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Clinical Practice Keywords Incontinence/ Sustainability/Products Discussion This article has been Continence double-blind peer reviewed In this article... ● Types of continence product available and their advantages and disadvantages ● Why a single-use culture currently exists and how this can be addressed ● Why a ‘mix and match’ approach may be best for most product users

Sustainability 2: are sustainable continence products a realistic option?

Key points Authors Margaret Macaulay is senior research fellow, Sandra Wilks is lecturer in There are medical microbiology, Catherine Murphy is senior research fellow and Mandy Fader is advantages and professor of continence technology at School of Health Sciences, University of disadvantages of Southampton; Bill Gillespie is chief executive at Wessex Academic Health Science both reusable Network, and Alan Cottenden is emeritus professor of continence technology at and single-use Medical Physics and Bioengineering, University College London. continence products Abstract Incontinence management currently depends largely on single-use Evidence shows products. Reusable products exist but are less developed and less widely used. There that some reusable are advantages and disadvantages to both types of products. Some evidence exists products can be to support the use of reusable products instead of, or as well as, single-use ones. effective alternatives Currently it is likely that some use of reusable products, in a mix with single-use to single-use ones products, is the best route to more sustainable product provision. This article discusses the evidence for, and barriers to, the use of reuseable products, and A ‘mix and match’ suggestions to promote it. Part 3 of this series (p38) discusses how nurses can reduce approach of both the environmental impact of inhalers. types of product may be the best Citation Macaulay M et al (2020) Are sustainable continence products an aspiration option for many or a current option? Nursing Times [online]; 116: 9, 32-37. people

There are barriers to ustainable healthcare is a major NHS Inform (2020) estimates that three the use of reusable goal both worldwide and for the million to six million people in the UK products, which NHS, where single-use products experience urinary incontinence and that should be addressed Sare a key contributor to plastic demand for continence products is likely waste (Sustainable Development Unit, to rise because risk factors for inconti- Investment in new 2020). Incontinence management is nence are increasing. Risk factors include reusable designs heavily dependent on single-use products advancing age, lifestyle factors, dementia, and materials is – mainly plastic-backed disposable pads complex comorbidities and obesity. needed to improve and other products containing non-biode- their acceptability gradable plastics, such as urinary drainage The three Rs: reduce, reuse, and effectiveness sheaths and catheters. These containment recycle products are essential for people with With origins in the American ‘Earth move- intractable incontinence: their dignity, ment’ of the early 1970s, the three Rs are quality of life, independence and physical often used as a framework to consider health depend on them (Cottenden et al, ways of reducing waste. They are now part 2017). The number of single-use conti- of day-to-day environmental language: nence products used per annum is hard to “reduce the amount of waste created, estimate, but it is a large and growing reuse items that could have a future pur- market estimated to be worth US$12.9bn pose and recycle whenever possible” (£10.3bn) across 41 countries in 2018 and is (Recycle Nation, 2015). In continence care, expected to increase to US$15.8bn (£12.6bn) reducing or curing incontinence is the by 2026 (Absolute Reports, 2020). most desirable goal; assessment

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Table 1. Categorisation of continence products: single-use or reusable Typical lifespan of single-use products/devices* (manufacturer’s instructions for use vary) Multiple products/ 12-24 hours 24 hours 7 days 1 month 3 months devices per day ● Disposable ● Internal vaginal ● Urinary sheaths ● Catheter valves ● Short-term ● Long-term absorbent pads devices ● Body-worn ● Drainable indwelling indwelling (body-worn pads retracted penile urine-collection catheters catheters and under-pads devices bags for bed/chair) ● Non-drainable ● Intermittent urine-collection catheters bags ● Internal vaginal devices ● Anal plugs and inserts ● Body-worn faecal collectors

