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Incontinence products and devices for the elderly

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Incontinence Products
And Devices for the Elderly
Diane K. Newman
M
ore than 7.4 million
people over the age
of 65 are estimated
to have urinary
incontinence (UI). The median
range of prevalence estimates in
elderly women is 30% to 50%.
Aging and medical conditions
such as diabetes, stroke, atrophic
vaginitis, incomplete bladder
emptying, rheumatoid arthritis,
and prostatitis, place an elder
man or woman at increased risk
for UI. These same conditions
can lead to complications of
using products and devices for
managing urine leakage. There
are significant limitations to the
use of these products and
devices especially in elderly
patients. There is a need for evi-
dence-based research and clini-
cal protocols on the use of prod-
ucts and devices to manage, col-
lect, or contain UI (Newman,
2003). However, in many elderly
patients, they offer the only
option in the management of UI.
Absorbent Products
Absorbent incontinence prod-
ucts include a variety of designs:
(a) perineal pads or panty liners
for slight or light incontinence, (b)
undergarments and protective
Diane K. Newman, MSN, RNC,
CRNP, FAAN, is the Co-Director, Penn
Center for Continence and Pelvic
Health, University of Pennsylvania
Medical Center, Division of Urology,
Philadelphia, PA.
Note: CE Objectives and Evaluation
Form appear on page 334.
Devices and products to contain or collect the urine are part of the
management of bladder dysfunction, particularly urinary inconti-
nence (UI) (Newman, Bliss, & Fader, in press). The aim of continence
nurse experts and those who care for incontinent individuals during
the past decade has been to greatly decrease the indiscriminate use
of absorbent pads and garments, external collecting devices, and
indwelling catheterization, through the successful treatment of uri-
nary incontinence (UI) with behavioral interventions, drug therapies,
and new surgical procedures. However, these products and devices
can be beneficial for persons who are elderly, fail treatment and
remain incontinent, who are too ill or disabled to participate in behav-
ioral programs, who cannot be helped by medications, or who have a
type of UI that cannot be alleviated by other interventions (Newman,
2003). The judicious use of products to contain urine loss and main-
tain skin integrity is a first-line defense for these patients (Fantl et al.,
1996). Urinary collection devices and products that are appropriate
for elderly patients, that are used by nurses in all clinical settings, and
are available at local pharmacies, retail stores, medical equipment
dealers or directly from manufacturers are discussed.
underwear for moderate to heavy Pettersson, Fader, Cottenden, &
leakage, (c) guards and drip col- Brooks, 2004; Dunn, Kowankop,
lection pouches for men, and (d) Paterson, & Perry, 2002), most of
adult briefs (diaper-style prod- the products evaluated in this
ucts) for moderate or heavy research are not comparable to
incontinence (Newman, 2002). products available in the United
Figure 1 shows the type of States.
absorbent product with their Unlike feminine hygiene
absorbencies. These products products that are designed to
absorb or contain urine leakage absorb menstrual blood, absorbent
and are either disposable or incontinence products are de-
reusable. There are also under- signed specifically to absorb and
pads of differing sizes for bed contain urine. These products
and furniture protection that are have a surface area that is against
disposable and reusable. the perineum which collects and
Although there are many transmits the urine to a super
well-known brands which are absorbent polymer inner core
readily available and advertised, (Clarke-O’Neill et al., 2004). This
there is little information or absorbent inner core allows the
research available to base a deci- urine to spread throughout the
sion for use. Although systematic entire pad facilitating absorption
reviews of absorbent products capacity while preventing urine
are available (Clarke-O’Neill, leakage and odor. They also have

