthy skin. The healthy epidermis provides a very effective barrier to pathogens and irritants. Factors contributing to an intact barrier include the epidermal cells themselves (keratinocytes), the skin oils (lipids) that provide the intercellular matrix, and the acidic pH of the skin. The structure of the epidermal barrier is a "brick and mortar" configuration, in which the keratinocytes are the "bricks" and the skin lipids are the "mortar" (Fiers & Thayer, 2000; Gray, Ratliff, & Donovan, 2002).
Pathophysiology of perineal dermatitis. Incontinence and incontinence care can cause perineal dermatitis by compromising the epidermal barrier and exposing the epidermis to pathogens and irritants (Faria et al., 1996). Two factors known to adversely affect the barrier function of the skin are overhydration and elevated skin temperatures. These conditions are created when occlusive absorptive products trap body heat and moisture. To avoid an occlusive environment, absorptive products should not be secured too tightly (Akin et al., 2001; Gray et al., 2002). Repetitive skin cleansing increases the rate at which the epidermal cells and surface lipids are removed, leading to compromised skin barrier properties. The elderly are at higher risk for dermatitis because of the age-associated changes of a thinner epidermis and reduced production of skin lipids. The acid mantle of the skin is disrupted by exposure to alkaline urine and stool and by repetitive cleansing. Fecal incontinence is more damaging than UI, because stool contains pathogens and intestinal enzymes are activated in an alkaline environment (Atherton, 2001; Fiers & Thayer, 2000; Haugen, 1997).
Preventive care. Preventive care maintains the surface barrier function of the skin by minimizing exposure...
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