IAD: Dealing with the incontinence issue
Managing urinary incontinence
There are several types of urinary incontinence: stress incontinence, urge incontinence, and mixed incontinence. In addition, urinary incontinence may result from a chronically overfilled bladder due to obstruction such as benign prostatic hyperplasia or prostate cancer.
Many elderly patients, however, have a form of urine incontinence, which is called functional incontinence. This means that the patient leaks urine because of decreased mobility, cognitive changes, or impaired bodily functions because of severe disease.
In younger patients (stress/urge/mixed incontinence), several interventions can be used to improve the situation. Specific exercises for the pelvic floor muscles, vaginal rings, and even collagen injections around the neck of the urinary bladder, transcutaneous stimulation, and several surgical procedures can improve the situation. These techniques are usually not applicable for patients with the highest risk of developing IAD (the elderly/frail).
If an elderly patient suddenly becomes incontinent for urine, you also have to consider a urinary tract infection as the cause. Remember that a positive urine stix is not unusual in the elderly ( especially older women). This does not necessarily mean that the patient has an acute urinary tract infection that needs antibiotic treatment. Quite many older women have an asymptomatic chronic bacterial colonization (ASB) which in most cases is asymptomatic and does not cause any harm. Cloudy urine with small flakes does not necessarily mean that the patient has an active urinary tract infection.
Figure 1 In elderly patients who suddenly become incontinent for urine, you should always rule out a urinary tract infection as the cause. Be aware that cloudy or flaky urine does not necessarily mean that the patient has an acute urinary tract infection (UTI) that warrants antibiotic treatment! So-called asymptomatic bacteriuria (ASB) is not uncommon, especially in older women. Unfortunately, the urine dipstick where we look for increased leukocytes or nitrites is not a reliable test either. In some studies, the false positive percentage was >60%. So it is essential to look at the whole clinical picture before deciding on whether the patient has a UTI that needs treatment. Does the patient have other signs of infection like a fever? Do they complain of a burning sensation in the pelvis area?
In elderly patients with functional urinary incontinence, you will have to use an individualized approach. Some only have incontinence at night time. These patients can be helped by reducing diuretics at night, reducing the amount of fluid intake in the evenings, and encouraging going to the toilet before retiring to bed. In other patients - including those with impaired cognitive function- a certain degree of bladder training may be achieved by assisting them to the toilet several times a day and encouraging them to urinate. You can find several protocols online on how to do this - you will get most hits in a google search if you type " prompted voiding protocols" into the search bar.
Figure 2 Link to an article on "prompted voiding" in nursing home residents with urinary incontinence. Click on the image above to get to a pdf of the article.
Diapers
Diapers are the primary measure used to manage incontinence in the elderly. Historically adult diapers have a bad reputation - that they actually can be the cause of IAD. Studies show, however, that diapers are a safe choice - but only as long as they are used correctly. The obvious mistake is to change the diaper too seldom, which will lead to skin damage. Modern diapers have an excellent capability to lead fluids to the diaper's core, but even they will cause skin damage if they are saturated. No matter how modern or fancy the diaper, there will always be a higher moisture level surrounding the skin under a diaper. In addition, the temperature is higher here, which accelerates the accumulation of ammonia.
The choice of diapers is, in most cases, determined by the financial resources available. Diapers are paradoxically surprisingly expensive in most countries in the world. It is not costly to make a diaper- they can be bought wholesale in bulk from China for as low as 0.10 US Dollars/diaper. Yet, in shops and online, the price is something entirely else. Even in Africa, it is not rare to see a 10- pack of adult diapers costing 50 US Dollars. It is not hard to understand that when diapers become an economic burden, it is tempting to save on costs by changing them more seldom. Make sure to check different shops/ online sellers for price comparisons. You will be surprised by the price differences in your country between sellers.
Suppose the patient already has developed a severe IAD. In that case, it can be best to treat the patient without a diaper for some time and instead use an absorbable material under them. It is essential to check the absorbable pad regularly- the patient must not be left lying on wet absorbable padding!
In many situations, it isn't easy to use anything other than a diaper. Again, make sure to change the diapers often, several times a day. Be aware that there also are considerable quality differences between diapers- the best have an astonishing ability to draw fluids quickly into the center of the diaper and keep the inner surface surprisingly dry. There are also different grades of diapers- some are graded for light incontinence, others for heavy incontinence. Many brands mark the packaging with droplet symbols- the more droplets, the higher the diaper's absorbent qualities. In addition, diapers come as pull-ups or with tabs. Pull-up diapers are better for mobile patients, while diapers with tabs make it easier to change a diaper in bedridden patients.
In Africa, the challenge is obviously the economic burden of diapers. Most people will be happy if they can get hold of a reasonably priced diaper and will have to accept that this is of inferior quality. In many areas of the continent, a disposable diaper is simply not affordable, and here absorbent material can be placed in the groin area and beneath the patient. This can absolutely be an acceptable solution as long as it is possible to check on the patient every hour to make sure they are not left lying with wet material on the skin.
