Fourth International Consultation On Incontinence (ICI) - Management Using Continence Products Committee Highlights

Main Category: Urology / Nephrology
Article Date: 25 Jul 2008 - 2:00 PDT

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PARIS, FRANCE (UroToday.com) - Dr. Cottenden presented Committee 20's findings for the final session of the day. He presented a brief overview of the different devices for urinary retention, urinary incontinence and fecal incontinence, and he stated that there is some overlapping usage for certain products across these conditions. In general, he stated that the committee evaluated device designs and general categories rather than specific branded products. These products are used by a variety of patients, including those who are not able to be cured, those who do not desire treatment, and those who are awaiting treatment or treatment effect. These types of patients often have the most severe and difficult to treat problems, and these devices can have very positive or negative impacts on the patients' quality of life. The committee defined severity of UI as "light" (median pad weight ~ 20 g/day) and "heavy" (median pad weight ~ 150 g/day). Severity of fecal incontinence is more difficult to quantify for obvious reasons. Dr. Cottenden next presented a laundry list of issues that should be considered when choosing a product for a patient, including issues such as gender, manual dexterity and mobility, independence, laundry/disposal facilities, assisted care and financial situation. Flow chart algorithms for choosing devices for UI and FI were presented and are available in the complete slide set.

Dr. Cottenden next addressed specific categories of devices and described the evidence and factors that promote or discourage use of specific choices. There is Level 3-4 evidence for female urinals. Women with mobility issues, urgency and access to toilet problems would encourage use of these types of products (Grade B-C) recommendation. Ability to stand, crouch, or move forward in a chair are important considerations (Grade B-C). The committee suggested that patients experiment with a variety of products to find one that is preferable.

Recommendations for the use of male urinals were similar to above, with the caveats that the inability to empty the urinal, balance problems, impaired arm reach and wrist function and impaired cognition were factors that would discourage the use of male urinals (Grade C).

One new observational study contributed to Level 3 evidence for the use of commodes in both sexes. Commodes are a good option for any patients with mobility or access problems. They may be less satisfactory in showers (shower chairs preferred), in situations where patients share a room, or in patients at risk for falls (Grade C).

Mechanical devices for light UI in women were addressed. Many products have been introduced and later discontinued over the years and there are numerous observational studies regarding these devices. These devices may be favored when UI is stress-predominant and in patients with good hand dexterity and coginition (Grade C). These devices may be less applicable in women with urge-predominant symptoms and those at risk for UTIs (Grade C). With respect to incontinence pads in women, Dr Cottenden discussed a 2008 clinical trial comparing the four different types of pads for light UI, namely disposable inserts, washable inserts, menstrual pads and washable pants. Grade B/C recommendations were given for factors that promote or discourage use for all types. The disposable inserts were found to be the most effective at controlling leakage, but also are the most expensive. Five different types of products were reviewed as part of the same trial for men and women with heavier degrees of incontinence. Disposable inserts are favorable when discretion is a priority and for ease of use. They may not be as useful in active patients and those with more severe incontinence. Pull-ups were found to be reliable, easy to use and discreet, but they can be expensive and difficult to change at night by a caregiver. Both inserts and pull-ups are preferable in female patients. Disposable diapers are good for men with heavy incontinence but are not discreet. Disposable T-pads are also useful for male patients and reliably contain leakage. Washable diapers are good for male patients and in those with heavy nocturnal leakage, but require laundry facilities and are not discreet.

Dr. Cottenden next addressed devices for male UI. For heavy leakage, Level 3 evidence was presented for penile clamps. These devices are useful for men with stress-predominant symptoms, those who need intermittent use and in patients who prefer to prevent leakage rather than contain it (Grade C). Men with urge-predominant incontinence, manual dexterity issues or those at risk for skin breakdown may be less suitable candidates. The committee found no evidence regarding dribble containers. Data from a 4-armed crossover trial studying four different designs of male incontinence pads for light leakage was reviewed (Level 2 evidence). To summarize, disposable pouches are most useful for those desiring discretion and are not as effective in men with buried penis or with heavier degrees of incontinence. Disposable leaf products are acceptable for general use, and disposable inserts are inexpensive. Washables are also inexpensive and are effective for very light incontinence and with active patients (Grade B-C recommendations). Data regarding different types of condom catheters, or sheaths, was also presented. All recommendations were Grade C including fewer UTIs compared to indwelling catheters (IDC) and more comfortable compared with IDCs. Condom catheters require manual dexterity and decent cognitive function. Products with built-in adhesives are preferred to those with separate adhesives, and sheath applicator systems were unpopular.

IDCs for men and women were reviewed; Dr. Cottenden noted a wealth of evidence, including 6 Cochrane reviews. Catheters are preferred if skin breakdown is an issue, if pads or other devices are ineffective, and in patients unable to perform CIC (Grade C). IDCs are discouraged in patients with a history of urethral trauma (Grade A), at risk for UTIs, and patients with poor cognition.

CIC was briefly discussed and encouraged for use in patients with elevated residuals over IDC. CIC, of course, requires patient or caregiver motivation and manual dexterity (Grade C). Dr. Cottenden discussed the lack of evidence with respect to UTI prevention and catheter type or design.

Drainage bags for catheters were examined, and the committee recommended sterile bags for acute care settings, while the need for sterile bags in outpatient settings is unclear. More research was recommended regarding bag change frequency, use of antiseptics and other care practices in UTI prevention. Body-worn urinals for men with heavy UI were evaluated, and there is essentially no evidence on these devices. The committee made Grade C recommendations that these devices may be preferable to pads for some men and can be useful in ambulatory patients.

Lastly, devices for fecal incontinence were addressed. Pads may be recommended for general use but should be discouraged in those with skin problems. Anal pouches may be favored in acute settings, with liquid bowel movements and in immobile patients (Grade C). 1 RCT exists for anal plugs (Level 2-3 evidence) and were found to be useful in neurogenic patients and periodic use. These devices should be discouraged in patients with a history of autonomic dysreflexia triggered by rectal distention (Grade C). Level 2 evidence was also available for rectal catheters and rectal trumpets. Both devices may be preferred in acute settings and in patients with liquid stools. They are also more useful in bed-bound patients. Rectal catheters in particular may not be useful in patients with rectal/anal stenosis, hemorrhoids, or recent rectal/anal surgery (Grade C). In closing, Dr. Cottenden suggested several areas for further research. More Level 1 evidence is needed to drive clinical practice and patient education programs, especially regarding the efficacy, cost-effectiveness and patient satisfaction with different designs and categories of devices.

Alan Cottenden, MD, Committee Chair

Moderated by Joachim W. Thüroff, MD, and Masaru Murai, MD, at the Fourth International Consultation on Incontinence (ICI) - July 5 - 8, 2008. Palais des Congres, Paris, France.

Written by William Jaffe, MD, a Contributing Editor with UroToday.com

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