Typical lifespan of reusable products/devices** (manufacturer’s instructions for use vary) 24 hours 28 days 1 month plus Emteva intermittent catheter Cliny intermittent catheter (not available in ● Washable absorbent pads (body-worn the UK) pads and under-pads for bed/chair) and pull-on pads ● Body-worn urinals ● Penile compression devices ● Metal intermittent catheters ● Hand-held urinals and toileting devices ● Internal vaginal devices * Used once then thrown away. **Used repeatedly when cleaned between uses. For all products/devices, lifespan varies according to the manufacturer’s instructions for use and local licensing regulations. interventions to prevent and reduce incon- Fig 1. Single-use symbol or reusable (used multiple times by the tinence should, therefore, be the highest same person then thrown away). In addi- priority. Appropriate reassessment of indi- tion, the lifespan of single-use and reus- viduals’ continence product requirements, able products varies (Table 1). using validated tools where available Most commonly used continence prod- (Yearwood-Martin et al, 2018), can help ucts are single-use. This means they are reduce the number of products used, licensed only to be used once then dis- avoiding over-supply and product waste. carded, as indicated by the symbol Fewer highly absorbent pads of the most showing a crossed-out two (Fig 1) on their appropriate design may be more effective packaging. Whether a product is for than several less-absorbent or less-effec- single- or multi-use is regulated by its tive ones. The potential for recycling license for use. The European Union (2017) products is currently very limited. Conti- directive requires that products which are nence products typically utilise non-bio- intended or designed for reuse must be degradable plastics, superabsorbent poly- provided with cleaning instructions that mers and other materials that make them restore the product to its original state. unsuitable for recycling. single-use and reusable products; Reusable products have existed for a l Whether the lifespan of all single-use Advantages and disadvantages long time but have limited uptake com- and reusable products is equal; of reusable and single-use pared with single-use options. Continence l The evidence that shows reusable continence products products are needed while users are waiting options are effective or acceptable; There are some generic advantages and dis- for treatment to take effect and when it fails l Whether, given the limitations of both advantages of both types of product, which or is unsuitable, and there is potential for types of product, a mixed approach is are not design-specific (Table 2). These fac- the number of single-use products used to the best way forward. tors can strongly influence product choice: be reduced by substituting reusable vari- someone may find a product very effective ants where available and acceptable. Categorisation of continence at containing their incontinence but unac- Drawing on the available product evi- products ceptable in its reusability, for example, due dence, this article will focus on the use of Continence products are usually catego- to an unwillingness to clean it or a lack of reusable products as a strategy for more rised by design, for example, products suitable washing facilities. sustainable incontinence management, might be categorised as pads, male devices It is evident from Table 2 that the disad- asking whether it is a feasible option. It or catheters. In terms of sustainability, vantages of reusable products are likely to will address: they can be categorised as either single-use make their wholesale use unsuitable for l The advantages and disadvantages of (disposable, used once then thrown away) most people, even if they are as effective as

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Table 2. Advantages and disadvantages of single-use and reusable products Reusable products/devices Single-use products/devices Advantages Disadvantages Advantages Disadvantages GENERAL Waste Fewer products to throw Energy, water and More products to throw away detergents required for away cleaning Energy Fewer products Energy required for More products produced produced washing machines/ dryers Cost Cost per use diminishes Relatively high capital Unit cost relatively low, Cost is repeated for each with increasing use, outlay, so trial and error so trial and error is use and does not therefore, cost-effective is more expensive inexpensive diminish over time if used multiple times Quality Potential for high-quality Potential for quality of products less limited products to be limited by cost by cost INDIVIDUAL Cleaning burden ● Cleaning may be too Always in a state ready burdensome for the for use, with little user/carer preparation required and ● A washing machine/ no need for cleaning dryer may be needed after use ● May be unsuitable in institutional settings where individual laundry of personal items is limited Infection prevention Some product types Sterility perceived to be perceived to cause essential to avoid some infection, for example, product types causing reusable catheters infection, for example, causing urinary tract single-use catheters infections Running out Product can be reused, ● Fear of running out so reduced likelihood of ● Potential lack of running out access to products Lifestyle Need to carry used Need to dispose of used (soiled) products when products in public places out Storage Fewer products, Large quantities of therefore, less storage products to be stored required

– or more effective than – single-use prod- Although limited for reusable conti- l For specific activities; ucts. It is also evident that some of the dis- nence products, there is evidence to show l For other preferences. advantages of single-use products may be that, for some people, circumstances and It does not refer to the simultaneous offset by the use of reusable versions. This product designs, reusable variants may use of different products, for example, raises the question of which reusable prod- not only be effective but preferred by users using a disposable, plastic-backed pad ucts are sufficiently effective to be able to to single-use options. This provides an inside a pantegral (washable pants with an replace the use of some single-use products. opportunity to either avoid single-use integral pad). products entirely or, more realistically, The ‘mix and match’ approach requires What is the evidence for reusable reduce the quantity used by combining users to be offered, and encouraged to con- products over single-use products single-use and reusable versions. sider using, more than one product variant for specific product designs? or design, including both reusable and Although there is evidence that users are Mix and match single-use products. Although the concerned about the quantity of waste Most studies of continence products show approach is most suitable for men – for they generate (Avery et al, 2018), single-use that one product type does not suit an indi- whom there is a more diverse range of products – particularly body-worn vidual at all times, and the concept of a products available – women have some (plastic-backed), disposable pads – are ‘mix and match’ of products has been similar options, as shown in Table 3. highly effective. However, there is evi- shown to be preferred by both women dence in different product categories and (Fader et al, 2008) and men (Macaulay et al, Addressing barriers to more for different patient groups that reusable 2015). This term refers to using different sustainable approaches alternatives can also be effective and products: Using available evidence, we have suggested acceptable (Table 3). l At specific times of the day or night; ways in which reusable products can be used