Figure 3 Disposable adult diapers are commonly used in patients with urinary incontinence. They are readily available in most African countries but are unfortunately very expensive. This often leads to the diapers being changed, seldom increasing the chance of IAD developing.
Figure 4 The best diaper brands come in various grades for light to heavy incontinence. In addition, they come as pullups or with tabs. Most mobile patients will prefer pull-up diapers, while it is easier to change a diaper on a bedridden patient if the diaper has tabs.
All patients with incontinence need to have their skin inspected at least once daily to check for signs of IAD. If the patient has more severe urinary incontinence or even fecal incontinence, the inspection has to be carried out several times daily. A diaper must never become a "resting pillow" for the caregiver! Remember also to check skin folds and in between the groin areas where moisture and soiling can accumulate.
An incontinent bedridden patient urinates on average seven times daily. If IAD already has developed, change the diapers often and check the skin at every opportunity.
Diverting urine using a catheter
A temporary or permanent catheter can be necessary in cases with severe IAD due to urinary incontinence. You will have to consider the advantage of a catheter against its disadvantages ( for example, urinary tract infection- UTI). As a rule of thumb, you should keep the duration of the catheter as short as possible to reduce the chance of causing a UTI. At the same time, you do not need to have an exaggerated fear of causing a UTI when using a catheter. If there are signs of serious moisture damage around the groin area, this will often be a good indication for a temporary catheter. Often the patient will only need the catheter for about a week until the skin condition has improved. In situations where the patient has recurring episodes of IAD despite other good measures, a permanent catheter can be indicated. Remember that these catheters need to be changed every three months.
Some patients are difficult to catheterize. This is more common in older men where an enlarged prostate, for example, can make the procedure difficult. In these cases, a uridome can be an alternative. Otherwise, you also have to remember the possibility of placing a suprapubic catheter. The latter is placed through the abdominal skin directly into the bladder- a procedure done under local anesthesia. Suprapubic catheters also need to be changed every third month. Note: a suprapubic catheter may also be the best choice if the patient has chronic fecal incontinence. It will be less likely to be contaminated with fecal bacteria than a transurethral urinary catheter.
Some patients have urinary incontinence because of a partial obstruction due to, for example, an enlarged prostate, a descent of the uterus, or neurological disorders. These patients may have a chronic full bladder, and the "overflow" continuously drips from the urethra. A handheld bladder scanner is very useful to check how full the bladder is. If the patient is bedridden, a residual volume of 100-150ml is acceptable unless the patient has recurring UTIs. A permanent catheter is usually indicated if a chronic overfilled bladder causes incontinence.
In any case- for each patient, you will have to use an individual approach. Each patient with incontinence is different and has different needs. For some patients, for example, intermittent catheterization at night may be enough to prevent IAD.
Figure 5 In cases with severe IAD due to urinary incontinence, you will have to consider using a urinary catheter as either an intermittent, short-term or permanent measure depending on the pattern of incontinence. The right image shows a suprapubic catheter placed directly through the abdominal wall into the bladder under local anesthesia. The latter is often preferable in patients with simultaneous fecal incontinence as it lowers the chance of contamination of the catheter with fecal bacteria.
Figure 6 The upper image shows a Category 1 IAD due to urinary incontinence. If other measures did not lead to an improvement, you could, for example, consider intermittent catheterization until the skin condition has improved. We are not saying that this particular patient needs intermittent catheterization - we want to clarify that sometimes you need to look at other options to manage an IAD. The lower image shows a more severe IAD where a temporary catheter ( or permanent) may be indicated.
Dealing with fecal incontinence
All patients with fecal incontinence should have their skin inspected at least once daily, just like patients with urinary incontinence. Obviously, with more severe incontinence or even diarrhea, you have to establish a routine to inspect the skin several times daily. Again, make sure to inspect skin folds and well up in the groin area where moisture and fecal rests can easily collect.
Be aware that chronic constipation paradoxically can lead to frequent episodes with loose stool as only the thinner fecal matter can pass the area with faster stool. If laxatives are used, this can deter the situation further. We are not saying that these patients should not receive laxatives - we want to point out that laxatives sometimes can cause unwanted effects. In patients with chronic constipation, we should try to regulate bowel movements through a more balanced diet, and many food substances can act as natural laxatives. Examples are linseeds, prunes or prune compote, dried figs, apple compote, or papaya. These are only a few examples of such foods- we are sure that there is local knowledge in your area about which locally available fruits/seeds have such properties.
