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338
shape design, the thick rectangle gave way to a more ergonomic, hourglass shape
[12, 13] and nally, in 1978, the rst adult disposable brief (diaper) was introduced
in the United States.
15.2.4 Superabsorbent Polymer (SAPs) Technology
In 1984, a signicant advancement occurred that revolutionized diaper technology
with the introduction of sodium polyacrylate, the rst superabsorbent polymer
(SAP). SAPs are capable of absorbing and retaining extremely large amounts of
liquid relative to their mass, up to 300 times their weight. As the result of introduc-
ing the SAP core, the diaper design became thinner despite the ability to absorb 50
times the amount of urine than its predecessors plus, drastically reduced ‘overow’
leakage from diapers from 10% to less than 2%. Furthermore, a novel wicking sys-
tem enabled the uid within the diaper to be drawn toward the central core, main-
taining dryness near the body and effectively separating urine from feces thereby
reducing the risk for irritant contact dermatitis [13]. Consequently, the initial intro-
duction of adult high-performance briefs featuring this technology made their debut
in the market in 1985.
15.2.5 Spiral-Shaped or “Curly” Fiber
In 2010, researchers continued their efforts to enhance diaper design by incorporat-
ing breathable side panels to reduce skin occlusion and overhydration. They also
utilized spiral-shaped ber (referred to as “Curly” ber; Hartmann, Rock Hill,
South Carolina) within the upper layer of the absorbent core in incontinence briefs
or pads to maintain a skin-friendly pH.This plant-based cellulose ber was found
to lower the skin’s pH when exposed to an alkaline solution (similar to urine or
feces) compared to industry standard briefs [14, 15]. In a study by Bliss etal. [15],
the spiral-shaped ber brief design was compared to standard briefs on the forearms
and inner thighs of 26 older long-term care (LTC) residents. The optimized spiral
ber design effectively lowered cutaneous pH even when wet with an alkaline sub-
stance. Additionally, Beguin et al. [14] applied the skin-adapted design to LTC
patients with pre-existing irritant contact dermatitis due to incontinence lesions for
21days, resulting in complete resolution of skin lesions in 75% of the 12 patients,
while reducing the severity index in the remaining cases. Studies conrm excessive
moisture and exposure to alkaline urine or stool elevate skin pH and pose a risk fac-
tor for irritant contact dermatitis due to incontinence as well as pressure injury [16,
17]. Although limited, studies suggest that combining highly breathable side panels
with an acidic skin surface pH using spiral-shaped ber technology may help pre-
vent or mitigate the severity of irritant contact dermatitis due to incontinence [14,
18] and reduce the incidence of pressure injury in those at risk. See Chap. 14 for an
in-depth discussion of irritant contact dermatitis due to incontinence in individuals
with fecal or double (urine and stool) incontinence.
J. Ermer-Seltun and K. Borchert
339
15.3 General Categories andDesign ofSingle Use
Absorbent Products
In general, hygiene absorbent products are meant to either protect surfaces or the
incontinent individual. In addition, they are categorized as reusable (washable) or
disposable (single use). Disposable absorbent products have the notable disadvan-
tage of producing 20 times more solid waste than washable products. Interestingly,
utilization of absorbent hygiene products (AHPs) by newborns and adults in
Australia was projected from 2020 to 2030, indicating that adult AHPs waste will
comprise 4–10 times that of infants by 2030, attributable to an aging demographic
[19]. The biodegradability of soiled absorbent products in landlls may be ham-
pered by the 20% non-biodegradable material included in their average composi-
tion, which includes 60% urine and feces by mass [19]. In addition, Velasco etal.