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Table 3. Reusable alternatives that have the potential to reduce use of single-use products

Table 3.1. Body-worn containment products and male devices Type and Typical Reusable (and Potential for Guidance and evidence degree of single-use longer-lasting) use (either on incontinence product used option its own of in a mix of products) Women with Small Washable pants Recommended Can be effective and acceptable for women with very light or very disposable with integral light leakage, for example, used alone when at home or light urinary pads pad combined with disposable pads when away from home incontinence (pantegrals) (Fader et al, 2008) (UI) Washable pads Not When tested they were lowly rated (Fader et al, 2008) recommended Internal vaginal Consider Can be used intermittently for specific activities and/or devices daytime use, but many women find them unacceptable or derive only limited benefit. They require a degree of manual dexterity for insertion and removal (Cottenden et al, 2017; Lipp et al, 2014) Women with Single-use large Different Consider May be effective, but generally unacceptable for women at all moderate or disposable designs of times, particularly due to appearance and lack of discreetness heavy UI pads/pull-on purpose-made (Fader et al, 2008) pads/all-in-ones all-in-ones or (wraparounds) traditional cotton- towelling pads and waterproof pants Men with light Single-use small Washable Recommended Can be effective and acceptable for men with very light or very light UI pads/male pantegrals leakage, for example, used alone when at home or combined pads/pouches with disposable pads when away from home (Fader et al, 2008). Particularly suitable for active men as they are more secure than pads (Fader et al, 2006) Washable male Not No evidence, but likely to be rated lowly as they were for pads recommended women Urinary Consider A discreet, acceptable alternative to pads, particularly when drainage sheath containment is required over long periods and changing a plus catheter pad would be difficult, for example, when playing golf valve or (Macaulay et al, 2015; Chartier-Kastler et al, 2011) or when collection bag seated, such as wheelchair use. Less suitable if there is skin damage around the penis, the penis is retracted or urinary tract infection is a problem (Macaulay et al, 2015) Body-worn Consider May be an acceptable alternative for standing activities where urinal with tap there is a preference for a device that does not require glue or collection (from a sheath) on the skin. Less suitable when seated or bag lying down (Macaulay et al, 2015) Penile compres- Consider May be useful as part of a mix of the above devices when sion devices secure leakage prevention is needed for short, vigorous activities, such as dancing or swimming. Not suitable when memory, genital sensation, urge to void or manual dexterity is poor or penile skin is damaged (Macaulay et al, 2015; Moore et al, 2004) Men with Single-use large Washable Consider The most absorbent of the washable products for moderate moderate or disposable purpose-made or heavy UI have been found to be more absorbent than their heavy UI pads/pull-on or traditional disposable equivalents (Fader et al, 2008). Effective for men pads/all-in-ones cotton- at night when their UI is particularly heavy, and absorbency is (wraparounds) towelling pads needed over the hips if they are lying on their side. Very bulky and waterproof and less acceptable when discreetness is a priority (Fader et pants al, 2008) Other products Recommended As for ‘Men with light or very light urinary incontinence’ – see (sheath/ above body-worn urinal/clamp) Faecal Single-use Anal plugs or Consider May be useful for preventing or reducing faecal incontinence, incontinence disposable inserts but can be difficult to tolerate (Deutekom and Dobben, 2015) pads

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Table 3.2. Under-pads Single-use Reusable Potential for Guidance and evidence product option use Disposable bed Washable bed Consider Useful alternative to body-worn products but the user should be naked below pads pads the waist, which is unacceptable to some people. Pads with tuck-in flaps can stay in place better (Cottenden et al, 2017) Disposable Washable chair Consider No published evidence. The presence of a chair pad denotes the user as having chair pads pads a leakage problem. Should only be used as a back-up to a body-worn product (Cottenden et al, 2017) Table 3.3. Intermittent catheters Single-use Reusable Potential for Guidance and evidence product option use PVC/silicone Cornstarch* Consider No published evidence for cornstarch, reusable intermittent catheters** intermittent catheters Silicone CE-marked but No published evidence for silicone, reusable intermittent catheters** not available in the UK Stainless steel* Consider No published evidence for stainless steel, intermittent catheters** *Rigid catheters for women only; **Qualitative data from users suggest that single-use and reusable catheters have different advantages and disadvantages (Avery et al, 2018). Table 3.4. Devices to aid toileting (and avoid the need for containment products) Single-use Reusable Potential for Guidance and evidence product option use Disposable Reusable Recommended ● Women: suitable when users can stand, crouch or move to the edge of a hand-held hand-held chair or bed; less suitable when lying down or sitting back in a chair urinals urinals (Macaulay et al, 2006; Fader et al, 1999). ● Men: suitable for users with reasonable hand control; less suitable when unable to empty independently, and when balance or cognition are poor (Vickerman, 2006) Disposable bed Reusable Consider Only suitable when access to a toilet, commode or urinal is not possible pans bedpans (Fader, 2002) Disposable Commodes Consider Only suitable when access to a toilet is not possible. For users in hospital, a inserts for shower chair to the toilet may be preferable. Commodes can be unsafe commodes (Fader et al, 2004)

