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348
Table 15.5 Selection guide for body-worn absorbent products
User characteristics and type of incontinence Design features
Daytime
Ambulatory people, regardless of gender with
light fecal incontinence
First-line recommendation: disposable cotton
gauze dressing or an absorbent buttery-
shaped pad with gentle adhesive strips placed
against the anus that is held in place between
the buttocks
Consider the use of a pull-on or all-in-one
design if absorption inadequate
Ambulatory men and women with moderate
to heavy fecal or double incontinence
First-line recommendation: disposable pull-on
pad with superabsorbent polymer technology
(SAP)
Consider disposable all-in-one design for both
genders if heavy liquid stools
Alterative recommendation for WOMEN:
disposable pad with close-tting underwear
especially if feces is more solid
Alternative recommendation for MEN:
disposable all-in-ones with SAP technology
Night-Time
Ambulatory or nonambulatory men with
moderate to heavy fecal or double
incontinence
First-line recommendation: disposable
all-in-ones with SAP technology
Consider use of backless pad inside all-in-ones
to maximize containment and minimize sleep
interruption
Ambulatory women with moderate to heavy
fecal or double incontinence
First-line recommendation: disposable pull-on
pad with technology SAP
Nonambulatory women with moderate to
heavy fecal or double incontinence
First-line recommendation: disposable
all-in-ones with SAP technology
Consider use of backless pad inside all-in-ones
to maximize containment and minimize sleep
interruption
Adapted from Gray etal. [42] and Continence Product Advisor [43]
Images printed with permission of the International Continence Society; Source is Fader etal. [5]
J. Ermer-Seltun and K. Borchert
349
mass index (BMI) as a sizing reference. Note the limitation in BWAP designs for
morbidly obese individuals.
• Mobility: ambulatory, assistance with transfers, bed-bound determines toiletabil-
ity and the ease of donning and dofng of a BWAP independently or per carer.
• Dexterity: ability to apply and remove BWAP and clothing independently.
• Cognition: use validated instrument, if impairment suspected, absorptive product
should normalize the toileting experience, facilitate toileting program, reduce
agitation, enhance safety and dignity.
• Perigenital skin health: presence of irritant contact dermatitis due to inconti-
nence, friction, pressure injury, cutaneous infection; need for a structured skin
care program or referral; avoid the overuse of occlusive skin protectants which
may affect BWAP absorption capability [45–48].
• Care setting: home, acute or long-term care may affect design elements.
• Caregiver: availability, functional status to position user, apply, remove, and
manipulate BWAP.
• Preference and acceptability: goals of care, consider multiple designs to accom-
modate different circumstances (home versus out of the house), aesthetics, cost,
economic impact, laundering availability.
• Educational needs: how to obtain, use and care of BWAP, sizing, use of inconti-
nence supplier, and need of structured skin care regime.
15.6 Recommendations forLight Fecal Incontinence
As stated previously, studies and evidence focusing on the containment needs of
those with fecal incontinence are scarce, therefore, it is difcult to make strong
recommendations for containment [22, 35, 42, 49, 50]. However, there are some
manufactured products (Fig.15.1) specically designed for light fecal incontinence
(e.g., feces/mucous stays trapped between the buttocks without underwear soiling)
to be placed over the anus to absorb anal seepage of feces or mucous that are accept-
able to some individuals [4]. In a survey of 189 community-living individuals with
fecal incontinence, Bliss and colleagues reported that 45% used an absorbent prod-
uct to manage fecal incontinence, with most users (63/189) wearing pantiliners and
disposable briefs and underwear worn by the fewest (13/189) [4]. Individuals have
been reported employing creative solutions to absorb anal seepage, which may or
may not promote perigenital skin health such as toilet tissue, cotton balls, small
gauze, a cosmetic pad, or a paper towel between the buttocks [4].