[20] conducted a literature review on the estimation of AHP waste in various coun-
tries, as well as the management alternatives and environmental impact of AHPs. It
was noted waste management in industrialized countries often involves landlling
and incineration, however, in undeveloped countries, it is often disposed of in
dumpsites and landlls. Life-cycle analyses show considerable environmental
impacts during raw material manufacturing, whereas end-of-life scenarios such as
incineration and landll contribute signicantly to global warming [20]. As result,
there is signicant concern regarding the detrimental health and environmental
impact of disposable AHPs lling landlls which take an estimated 500years to
biodegrade according to the U.S.Environmental Protection Agency [21]. Moreover,
the impact has created a signicant interest in incorporating sustainable practices by
reducing waste, recycling, and reusing items that could serve a future purpose [20].
For example, a Taiwan recycling plant developed an onsite washing machine poten-
tially for acute and long-term care facilities that sanitizes and processes used
BWAPs to create 220 pounds of reusable raw materials in 1h that could be used for
construction materials and highways [12]. Other novel technologies to remediate
AHP waste have been put forth and tested in experimental settings, such as the use
of enzymes, fungus, dark fermentation, and combustible pellets to degrade
waste [20].
Nevertheless, it’s important to recognize that each choice, disposable or reus-
able, comes with its own set of challenges. Reusable briefs are currently not recom-
mended for long-term care due to the labor intensity, potential for fecal staining, and
the need for laundry facilities to prevent cross-contamination nor for community-
dwelling individuals with fecal incontinence that goes beyond light smears that
stain [5, 22]. Table15.1 outlines the advantages and disadvantages of disposable
versus reusable products.
Terminology Use for Disposable Design
Terminology to describe single-use absorbent products differs in the literature due
to culture, country, and marketing information provided by industry suppliers, mag-
azines, and social media. The preferred terminology to describe single-use absor-
bent products for this chapter will reect the results of International Continence
15 Absorbent Products: Types, Selection, andPros andCons
340
Table 15.1 Disposable versus reusable characteristics
Product Type
Advantages
Disadvantages
Disposable Less cost initially
Convenient, great for
travel
Ease of use
Better for heavy UI
*
May have wetness
indicator
May use for Fecal
incontinence
Fewer issues with irritant
contact dermatitis
Caretaker ease
Long-term more cost
Environmental concerns, landlls
Storage area needed
Aesthetics issues
Noise, elastic edges
Lack of industry standardization
Reusable Less cost over time
Softer on skin
Looks more like
underwear
Best for light to
intermittent UI
Best for home use
High initial cost
Less absorbent
May feel or look bulky
More issues with irritant contact
dermatitis
Environmental issues with laundering
Labor intensive; rinse out before
laundering
Not appropriate for use in long-term
care
Not recommended for heavy
incontinence
Not recommended for fecal
incontinence
Printed with permission with WEB WOC
®
Programs, Minneapolis, MN
a
Urinary incontinence disposable and reusable BWAPs
Society’s (ICS) appointed working group of incontinence experts to provide pre-
ferred terms to facilitate comprehension and dialogue among clinicians, research-
ers, caregivers, and end users [6]. The ICS’ report described seven product design
categories along with an acceptable alternative term: (1) pads; (2) unbacked pads;
(3) male pads; (4) male pouches; (5) pull-on pads; (6) all-in-ones; [7] belted pads
[6]. Obviously, some product categories are not suited for those with fecal or double
incontinence (i.e., male pads or pouches), thus will not be discussed further. See
Table15.2 for dening and variant characteristics of each design category.
15.3.1 Terminology Use forDesign Feature
While single-use BWAPs fall into several design categories, they do share common-
alities in design features agreed upon by the ICS work group such as topsheet,
acquisition and distribution layer, absorbent core, backsheet, fasteners, elastication,
and leg cuffs [6]. Table15.3 denes each of these common features.
