Despite recent advances in multiple areas of continence management including pharmacotherapy, surgery, physiotherapy, and neuromodulation, evidence suggests that use of incontinence products remains the most prevalent strategy among adults with urinary or fecal incontinence.1–3 For example, Uchil and colleagues1 surveyed 763 community-dwelling elder women with urinary or fecal incontinence and found that 75.7% reported using pads on a daily basis. Similarly, Subak and colleagues2 surveyed 293 community-dwelling women with urinary incontinence, with a mean age of 56 ± 11 years and found that 74% reported daily use of pads, absorbent briefs, or pull-ups. Roe and associates3 reported findings of a systematic review of 60 studies and reported that 92.9% of nursing home residents in the United States and 71.6% of residents in Iceland used incontinence pads or briefs on a daily basis.
In 2009, the WOCN Society published a statement clarifying the role of the WOC nurse in continence care.4 Though only briefly mentioned, overseeing and providing direct care related to the selection, use, and evaluation of absorbent products were identified as an essential component of this care. Despite this important acknowledgement, evidence concerning the use of absorbent products for the management of fecal or urinary incontinence remains sparse, few up-to-date resources are available that provide guidelines for the use of absorbent products, and clinical knowledge of the design and use of these products is limited.5–7
Absorbent Products: Principles and Design
Absorbent products are a group of disposable or reusable devices used to contain or conceal urine or stool.5 They draw urine or liquid stool into an absorbent core until the product is changed.6–8 Historically, these products were made from natural materials such as linens or moss that had little ability to absorb urine or liquid stool; in addition, their use was limited to infants and young children prior to the age of toilet training.6 Reusable cloth diapers became widely used in the later 19th century; they were typically made from cotton-based materials (muslin) or linen and held in place with pins. Cloth diapers were widely used in the early 20th century. Single use, disposable diapers were introduced around 1942, closely followed by introduction of plastic coverings that ultimately evolved into the waterproof backings of modern absorbent products. During this period, the materials used in the most important component of the diaper, its absorbent core, evolved from cotton cloth to fluff pulp (natural fibers found in woods). In 1978, superabsorbent polymers which are synthetic granular polymer crystals capable of absorbing up to 30 to 50 times their weight, revolutionized the design and manufacture of absorbent products. The first disposable products specifically designed for the management of incontinence in adults became commercially available in the 1970s.
The design of most absorbent products commercially available in the 21st century comprises 4 distinct layers.8 , 9 The coverstock is the innermost layer that lies in direct contact with the user's skin. Immediately beneath that is an acquisition layer that consists of a thin, porous materials designed to rapidly transfer fluid into the absorbent core. The third layer is the absorbent core; 21st century designs usually contain multiple layers of superabsorbent polymers or fluff pulp enabling it to rapidly absorb liquid and retain it away from the skin. The outermost layer is a film barrier that resists leakage of fluid. Contemporary designs provide variable degrees of breathability, allowing airflow to the inner aspect of the product and the user's skin without compromising containment of liquid within the product. A variety of body-worn absorbent products are commercially available, including pads, briefs, and pull-ups that incorporate this 4-layer structure and are designed to be worn against the body in order to absorb and conceal urinary and/or fecal incontinence.5 , 7
The purpose of this article is to report findings of a scoping review of articles identifying knowledge and evidence-related use of body-worn products for the management of urinary and fecal incontinence and to identify gaps in current knowledge and evidence. This article also summarizes results of a conference convened to generate consensus-based statements that, when combined with the evidence-based statements generated from the scoping review, will be used to generate a decision-making algorithm for assessment, selection, use, and evaluation of body-worn absorbent products in persons with urinary and/or fecal incontinence.
Because of the paucity of evidence in this area of care, the Task Force elected to complete a scoping rather than systematic review to identify current best evidence. A scoping review is a structured technique of searching the literature in order to identify key concepts, types of evidence, and gaps in evidence. Our review used the approach described by Levac and colleagues10 and refined by Colquohoun and colleagues.11 The primary aim was to identify current knowledge and clinical evidence guiding assessment, selection, and evaluation of body-worn absorbent products and to identify gaps in evidence requiring generation of consensus-based best practice statements needed to generate a decision-making algorithm for care. Results of the structured review were also used to generate levels of evidence underlying these statements using a 3-point ordinal scale adapted from a taxonomy for Statements for Recommendations for Treatment statements promulgated by the American Academy of Family Physicians and routinely used by the WOCN Society to generate similar scholarly documents.12–14 The methodologic quality of individual studies was ranked using a 3-point scale where A indicates high quality, B indicates good quality, and 3 indicates low quality using the Johns-Hopkins Evidence-Based Practice methodology.15
Consistent with guidelines for scoping literature reviews, we included a wide variety of study designs including randomized controlled trials, nonrandomized comparison cohort studies, cross-sectional studies, multiple case series, single case studies, N of 1 trials, and qualitative studies. We also included studies that used healthy volunteers or in vitro techniques to evaluate product performance. In addition, we searched for and incorporated systematic and scoping reviews, clinical practice guidelines, and documents containing evidence-based recommendations for treatment such as book chapters. Exclusion criteria were articles published prior to 2000, and conference abstracts, proceedings, and other gray literature sources.