Adapted from Newman (2002).
Photo courtesy of Kimberly Clark, makers of Depend™ and Poise™ products.
a waterproof back for added pro-
tection. Newer products have a
“breathable” plastic film layer
with microporous openings that
allow water vapor to pass to the
outside while retaining fluid and
odors. There is less skin break-
down in patients using dispos-
able diapers with absorbing prop-
erties. Reusables are made of cloth
material with a rayon or polyester
fiber core. The number, size, and
arrangement of these fibers are a
factor in the absorption.
Personal preferences in prod-
ucts may vary. However, despite
the technology, the clinician and
patient must remember that
every absorbent product has a
saturation point, depending on
the frequency, the quantity of
urine loss, and the changing
schedule.
When choosing an absorbent
Figure 1.
Absorbent Products
incontinence product for an
older patient, consider the fol-
lowing:
• Gender: There are specific
products for men called
“guards” that are held in
place inside the front of regu-
lar underwear with an adhe-
sive strip. Drip collectors
attache to underwear, plac-
ing the penis inside, allow-
ing the pad to absorb urine
leakage (see Figure 3B).
• Ease of use in those patients
who are independent and self-
toileting but need protection
for occasional urine leakage.
Products that promote inde-
pendence include undergar-
ments which are designed
with a form-fitting large pad
that extends to the waist and is
held in place by elastic side
straps using Velcro or buttons.
Other products have double
waist elastics with Velcro fas-
teners (see Figure 2). In gener-
al, undergarments can be eas-
ily self-removed and self-
applied without having to
completely remove outer gar-
ments. However, the button
type undergarment may be
more difficult for older
adults with arthritis to
manipulate. A very popular
product that is often seen in
the more active older adult
patient is protective under-
wear that is pulled on like
cloth underwear and has a
“natural feel.” A nice addi-
tion to this product is refas-
tenable tabs which allow
changing without removal of
outer clothing.
• Selection of a more absorbent
product in those patients
 Figure 2.
TENA Flex-I-fit Belted Brief
Photo courtesy of SCA Personal Care.
who are not capable of main-
taining continence indepen-
dently or through regular toi-
leting or other measures. The
adult brief (diaper) is used
for severe UI and may be
appropriate (see Figure 3A).
This is especially true if the
patient has double inconti-
nence, both fecal and UI. The
brief can be easily applied to
the patient who is primarily
bedbound.
• Cost: Many elderly patients
are on fixed incomes.
“Homemade” products may
be the best option as patients
will invent their own
method of protection. They
will usually throw away the
self-made product as it
becomes saturated.
• Use of panty liners or perineal
pads: These attach to the
underwear or panties with an
adhesive strip and side gath-
ers for fit in women with
small or slight UI. Some are
designed with a wide front or
back for larger volumes of
leakage. These are preferred
for their discreetness (Baker &
Norton, 1996). McClish, Wy-
Figure 3A.
TENA Adult Brief
Photo courtesy of SCA Personal Care.
man, Sale, Camp, and Earle Figure 3B.
(1999) reported that 77% of Drip Collectors for Men
women who enrolled in a
clinical trial for UI used a per-
ineal pad at least once per
week. This study also showed
that women used lower-cost
products such as menstrual
pads rather than specific
incontinence pads. Women
still choose a small, discreet
pad like a panty liner despite
the need to change the prod-
uct more frequently.
Overall, the aim should be to
select the best product consider-
ing comfort, ease of applica-
tion/removal, containment of
urine, control of odor, and cost.
Toilet Substitutes
Toilet substitutes are portable Photo courtesy of
devices that substitute for a regu- Coloplast/Conveen.
lar toilet. There are two general
categories: one is commode seats
or bedside commodes and the wheelchair), (c) nocturnal fre-
other is hand-held devices such quency and urgency is a signifi-
as a bedpan or urinal. These cant problem, and (d) decreased
devices are appropriate when (a) mobility. Current designs have