J. Ermer-Seltun and K. Borchert
341
Table 15.2 Central and variant characteristics of each absorbent product design category
Preferred
term
Central characteristics
Variant characteristics
Pad An absorbent product with a waterproof
backing that is secured in place with
separate, form-tting underwear, either
conventional or specically made
Products can be disposable or
reusable
Although products can be used by
either sex, some are designed
specically for men or women
based on factors including color,
style, shape, or the location of
absorbent material
Products have varying capabilities
for absorption
To enhance t, comfort, and stop
leaks, leg cuffs on either side of the
crotch and longitudinal elastic side
barriers may be added
Disposable versions may have a
wetness indicator
Disposable versions may have an
adhesive strip on the back or
adhesive wings to the sides to help
secure them in underwear
Products may or may not be
appropriate for both fecal and
urinary incontinence containment
Unbacked
pads
To increase absorbent capacity, a
disposable, absorbent, ow-through pad
(without waterproof backing) is placed
inside the primary body-worn absorbent
product (BWAP), such as a pull-on, or
all-in-one. It also can be secured by
placing into form-tting underwear that
has a waterproof pad region
After it gets wet, it may be taken off
without having to swap out the main
BWAP
Both sexes can utilize the products
To better t the wearer, products
may be curved or rectangular
Products have varying capabilities
for absorption
Products may or may not be
appropriate for both fecal and
urinary incontinence containment
(continued)
15 Absorbent Products: Types, Selection, andPros andCons
342
Table 15.2 (continued)
Preferred
term
Central characteristics
Variant characteristics
Pull-on
pads
(Protective
underwear)
A device that looks like ordinary
underwear and combines an absorbent
core, waterproof backing, and a way to
secure it in place. A tight t is facilitated
by elastic linings around the hips and
waist
While products can be used by
either sex, some are designed
specically for men or women
based on factors like color,
appearance, or the location of
absorbent material
Products are made to t a range of
body sizes and have varying
absorption capabilities
To enhance t and comfort and stop
leaks, leg cuffs on either side of the
crotch and longitudinal elastic side
barriers may be added
Side seams in certain patterns can
be easily removed by tearing them
away
Wetness indicators may be present
in products
Products may or may not be
appropriate for both fecal and
urinary incontinence containment
Adapted from Fader etal. [5]
Images printed with permission of the International Continence Society; Source is Fader etal. [5]
Table 15.3 Common product design features
Feature Description
Top sheet Soft web or porous lm in direct contact with the skin that quickly
wicks away moisture from the skin to keep it dry
Acquisition and
distribution layer
Nonwoven wicking layer made of synthetic or modied cellulose
bers that serves to quickly absorb and disperse moisture from the skin
into the absorbent core
Absorbent core Central layer made of superabsorbent polymers (SAP) and cellulose
uff pulp designed to absorb and retain uids evenly throughout the
core
Backsheet The outermost layer, made of a waterproof or water-resistant material,
that prevents uids from seeping out. Often includes varying degrees
of breathability to improve airow and maximize the microclimate
between the skin and the absorbent product
Fasteners The use of hook-and-loop fasteners (Velcro) or tape tabs (single-use or
resealable) as a method to secure all-in-ones or pads onto an
undergarment. Resealable fasteners allow for easy adjustment to
ensure a snug t to reduce risk of leakage and provide comfort
Elastication Highly elastic materials composed of polymers (spandex or rubber)
that return to original shape after being stretched used in leg gathers,
waistbands, and side panels to allow a snug and secure t that adapts
to the wearer’s body movements and changes in size
Leg cuffs Elasticized sections located at the leg openings of pull-ons or
all-in-ones designed to provide a snug t around the legs to prevent
leakage
J. Ermer-Seltun and K. Borchert
343
15.3.2 BWAP Performance Standardization
In addition to having distinct design categories, manufacturers offer BWAPs in a
wide variety of sizes, styles, and absorbencies, to name a few, to accommodate
users’ needs with varying degrees of incontinence. For instance, the absorbency
capacity of disposable BWAP can be found using one of three widely accepted
industry standards. First, the re-wet test gauges a product’s capacity to hold onto
moisture while being compressed. Second, the absorptive capacity test determines
how rapidly a product acquires a specic amount of uid, and lastly, the total absor-
bent capacity test (International Organization for Standardization [ISO] standard
11948-1) determines how much uid a pad can absorb. The outcome of these tests
determines between light, moderate, and heavy absorbency levels [23]. Furthermore,
gender-specic products exist that dene the position of crucial absorbency, also
known as the landing zone for superabsorbent polymers (SAPs). Females evacuate
urine between their thighs, so SAPs land in the crotch, but males ow outward, with
SAPs landing in front of the BWAP.Consumers have signicant challenges since
the performance criteria of BWAPs are hindered by a lack of guarantee that the
product will offer a sufcient degree of absorption without leaking, especially feces,
as well as a lack of manufacturer uniformity.
