Committee 20 Management Using Continence Products Chairman A. COTTENDEN (U.K) Members D.Z.BLISS (USA), B. BUCKLEY (Irland), M. FADER (U.K), K. GETLIFFE (U.K), J. PATERSON (Australia) R. PIETERS (Belgium), M. WILDE (USA) 1519 CONTENTS I. INTRODUCTION IX. BODYWORN URINALS II. OVERALL GUIDELINES FOR X. MECHANICAL DEVICES FOR SELECTING CONTINENCE WOMEN WITH URINARY PRODUCTS INCONTINENCE III. PRODUCT EVALUATION XI. MECHANICAL DEVICES FOR MEN METHODOLOGY WITH URINARY INCONTINENCE XII. CATHETERS IV. HANDHELD URINALS XIII. PRODUCTS FOR PREVENTING V. COMMODES AND BEDPANS OR CONTAINING FAECAL INCONTINENCE VI. ABSORBENT PRODUCTS XIV. SKIN HEALTH AND CONTINENCE PRODUCTS VII. SHEATHS XV. ODOUR CONTROL PRODUCTS VIII. URINE DRAINAGE BAGS AND ACCESSORIES REFERENCES 1520 Management Using Continence Products A. COTTENDEN, D.Z.BLISS, B. BUCKLEY, M. FADER, K. GETLIFFE, J. PATERSON, R. PIETERS, M. WILDE of broad groups based on gender, age (adult or child) I. INTRODUCTION and the nature and severity of their incontinence. A table is provided for each group summarising the user Not all incontinence can be cured completely and characteristics, priorities and contexts which commonly even those who are ultimately successfully treated favour or discourage the use of each of the major may have to live with incontinence for a time, for product categories available to them. Following these example, whilst they wait for surgery or for pelvic floor overall guidelines and preceding the sections on the muscle training to yield its benefits. Still others – major product categories, a review is provided of the depending on their frailty, severity of incontinence methodological challenges of conducting continence and personal priorities – may not be candidates for product evaluations and interpreting the results. treatment or may choose management over attempted Unfortunately, much of the evidence base for product cure. For all such people, the challenge is to discover selection and effective use is patchy and, where there how to deal with their incontinence so as to minimise is little published data to provide confident evidence- its impact on their quality of life. This usually involves based advice on an issue commonly raised by patients using some kind of continence product(s) to control and caregivers, an expert opinion is offered as the best or contain leakage of urine and / or faeces, and /or to manage urinary retention. In short, the possible role advice available. The hope is that highlighting of continence products should be considered at each knowledge gaps in this way will help stimulate the stage of patient assessment and treatment and, if research necessary to provide more robust evidence- treatment is not available, appropriate, acceptable or based advice in the future. (fully) successful – subsequent management. The literature search strategy to identify material for Managing incontinence successfully with products is this chapter additional to that reviewed for the third often referred to as contained incontinence, managed consultation [2] was conducted as follows. MEDLINE incontinence or social continence, in recognition of the and CINAHL databases were searched from 2003 – substantial benefits it can bring to quality of life even 2008 for English language publications. Detailed though cure has not been achieved [1]. search strategies were developed for each electronic This chapter is aimed primarily at healthcare database searched. Consideration was given to professionals seeking to make informed decisions as variations in terms used and spellings of terms in they choose – or help their patients to choose - different countries so that studies were not missed. between continence product categories and then Relevant abstracts were examined and then pertinent select a specific product within their chosen category. articles were retrieved and reviewed, and the reference We have also aimed to make this information lists searched for further studies. For product accessible to the user, particularly in the summary categories associated with little or no research and recommendation sections. The chapter includes literature, analysis relied on expert opinion from clinical a section for each of the major product categories, practice papers. each section reviewing published data and – where The following main search terms were used: possible - identifying evidence-based recom- incontinence AND device*, toilet* AND facilities, mendations for product selection and use. Products commode*, urinal*, bedpan*, urinary AND sheath*, designed to deal with skin and odour problems caused condom AND catheter*, incontinence OR absorbent by incontinence are also addressed. pad*, urinary AND catheter* (in title), urinary AND leg The sections on the major product categories are bag* OR legbag* OR drainage bag, faecal OR fecal preceded by two others. The first provides overall AND incontinence AND plug OR pouch OR bag OR guidelines for product selection, describing the key manage* system, flatus AND odour OR odor AND elements of patient assessment and suggesting a device, incontinence OR perineal AND dermatitis OR classification of people with incontinence into a number inflammation OR skin damage. 1521 II. OVERALL GUIDELINES FOR SELECTING CONTINENCE PRODUCTS Selecting suitable continence products is critical for the well-being and quality of life of patients and carers. The ability to contain and conceal incontinence enables individuals to protect their public identity as a “continent person” and avoid the stigma associated with incontinence [3]. Failure to do so can result in limited social and professional opportunities, place relationships in jeopardy and detrimentally affect emotional and mental wellbeing [4]. The ability to contain and conceal incontinence enables carers to feel confident that the person(s) they care for will not be embarrassed publicly. It reduces the level of care required in relation to maintaining hygiene, skin care and laundry for the person who is dependant upon continence products [5]. Fortunately there is a diverse range of different products to choose from. However, without comprehensive and current information on the Figure II-1: Products for toileting (top) and for man- products available, this plethora of choice can be aging incontinence and / or urinary retention (bot- overwhelming and confusing [5]. Furthermore, the tom). CIC = Clean intermittent catheterisation; IDC range of products actually accessible to users can = Indwelling catheter. vary enormously between and within countries, depending on the funding available, healthcare policy All toileting products can be useful for dealing with urine and the logistics of supply [5]. and / or faeces except for handheld urinals which are The choice of appropriate products for an individual just for urine. Containment / control products are with incontinence is influenced by the resources and subdivided into three overlapping classes: those for care available and patient / carer preference, as well urinary retention, urinary incontinence, and faecal as assessment of specific client characteristics and incontinence. So, for example, someone with urinary needs [6,7]. retention is most likely to benefit from one of the products in the red ellipse, while someone with urinary The stigma associated with incontinence means that incontinence will most likely benefit from one in the another measure by which the success of products blue ellipse. A patient experiencing both problems will is judged is their ability to conceal the problem [8]. Such need two products (one from each ellipse) or one concealment may involve compromises: for example, product from the intersection of the two ellipses. in order to prevent leakage from a product, those with a larger capacity than strictly necessary may be 2. IDENTIFYING THE NEEDS preferred but this can in itself introduce issues to do The algorithms below (Figs II-2 and II-3) are designed with discretion when the product is worn. The intimate to provide guidance for determining broadly which and stigmatised nature of incontinence means that product(s) is likely to be of benefit to a particular issues relating to self-image can affect some patients’ patient. There are three main questions: preferences. This may be especially marked in younger people for whom body-image may be particularly • Is there urinary retention (with or without incon- important and for whom disruption to normal social and tinence)? interpersonal development may result in isolation or • Are there problems with toilet access (e.g. the lack of access to normal experiences [9,10]. proximity or design of the toilet; mobility or urgency 1. PRODUCT CATEGORIES problems for the patient)? The continence products considered in this chapter • Is there urinary incontinence or faecal incontinence may be divided into those that are intended to assist or both? with toileting and those to manage urinary retention Answers to these questions will determine which one and / or contain incontinence (urinary and / or faecal) (or both) of the algorithms is most appropriate for an (Fig II-1). individual and help identify the category(s) of products most likely to help. 1522 Figure II-2: Algorithm to help identify the category(s) of products most likely to help a patient with urinary incontinence and / or urinary 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