there are inaccessible toilet areas, changed little and none have
(b) doorways and bathrooms are been specifically designed for
too narrow for access (for exam- frail or disabled elderly patients.
ple, when using a walker or a Some commodes have drop
 Figure 4.
Toilet Risers
arms and adjustable heights to to as toilet raisers) that are placed
allow for individual needs. A over a regular toilet that allows
bedside commode can be placed patients to get up and down on
close to the bed for easy use at their own, thus allowing for self-
night or on the floor of the house toileting (see Figure 4).
that does not have a bathroom. Bedpans are generally the
Problems with commode design least-effective container for max-
include difficulties with side- imizing continence as they are
ways transfer, ineffective brakes difficult to position without cre-
causing commodes to move dur- ating excess pressure on the
ing transfer, and poor trunk sup- sacral area. Also, they do not pro-
port (Malassigne, Nelson, Cors, & mote correct position to aid in
Amerson, 1995; Nazarko, 1995). complete bladder emptying. The
There are general areas that need most successful bedpan is a
consideration when selecting a “fracture pan” that is commonly
commode: (a) height and weight used in the acute care setting in
of the person using the com- post-surgical patients.
mode, (b) mobility and dexterity, The basic design of the urinal
especially if the person will need has remained unchanged for
to empty and clean the com- years although disposable plastic
mode, (c) cost as most insurers variants are more often used.
will pay for at least one com- Urinals have the potential to
mode per person with a letter of enable elderly men and women
medical necessity, (d) type of seat who experience difficulty access-
as a plastic seat with a large soft ing a toilet to regain continence.
surface area may allow even dis- They are useful for patients who
tribution of body weight, and (e) have severe mobility restrictions,
seats with grab bars on either particularly when visiting places
side are most often recommend- with inaccessible restrooms,
ed to prevent falling and to aid when traveling, or in those
with rising. If a portable com- patients who are confined to a
mode is not feasible, consider the bed or chair. It is very difficult to
use of a raised toilet seat (referred find a female urinal that can be
used effectively by women with
very poor mobility. There are dif-
ficulties both with positioning
the urinal, enabling drainage
towards the front, and providing
sufficient volume without pro-
ducing a cumbersome product
(Fader, Pettersson, Dean, Brooks,
& Cottenden, 1999; MacIntosh,
1998). For women, the most suc-
cessful urinal is one that cups the
perineal opening (see Figure 5).
This type of urinal is more likely
to be successful when used in the
standing or squatting positions.
Most urinals have handles so
they can be placed next to the
patient, can be hung on a bedrail,
wheelchair, or walker, or can be
laid flat on the bed. For men,
there are rehab, spill proof uri-
nals with large funnel openings
to deal with a retracted penis (see
Figure 6A). Often these rehab uri-
nals have a flat bottom so that
they can be placed on the bed.
The openings in rehab urinals
have a flange that extends into
the urinal and does not allow
backflow even when held almost
upside down.
Catheters
Catheters are an integral part
of managing bladder dysfunc-
tion, both urinary retention and
UI, but the actual number of
elderly patients who use a
catheter indefinitely to manage
UI or because of chronic urinary
retention has not been well docu-
mented in the medical or nursing
literature. The different catheters
used and more frequently occur-
ring complications are reviewed
in Table 1. An indwelling urinary
catheter consists of a flexible
tube inserted in the bladder (either
via the urethra or a suprapubic
opening), held in place with a reten-
tion balloon (see Figures 6B & C)
and attached to a drainage bag (see
Figure 6D). Urethral catheters are
inserted and managed by nurses.
Most are secured with a strap (see
Figure 22). Suprapubic catheters are
initially inserted by an urologist
through a surgical incision made 2
 Figure 5. Figure 6A.
Female Urinal Male Urinal