An experienced reference librarian searched 3 multidisciplinary electronic databases (September 19, 2017) to find literature related to body-worn absorbent products—CINAHL, PubMed, and Embase. These databases were selected for their robust, international scope of searchable literature. Search filters were applied to identify English language articles. Article types included Scholarly Journals for CINAHL and Articles, Articles in Press, and Reviews for EMBASE. Medical Subject Heading terms as identified in the MEDLINE database and used in PubMed were “incontinence pads,” “adult diapers,” “urinary incontinence,” and “fecal incontinence.” Additional key terms were “containment devices,” “incontinence products,” “absorbent products,” “incontinence briefs,” “male guards,” “incontinence inserts,” and “incontinence shields.”
Selection of Articles
The initial search returned 444 results from the CINAHL database, 439 from PubMed, and 269 results from EMBASE; these 1152 citations were transferred to a proprietary citation management software. This process retrieved 422 citations for further scrutiny. An initial title review of these abstracts by 3 task force members removed 306 citations, leaving 116 for additional review. Task force members then read each article in full, resulting in the 32 sources included in this review. Following this search, we reviewed bibliographic review of selected articles in order to identify any articles missed in the electronic database search. Finally, we searched the Google search Engine and Google Scholar database (Google, Mountain View, California), US Agency for Healthcare Research and Quality National Guideline Clearinghouse, Web pages of the WOCN Society, Society of Urologic Nurses and Associates, American Urological Association, European Association of Urology, American Urogynecologic Society, Society of Urodynamics and Female Urology, International Continence Society, and International Urogynecological Association for relevant clinical practice guidelines. These searches identified 4 sources not identified in the electronic database search (Figure).
Our search identified 8 records that reported or summarized studies that employed in vitro techniques or healthy volunteers to evaluate product performance of body-worn absorbent products (Table 1).16–22 The quality of these studies varied from good to low, and caution is needed when attempting to apply this evidence to clinical decision making.
Two studies evaluated absorbent properties of body-worn absorbent products. Yamasato and colleagues17 evaluated leak volumes (defined as the volume of fluid instilled when loss of fluid from the absorbent product occurs) in 12 commercially available absorbent pads or briefs and found considerable variability between products and among products within the same category. Nevertheless, they found that brand name products tended to perform better than generic products, and products designed for moderate to heavy incontinence had greater absorbent capacity than products designed for light incontinence. Erekson and colleagues19 compared 7 commercially available pads or briefs using a wetback technique and reported broadly similar findings. They also reported variability between types of designs and among products within the same category, and they also found that brand name products tended to outperform generic products. Considered collectively, findings from these studies demonstrate clinically relevant variability in performance among commercially available products and the need to differentiate quality of individual products based on their performance in the laboratory and clinical setting. This evidence also indicates that selection of body-worn absorbent products for formulary use requires the same level of expertise WOC nurses currently apply to ostomy and wound care products.
Four studies were identified that evaluated the magnitude of transfer and effect of various skin protectants on urine absorption.16 , 18 , 20 , 21 Findings from these studies consistently suggest that cyanoacrylate-based skin protectants exert the least adverse effects on absorption. Evidence further suggests that creams and ointments exert deleterious effects on the liquid acquisition rate of absorbent products, and the greatest effects may be exerted by petrolatum-based ointments. However, Fleming and colleagues18 noted that the degree of transfer of a particular skin protectant was not strongly correlated with its impact of fluid absorption rates. Additional research is this area is clearly indicated, and findings from these studies must be evaluated in the clinical setting before firm conclusions can be reached.
Finally, we identified a single study that evaluated differences in tissue interface pressures when an anthropometric dummy was placed naked or wearing a body-worn absorbent product on a standard, viscoelastic, and cut foam support surface. Fader and colleagues22 found that placement of a body-worn absorbent product on the dummy raised interface pressures 20% to 25% when compared to placement without clothing. They reported that wetting the product with 200 mL of fluid had no impact on these pressures. Instead, they observed that folds in the absorbent brief created the highest interface pressures, and they found that these pressures could be lowered by smoothing the absorbent product. While these findings are interesting, additional research in healthy volunteers is needed to evaluate the influence of wetting with higher volumes of fluid on tissue interface pressures and the impact of various types of absorbent products including underpads versus body-worn products on immobile patients in the acute and critical care settings.
A single guideline was identified and read in full that provides guidelines for performance standards of disposable absorbent products.23 Recommendations were generated using a nominal group process, a structured methodology that incorporated clinicians, commercial stakeholders, consumers, a lay caregiver representative, and a professional society delegate to build consensus around a common problem (in this case performance of disposable absorbent products).24 The group generated 9 recommendations that provide minimum performance standards for absorbent products based on outcomes beyond total absorption capacity. The total absorption capacity is the primary parameter used to measure performance of absorbency; it has been standardized by the International Organization for Standardization (ISO, 15621:2017), the most widely used standard by manufacturers of these products.25 These recommendations are based on 9 variables: 1) rewet rate, 2) rate of liquid acquisition, 3) retention capacity, 4) sizing and sizing options, 5) absorbency levels, 6) safety, 7) presence of a closure system, 8) breathable zones, and 9) elasticity.23
Clinical-Based Articles and Resources
Two book chapters were retrieved—1 from the 6th edition of a textbook from the International Consultation on Incontinence and the International Continence Society, and 1 from the WOCN Society's Core Curriculum series.5 , 7 Cottenden and colleagues7 completed a comprehensive review of research related to clinical use of various continence products including bedside commodes, urinals, bedpans, absorbent products, indwelling and intermittent urinary catheters, and indwelling devices for fecal incontinence. Evidence was summarized using ordinal ranking systems and recommendations for both clinicians and consumers were generated based on this evidence. Wilde and Fader5 provided guidance to students and practicing WOC and continence nurses concerning use of various absorbent products, including body-worn products, in this academic textbook that serves as the Core Curriculum for Wound, Ostomy and Continence specialty nursing practice.
