While the goal of every individual and healthcare professional is to cure/improve the symptoms of bladder and/or bowel incontinence, not all incontinence problems can be completely or permanently cured (Fader et al, 2020). The challenge for both healthcare professionals and patients is to deal with incontinence to minimise the impact on health and quality of life (Fader et al, 2020). This usually means managing the incontinence with some sort of equipment/device or product. Successful management of incontinence is often referred to as ‘contained incontinence’ (Fader et al, 2020), which, even if not a cure, can significantly improve quality of life. There is a vast range of equipment/devices and products catering for different clinical/continence needs, as outlined in Figures 1 and 2. How to assess individuals for the most appropriate individual containment products has been highlighted by the International Continence Society (ICS, 2017) (Table 1).  

Table 1. Key elements of assessing a patient and their environment for correct management products (ICS, 2017). 
 
Figure 1. Products for toileting (adapted from ICS, 2017). 
Figure 2. Products for managing incontinence and/or urinary retention (adapted from ICS, 2017). 
This article discusses types of equipment for urinary retention, e.g. catheters; urinary incontinence, e.g. urinals, sheaths; and devices, and products/devices used for faecal incontinence, as well as pad containment products. All of the products discussed are available either via prescription or NHS unless stated. 


EQUIPMENT/DEVICES FOR URINARY RETENTION  


Urinary retention is one of the identified clinical conditions that is usually treated by the insertion of a urinary catheter (Yates, 2019a; Royal College of Nursing [RCN], 2021). Urinary catheters come in two forms, namely indwelling or clean intermittent catheterisation (CIC)/intermittent self-catheterisation (ISC). Indwelling catheters have an integral balloon to keep the catheter in place (Figure 3), while intermittent ones are inserted, urine drained and then immediately removed.  
 
Intermittent catheters have less complications than indwelling and are the preferred choice, if possible, for both patients and clinicians, as there is less risk of infection compared to indwelling catheters, improved quality of life and symptom management (RCN, 2021). However, unfortunately, not everyone can successfully undertake CIC. Yates (2017) identified that for CIC to be successful, patients must: 
  • Be able to store urine in their bladder  
  • Be able to understand the technique for CIC  
  • Have reasonable dexterity and enough strength to be able to correctly hold and insert the catheter  
  • Be able to position themselves into a suitable position to undertake the procedure  
  • ​Be motivated to commit to the procedure, which could be a lifelong commitment.  
A wide range of intermittent catheters are available on drug tariff, including:  
  • Hydrophilic-coated (single use) — these require water to activate and hydrate the coating  
  • Pre-gelled (single use) — these have gel in the pack  
  • Reusable Nelaton catheters (single patient use) — these can be used with water-soluble lubricating/anaesthetic gel. This type of catheter can be reused at home, as it can be cleaned according to the manufacturer’s instructions (Yates, 2017). 
Indwelling catheters can be used to treat retention. However, they are associated with more complications than CIC, including urinary tract infections (UTIs) (Loveday et al, 2014; Centers for Disease Control and Prevention, 2016), bypassing, encrustation, luminal problems, loss of bladder tone, to name but a few (Yates, 2019a; RCN, 2021).To prevent or minimise the risks of these issues occurring, there are a number of precautions that healthcare professionals can advise (Table 2).  
While the indwelling catheter device is mainly chosen by the healthcare professional inserting it, the drainage device that an individual is set up with will depend on a variety of reasons (Yates, 2016; Yates, 2019a) and should be discussed with the patient. Reasons for selection may include (Yates, 2016; Yates, 2019a):  
  • Patient preference  
  • Care of the system  
  • Required bag capacity/length of tubing/tap design (if drainage bag used)  
  • Placement and ease of use for individual, based on dexterity/mobility/cognitive ability  
  • ​Bladder capacity for use of catheter valves, ability to open tap/valve.  
Drainage bags (Figure 4) are sterile and should be maintained as a closed system and changed within manufacturer’s recommendation, i.e. every five to seven days. They come in different lengths of direct, short or long tube. Within community settings, the most common capacities are 350mls, 500mls, 750mls and 2 litre. It is imperative that whichever bag is attached, the catheter remains in situ and is not disconnected to reduce risk of infection (Yates, 2019a), unless for a clinical reason, i.e. routine change of bag every five to seven days (Loveday, 2014). If a larger drainage bag is required overnight, a non-drainable 2 litre bag can be connected to the outlet of the day bag. These should be disconnected, drained and disposed of each morning (Yates, 2016; Yates, 2019a)  
 

Table 2. Urinary catheter continuing care principles (adapted from Loveday et al, 2014; Yates, 2016; Yates, 2019a). 
 
Figure 3. Indwelling catheter with integral balloon. 