Figure 6B.
cm above the pubic bone with long-term manage- Latex Indwelling Catheter with Inflated Balloon
ment mainly by nurses.
The use of an indwelling urethral (Foley)
catheter is indicated for long-term use (>30 days) in
certain instances: (a) when urethral obstruction or
urinary retention is present and surgical interven-
tions and/or the use of intermittent catheterization
is not feasible, (b) if irreversible medical conditions
are present (for example, metastatic terminal dis-
ease, coma, end stages of other conditions), (c) pres-
ence of significant pressure ulcers that are not heal- Photo courtesy of Bard.
ing because of continual urine leakage, and (d)
instances (for example, homebound patients) where
a caregiver is not present to provide incontinence Figure 6C.
care (Center for Medicare & Medicaid Services, Silicone Indwelling Catheter with Inflated Balloon
2004; Fantl et al., 1996; Mercer Smith, 2003). Unlike
other continence products an indwelling catheter is
an invasive device and is associated with significant
complications, in particular, infection and obstruc-
tion of the catheter by proteus mirabilis biofilms
(Morris, Stickler, & Mclean, 1999), which in turn can
result in urethral trauma and blockage of the catheter.
Long-term use of catheters provides access for bacte-
ria from a contaminated environment into a vulnera-
ble body organ and system. As a result, catheter-asso- Photo courtesy of Bard.
ciated urinary tract infections (CAUTIs) are the most
common type of infections that are acquired in hos- Figure 6D.
pitals and long-term care facilities. In addition to Pre-Connected Sterile Catheter Insertion Set
catheter-related complications, there are also nursing
care problems arising from long-term indwelling
catheters (see Table 2).
There is a wide range of catheter materials avail-
able and the material selected should be chosen for
the following characteristics: comfort, presence of
latex-sensitivity, ease of insertion and removal, and
ability to reduce the likelihood of complications
such as urethral and bladder tissue damage, colo-
nization by micro-organisms, and encrustation.
Catheter types include (a) silicone-coated latex
catheters which have a chemically bonded coating
of silicone elastomer or Teflon which prevents ure-
thral contact with the latex; (b) Teflon-coated
catheters which are felt to reduce the rate of absorp-
tion of water; (c) 100% silicone catheters which are Photo courtesy of Bard.
 Table 1.
Catheter-Related Complications and Approaches
Catheter Complications/Problem
Indwelling Bacteriuria usually occurs within 2 to 4
catheter weeks after the catheter is inserted.
The most important risk factor for bac-
teruiuria is catheterization.
There are three catheter-associated entry
points for bacteria: the urethra meatus,
the junction of the catheter/bag connec-
tion, and the drainage port of the collec-
tion bag.
Catheter-associated bacteriuria is usually
asymptomatic, uncomplicated, and
resolves after the catheter is removed.
Urinary tract infections (UTIs) are the
most common complication seen with
long-term use of indwelling catheters and
may occur at least twice a year requiring
hospitalization.
Infection is more common in women than
men due to anatomical differences. The
urethra in women is only 1.5 cm in length
and the proximity of the anus to the ure-
thra causes migration of Escherichia coli
(E coli), the most frequent organism seen
in catheter related infections.
A problem in institutions is vancomycin-
resistant enterococci (VRE) infection and
methicillin-resistant staphylococcus
aureus (MRSA). Residents in long-term
care facilities are felt to be especially at
risk because of their exposure to patients
transferred from acute care hospitals
where there are high VRE and MRSA
prevalence rates.
Approaches
Therefore, insertion of an indwelling catheter should
be performed under aseptic technique.
Microorganisms that are present on the meatus or
distal urethra can be transferred directly into the
bladder through three entry points. During insertion
of the catheter is the first entry point (see Figure 21)
(Sedor & Mulholland, 1999). The second entry point
is the junction at the catheter tubing and drainage
bag. If at all possible, the catheter should never be
disconnected from the drainage tube as bacteria can
enter the system. Preconnected sterile insertion sets
are available (see Figure 6D). The third point of entry
is the drainage bag outlet port. All drainage bags
should be kept off the floor and the outlet tube
should not be dragged. Selecting a bag that pre-
vents migration of bacteria through this port (antire-
flux chamber) is preferable.
Two catheter hygiene principles should be used to
prevent bacteriuria: use a “closed” system and
remove the catheter as soon as possible (Warren,
1997).
In the past, standard practice was catheter irrigation
to “wash out” the bacteria. However, the use of such
irrigation to prevent or eradicate bacteria in
indwelling catheters is ineffective, as more organ-
isms will gain entry to the irrigated catheters
through disconnection of the system.
Urine cultures should only be obtained when there
is suspected clinical sepsis based on objective
signs or symptoms. If a symptomatic infection
does occur, change the catheter and obtain the
urine specimen from urine draining through the
new system as the old system urine may not
reflect bladder urine but “catheter” urine.
To prevent or minimize CAUTIs, maintain sterile,
closed drainage system, avoid disconnecting the
catheter from the drainage bag, empty the collec-
tion bag regularly, and keep drainage bag below
level of the bladder.
If patients with VRE are identified and isolated at
the time of admission to the LTC facility, the
chance of spreading the VRE is low (Silverblatt et
al., 2000; Terpenning et al., 1994) . Despite com-
mon belief by LTC staff, an indwelling catheter
does not “contain” these infections. In addition to
identification and isolation of residents, staff
should practice strict handwashing and standard
precautions (single room, gowns, gloves, and
additional cleansing) to prevent spread due to
environmental contamination (Gray, 2004).
 Table 1. (continued)
Catheter-Related Complications and Approaches