Current rst-line recommendation for light fecal incontinence in ambulatory
individuals regardless of gender is to place an absorbent buttery-shaped pad with
gentle adhesive strips or cotton gauze dressing against the anus that is held in place
by the buttocks. If containment is inadequate, consider the use of a pull-on [42].
15 Absorbent Products: Types, Selection, andPros andCons
350
Fig. 15.1 Buttery-
shaped pad for light fecal
incontinence. (Image
printed with permission of
the International
Continence Society;
Source is Fader etal. [5])
15.7 Recommendations forModerate-to-Heavy
Fecal Incontinence
Fader and colleagues [35] conducted a systematic review and meta-analysis of
body-worn absorbent products for moderate-to-heavy fecal, urinary, or double
incontinence in women and men. Two studies were discovered. The rst study
included 85 British community-dwellers (49 women and 36 men) in a randomized
crossover trial of four disposable BWAP (inserts kept in place with a mesh brief,
disposable briefs, T-shaped diapers, pull-ons) and one reusable all-in-one (brief).
The second randomized, crossover study included 100 nursing home residents (73
women and 27 men) and used the same four types of disposable BWAP as the rst
study but did not use a reusable all-in-one due to labor intensity in nursing time,
poor staff acceptability, reporting logistics, and laundering constraints [35].
Outcomes of the study established that no single design was superior to other
designs but signicant clinical differences in preferences were based upon gender
and subtle variations between residence (community dwelling versus nursing home)
and if toiletable (the ability of an individual to transfer to toilet or commode with or
without assistance for elimination bowel/bladder). Final recommendations for opti-
mal cost-effective containment are to allow consumers to choose combinations of
BWAP designs (mix and match) for different situations and budgets, i.e., home use
versus out of the household or day versus night [5, 35, 42, 51].
15.8 First-Line Recommendations
Since there is not any evidence to support the use of any specic absorbent design
[5], recommendations will be based upon consensus statements for individuals with
double (urine/fecal) incontinence [42]. Currently, rst-line recommendation for
ambulatory men and women with moderate to heavy daytime fecal, urinary, or
J. Ermer-Seltun and K. Borchert
351
double incontinence is a pull-on with SAP technology [42]. However, if an indi-
vidual prefers an inserted pad design, it would be advantageous to nd a product
with extra protection and extra-wide rear coverage and elastication worn with close-
tting underwear. If the stool is solid, consider adding a ushable liner on top of the
selected product so it could be easily discarded without soiling and changing the
original absorbent product [43]. Additional tips for odor control for those with mod-
erate-to- high fecal incontinence is to use an all-in-one (brief) with plastic outer
covering since this will reduce odor being eliminated as compared to the all-in-one
or pull-on with breathable materials. Moreover, snug elasticating around the leg and
waist will optimize loose stool containment [52]. See Table15.5 for further recom-
mendations depending on day or night-time, gender, mobility, and toileting abil-
ity status.
15.9 Helpful Consumer andClinician Resources
Due to the plethora of absorbent products available, individuals living in commu-
nity settings and who experience urinary, fecal, or double incontinence and caretak-
ers may need assistance in choosing the most suitable containment option. An
exceptional online resource is an interactive continence product advisor website
[43] that provides evidence-based guidance based upon a chapter regarding conti-
nence management products in Incontinence, seventh edition [5] for consumers,
caregivers, and advising nurses at all levels. The International Continence Society,
an international, multi-disciplinary organization for incontinence education and
research, hosts and manages this non-prot website without industry assistance.
The website guides users to options for design, available features, absorbency lev-
els, and t based on their type and level of incontinence. The website offers odor-
control suggestions, water-proof containment solutions for swimming, high-quality
product photos, international supplier lists, how-to videos, brochures, and user-
generated tips. The content is written by continence experts and by product users.
Table15.6 provides general user characteristics, priorities, and contexts which favor
or discourage the use of different BWAP designs for adults with moderate-heavy
fecal, urinary, or double incontinence.