 
Figure 4. Sterile closed leg drainage bag. 
Figure 5. Sterile closed drainage catheter valve. 
Catheter valves (Figure 5) have gained in popularity, as they allow the bladder to fill and empty over a period of time, mimicking the micturition cycle, which may contribute to a more successful trial without catheter (TWOC) (Carr, 2019). They offer patients comfort, independence and a convenient way to manage their catheter (Fader et al, 1997; Yates, 2019a). However, they are not for everyone, especially individuals with poor dexterity or confusion/dementia/cognitive problems, who may forget to open regularly (Simpson, 2017; Yates, 2019a).  

There is now growing best practice that catheters and drainage devices should be well supported and secured in a comfortable position to prevent complications (Yates, 2019a; RCN, 2021) (Figures 6 and 7). These complications can include (Yates, 2018):  
 
  • Catheter migration, which can lead to accidental removal of the catheter, urethral trauma, including cleaving  
  • ​Infection due to friction, and patient discomfort  
  • If the catheter drainage bag is not well supported, it can get too heavy and potentially damage the urethra and bladder neck  
  • Inflammation, which can lead to infection, tissue necrosis, blockage, bladder irritability, spasms and bypassing, and may lead to frequent unnecessary changes of the catheter.  
Securing devices include Velcro straps (Figure 6) or sleeve devices (Figure 7), both of which have their own advantages and disadvantages. It is important that healthcare professionals discuss and agree with the patient the best option for them.  
 
As well as securing devices, a fixation device should be used. They provide stabilisation for the catheter and prevent tension and pulling on the device. These devices come in a variety of forms from strap fixation to adhesive devices. Individuals should again be assessed for the most appropriate device (Yates, 2018) (Figure 8).  

 
Figure 6. Catheter securing leg straps. 
Figure 7. Catheter securing sleeve. 
Figure 8. Types of fixation devices. 
 
 
 

EQUIPMENT/DEVICES FOR URINARY INCONTINENCE  

 

While some urinals exist for female urinary incontinence (Figure 9), most of the devices and equipment are more male orientated and include sheaths, urinary direction aids, pubic pressure devices, penile pouches and penile clamps.  
 
Male urinals come in a variety of shapes and sizes (Figure 10), some with an integral tap (Figure 11). However, prior to their successful use, individuals should be able to have a degree of mobility, some manual dexterity and the design concept should be agreeable to them (ICS, 2017). Their use should be discouraged if the patient cannot empty the urinal, has poor balance, impaired forward arm reach and wrist function, or impaired cognition (ICS, 2017).  
 
Urine directional aids can be used on their own via the toilet, or some can be attached to a drainage bag (Figure 12) and used, e.g. at night when mobility to the toilet may be an issue.  
Figure 9. Sample of female urinal devices.

Figure 10. Pocket urinal.

Figure 11. Urinal with integral tap.

Figure 12. Urine directional aid.

Urinary sheaths


Sheaths, also known as male external catheters (MEC), look in appearance similar to a contraceptive condom (Figure 13). These devices are soft, flexible sleeves designed to fit over the penis and can be attached to a urinary drainage bag or valve. It is vitally important that healthcare professionals are competent in assessing the need for a sheath and have the skill and expertise in applying correctly and passing this knowledge on to individuals (Yates, 2019b). They are available in different materials, sizes, adhesive and non-adhesive, with or without applicators, and have different features such as anti-kinking, anti-blow off to assist drainage (Smart, 2014; Macauley et al, 2015). To use a sheath, individuals should have good dexterity, some degree of penile length, and usually moderate-to-severe urinary incontinence. They may be unsuitable for individuals with confusion, retracted penis, urinary retention or large glans, and narrow penal shaft due to ill fitting (Smart, 2014; ICS, 2017). The main disadvantage of sheaths is that they sometimes fail to stay in place, which is usually due to incorrect sizing or fitting.


Figure 13. Types of urinary sheaths. 

Pubic pressure device  


If a sheath is not suitable due to penile retraction, a form of body worn device such as a pubic pressure device may be used (Figure 14). These devices are usually made from latex and require initial assessment and fitting by a specialist.  

They are suitable for men (Yates, 2019b):  
  • With a retracted penis  
  • With moderate-to-heavy urinary loss  
  • With urinary urgency/frequency  
  • Who prefer a body worn device rather than pad products  
  • With the ability to be mobile/sit in a chair, as they do not work well in a lying position.  

Figure 14. Sample of a pubic pressure device. 

Penile compression clamps  


Although these can be used for urinary incontinence, they are not usually available on prescription so less commonly seen. They are designed to prevent leakage by compressing the penile urethra (Yates, 2019b) and are used mainly for individuals with stress urinary incontinence, rather than urgency, and only for short periods of time (approximately 60 minutes), i.e. for exercise, swimming, going to the theatre etc to prevent reduced penile blood flow and skin damage (Lemmens et al, 2019). 
 

EQUIPMENT/DEVICES FOR FAECAL INCONTINENCE


Containing urinary incontinence can be challenging, but faecal incontinence can be extremely difficult to manage and contain. There are certain devices that may assist patients, however, they need to be adequately assessed before use. These include rectal pouches, anal plugs and transanal irrigation (TAI).
 