Three systematic reviews were identified and retrieved—2 are systematic reviews with meta-analysis from the Cochrane Database of Systematic Reviews and 1 is a Health Assessment Technology Assessment for the National Health System of the United Kingdom.25–27 Fader and colleagues25 reported findings of a systematic review of body-worn absorbent products in women with light urinary incontinence. They identified only 1 study with 85 participants that met inclusion criteria; findings from this study were also reported as part of the Health Assessment Technology Report.26 This randomized crossover trial of 85 community-dwelling British women who tested 3 products from 4 product categories (disposable pads, disposable menstrual pads, reusable pants with integral pad, and reusable pads with washable inserts). Findings were based on product performance parameters (leakage, remains in place, smell, discretion, dry and wet comfort, skin dryness, and overall opinion when worn day and night). They found that disposable pads were most commonly used for light incontinence, and products in this category were better for leakage and other variables than alternative designs including washable or menstrual pads. Nevertheless, some women preferred menstrual pads which were less expensive.
Fader and colleagues27 also reported findings from a systematic review and meta-analysis of body-worn absorbent products for women and men. Two studies enrolling 185 subjects met inclusion criteria. Similar to the Cochrane Review reports mentioned previously, data from this study were reported as part of the Health Assessment Technology Report.26 The first was a randomized crossover trial of 49 community-dwelling women and 36 men who used 4 disposable body-worn absorbent products (disposable inserts held in place with a mesh brief, disposable briefs, T-shaped diaper, pull-ups) and 1 reusable brief. The second was a randomized crossover trial of 73 women and 23 men who were able to complete questionnaires evaluating the same performance parameters described for community-dwelling women.26 , 27 Analysis revealed that no single design was superior to other designs. Nevertheless, they reported clinically relevant differences based on gender and more subtle differences based on residence (community vs nursing home). Men living in the community or nursing home experienced higher volume urine loss with a given episode of incontinence and tended to use more products per day than did women. They preferred the performance of disposable briefs over pads held in place by a mesh brief. They did not report significant differences in the performance of the disposable brief versus T-shaped diaper, but briefs were less costly. Community-dwelling women preferred disposable pull-ups, but women residing in nursing homes preferred disposable briefs at night. A minority of community-dwelling women indicated a preference for reusable briefs based on cost, and a minority of men preferred reusable briefs at night based on cost.
Considered collectively, pooled findings from these studies provide the best evidence concerning performance and preferences of users of body-worn absorbent products. Nevertheless, the generalizability of these findings is limited when applied to our goal of generating a decision-making algorithm for clinicians practicing in North America. Limitations to generalizability included the paucity of studies identified (n = 3), the small pooled sample sizes from these 3 studies (pooled samples = 85 and 185, respectively), lack of diversity in study settings, age of the studies, and differences in health care delivery systems (predominantly national health system vs predominantly private insurance-based system).
The scoping review also retrieved 21 individual studies that met inclusion criteria (Table 2). We identified 10 studies that evaluated performance parameters of body-worn absorbent products in users of these products.1 , 28 , 31 , 33 , 34 , 41–45 , 48 Several reported an overall assessment of use of body-worn absorptive products to manage incontinence.1 , 34 , 41 The proportion of users indicating that they were satisfied, pleased, or delighted with use of body-worn products varied from 39% to 67%; the proportion of users who indicated overall dissatisfaction with body-worn absorbent products varied from 32% to 33%.
Getliffe and coworkers43 interviewed community-dwelling women and identified the characteristics they used to evaluate performance of body-worn absorbent products; they were: containing urine and related smells, discreetness when worn under clothing, likelihood of staying in place, wet comfort, and dryness of skin in contact with the product. Fader and colleagues33 evaluated performance of 4 categories of absorbent products in adults with moderate to heavy incontinence using a validated questionnaire based partly on Getliffe and colleagues'43 findings that addressed multiple aspects of performance. Fader's group found that absorbent product users preferred to purchase more than 1 type of product to meet individual needs For example, participants reported purchasing different product for use at home versus use while away from home and day versus nighttime use. Gender also influenced preferences; men found that disposable pads held in place with a mesh brief performed poorly. In contrast, women preferred disposable pull-ups and they were more accepting of a pad held in place with closely fitting underclothing. Budget was found to influence product choice, but 91% expressed willingness to pay additional costs to obtain absorbent products with superior performance. Fader and colleagues45 also evaluated 14 brands of body-worn absorbent products in men with light urinary incontinence-based weight testing and found variability in some brands within the same category. Nevertheless, absorbent pouch performance was consistently ranked low when compared to other designs. In contrast, a single brand of leaf (shield) ranked significantly higher than all other products evaluated.
We found 3 studies that reported the effect of various body-worn absorbent products on incontinence-associated dermatitis (IAD). Clarke-O'Neill and coworkers31 reported findings from a crossover randomized controlled trial that evaluated IAD in 78 nursing home residents using 4 designs; no significant differences were found when IAD occurrences were compared.