Another exceptional online resource is the National Association for Continence
(NAFC) [52]. It is a private, non-prot organization committed to enhancing the
quality of life for individuals with all types of incontinence, voiding dysfunction,
and related pelvic oor disorders. It provides online educational resources, advo-
cacy, and support for clinicians and the public to help manage these conditions
effectively. NAFC provides insightful counsel when selecting a BWAP for fecal
incontinence as well. Consumers are reminded that absorbent products are designed
for urine absorption, so the goal for users with fecal incontinence is for the product
to “contain” the stool rather than absorb it until they can access a restroom to change
it promptly [52].
15 Absorbent Products: Types, Selection, andPros andCons
352
Table 15.6 User personal preferences or priorities
Containment Ability Capacity of an absorbent product (pad, pull-on, all-in-one) to securely
hold and absorb urine, feces, or both, preventing leakage and
maintaining hygiene
Reliability Consistency in effectively absorbing and retaining urine, feces, or both
without leaking
Discreetness The ability of a BWAP to be worn and used without being noticeable
to others under clothing. Features may include slim prole, quiet
materials, odor control, color, and design
Comfort The sense of Well-being when wearing a dry or wet BWAP.Being
comfortable is often inuenced by fabric softness, thickness, form,
contouring, moisture wicking capacity, and breathability of the product
to promote skin health
Ease of use How simple and convenient it is for the user or caregiver to apply,
adjust, and remove the BWAP
Allergies Individuals with sensitive skin may react to certain materials, such as
latex, dyes, fragrances, preservatives, or specic types of adhesives
Materials Common materials used in absorbent products include polyethylene/
polypropylene (plastics), super absorbent polymers, non-cellulose
bers, woven fabrics, spandex or rubber, adhesive tapes, Velcro, and
fragrance
Aesthetics Visual and sensory appeal of the product including design style, color
and patterns, texture, thickness, and amount of rustle or noise during
movement
Add-on features Additional features may improve overall user experience,
functionality, and comfort of the BWAP including technologies that
neutralize odors, wetness indicators, Bluetooth sensors that transmit
data to SMART phone or other devices, multi-layer absorbent core,
curly bers that enhance an acidic skin pH, quick-dry layers,
breathable outer layers, discreet or printed pattern designs, soft,
comfortable materials, adjustable tabs, eco-friendly options made with
biodegradable materials, antibacterial layers, and double leg cuffs
15.10 Protection ofSurfaces withUnderpads
First-line strategies to protect seating or lying surfaces (bed, chair, sofa, car seat)
from urine or feces in any care setting but especially in acute and long-term is the
use of disposable or reusable underpads (see Fig.15.2). Underpads come in a vari-
ety of absorbencies, sizes, materials/fabrics, and pricing. Plus they may have added
features such as waterproof polyvinyl chloride backing to prevent break through
leakage onto the surface, wings to tuck under a single mattress to hold it in place,
odor control properties by incorporating activated carbon, odor-neutralizing agents,
or antimicrobial additives, variable degrees of softness and thickness for added
comfort, non-slip properties, handles to assist a caregiver in repositioning an indi-
vidual, or color indicators to alert the item is wet. There is a scarcity of research
comparing the performance of disposable underpads [53–55] which hinders the
J. Ermer-Seltun and K. Borchert
353
Fig. 15.2 Underpad to
protect bed. (Image printed
with permission of the
International Continence
Society; Source is Fader
etal. [5])
ability to draw denitive conclusions regarding the efcacy of various product
design components and materials [5].
Disposable and Reusable Underpads
It is important to revisit the advantages and disadvantages of utilizing reusable as
opposed to single-use underpads (see Table15.1). First, consider that the usage of
an underpad typically indicates that the user is incontinent; the lack of concealment
may be a cause for embarrassment. Furthermore, if the underpad is solely used for
the management of the incontinence, it requires the person to be partially naked
potentially compromising their dignity and personhood. The ICI and ICS do not
recommend the use of any type of underpad for the sole purpose of containment
management but only as an adjunct to protect surfaces periodically as needed [5].