15.3.3 Standardization ofAbsorbent Products
Since it is difcult to compare brands without established baseline standards, the
National Association for Continence (NAFC) formed a panel of continence experts
and important stakeholders in response to the lack of standardization of all absor-
bent product types [24]. As a result, the panel produced nine detailed recommenda-
tions for minimum performance standards that go beyond the total absorption
capacity (outlined in Table 15.4) in hopes of creating a quality and performance
benchmark for manufactures, minimize fraud, waste, or abuse by product suppliers
[24]. Moreover, buyers of standardized products including end users, group pur-
chasing organizations (GPOs), state assistance programs, will be better informed on
which products to buy and purchase value [24]. Familiarity with these design cate-
gories, features, and performance standards may aid the advanced practice nurse
(APN) in assisting consumers to determine the best option for absorption, t, ease
of use, comfort, aesthetics, nancial burden, and environmental impact.
15 Absorbent Products: Types, Selection, andPros andCons
344
Table 15.4 Recommended performance standards in disposable absorbent products
Denition of terms
Signicance
Standards
Rewet rate: ability to
withstand multiple
incontinent episodes between
changes
Quanties efciency of the
product’s wicking action
Assesses product capacity to
absorb and hold uid over
time
Essential feature in skin
protection by preventing the
skin from being “rewet”
Light/Moderate incontinence:
Standard Briefs <2.0g
Standard underwear <1.0g
Heavy/Severe incontinence:
Premium briefs <1.0g
Premium underwear <0.5g
Rate of acquisition (ROA):
speed at which urine is
wicked, or drawn away from
the skin
One function of multilayer
construction
Measures strength of wicking
action; the amount of time for
a product to absorb a given
amount of uid
Light/Moderate incontinence:
Standard Briefs <60 secs.
Standard underwear <45 secs.
Heavy/Severe incontinence:
Premium briefs <50 secs.
Premium underwear <35 secs
Retention capacity: capacity
to hold uid without leaking
or rewetting the skin
Standard test for measuring is
centrifugation- spinning out
interstitial uid trapped
between the layers of the
product
Light/Moderate incontinence:
Standard Briefs >250g
Standard underwear >250g
Heavy/Severe incontinence:
Premium briefs >400g
Premium underwear >400g
Breathable zones: required
for an acceptable minimum
“air ow”
Background: ability for air to
ow through a fabric is air
permeability. Fabrics with
high air permeability tend to
have high moisture vapor
transmission rates
A nonbreathable plastic outer
layer or pant is heavily
discouraged due to its
negative impact on skin
health and contributes to
odor-causing bacteria
The Frazier Differential
Pressure Air Permeability Test
with minimum value >100
cubic feet per minute (cfm) is
recommended for determining
the quantication of this
feature
Sizing and sizing option:
measure the larger of the
waist or hip circumference if
available, otherwise base size
on weight
Having different sizes to
accommodate different body
types and mass optimizes t
and reduces leakage
Fit contributes to comfort and
reduces risk of pressure in
folds
Options:
Youth (80-120lb), Small
Adult (110–150lb), Medium
Adult (140-190lb), Large
Adult (180-250lb), Extra-
large Adult (240–300lb),
XX-Large Adult (250–300lb)
and Bariatric (>300lb)
Absorbency levels: choice
among products that
addresses a range of severity
of incontinence
Categories of absorbency
ratings that differ in total
retention capacity by 20%
Optimize cost efciency in
product usage, increase skin
health, and reduce product
waste
Nighttime product use may
require heavier absorbency
Light incontinence: minor
dribbling or slight leakage
with straining
Mediate incontinence: usually
ambulatory or self-toilet but
cannot always avoid an
accident
Heavy incontinence: Lack
bladder and/or bowel control
completely
(continued)
J. Ermer-Seltun and K. Borchert
345