Beguin and colleagues48 combined in vitro techniques, studies in healthy human volunteers, and a multiple case series in an evaluation of an absorbent brief with a curled, citric acid cross-linked cellulose fiber technology. In vitro testing showed that this technology reduced pH at the surface and within the absorbent core of the brief when compared to an absorbent brief without this design feature. Bliss and colleagues28 evaluated the influence of this technology using the skin of the forearms and inner thighs of 26 nursing residents and reported significantly lower cutaneous pH when the brief was applied dry, wet with water, or wet with an alkaline solution. Beguin and colleagues48 also reported findings from a multiple case series of 12 elderly adults cared for in a nursing home or rehabilitation facility; 75% experienced resolution of IAD over a 21-day period. While these findings are promising, a randomized controlled trial is needed to evaluate the efficacy of this technology on prevention and treatment of IAD.
Two studies specifically evaluated the use of body-worn absorbent products in patients with fecal incontinence. Bliss and associates34 evaluated absorbent product use in community-dwelling adults and found that nearly half (45%) used these products. Analysis revealed that absorbent product users had more severe fecal incontinence but many reported use of feminine hygiene or other products not specifically designed for fecal incontinence. Bliss and Savik42 also reported an evaluation of community-dwelling adults provided with a butterfly-shaped dressing used for light fecal incontinence. Ninety-six percent of postoperative adults with fecal incontinence reported using the device and 85% continued its use. A significant majority (92%) indicated that they preferred this product to absorbent pads of panty liners. The majority of body-worn absorbent products are designed for containment of urinary incontinence, but findings from these studies emphasize the importance of additional research and development of products specifically designed to meet the needs of persons with fecal incontinence.
We retrieved 2 studies that compared body-worn absorbent products to other types of incontinence produces. Chartier-Kastler and colleagues39 compared satisfaction and several dimensions of health-related quality of life in community-dwelling men randomly allocated to the use of an external collection device (condom catheter) versus self-selected body-worn absorbent products and reported higher satisfaction with the external collection device. Denat and Korshid35 compared IAD occurrences and time to onset in acutely ill adults with diarrhea and fecal incontinence randomly allocated to use of disposable absorbent briefs versus an anal pouch. Subjects allocated to the anal pouch were less likely to develop IAD and experienced a later onset of IAD when compared to those allocated to absorbent briefs. Findings from these studies reinforce the variety of continence products available for containment or diversion of fecal or urinary incontinence and the need to select the best product with the same care and knowledge base WOC nurses apply when counseling patients and their caregivers about ostomy pouching systems or topical wound care products.
Four studies were retrieved that evaluated the effect of use of body-worn absorbent products on urinary continence. Three studies evaluated the effect of regular use of absorbent products upon admission and following discharge from an acute care facility.36 , 37 , 44 While none were designed in a manner capable of demonstrating cause and effect, all found associations between use of absorbent products and an increased likelihood of incontinence or continued use of these products following hospital discharge. In addition, an N of 1 trial study in a young adult with cognitive impairment found that withdrawal of absorbent briefs reduced the frequency of involuntary voids.46
Considered collectively, findings of these studies appear to suggest that absorbent products may be a risk factor for incontinence, and refraining from use of these products may alleviate or resolve incontinence. However, this observation must be carefully weighed against the culture of continence present in many acute- and long-term care facilities characterized by widespread use of absorbent products rather than targeted use based on careful assessment. Zurcher and coinvestigators38 evaluated nursing recognition of urinary incontinence via their written documentation and interventions used for its management. They reported that nurses identified incontinence in 24% of patients who reported its presence when specifically queried about urinary leakage; analysis also revealed that use of absorbent products was the only intervention used to prevent or manage incontinence. Fernando and Wagg29 reported results of a cross-sectional survey that compared perceptions of patients and direct care producers (RN, licensed practice or vocational nurses, and nursing assistants) on wear time following a urinary or fecal incontinence episode. They reported clinically significant differences in acceptable wait times following urinary incontinence episodes.
We assert that findings from these studies suggest that presence of incontinence upon admission to hospital is often unrecognized and many clinicians rely exclusively on absorbent products rather than assisted toileting or a variety of alternative strategies. Whether this creates a culture that paradoxically promotes overuse of absorbent products and fecal or urinary incontinence deserves additional study. We further assert that these findings emphasize the need to establish policies concerning selection and use of body-worn absorbent products rather than the more casual approach often used when delivering this important aspect of patient care.
In contrast to these findings, Teerawattananon and coworkers32 reported positive impact of the use of body-worn absorbent products when made available to vulnerable patients receiving care from community-based rehabilitation centers in Thailand. Findings from this study serve as an important reminder of positive aspects of these products including enhanced personal dignity, increased ability to interact with others while containing and concealing incontinence, and higher health-related quality of life.
In addition to identifying gaps in evidence needed to generate consensus-based statements needed to construct a clinical algorithm, results from the scoping review were used to generate evidence-based statements needed for construction of an algorithm for assessment, selection, use, and evaluation of body-worn absorbent products. Thirty-eight statements were generated that were supported by level A or B evidence (Table 3). These statements were provided to the Consensus Panel, but they were not submitted to the formal consensus process and subsequent validation used for statements based on level C evidence.