Catheter Complications/Problem Approaches

Indwelling Research has proven that use of prophylactic
catheter antibiotics and/or antimicrobials is not of any ben-
(continued) efit in preventing symptomatic UTI.

Urosepsis can result from frequent and

repeated catheter-associated urinary tract
infections (CAUTIs) leading to sepsis.
Mortality has been documented as more
than three times higher in catheterized
patients than in noncatheterized patients.

Urethral damage
Urethritis, inflammation of the urethral
meatus, is seen and may be due to fre-
quent insertion of catheters.

Erosion of the urethra especially in men.
Creation of a false passage can occur pri-
marily in male patients with persisting
urethral strictures. Men with enlargement
of the prostate gland are most at risk.
Securement of catheters with some type of
anchor strap or device (see Figure 22) to prevent
catheter tension on the distal urethra at the mea-
tus is recommended (Hanchett, 2002).

Fistula formation develops in females Consider insertion of a suprapubic catheter which

between the bladder and the anterior vagi- may reduce the risk of urethral erosion and fistula
nal wall. Many times the female patient who formation especially in men.
has developed a fistula will present with
complaints of leakage and drainage from
the vagina. Fistula formation occurs in men
between the prostate and urethra.

Epididymitis due to urethral and bladder

inflammation and scrotal abscess are
seen in men.

Hematuria occurs in patients who have

long-term catheters and is a possible sign
of CAUTIs, bladder cancer, or stones.

Bladder stones can occur in at least 8% of Annual cystoscopy by an urologist is recommend-

patients with indwelling catheters. ed to determine the environment within the blad-
Bladder cancer can occur in patients. Long- der and the presence of stones or cancer.
term catheter users are the most at risk for
developing squamous cell carcinoma.

External Infection risk is less than with indwelling Changing the catheter every 24 to 48 hours will
(condom) catheters because it avoids instrumenta- decrease chance of infection. In hot and humid
catheters tion of the urethra. weather, condoms need more frequent changing.

Skin maceration and irritation secondary Instruct the man to trim the hairs on the shaft and
to catheter friction. base of the penis so they won’t stick to the adhe-
sive tape on the inside of the catheter thus
increasing skin irritation.

Washing and drying the penile shaft before each

catheter change will protect the skin from urine. If the
patient is at risk for possible breakdown, consider
applying a barrier film product when using the device.

Avoid use of betadine solution since this can irritate

the skin.
 Table 1. (continued)
Catheter-Related Complications and Approaches
Catheter Complications/Problem
External Phimosis is present when the orifice of
(condom) the foreskin is constricted, preventing
catheters retraction of the foreskin over the glans.
(continued) This can occur as a result of over-constric-
tion of the penis from a condom catheter
(Fader et al., 2001b).
Intermittent Bacteriuria is seen in 50% of clear inter-
catheters mittent catheterization (CIC) patients and
is often referred to as “colonization.”
Rarely leads to urinary tract infections
(UTIs). Majority of patients usually have
no symptoms and therefore should not be
treated with antibiotics.
Urinary tract infections – 20% annual inci-
dence, most common cause of sepsis and
mortality in patients. More prevalent in
patients who have higher residual urine
volumes (> 400 cc) at the time of catheter-
ization. Chronic pyelonephritis rarely
develops.
Urethral damage in men is similar to the
problems seen with indwelling catheteri-
zation and include:
• Urethritis, inflammation of the urethral
meatus, is seen and may be due to fre-
quent insertion of catheters especially
if there is a forceful catheterization
against a closed sphincter.
Approaches
Consider use of a:
• Reusable system that is a nonadhesive con-
dom (see Figure 24B).
• Foam-and-elastic reusable band fastened with
Velcro to secure a nonadhesive catheter.
• 100% silicone material which will cause less
irritation and adverse reactions and are recom-
mended for persons who have an allergy to
latex. The clear material of these devices
allows for skin monitoring (see Figure 23).
• Avoid overconstriction of the penile shaft if
using catheter with hydrocolloid strips that
have adhesive on both sides that can be
applied around the penile circumference. There
are two types of strips: adhesive-coated foams
and adhesive-barrier strips (see Figure 24A).
Foam straps are not elastic, so they will not
stretch. Barrier strips stretch and have the
capacity to return to original size and shape.
• Catheters with circumferential band strips may
be too restrictive for the shaft of the penis and
should only be used by patients who are cogni-
tively intact and have penile sensation.
Instruct patient to use meticulous attention to
handwashing before and after catheterization.
Immediately after use, catheters should be rinsed
under running lukewarm tap water for at least 30
seconds.
Allow catheter to dry and store in a clean, ventilat-
ed container.
To decrease incidence of UTIs:
• Increase catheterization frequency (base on the
urine volume; general rule should not exceed
400 to 500 mls).
• Change type of catheter – consider catheters
with “introducer tip.” They bypass the colo-
nized 1.5 cm of the distal urethra and may
decrease incidence of UTI (Giannantoni et al.,
2002).
• Switch to new, sterile catheter each time.
(Medicare will cover six catheters/day or 186
catheters/month with medical necessity, which
includes two documented UTIs and laboratory-
positive urine cultures with a medical necessity
letter.)
Rule of thumb is to use catheter (for example, 14-
French gauge units) with smallest diameter possi-
ble that allows for adequate urine drainage, but
causes less urethral irritation, and less occlusion
of periurethral glands.
Liberal use of water-soluble lubricant along entire
length of catheter will decrease urethral trauma
especially in men.
 Table 1. (continued)
Catheter-Related Complications and Approaches