Second, consider the impact of underpads on skin health. Motta etal. [56] noted
a statistically signicant reduction of irritant contact dermatitis due to incontinence
in 40 incontinent nursing home residents (n=25 residents with irritant contact der-
matitis due to incontinence, n=15 residents with intact skin) followed for 4weeks
by replacing a disposable brief and nonvapor permeable absorbent underpad with
single-use high-uid capacity underpad. Francis etal. [57] conducted a randomized
control trial in a 711-bed acute care facility to see if there was a difference in the
incidence of hospital-acquired pressure injuries (HAPIs), irritant contact dermatitis
due to incontinence, and length of stay in incontinent adults using a washable (con-
trol group, n=252) versus a single-use absorptive underpads (intervention group,
n=210) on four randomly chosen medical units. The outcomes of the study noted
signicantly less incidence of HAPIs in patients using the absorbent disposable
underpad (5% versus 12%; P=0.02), as well as hospital length of stay (6days vs
8days; P=0.02). No signicant difference was found in irritant contact dermatitis
due to incontinence incidence between the two groups (P=0.22).
15 Absorbent Products: Types, Selection, andPros andCons
354
15.10.1 Environmental Considerations
Lastly, consider the environmental impact or carbon footprint created by disposable
and reusable underpads. Grifng and Overcash [58] conducted a complex life cycle
analysis (soiling, reusable cycles before removal, supply chains, laundry use, and
end-of-life environmental impact) comparing disposable and reusable underpads to
ultimately see which design was more eco-friendly in terms of reducing medical
solid waste and the environmental footprint. The data was obtained from 8 laundries
of reusable underpads and 10 facilities using disposable under pads servicing hos-
pitals and LTC facilities. The results showed that using reusable underpads rather
than disposables reduced overall natural resource energy consumption by 71%,
greenhouse gas emissions by 61%, blue water usage by 57%, and solid waste by
97% [58]. The metric of comfort nor economic measurement was assessed in
the study.
APNs in their healthcare organizations can use this information, together with
the limited research ndings on the impact of underpad designs on skin health, PI
development, comfort, and cost, to make an informed decision about whether to
invest in reusable or disposable underpads for their patient population.
15.11 Evaluation Considerations
In evaluating absorbent product performance and user satisfaction, APNs will need
to consider collectively the effectiveness of containment, dry and wet comfort, odor
control, aesthetics or discreetness, and skin health.
15.11.1 Effectiveness ofContainment
While absorbent products are intended to be used for UI, some individuals may
require a product design for both bladder and bowel leakage. Manufacturers of
BWAP indicate the level of absorbency (based on the Rothwell Method) (see
Table15.4) on the packaging to guide user selection. However, it cannot account for
differences between individual’s habitus, activity levels, or different situations. The
effectiveness of containment products for fecal incontinence alone is even less well
understood [5, 42]. The best counsel is for the user to trial a product based upon a
thorough assessment and evaluate its performance. Changes in design could be
made based upon location of leakage, i.e., leg gathers, near the rear or front. If leak-
age occurs at the leg gathers, a design with increased elastication may improve
containment, if incontinence occurs more to the rear as in fecal incontinence, a
design with extra wide rear coverage may be advantageous or the additional use of
a backless pad (ow through technology) inserted in a pull-on or all-in-one product
for enhanced absorbency for those with heavy fecal and urinary incontinence.
Containment failure of two BWAP after a seven-day trial is an indication for referral
to APN or continence nurse specialist for further evaluation (BWAP Guide).