Given the significant gaps in evidence revealed by the scoping review, a Consensus Conference was held in Philadelphia, Pennsylvania, to generate and achieve consensus on best practices needed to construct a clinical algorithm for selection, use, and evaluation of body-worn absorbent products. Seventeen clinicians with expertise in this area of care were invited to participate based on their educational background, years of clinical experience, practice setting, and level of expertise (Table 4). The conference was facilitated by Laurie McNichol, a skilled moderator who has knowledge of this field and extensive expertise in the area of constructing and validating this type of algorithm. The 3-member task force and moderator McNichol generated draft statements for consideration by the panel. Each statement was read by the moderator and an initial vote was taken to determine level of agreement with the consensus. Votes were cast using an anonymous electronic system with a quota for approval of 80%. If an individual element did not reach an 80% quota after its introduction, up to 3 rounds of moderated discussion were held to see if the statement could be clarified or altered in a manner that enabled it to gain consensus. This process led to the generation of 42 consensus statements (Table 5).
DEFINITIONS DERIVED BY CONSENSUS
Assessment, product selection, and evaluation are based on multiple factors including volume and frequency of incontinence.5 Multiple studies and both systematic reviews with meta-analysis identified 2 categories of urinary incontinence, light and moderate/heavy.7 , 25–27 However, our search did not reveal standard definitions for these categories. In order to provide consistent criteria for this essential distinction, panel members research consensus on the following statements:
- Light urinary incontinence varies widely based on volume, flow, and frequency. Body-worn absorptive products for light urinary incontinence are designed for leakage up to 100 mL.
- Moderate/heavy urinary incontinence varies widely based on volume, flow, and frequency. Absorptive products for moderate/heavy urinary incontinence are designed for leakage of more than 100 mL.
Additional definitions to terms used in this article are summarized in the Glossary.
- When assessing incontinent patients for selecting an absorbent product, consider the following factors:
- Waist or hip circumference, if these cannot be measured, use body mass index as a reference
- Mobility (ambulatory, assistance with transfers, bed bound)
- Dexterity (ability to don and remove absorptive product independently)
- Patient preference and acceptability and goals of care (consider cost and environmental impact)
- Caregiver time, availability, and functional status
- Assess incontinence type (urinary, fecal, or dual incontinence) and severity.
- When assessing incontinent patients for selecting a body-worn absorbent product, consider timing of incontinence: day, night, or both.
- Consider multiple designs of body-worn absorbent products to manage incontinence in users depending up performance and personal preference.
Panelists engaged in a robust discussion of variety of factors pertinent to assessment of persons with incontinence related to use of body-worn absorbent products. However, the final statement reflects those elements panelists found both necessary and essential for basic assessment of an individual considering use of an absorbent product. Panelists acknowledged that additional parameters may be included as part of the assessment in selected situations such as use of a bladder diary or weighted pad test to determine severity of incontinence, but these assessments were recognized as important for the evaluation of selected individuals in a specialty care or research setting rather than essential elements of basic assessment in a variety of care settings.
WOMEN WITH LIGHT DAYTIME URINARY INCONTINENCE
- In women with light daytime urinary incontinence, disposable pads designed for urine are a first-line containment recommendation.
While supporting evidence is limited, disposable absorbent pads were ranked highly in community-dwelling women with light urinary incontinence.25 , 26 A variety of these products are commercially available and they are commonly used in facilities across the continuum of care and are widely used in community-dwelling women.
- Based on patient preference and acceptability, disposable menstrual pads are an alternative in women with infrequent, light daytime urinary incontinence.
Effective containment of urine and related odor, remaining in place, discreetness when worn under clothing, and wet comfort are the dominant factors influencing women's perceptions of the effectiveness of absorbent products. Women are familiar with the use of disposable menstrual pads, and evidence reveals that many prefer them for management of light urinary incontinence.25 Discussion among panel members focused on the limited absorptive capacity of feminine hygiene pads (about 5-15 mL of fluid), but panelists also recognized existing evidence that some women prefer to change pads more frequently rather than use fewer absorptive pads specifically designed for containment of urinary incontinence. Panelists also observed that the lower costs and a wide availability of feminine hygiene pads may contribute to their attractiveness as an option for managing light urinary incontinence.
MEN WITH LIGHT DAYTIME URINARY INCONTINENCE
- Disposable menstrual pads are not recommended for men with light daytime urinary incontinence.
Disposable menstrual pads are sometimes used in the front of men's undergarments as a way to manage UI, and at least 1 cross-sectional survey found that men used these products for light fecal soiling.34 However, panelists observed that these pads are not designed for the management of urinary or fecal incontinence in men, and sparse evidence suggests that they do not find their use especially effective.
- In men with light daytime urinary incontinence, disposable pads (guards and shields) for urine are a first-line containment recommendation.
- In men with light daytime urinary incontinence, consider contour, shape, and other design elements of pads (guards and shields) to maximize effectiveness and comfort.
Findings from multiple studies indicate that no single product is best for all users.5 , 7 Panelists noted that while these absorbent products are specifically designed for men, variability in their design is necessary given the variety of body contours of the various men seeking effective containment of light urinary incontinence, and no particular design can be identified as suitable for all men with light urinary incontinence.
AMBULATORY WOMEN AND MEN WITH LIGHT DAYTIME FECAL INCONTINENCE
- Disposable absorbent products positioned over anus and between the buttocks are a first-line recommendation for women and men with light fecal incontinence or mucus incontinence.
- In men and women with light fecal incontinence or mucus incontinence, consider contour, shape, and other design elements to maximize effectiveness and comfort.
- If absorbent products used for light fecal incontinence become inadequate for containment or bothersome, consider use of absorbent brief or pull-up.