Catheter Complications/Problem Approaches

Intermittent • Urethral stricture is the result of ure- To avoid trauma have man hold penis in an
catheters thral inflammatory response to repeat- upright position during catheter insertion to
(continued) ed catheterization. The risk of a urethral straighten the S-shape of the male urethra.
stricture increases with the number of
years performing CIC. Difficulty with
insertion is a sign of the presence of a
urethral stricture.
• Creation of a false passage can occur The use of hydrophilic catheters may decrease the
primarily in male patients with persist- incidence of strictures and false passage.
ing urethral strictures. The false pas-
sage occurs because of trauma to the
urethra and the site of the external
sphincter.

Prostatitis – especially in aging men.

Epididymitis, due to urethral and bladder

inflammation, and scrotal abscess are
seen in men.

Bladder stones may occur in patients who
perform CIC long term. Stones have been
shown to grow around introduced pubic
hairs.
Adapted from Newman (2002).
Instruct the patient to trim the hairs on the penile
shaft so they will not be introduced at the time of
catheter insertion.

thin-walled, more-rigid, larger-
diameter, drainage lumen
catheters; (d) hydrogel-coated
latex catheters which absorb
water to produce a slippery out-
side surface; and (e) catheters
coated with silver alloy or
antimicrobials. There is debate as
to which catheter may decrease
CAUTIs. The large diameter of
silicone catheters may prevent
the formation of biofilms as they
are more compatible with the lin-
ing of the urethra and do not
allow build-up of protein and
mucous. There are reported
increases in latex allergies and
reactions in patients with
indwelling catheters.
In an attempt to prevent colo-
nization, some catheters have been
coated with antibiotics. Usually
the outer-wall and inner-drainage
lumen of these catheters are
impregnated with an antibacterial
agent (such as nitrofurazone),
which exudes from the catheter
over a period of days after insertion
(Johnson, Delavari, & Azar, 1999).
It is unclear if these catheters,
which are more expensive, have
any effect on the development of
infection in patients requiring
long-term catheterization. Silver-
coated catheters are believed to
cause less inflammation and have
a bacteriostatic effect when
catheters are used on a short-term
basis (Karchmer, Giannetta, Muto,
Strain, & Farr, 2000).
Catheters vary in tip shape
(Coudé or Tiemann) and size of
the lumen. Catheters are sized
according to the French (FR)
scale; each unit equals 0.33 mm
of internal diameter.
Suprapubic Catheter
A suprapubic catheter may
be used in elderly persons who
need to have a catheter in place
for a long period of time because
it is more convenient for the
patient and caregiver. Suprapubic
catheters have a higher rate of sat-
isfaction and a lower risk of
CAUTIs than indwelling urethral
catheters. Swelling at the site of
insertion, bleeding, and bowel
injury can occur at the time of
catheter insertion; however,
these incidents are rare. A supra-
pubic catheter is preferable
because it decreases the risk of
contamination with organisms
from fecal material, decreases the
risk of infection, and eliminates
damage to the urethra. The ante-
rior abdominal wall possesses a
lower microbial load than the
periurethal area and has a lower
risk of infection (Sedor &
Mulholland, 1999). Additional
advantages are that the catheter
is easier to change and clean
(Fantl et al., 1996). However,
clinical protocols for long-term
medical and nursing manage-
ment of suprapubic catheteriza-
tion are lacking.
External Catheter Systems
External catheter (condom)
systems, referred to as penile
 Table 2.
Common Problems with Long-Term Indwelling Catheterization
Problem Causes
Inadvertent Occurs in 41% of patients. Due to:
dislodgment • Patient pulls the catheter out due to
(catheter falling confusion, discomfort, or doesn’t like
out usually with or want the catheter.
balloon inflated) • Secondary to catheter tension where
increased pressure and weight on the
catheter causes it to dislodge.
• Detrusor overactivity or bladder
spasms will be cause expulsion of
catheter with balloon intact.
Leakage of urine Occurs 65% of the time. Due to:
around the • Bladder spasms.
catheter • Infection.
(referred to as • Urethral obstruction.
catheter bypass) • Catheter size, too large catheter.
• Secondary to an irritated bladder