J. Ermer-Seltun and K. Borchert
355
15.11.2 Comfort
Comfort (Oxford Languages) is dened as a pleasant and satisfying feeling of being
physically or mentally free from pain, discontentment, or irritation. Several studies
[4, 22, 50, 59] found the characteristic of dry or wet comfort to be a measure of
product performance. Product Comfort is often inuenced by a variety of factors,
including fabric softness, thickness, form, contouring, moisture wicking capacity,
and breathability of the product to promote skin health [5, 50, 59]. Given the subjec-
tive nature of comfort, which varies among individuals and is inuenced by per-
sonal preferences, it is important for APNs to evaluate the satisfaction of users in
terms of comfort and offer suggestions on available designs and features which may
improve comfort satisfaction.
15.11.3 Odor Control
One of the main concerns for many incontinence sufferers is the smell of leaking
urine, feces, or gas. Worrying about unpleasant smells might disrupt social interac-
tions, lead individuals to isolate themselves at home, or prompt them to seek profes-
sional help [5]. Hypervigilance can even cause individuals with incontinence to
perceive odors that do not actually exist, known as “phantom odors.” Investigating
an individual’s perception of odor and others’ capacity to perceive odor at close
proximity (<5feet) versus 5feet away may reveal the impact of odor on their psy-
chosocial wellness as well as help alleviate people’s anxieties about real or per-
ceived smell linked with incontinence.
The APN has an opportunity to provide counsel regarding odor control products
to improve the sense of personhood and social connectiveness although there is lim-
ited ability of single-use BWAPs reducing odor from fecal incontinence [4]. Current
evidence notes individuals who experience signicant atus incontinence, all-in-
ones (briefs) with activated charcoal are better able to absorb and conceal the odor
than inserted pads or cushions [60]. APNs could provide counsel on foods and bever-
ages that may induce excess gas or bowel irritability (see Chap. 6). Compelling
research supports the effective use of over-the-counter ingestible products to reduce
excessive and malodorous atus such as probiotics (Lactobacillus plantarum, 1g
Clostridium butyricum MIYAIRI, or 300mg Bidobacteriuongum BB536), enzymes
(a-galactosidase or Aczym), oral charcoal mixtures, or bismuth subgallate [61–67].
Currently, the most effective method for reducing embarrassing odor from fecal
incontinence is to encourage individuals to change soiled undergarments, perform
personal hygiene, and properly discard the soiled product as soon as possible. Plus,
the usage of a room deodorizer eliminator can be an adjunct to ridding foul smells [5].
15.11.4 Skin Protection
Irritant contact dermatitis due to fecal, urinary, or dual incontinence (previously
referred to as incontinence-associated dermatitis) and pressure injury (PI) are two
15 Absorbent Products: Types, Selection, andPros andCons
356
common complications of fecal incontinence, especially if the individual is experi-
encing double incontinence with loose feces [16, 42]. Chapter 14 discusses patho-
physiology, risk factors, skin assessment, prevention and management of both skin
issues, and the vital role of the APN in evaluating skin protection needs.
Skin assessment should be done daily by the individual or carer in areas exposed
to urine and or feces. During APN clinical visits, assess for intact skin, erythema,
denudement, blisters, erosions, pustules or evidence of abrasion from friction, skin
lesions or discolorations over bony prominences or under devices, excoriations,
bright erythema with or without advancing borders, and the presence of satellite
lesions. Educate individuals on a structured skin care regimen to gently cleanse,
protect, and restore perigenital skin health following bladder and/or bowel accidents
(bwap.wocn.org) [68]. It should include the use of a non-irritating surfactant skin
cleanser to gently remove urine and/or stool after each incontinent episode and
application of skin barrier cream or lm-forming product to prevent or treat irritant
contact dermatitis due to incontinence [69–71]. Systematic reviews found no one
skin protectant to be superior to another, but the most important aspect is to use a
skin protectant on a regular basis after an incontinent episode [69–71]. For obvious
reasons, clinicians should prioritize the replacement of soiled BWAPs as soon as
feasible, especially if fecal incontinence [57, 72, 73].