Panelists readily agreed that research and evidence focusing on the use of absorbent products in persons with fecal incontinence are especially sparse. This paucity is reflected in the dearth of body-worn absorbent products specifically designed for fecal incontinence. Fortunately, a small number of products have been developed or adapted for placement over the anus that may provide effective containment of light leakage of fecal material or mucus from the anus.42
Nevertheless, panelists also recognized that individuals experiencing more frequent or severe fecal incontinence, such as that associated with high-volume diarrhea or involuntary defecation of formed stool, require a different type of absorbent product. While panelists engaged in a robust discussion of the need for further innovation in the design and manufacture of body-worn absorbent product for the management of fecal incontinence, they recognized the absorptive brief or pull-up as the most widely available and generally effective alternative for these individuals.
AMBULATORY ADULTS WITH MODERATE TO HEAVY DAYTIME URINARY, FECAL, OR DUAL INCONTINENCE
- In ambulatory men and women with moderate/heavy daytime urinary, fecal, or dual incontinence, disposable pull-ups including superabsorbent polymer technology are a first-line recommendation.
Mobility is a significant indicator when selecting absorbent body-worn products for men and women experiencing moderate/heavy dual urinary and fecal incontinence. Ambulatory adults who are mobile and able to transfer onto a toilet (toiletable) are likely to benefit from an absorbent product that can be removed and replaced in a manner similar to regular underclothing, and panelists recognize that pull-ups provide this design while briefs do not.
- Consider effective containment, comfort, cost, skin protection, and odor control when selecting pull-ups and briefs. When using a disposable brief also consider tab seal/reseal properties.
- Consider fit, comfort, and skin barrier function when selecting body-worn absorptive products.
- Consider design elements including size (waist and hip circumference, surface area, and location of absorptive area), elastication (leg elastics and standing leg gathers), and maintenance of skin barrier properties (optimal pH, breathability or breathable side panels, pressure redistributing properties, and low friction coefficients).
Design elements absorptive capacity, liquid acquisition rates, skin dryness, and rewet are standard measures for evaluating product performance in the laboratory, and performance attributes of effective containment of urine, stool and related odors, discreetness when worn under clothing, wet comfort, and skin dryness underneath an absorbent product have been identified as important performance parameters among users.7 , 49 While additional research is needed to establish the relevance and clinical correlation of each of these parameters and how they are best measured in the laboratory and clinical settings, panelists concurred that attention to these design elements is a necessary component of assisting users and caregivers as they seek the best body-worn absorbent product or combination of products.
- In ambulatory women with moderate/heavy daytime urinary incontinence, disposable-shaped pads including super absorbent polymer technology worn with close fitting underwear are an alternative first-line recommendation.
Multiple panelists observed that women tend to prefer pads over alternative body-worn absorbent products. While many absorbent pads are designed for the management of light incontinence, other designs have higher absorptive capacities and, when combined with snug-fitting underclothing, can effectively contain larger volumes of urine while remaining discreetly in place.
- In ambulatory men with moderate/heavy daytime urinary, fecal, or dual incontinence, disposable absorptive briefs including superabsorbent polymer technology are an alternative recommendation.
Men with moderate/heavy urinary incontinence tend to leak at higher volumes than do women and they consider absorbance without leakage and comfort as the most important performance characteristics of a body-worn absorbent product.7 , 27 Panelists observed that absorbent briefs provide these design features, and limited evidence suggests that men with moderate/heavy incontinence urinary incontinence prefer briefs to pull-ups or pads with snug-fitting underclothing.
AMBULATORY AND NONAMBULATORY PATIENTS WITH MODERATE TO HEAVY NIGHTTIME URINARY, FECAL, OR DUAL INCONTINENCE
- In nonambulatory women with moderate/heavy urinary, fecal, or dual incontinence, the use of disposable briefs including superabsorbent polymer technology at night is a first-line recommendation.
Panelists acknowledge that the term nonambulatory can be used to describe individuals who require assistance with movement or may be deemed bedridden. Several participants observed that disposable briefs are easier and safer to apply and remove by caregivers. Additional benefits discussed were the ability to contain moderate to heavy urinary fecal and dual incontinence and allow less frequent changes than other designs. Based on these considerations, the panel reached consensus that disposable absorbent briefs are a first-line recommendation.
- In ambulatory women with moderate/heavy nighttime urinary, fecal, or dual incontinence, the use of disposable pads including superabsorbent polymer technology with close-fitting underwear is an acceptable alternative.
Even when managing moderate/heavy urinary or fecal incontinence, evidence suggests that many ambulatory women prefer disposable pads, as long as they are able to provide effective and discrete containment of urine.7 , 27 Panelists experienced in this area opined that the key to success for this use is the presence of the close-fitting underwear to ensure that they remain in place and ready to contain urinary leakage.
- In ambulatory and nonambulatory men with moderate/heavy urinary, fecal, or dual incontinence, the use of a nighttime disposable brief including super absorbent polymer technology is a first-line recommendation.
Panelists concurred that briefs are a first-line recommendation because of their high absorptive capacity and ability to rapidly absorb the higher-volume urinary incontinent episodes many men experience.
- To minimize sleep interruption in the user and to maximize containment in individuals with high-volume urine output, consider the use of a booster pad as an adjunct to an absorptive brief or pull-up. Use of product should not be based on staff convenience.
