CHAPTER 4 Committee 22 Management with Continence Products Chairman A. COTTENDEN (UK) Members D. BLISS (USA), M. FADER (UK), K. GETLIFFE (UK), H. HERRERA (USA) J. PATERSON (AUSTRALIA), G. SZONYI (AUSTRALIA), M. WILDE (USA), 149 CONTENTS A. PATIENT ASSESSMENT AND C. PRODUCTS FOR PRODUCT EVALUATION PREVENTING OR CONTAINING FAECAL INCONTINENCE B. PRODUCTS FOR PREVEN- TING OR CONTAINING URINARY INCONTINENCE D. OTHER CONTINENCE PRODUCT RELATED ISSUES 150 Management with Continence Products A. COTTENDEN D. BLISS, M. FADER, K. GETLIFFE, H. HERRERA, J. PATERSON, G. SZONYI, M. WILDE The product sections are preceded by two others: the A. PATIENT ASSESSMENT AND first provides overall guidelines for product selec- tion, while the second reviews the methodological PRODUCT EVALUATION challenges of conducting continence product evalua- tions and interpreting the results. I. INTRODUCTION II. PATIENT ASSESSMENT AND OVERALL GUIDELINES FOR Not all incontinence can be cured completely and SELECTING CONTINENCE even those who are successfully treated may have to PRODUCTS live with incontinence for a time while, for example, they wait for surgery or for pelvic floor muscle trai- Selecting suitable continence products is critical for ning to yield its benefits. Still others – depending on patient well-being. Ability to contain and conceal their frailty, severity of incontinence and personal incontinence enables individuals to protect their priorities – may not be candidates for treatment or public identity as a continent person and avoid the may choose management over attempted cure. For stigma associated with incontinence. Failure to do so all such people, the challenge is to discover how to can result in limited social and professional opportu- deal with their incontinence so as to minimise its nities, place relationships in jeopardy and detrimen- impact on their quality of life. This usually involves tally affect emotional and mental wellbeing (Mitte- using some kind of continence product(s) to control ness & Barker 1995); (Paterson 2000). or contain leakage of urine and / or faeces, and /or to Fortunately there are diverse ranges of different pro- manage urinary retention. Managing incontinence ducts to choose from; however, without comprehen- successfully with products is often referred to as sive and current information on the range of products contained incontinence, managed incontinence or available this plethora of choice can be overwhel- social continence, in recognition of the substantial ming and confusing (Paterson et al. 2003). Accessi- benefits it can bring to quality of life even though bility, affordability and supply of continence pro- cure has not been achieved (See Chapter 18 for a ducts are also complex and these issues are often more comprehensive discussion of these and related compounded by the lack of knowledge and informa- terms). tion readily available to incontinent people and their carers on how to choose a product that best meets This chapter is aimed primarily at healthcare profes- needs (Paterson, Dunn, Kowanko, van, Stein & Pret- sionals seeking to make informed decisions as they ty 2003). choose between continence product categories and select a specific product within a chosen category. Choice of appropriate products for an individual with The chapter includes a section for each of the major incontinence is influenced by resources and care product categories, each section reviewing published available and client / carer preference as well as data and – where possible - identifying evidence- assessment of specific client characteristics and based recommendations for product selection and needs (Gibb & Wong 1994); (Proudfoot, Farmer & use. Products designed to deal with skin and odour McIntosh 1994); (Paterson, Dunn, Kowanko, van, problems caused by incontinence are also addressed. Stein & Pretty 2003). 151 1. PRODUCT CATEGORIES • Is there urinary retention with or without inconti- nence? The continence products considered here may be divided into two broad types (Fig II-1): products to • Are there problems with toilet access (eg proximi- prevent incontinence by assisting toileting; and pro- ty or design of the toilet; mobility or urgency pro- ducts to manage urinary retention or to contain / blems for the patient)? control incontinence (urinary and / or faecal). Answers to these questions will determine which one All toileting products can be useful for urinary and / (or more) of the algorithms is most appropriate for an or faecal incontinence except for handheld urinals individual and guide the pathway in the algorithm to which are just for urinary incontinence. Containment be followed in finding the most appropriate category / control products are subdivided into three overlap- of product(s). ping