15.11.5 Aesthetics andDignity
When wearing absorbent products, the APN should consider whether the product is
discreet (blends seamlessly with the wearer’s clothing), noise control (absence of
rustling or other noises), comfortable (ts well, soft materials, and does not cause
irritation as described above) and other design features, such as color and pattern to
help normalize the toileting experience and maximize user dignity. However, aes-
thetics should not detract from the absorbent product’s ability to reliably contain
urine and/or stool. Numerous studies over time have shown that the performance
quality of discreetness is a signicant factor in the selection of absorbent products
in addition to leakage resistance [42, 50, 74].
15.11.6 Special Considerations inIndividuals withCognitive
Impairment andMorbid Obesity
Gray etal. [42] recommends that toiletable adults use underwear-type BWAPs dur-
ing the day, such as a disposable pull-on design or an inserted pad in snug-tting
pants. The goal is to normalize the toileting experience for people with impaired
cognition and as a therapeutic strategy to improve toileting program efcacy,
increase safety, reduce agitation, and maintain dignity [42].
Unfortunately, for those who are morbidly obese, there is not a wide range of
BWAPs available, if any at all. The emotional impact (dignity, personhood) and skin
barrier function (skin pH and microclimate), length of absorbent area from front to
J. Ermer-Seltun and K. Borchert
357
back, capacity to have room for abdominal girth and leg size, and skin folds should
be considered when choosing absorbent products for morbidly obese individuals
[75]. The all-in-ones design may offer greater versatility in t than pull-ons since
the refastenable tab system can be snugged or loosened depending upon preference
and body contours. Currently, the largest all-in-one design with stretchable side
panels available accommodates a waist circumference of 108 inches (274.32cm)
and a suggested weight of 250 pounds. Clearly, a call to manufacturers to develop
product lines for those who are morbidly obese (BMI 40.0–49.9kg/m2) or super
obese (BMI >50kg/m
2
) is urgently needed.
15.11.7 Change Frequency andUse
In a cross-sectional survey of 50 hospitalized adults, Fernando and Wagg [76] eval-
uated perceptions between bed-side care providers (RN, licensed practical or voca-
tional nurses, medical assistants) and patients with urine and/or fecal incontinence
on acceptable wait time in a soiled absorbent product before being changed.
Signicant differences in acceptable wait time were reported by patients versus bed-
side providers following a urinary incontinent episode (M: 38 vs 85min, P<0.001)
but no appreciable difference in wait times after a fecal incontinence episode (M: <
15min). Of interest, patients who had been in a long-term care facility prior to acute
care admission demonstrated a higher level of tolerance for waiting longer for a
change of soiled undergarments than their counterparts (OR = 6.2; 95% CI,
1.3–28.1), as well as previously used incontinence products (OR=2.0; 95% CI,
1.0–3.8) or walking aids (OR=4.0; 95% CI, 1.1–17).
The timing of changing absorptive products should prioritize the needs and pref-
erences of the patient, focusing on promoting skin health, controlling odor, facilitat-
ing sleep and elimination patterns while preserving dignity. Additionally, the
decision should consider the specic qualities of the product and should not be
dictated by a schedule or caregiver preferences [42]. Nevertheless, it is imperative
to promptly remove soiled absorptive products after a fecal incontinence episode to
maintain skin health, enhance odor control, and dignity [42, 76].
15.12 Technological Advances
Recent technological advancements in body-worn absorbent products (BWAPs) for
people with urinary and/or fecal incontinence have primarily aimed to enhance con-
tainment efcacy, comfort, odor control, and user satisfaction. Here are some inno-
vations addressing those desirable features:
1. Continued improvements on SAP technology, which can absorb 60 times its own
volume. Inspired by NASA’s maximum-absorbent garment (MAG) design,
which consists of three layers that swiftly wick moisture into a separate layer,
keeping skin dry and comfortable while also providing an odor lock feature. The
15 Absorbent Products: Types, Selection, andPros andCons