Table 15.4 (continued)
Denition of terms
Signicance
Standards
Safety: none of the
components in the absorptive
product, including additives,
can be listed in any federal
regulatory agency as “unsafe”
Absorptive products must
follow federal regulations of
a medical device
Vendor policy required to
ensure compliance with this
federal regulation
Presence of a closure system:
to allow for multiple
fastening and unfastening
Promotes better t
Relevant only for briefs and
protective underwear and
allows for some exibility in
a range of accommodating
various body types
Presence or absence of a close
system
Elasticity: relevant to
product’s ability to deliver a
gentle, nonbinding t
Not a critical characteristic
This can be a crucial
component for persons with
diarrhea or chronic loose
stools
Leg Elastic Contraction Test:
minimum percentage delta
value is 100% (subtract
unstretched length from the
stretched length and then
dividing the difference by the
unstretched length as the
divisor)
Adapted from Muller and McInnis [24]
15.4 Absorbent Products Effects onPerigenital Skin
Wearing dry and wet reusable and/or disposable absorbent product has been shown
in numerous studies to impact skin wetness levels, which in turn affects the skin’s
coefcient of friction, sensitivity to abrasion damage, permeability, pH, and support
for microbial growth [14, 18, 25–34]. Reusable absorbent product performance has
been shown to be inferior to disposable products regarding maintenance of optimal
skin health [14, 25, 27, 35]. Overhydration of the skin is well known to impair the
barrier function of the stratum corneum’s “brick and mortar” structure. The effects
of alkaline moisture sources such as urine, stool, or both on skin health and patho-
physiology of irritant contact dermatitis due to incontinence are outlined in Chap.14.
Of importance to this chapter, the presence of feces, especially if liquid, in a com-
promised alkaline environment increases fecal enzymes (proteases, lipase) activity
and expedites the breakdown of the stratum corneum [36]. Furthermore, skin mois-
ture levels can worsen during occlusion due to the increased heat generated by using
an occlusive absorbent pad, all-in-one or pull-on. As a result, it causes excessive
sweating, increases transepidermal water loss, then a subsequent rise in skin pH,
which further disrupts the lipid-protein matrix of the skin [18]. This may be suf-
cient to cause moisture-associated skin damage (MASD) and an environment con-
ducive to microbial overgrowth [31, 33, 34, 37]. Although limited, studies also
conrm skin hydration is elevated even if the BWAP remains dry [31, 38]. The co-
efcient of friction (drag-friction between two surfaces) is enhanced in skin overhy-
dration thereby increasing the risk of dermal abrasion.
15 Absorbent Products: Types, Selection, andPros andCons
346
Materials used in adult briefs, especially when they become wet, can create more
friction against the skin leading to a higher risk of skin irritation and abrasion.
Friction is widely acknowledged as one of the leading causes of contact dermatitis
and an important factor in determining textile comfort in personal hygiene products
[37, 39]. Soft nonwoven materials with a lower friction coefcient are preferred by
manufacturers because BWAPs need to conform snugly against the skin to avoid
leaks while still feeling comfortable, preventing chafng, especially along leg gath-
ers and skin irritation. As discussed previously, BWAP with spiral-shape ber tech-
nology and breathable side panels can mitigate some of the negative effects of
occlusion by reducing surface heat and normalizing skin pH [14, 18]. Modern SAP
technology and design used in today’s top absorbent product brands is clearly linked
to better skin health. This includes balanced skin hydration & pH, and enhanced
breathability of the perigenital skin, all of which lead to better performance and a
decrease in the frequency and severity of irritant contact dermatitis due to inconti-
nence [14, 18, 32].