Many individuals with heavy/moderate UI are not amenable to be awakened during the night for a change of product, especially if fecal incontinence has not occurred. Panelists noted that a booster pad may effectively contain urine or stool and provide an opportunity for these individuals to experience fewer interruptions of sleep, resulting in multiple health benefits.
- The use of an unbreathable plastic outer layer or rubber pants to protect outer clothing or mattress is not recommended.
Panelists argued that use of plastic or rubber as an outer layer or barrier impairs the moisture barrier of the skin, resulting in increased cutaneous pH and a greater risk of developing IAD or other forms of moisture-associated skin damage.
NONAMBULATORY PATIENTS WITH MODERATE TO HEAVY DAYTIME URINARY, FECAL, OR DUAL INCONTINENCE
- In nonambulatory women with moderate/heavy daytime urinary, fecal, or dual incontinence, disposable pull-ups or briefs including superabsorbent polymer technology are recommended.
Evidence suggests that women with moderate/heavy urinary of fecal incontinence tend to prefer disposable pull-ups to briefs and other designs of body-worn absorbent products.7 , 27
- In nonambulatory toiletable women with moderate/heavy daytime urinary incontinence, disposable pull-ups including super absorbent polymer technology are a first-line recommendation.
- In nonambulatory toiletable women with moderate/heavy daytime urinary, fecal, or dual incontinence, the use of disposable pad with close-fitting underwear is an acceptable cost-effective alternative.
Panelists observed that disposable inserts or pull-ups are easier and quick to change than briefs in women who are able to stand, but they are paradoxically more difficult to apply and remove in women who are unable so stand. The ability of the patient to toilet is an important consideration when selecting a product for a woman who is nonambulatory but able to stand and pivot onto a toilet. Panelists opined that proper selection and use of body-worn absorbent products should consider this frequently encountered scenario.
- In nonambulatory men with daytime urinary, fecal, or dual incontinence, disposable briefs including superabsorbent polymer technology are a first-line recommendation.
As noted earlier, multiple panelists with expertise in the care of disabled or elderly adults noted that the disposable briefs provide a desirable suite of features for the nonambulatory man. In this case, they strongly recommended selecting a brief with a seal/reseal mechanism that provides not only containment but also safety for the patient and the caregiver.
- In nonambulatory, toiletable men with moderate/heavy urinary incontinence, close-fitting underwear with integral pads or pull-ups is an alternative recommendation.
- In nonambulatory, toiletable men with moderate/heavy urinary, fecal, or dual incontinence, disposable pull-ups are recommended as an alternative for daytime use.
Similar to the scenario described in nonambulatory women who can stand and pivot onto the toilet with assistance, panelists argued that these designs provide a desirable alternative that is easier to remove and replace than are absorbent briefs.
- Disposable or reusable diapers for infants are not recommended for incontinence containment for men with urinary, fecal, or dual incontinence.
Infant diapers are not designed for adult use. The products do not allow for securement in the waist or any undergarment, and the landing zone for best absorbency and the total capacity for absorbency are not designed for the anatomy and body habitus of adults.
- In nonambulatory men with moderate/heavy urinary incontinence, consider use of a disposable wrap to augment containment.
Penile wraps are disposable absorbent products that encase the penis enabling more effective containment than absorbent pads or underpads. When used with a disposable pull-up or brief, this can extend life of the disposable pull-up or brief by allowing minimal interruption to change this penile wrap versus a complete change of the larger body-worn disposable.
- In men or women with moderate/heavy urinary incontinence, when briefs, pull-ups, or underpads provide inadequate containment, consider addition of a booster product. Booster products should not be used for staff or caregiver convenience.
Panelists opined that selective use of a booster pad may provide an opportunity for the patient to experience a longer interval of product use than when the booster pad is not used. As a result, they provide better containment for high-volume UI that may be used to decrease disruptions in sleep or preserve dignity during social activities.
PERIGENITAL SKIN CARE
- When assessing incontinent patients for selecting body-worn absorptive products, consider perigenital skin status (intact, incontinence-associated dermatitis, pressure injuries, friction injury, intertriginous dermatitis, fungal, or other).
Evolving evidence suggests that product design may influence the risk of skin damage associated with the use of body-worn absorbent products.28 , 48 Panelists asserted that clinicians should maintain knowledge of this line of research and alter their recommendations for specific products should stronger evidence emerge favoring inclusion one or more design elements for the prevention of skin damage under body-worn absorbent products.
- Consider overall formulation and application (frequency and quantity) of leave-on-skin protectants and their potential ability to clog and reduce the absorptive capacity and other properties of body-worn containment products.
As noted earlier in this manuscript, evidence concerning the effects of leave-on-skin protectants is mixed. Evidence strongly suggests that selection and application of leave-on-skin protectants have the potential to impair fluid transfer. Panelist concurred that their effect on patients' skin health should be carefully monitored when these products are used together.
AESTHETICS, DIGNITY, AND WAIT TIMES
- Change times of absorptive products should be patient centered (promote skin health, odor control, sleep and elimination patterns, and dignity) and should consider product properties. Change times should not be based on routine and caregiver convenience.
- Absorptive products should be changed as soon as possible after a fecal incontinent episode to preserve skin health and promote odor control and dignity. Change times should not be based on routine and caregiver convenience.
These statements arose from robust discussion and agreement that wet and soiled absorbent products should be changed as soon as possible.
- Consider profile when worn beneath clothing, absence of rustling or other noise, odor control, and other design elements including aesthetic properties to optimize user dignity.