mucosal caused by long-term catheter
use.
• Constipation and/or fecal impaction.
Obstruction or Occurs in over 50% of patients.
blockage of Due to:
catheter • Encrustation caused by the collection
of crystallization of protein or mucus
plugs. Crystalline deposits can cover
the balloon and obstruct the eye-hole
and lumen of the catheter. Formation
of encrustation usually occurs around
the tip of the catheter, around the bal-
loon, or within the catheter lumen.
Catheters are a good medium for bac-
terial growth as bacterial biofilms (lay-
ers of organisms) adhere to the many
surfaces of the catheter.
Catheter/balloon Failure of the balloon to deflate due to
malfunction malfunction of inflation valve; obstruction
of the inflation channel by external
encrustation of the balloon.
Pain and More than 50% find catheters painful
urethral (Saint et al., 1999). Discomfort may be
discomfort secondary to catheter size (too large) or
occlusion of periurethral glans.
Adapted from Newman (2002).
Intervention
Consider alternative suprapubic catheter or other
urinary collection device.
Use a securement device or strap.
Consider changing catheter more frequently.
Consider the use of an anticholinergic medication
(for example, oxybutynin, tolterodine).
If infection is suspected, obtain urine culture.
Consider changing catheter more frequently. Usual
medical practice is to change indwelling catheters
every month but most experts feel that changing
schedules should be arranged according to the
patient’s needs (Gray, 2004). Obtain bowel pattern
to ensure regularity.
Catheters should be changed proactively according
to the patient’s usual pattern of catheter life rather
than waiting till infection or encrustations occur. If
an infection occurs frequently or obstruction is com-
mon, the catheter should be changed more often.
Keep record of when catheter-related problems
occur so a changing schedule can be determined.
Maintaining a high fluid intake produces less con-
centrated urine, which impairs bacterial growth in
the bladder and catheter system. The flushing
action of large quantities of diluted urine will reduce
the likelihood of bacteria ascending the bag and
catheter.
If encrustation causes occlusion of the catheter, the
entire system must be changed.
As bacteria migration occur intraluminally and
along the outside of the catheter, it is recommended
that the drainage bag be emptied at least every 4
hours, if at all possible.
The benefit of acidification of urine with cranberry
products is unclear (Gray, 2002).
Cut the balloon at the port distal to the junction. If
this fails to deflate the balloon, push narrow-gauge
guide wire through the balloon port into the balloon
to allow the fluid to drain. Do not inject air, water, or
any chemical in the balloon port to rupture the bal-
loon.
Decrease catheter size. Use large amounts of lubri-
cation at time of insertion to decrease pain and dis-
comfort.
Consider removal of catheter and alternative man-
agement.
 Figure 7A. sheaths, direct urine into a Figure 8.
Latex External Catheter drainage bag and are used most Self-Adhesive External
commonly by men who use a Catheter
wheelchair and those who have
moderate to severe UI. Adhesive
strips (see Figure 24A) and other
fixation devices have now largely
been replaced by self-adhesive
sheaths, which are safer and
more popular with users (see
Figure 7A). Sheaths have
changed little in appearance over
the last 20 years, although the
material of newer sheaths is more
Photo courtesy of Coloplast. likely to be silicone than latex
(Edlich et al., 2000) (see Figures
7B, 7C, 8, & 23). Men at a VA
Figure 7B.
medical center found the con-
Latex Self-Adhesive
dom catheter more comfortable,
External Catheter
less painful, and less restrictive
on their activities (Duffy et al.,
1995). The only complaint was
from urinary leakage (Saint, Photo courtesy of Coloplast.
Lipsky, Baker, McDonald, &
Ossenkop, 1999). It is very com-
mon for elderly men to have a Figure 9.
“retracted” penis. An external External Retracted
catheter that adheres to the glans Penis Pouch
penis may be an option in these
Photo courtesy of Hollister. men (see Figures 8 & 24C). There
are adhesive urinary pouches
that are similar to ostomy appli-
ances that may be more appropri-
Figure 7C.
ate (see Figure 9). If an elderly
Self-Adhesive External
patient has difficulty with dex-
Catheter with Removable Tip
terity and manipulation of small
to Allow for Intermittent