categories: those for urinary incontinence, uri- nary retention and faecal incontinence. So, for 3. PATIENT ASSESSMENT FACTORS example, someone with urinary retention is most likely to benefit from one of the products in the red Many factors are known to influence the suitability ellipse, while someone with urinary incontinence of a particular product category or individual product will most likely benefit from one in the blue ellipse. for a patient and these are listed in Table II-1. Apatient suffering from both problems will need two products (one from each ellipse) or one product from 4. SUMMARY the intersection of the two ellipses. In conclusion, continence products find an impor- 2. CHOOSING BETWEEN PRODUCT CATEGORIES tant role in enhancing the quality of life and redu- cing stigma of incontinence of those who: are The algorithms below (Figs II-2 and II-3) are desi- awaiting treatment; are waiting for treatment to gned to provide guidance for determining broadly take effect; elect not to pursue cure options; are which type (prevention or containment / control) and unable to be fully cured and are living with an which category of products are likely to be of bene- ongoing bladder / bowel problem. How effective fit. Three main questions determine which types of they are in this role is determined by the correct products are likely to be suitable: choice and application of the product (Level of • Is there urinary incontinence or faecal incontinen- Evidence 4). ce or both? Figure II-1. Categories of continence products. 152 Table II-1. Key elements of patient assessment Element Rationale Independence / assistance If a carer is required to apply or change the product then it may be important to involve them in the selection of the product and to establish their willingness and ability to use it. Nature of incontinence The frequency, volume and flow rate of the incontinence influences product suitability. Generally smaller, more discrete products should be tried before larger bulkier products. Mental acuity Mental impairment can affect the person’s ability to manage the product. Products that resemble usual underwear (e.g. some absorbents) may be easiest to manage. Products which have health implications if used incorrectly (e.g. occlusives or cathe ter valves) should be avoided if mental impairment is present Mobility Impaired mobility may make some product choices impractical or require toilet or clothing modification to allow effective use of the product. Dexterity Problems with hand or finger movement can make it difficult to use some products, eg taps on leg bags, straps with buttons. Eyesight Impaired eyesight limits effective application and management of some products. Physical characteristics Anthropometrics (e.g. height and waist, thigh, penile circumference) will influence the comfort and effectiveness of a product Leg abduction problems Difficulty with abduction can make the use of some products impractical or in effective. Lifestyle Daily activities can influence the choice of product and a mixture of products may provide optimum management. Different products may be most satisfactory for day time and going out (when discreteness may be a priority) and night-time or staying in (when comfort may be a priority) or for holidays (when large quantities of disposables may be a problem). Laundry facilities Reusable continence products and bed linen may be very heavy when wet and take a long time to dry. It is important to check that the person doing the laundry has the ability and facilities to cope. Disposal facilities Ability to appropriately, safely and discreetly dispose of the selected products need to be considered Personal preferences Different people like different products and where possible patients should be given a choice of products with which to experiment to determine the most satisfactory product. Personal priorities Everyone wants to avoid leakage but other factors such as discreteness may be more or less important to individuals. 153 Figure II-2. Algorithm to guide choosing between categories of toileting and containment products for urinary incontinence and / or retention. (Y = Yes; N = No; U = unsatisfactory ie considered and deemed unsuitable or tried and found not to work satisfactorily). * Consideration should be based on assessment of the patient’s physical characteristics, cognitive ability and personal preferences, as well as the nature of their incontinence. Figure II-3. Algorithm to guide choosing between categories of toileting and containment products for faecal incontinence. (Y = Yes; N = No; U = unsatisfactory ie considered and deemed inappropriate or tried and found not to work satisfactorily). * Consideration should be based on assessment of the patient’s physical characteristics,