This statement arose from clinical experience and several studies that suggest that discreetness when worn under clothing is a significant consideration for persons selecting a body-worn absorbent product. In addition, other participants praised recent innovations in the aesthetic appearance of absorbent products and they expressed advocacy for the development of additional products that perform well while preserving pleasing aesthetic properties.
SPECIAL CONSIDERATIONS IN COMMUNITY-DWELLING, MORBIDLY OBESE, OR COGNITIVELY IMPAIRED INDIVIDUALS
- Individuals with incontinence and dementia should be considered for an underwear-type products (underwear with pads, pants with an integral pouch, or disposable pull-ups) as a first-line recommendation to enhance the effectiveness of a toileting program, to normalize the toileting experience, to reduce agitation, and to promote safety.
Normalization of the toileting experience is part of a therapeutic approach to patients with both dementia and incontinence. Though often overlooked, several panelists skillfully argued that selection of an absorbent product enables a more normal toileting experience. It may replace less acceptable toileting practices increasing both dignity and quality of life for these vulnerable individuals.
- The variety of body-worn absorbent products for morbidly obese individuals is limited. When selecting absorbent products for morbidly obese individuals, consider the emotional impact and skin barrier function (skin pH and microclimate, length of absorbent area from front to back, the ability to accommodate abdominal girth and leg size, and skin folds).
Panelists concurred that product design elements must be selected that optimally accommodate the special needs of this population. Less than good fit or using products not designed for this population can lead to emotional distress and a loss of personal dignity. Several panelists also argued for a call to manufacturers to develop and market designs better suited to this increasingly prevalent condition.
- Reusable body-worn absorptive products may be considered as an alternative for community-dwelling men and women with urinary incontinence based on user and caregiver preference and specialty use (eg, swimming).
Evidence clearly indicates that no one product meets every need, and users of absorbent products seek out a combination of products when engaging in a variety of activities. While disposable products are frequently preferred over washable ones, panelists noted that some users prefer reusable products based on the underlying activity or cost concerns.
Given the paucity of evidence in this area of care and the need for extensive reliance on consensus-based statements, content validation was completed to strengthen the validity of best practice recommendations generated by the consensus panel. The methods used for content validation were described by Grant and Davis.50 An independent and interdisciplinary panel of 21 clinicians with expertise in the field of continence care and use of absorbent products was empaneled (Table 6). Panel members were asked to rank their level of agreement on a scale of relevance ranging from 1 to 4 where 1 indicates that the statement is not relevant/appropriate, 2 indicates that the individual is unable to assess relevance without revision, 3 indicates that the statement is relevant but needs minor alteration, and 4 indicates that the statement is very relevant and appropriate.
Data analysis was conducted utilizing SAS/STAT software, version 9.4 of the SAS System (2012 SAS Institute, Cary, North Carolina). Data were coded and entered by a data coordinator, analyzed by the biostatistician, and reviewed by the authors. The content validity index was calculated for each consensus statement.
Table 5 summarizes the quantitative analysis on interrater agreement and lists the content validity index for each individual consensus statement. Polit and colleagues51 suggest a cutoff for agreement of 0.78 for 3 or more reviewers. The quantitative analysis revealed that the majority of the expert panel felt that the consensus statements were ranked as “very relevant and appropriate” or “relevant and needed only minor alteration.”
The results of this scoping literature review and subsequent Consensus Conference highlighted the paucity of evidence and clinical resources driving the selection, use, and evaluation of body-worn absorbent products for the management of fecal incontinence. While the Task Force, Consensus Conference participants and Content Validity experts agree that an interdisciplinary approach with multiple interventions is essential for the management of fecal and urinary incontinence, we also recognize the prevalence of use of body-worn absorbent products and the importance of their use for many incontinent individuals.
The scoping literature review identified several gaps in research that should be addressed without delay. The first is the gap between laboratory-based tests used to determine performance of absorbent products and clinically relevant outcomes that drive users, caregivers, and clinicians to select and use a particular product. Several groups have addressed this issue in detail49 , 52 , 53 and we strongly encourage others to build on their work and continue to seek methods that more closely link testing in the laboratory or in healthy human volunteers with outcomes measured during clinical trials.
A second major gap is the lack of research and product development for individuals with fecal incontinence. Even given the overall paucity of evidence in this area, we were concerned to find that the vast majority of studies and commercially available products are primarily designed for the absorption of fluid rather than the containment of stool, and solid stool in particular. We applaud the exploratory studies that have identified some of the key issues surrounding the development and refinement of body-worn absorbent products designed for persons with fecal or mixed fecal and urinary incontinence34 , 42 and strongly advocate for additional research and product development for these underserved patients.
Findings from a scoping review identified limited evidence and multiple gaps in research related to body-worn absorbent products. In order to address these gaps, the WOCN Society has committed itself to develop an evidence- and consensus-based algorithm for selection, use, and evaluation of body-worn absorbent products for the management of individuals with urinary and/or fecal incontinence. This algorithm will help to fill the gap in resources available to first-line and WOC specialty practice nurses guiding optimal use of these products.
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Keywords:© 2018 by the Wound, Ostomy and Continence Nurses Society.
Absorbency; Absorbent pads; Adult diapers; Body-worn absorbent products; Daytime incontinence; Fecal incontinence; Incontinence pads; Nighttime incontinence; Product selection; Urinary incontinence