Rectal pouches

These are usually adhesive pouches that may be put on to cover the anal canal and collect liquid faeces into the device (Figure 15). They are not suitable for individuals who produce solid faeces or who are mobile. Best results are achieved for immobile bed-bound patients with liquid stool production. There is a risk of skin problems due to adhesive, and especially if the liquid faeces is allowed to be in contact with the skin for some time (ICS, 2017).


Figure 15. Anal pouch system.Anal plugs

Available in two sizes and on prescription, anal plugs are small devices that can be inserted into the rectum to prevent faecal leakage/seeping. They tend to work better for patients with some degree of lack of rectal sensation, i.e. spina bifida, anorectal malformation, rectal sphincter damage (ICS, 2017), as when inserted and come into contact with bowel mucosa they become like a mushroom (Figure 16), and in patients with complete sensation can trigger the feelings of bowel fullness and frequent expulsion occurs. They can be used on a periodic basis, i.e. special occasions, swimming and when taking exercise.


Figure 16. Anal plugs.
 

Transanal irrigation (TAI)


A developing treatment for faecal incontinence, TAI is designed to empty the rectum and up to the descending colon (according to which device is used). By regularly emptying the bowel in this way, TAI is intended to help re-establish controlled bowel function and enable the user to choose the time, frequency and place of evacuation (Emmanuel et al, 2013; National Institute for Health and Care Excellence [NICE], 2018). In patients who have faecal incontinence, efficient emptying of the distal colon and rectum means that new faeces do not reach the rectum for an average of two days, preventing leakage between irrigations (Henderson et al, 2018; Yates, 2019c).

Before starting TAI, full assessment of the individual should be carried out. TAI has benefits, e.g. it is simple, reversible and minimally invasive, consistent regimen with regular bowel motions, can reduce faecal leakage and individuals can choose time/place of evacuation. However, there are also complications, including worsening of faecal incontinence in some individuals due to the possibility of leakage via irrigation fluid or increased bowel motility (Henderson, 2018; Yates 2019c). Other side-effects or consequences that have been noted are sweating, chills and general discomfort (Henderson et al, 2018; Yates, 2019c).

The device used will vary with what is required by the individual and can range from low volume (Figure 17) to high volume water devices (Figure 18).


Figure 17. Low volume TAI device.


Figure 18. High volume TAI device.

Practice point


Low volume devices usually do not hold more than 250mls of water and are used mainly for individuals who present with passive faecal soiling, post defaecation soiling and low anterior resection syndrome. High volume devices use more than 250mls of water and are used in individuals with obstructive defaecation syndrome, constipation, dominant irritable bowel syndrome, idiopathic constipation, neurogenic bowel and faecal incontinence. (Henderson et al, 2018; Yates 2019c).

PAD CONTAINMENT PRODUCTS


Pad containment products have specifically been left until last to discuss, as they are for all previously discussed forms of incontinence apart from urinary retention. Pad containment products vary between two ranges, namely reusable washables and single-use absorbent disposable pads (Fader et al, 2020).

Washables come in the forms of reusable pants/knickers and bed/chair protectors. These usually have a lower absorbency range are not suitable for faecal incontinence. These products are not ideal for individuals with moderate-to-severe incontinence, as they must be able to launder these products between uses.

Single-use absorbent disposable pads have been defined as ‘those that have been specifically developed to help manage leakage or soiling’ (Fader et al, 2020).These products come in a range of brands, sizes, shapes and absorbencies and are generally considered to be unisex. The manufacturer’s instructions should be followed with regards to measuring of products, fitting, storage and use of barrier products (Soliman et al, 2016).

They are usually available via the NHS only after a complete continence assessment has been undertaken by a competent healthcare professional in continence care. The use of a two-piece system (pad and net pants) must be promoted where possible. These designs are considered to have more defining features (Fader et al, 2020, ACA 2021), such as being unisex, having leg cuffs which improve fit, adhesive back strip or wings to help secure in place, and wetness indicators. They are also thought to be more dignified than using an all in one product if not clinically required. For individuals where this is not appropriate, the use of alternative styles may be necessary. Belted, wrap-around, or pull-on products should be limited for patients who are able or capable of being toileted/using a toilet, or for men with heavy incontinence, particularly at night or where two-piece designs are not easily useable (e.g. for some people with dementia) (Association for Continence Advice [ACA], 2021). For individual areas of the UK, NHS services will have their own specific criteria for issuing pad products, so please see local criteria.

CONCLUSION


As continence is a variable and complex condition, so must the range of equipment, devices and products available to contain it be varied. Healthcare professionals tend to opt for what they know best, which is usually pad products. However, there is a whole range of other equipment and devices which may be more appropriate and suitable for some individuals and improve not only their quality of life, but also their independence and self-care. Clinicians have a duty to know what is available and advise patients accordingly. They need to understand when a device/product is suitable, where to obtain regular supplies, and if it is available via prescription.

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This piece was first published in the Journal of Community Nursing. To cite this article use: Yates A (2021) Clinical skills. Part 4: Management with appropriate devices/products. J Community Nurs 35(6): 20-26 

 



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