As a general rule, the patient's diet should be rich in fiber, and the patient must be encouraged to drink sufficiently. Be aware that an electrolyte imbalance like low potassium can also cause obstipation - in cases of chronic constipation, it is a good idea to do a blood test and check electrolyte status. If dietary supplements do not improve chronic constipation, other laxatives should be considered. It is widespread to administer lactulose-based laxatives daily in these patients - these substances are usually very well tolerated and can be given over long periods. Suppose a patient experiences shorter but more severe obstipation episodes. In that case, it may be necessary to administer more effective laxatives like sodiumpicosulfate ( for example, Laxoberal drops), but these laxatives should only be given over a few days.
If the patient has diarrhea, try to improve the situation by dietary changes. Food sources like banana, rice, potatoes, porridge, and salty biscuits are beneficial in this situation. There is an ongoing discussion on whether supplementing with probiotics can treat diarrhea, but it is usually worth trying. An exception is immunodeficient critical care patients, where studies have shown an unexpected poorer outcome if probiotics were given. The reason for this is unknown.
If the patient has diarrhea, we should try to establish the cause. Is the patient using antibiotics that can explain the diarrhea? A fecal test for pathogenic bacteria should be done if the diarrhea had a sudden onset and did not pass within a few days. Clostridium difficile is a common bacteria causing chronic diarrhea, especially in patients who have recently gone through antibiotic treatment.
As long as an infection is the cause of the diarrhea is ruled out, additives that increase the consistency of the stool can be administered. In some cases, medical treatment with Immodium can be indicated. Again, be aware that using Imodium is contraindicated in patients with infection- for example, an untreated clostridium difficile infection.
If the patient is receiving tube feeding, it is common to see looser stool - this can aggravate underlying incontinence.
There are several technical aids to help deal with thin stool/diarrhea.
"Fecal management systems" (FMS) consist of a tube with an inflatable cuff. The tube is inserted into the rectum, and the cuff is inflated with air. Thin stool/diarrhea is collected in a bag. Obviously, this only works when the stool is very thin. AFMS can remain in place for up to one month. Many healthcare workers are unaware that this option exists. It should be used more often- especially in intensive care units and in other wards and elderly homes, this should be made available.
Figure 7 There are several brands of fecal management systems available. Most of these are relatively similar in design and use. One of the most common systems used is Flexi Seal by Convatec.
NB! It is contraindicated to use a regular urinary catheter in the rectum for dealing with diarrhoea, as this ca lead to complications such as perforation or damage to the sfincter. Besides, the lumen of these catheters is so narrow that they usually clog up quickly.
If it is not possible to get hold of a fecal management system you may be able to limit the amount of soiling by applying a fecal bag around the anus. This type of bag is similar to a stoma bag, and you can indeed use the latter for this purpose. However, if the skin around the anus is already damaged and moist, the bag will not adhere properly. A fecal bag only works if the skin around the anus is quite dry. If available, use a sel-drying barrier product containing acrylate to ensure that the bag adheres in a better way. To apply the bag in the best possible way you need two pair of hands. One person gently spreads the skin around the anus while the other places the fecal bag. If you work alone you will most likely not succeed in achiving a tight seal.
Figure 8 Fecal bags are similar to stoma bags but have a somewhat different shape. If you only have stoma pouches available you can improvise with these.
Anal plugs can be a short-term solution for fecal incontinence. These look like a tampon made of foam which are inserted into the rectum. When the foam comes into contact with fluid it expands and prevents fluid from passing. It is a gentle technique but some patients may feel some discomfort from the plug. Important! The plug can be left in place for maximal 12 hours. This does not mean that it should be left there for that long. Furthermore, it should only be used for patients with light to moderate diarrhoea. Do not use it if there is a suspicion of a serious gastrointestinal infection. It is really only a very short term solution for a selcetd group of patients. A situation where an anal plug could be indicated is, for example, an incontinent patient who is transported by ampulance from one care facility to another. An anal plug may also be indicated for an incontinent patient who has to undergo major surgery- for example a hip fracture surgery.
Figure 9 Anal plugs can be used as a very short-term solution for a select group of patients with fecal incontinence. Never use these in situations where there may be an acute gastronintestinal infection!
In more extreme cases of IAD ther may be indication for doing a colostomy. This can be done as a temporary measure where the stoma is reversed once the skin around the anus has healed. In other cases it may be better to keep mthis as a permanent solution. The situation where we usually consider doing stoma surgery are patients that have already developed a pressure ulcer, secondary to the IAD. Other indications can be major burns around the anus or perineum. It seems that there is a fairly high threshold for doing a stoma procedure in many of these patient. Many experts will argue that this is done far too seldomly. If you have a patient with a poorly controlled IAD and significat pressure injury simultaneously you should always consider this option - as long as you have tried other, more conservative approaches first.
Figure10 In situations with severe IAD and pressure ulcerations in additon, diverting stool via a colostomy can be a good solution. The colostomy can be temporary or permanent. Before a colostomy should be considered, other, more conservative options have to be tried first. copyright upper left image: oncolex.no