“A more sustainable Where to get help 3-6 million approach to continence There are many designs and brands of dis- QUICK People in the UK who posable and reusable products available and FACT experience urinary product provision currently discerning the most appropriate is not easy. incontinence depends on a reduction in Some products are much more familiar to use of single-use products, health professionals and patients than others. Easily accessible, user-centred information pads and cleaning of reusable catheters; use of longer-lasting is important for enabling effective product l Specific guidance for men with versions, and their selection. The Continence Product Advisor post-prostatectomy incontinence. substitution with reusable (www.continenceproductadvisor.org) is a alternatives” not-for-profit website, independent of Summary industry sponsorship, which provides A more sustainable approach to continence impartial, comprehensive, evidence-based product provision currently depends on a to reduce the use of single-use products. information for product users and health- reduction in use of single-use products, There is potential to build on this strategy care professionals. It contains an evidence- use of longer-lasting versions, and their through better understanding of the reasons based continence product decision aid, substitution with reusable alternatives. why reusable products are not more widely which guides users to product types that There are advantages and disadvan- used and how these can be addressed. might suit them, based on their characteris- tages to both reusable and single-use prod- Table 4 sets out some of the areas in tics, lifestyle and preferences. The website ucts and a ‘mix and match’ approach is key. which there are unknowns or other bar- also provides detailed information through: For many people, the introduction of reus- riers and suggests actions to address them. l Product pages (linked to the product able products may be acceptable, but only In particular, there is a need for innovation decision aid) with links to the websites in combination with other single-use ver- and new, effective designs of reusable of relevant manufacturers; sions. Working towards strategies for sus- products together with systems for adop- l Downloadable PDFs explaining tainability in continence care – such as tion and implementation into the NHS, product use, including laundering reduce, reuse, recycle – requires a thor- such as using the Academic Health Sci- reusable pads; ough understanding of the lifecycle of ence Networks. l Videos showing use of male devices and products and associated processes. It is the

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Table 4. Potential barriers to adoption of reusable continence products

Unknowns and other barriers Suggested actions Continence Lack of effective, high-quality, reusable variants Industry investment in high-performance reusable or products longer-lasting products, materials and designs with a higher unit cost but potential for cost-effectiveness Clinical evidence Lack of research evidence about effectiveness, ● More well-designed trials needed user acceptability and impact on clinical outcomes ● More qualitative research needed to understand user (such as infection) to inform their use needs and barriers to use of reusable products Cleaning methods Lack of evidence-based and user-friendly methods Published, evidence-based guidance needed to allow for cleaning regulatory bodies to license for reuse Other user Lack of guidance for using products, for example, Co-designed, user-friendly guidance needed processes storage and carrying Environmental ● Lack of lifecycle analysis, including the relative ● Increased focus on materials, manufacturing and impact environmental impact of cleaning (reprocessing) recycling processes reusable products compared with waste from ● Multidisciplinary approach, including manufacturers, single-use equivalents implementers (Academic Health Science Networks) ● Failure to achieve a circular economy, through a and users (clinical groups) lack of recycling methods, leading to lost potential ● Used continence products need to be viewed as a value in used products (waste) useful commodity ● Providers (product users) reimbursed for their contribution Stakeholder ● Clinicians’ and policymakers’ attitudes towards ● Utilisation of available research by clinicians seeking attitudes reusable products vary to modify their practice and maintaining an open ● A single-use culture in healthcare, in which reuse mind to changes in practice is considered to be outdated, burdensome and/or ● Working towards a change in approach in which the unsafe (although there is evidence that this is single-use culture is questioned and reusable options changing) are always considered

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CONTINENCE PRODUCT ADVISOR CONTINENCE Neurourology and Urodynamics; 37: 5, 1650-1657.

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