15.5 Selection ofBody-Worn Absorbent Products
15.5.1 Wound Ostomy Continence Nurses Society’s™
Consensus Conference
With a plethora of BWAP options, APNs advising individuals, families, healthcare
facilities, and GPOs on which absorbent product to use can be overwhelming. The
good news is that the Wound Ostomy Continence Nurses Society (WOCN
®
) offers
the BWAP Guide, a user-friendly tool based on scientic proof and consensus, free,
and it is easily accessible on any information technology device such as a mobile
phone [40]. This easy tool walks the clinician through an array of questions, culmi-
nating in an individualized, evidence-based, rst- and second-line recommendation
for a BWAP for the adult with light, moderate/heavy fecal, urinary, or double incon-
tinence [40]. Plus, the tool offers additional insights on BWAP assessment, use,
perigenital skin care, evaluation parameters, and indications for referral.
15.5.2 Body Worn Absorbent Product Guide
(BWAP) Development
The BWAP Guide development was based upon a scoping literature review per-
formed by a WOCN
®
Society supported task force and consensus conference panel
of continence care nurse experts to create and validate evidence-based statements
on the selection, use, and evaluation of BWAPs. The outcome of this consensus
conference generated 45 consensus-based statements, with 16 statements derived
from an extensive research review by Cottenden and colleagues [41] related to the
use of incontinence containment products reported in International Consultation on
Incontinence (ICI) and International Continence Society (ICS) textbook and 29
J. Ermer-Seltun and K. Borchert
347
statements from the task force’s scoping review [42]. Content validation of 45 con-
sensus statements underwent a second cycle of content validation by a different
panel of nurse experts to strengthen the validity of the best practice
recommendations.
The task force noted that the scoping literature review and consensus conference
revealed signicant gaps in evidence and especially product development for indi-
viduals with fecal incontinence to guide BWAP selection, use, and evaluation, with
most studies and absorbent products focusing on uid (urine) absorption rather than
fecal containment, especially solid feces [42]. Since many individuals with fecal
incontinence also have urinary incontinence, product selection will include recom-
mendations for double incontinence. Table15.5 highlights evidence and consensus
statements from the electronic WOCN
®
BWAP Guide selection for light fecal
incontinence, moderate to heavy fecal, urinary, or double incontinence during the
daytime or nighttime in ambulatory or non-ambulatory males or females.
15.5.3 Assessment Considerations
A study by Sacco etal. [44] demonstrated the importance of a thorough assessment
to nd the most appropriate type of absorbent product for the level of incontinence.
A total of 14,493 individuals from ve continence centers had a baseline evaluation
of the current absorbent product prescribed and subsequently participated in a 48-h
pad weigh test and bladder diary. A continence specialist then evaluated whether the
level of absorbency of the product was acceptable for the actual level of leakage
experienced by the individuals. Interestingly, 60% of the products were determined
to be inappropriate. Most products (75%) were deemed unacceptable due to being
too large. Without an objective assessment, patients are typically given inappropri-
ate absorptive products with excessive capacity [44]. While this study focused just
on UI, the signicance of the ndings sheds light on the importance of doing a
thorough evaluation when choosing BWAPs. Therefore, optimal selection of any
absorbent product begins with a thorough assessment of the individual to obtain the
best match between the user and product. According to the WOCN
®
consensus
panel, the following factors need to be considered [42]:
• Type, severity, and timing of incontinence—fecal, urinary, or double; light or
moderate to heavy; day or night. Quantications of incontinence as light (<
100mL), moderate to heavy (>100mL) was based on urinary volumes; fecal
incontinence was less dened.
• Gender: location of the maximal absorbency (landing zone) differs as well as
preferences in design.
• Body habitus, due to lack of product-sizing standardization between manufac-
tures, choose measurement of inches or centimeters as sizing indicator. Waist or
hip circumference in inches/centimeters should be used as a reference to deter-
mine product size; whichever is larger. If these cannot be measured, use body
15 Absorbent Products: Types, Selection, andPros andCons