objects, the ease of application
Self-Catheterization
and removal of an external
catheter may be an issue.
Identification of a caregiver or
family member who will apply
the catheter must be considered.
In an institution, the staff can be Photo courtesy of Hollister.
taught to apply these catheters.
Because there are several
sizes of condom catheters, it is
important to use a measuring or rolling on the catheter. A skin
“sizing” guide supplied by man- barrier product can be applied to
ufacturers. When choosing a size, the penis to protect penile skin
allow for nocturnal erections in from breakdown secondary to
the sizing of the device. A med- repetitive application and
ical adhesive (commonly used removal of an adhesive device.
when applying ostomy bags) can There are external collection
be applied around the circumfer- devices for women that funnel
ence of the penis to ensure that the urine via a pouch to a tube
Photo courtesy of Hollister. the catheter “adheres” to the and collection bag (see Figure
penis (Newman, 2000). The 10). However, none have proven
adhesive must be dry before to be totally useful for elderly
 Figure 10.
External Female Pouch
Photo courtesy of Hollister.
women in wheelchairs or those
who are bedbound.
Urine Drainage Bags
Both indwelling and external
condom catheters are connected
to a drainage bag which acts as a
reservoir for urine drained from
the bladder (see Figures 11A, B,
& C). An overnight or bedside bag
can hold 1,500 to 2,000 cc. The
bag should be hung over the side
of the bed below the level of the
catheter so that the urine will
flow easily and prevent urine
backflow.
A leg bag is a smaller collec-
tion bag for use in the ambulat-
ing, elderly patient as it allows
more freedom of movement. This
smaller bag is more discreet and
can be attached to the calf and be
concealed under clothing (see
Figures 12A & B). Leg bags come
in different sizes (horizontal or
vertical) and are made from a
variety of material. The calf is
usually the easiest place on
which to strap a leg bag, but
women who wear skirts will
need to use a thigh bag or waist
belt. The smaller bag can be
strapped to the leg (thigh or calf)
or held in place with a net sleeve
or stocking and is easy to hide
under clothing. Strips that are
too tight can restrict circulation
resulting in lesions (see Figure
13). Attention should be paid to
Figure 11A. Figure 12A.
Leg and Overnight Leg Bag
Drainage Bags
Photo courtesy of Coloplast.
Figure 11B.
Bedside Drainage Bag
Photo courtesy of Mentor.
Figure 12B.
Leg Bags
Photo courtesy of Hollister.
Figure 11C.
Photo courtesy of Bard.
Bedside Drainage Bag
the selection of the drainage port
as some patients may be able to
manipulate a flip-flow valve but
not a sliding type. A bag of urine
can be quite difficult to accom-
modate discreetly on the body
and can present problems with
appearance and noise from urine
movement. More recent innova-
tions include a bag strapped onto
Photo courtesy of Bard. the abdomen (belly bag) (see
Figure 14).
Intermittent Catheterization
Intermittent catheterization
 Figure 13. Figure 14. Figure 15A.
Leg Lesions Secondary Belly Bag PVC Straight Catheters
to Constriction from a
Leg Bag Strap

involves the regular introduction

of a catheter to empty the bladder
and then removal of the catheter; Photo courtesy of Life Tech, Inc. Photo courtesy of Coloplast.
this leaves the patient catheter- (Now distributed by Rusch)
free in between. The catheter (a
flexible, fine tube) is passed into Figure 15B.
the bladder via the urethra; urine Intermittent Straight Catheter
is drained and the catheter
removed and washed or discard-
ed (see Figures 15A, B, & C).
Research has shown that regular
bladder emptying reduces intrav-
esical bladder pressure and
improves blood circulation in the
Photo courtesy of Coloplast.
bladder wall making the bladder
mucous membrane more resis-
tant to infectious bacteria. Figure 15C.
Intermittent catheterization (IC) Intermittent Straight Catheter without Coating
dates back thousands of years
(with use of silver, gold, and then
stainless steel) but the practice
has only become more acceptable
over the last 40 years when it was
pioneered by an American urolo-
gist, Dr. Lapides, who showed
that “clean” as opposed to “ster-
ile” self-catheterization did not
increase the incidence of renal
damage or urinary tract infec-
tions. Clean intermittent catheter- Photo courtesy of Astra Tech.
ization (CIC) is most used in
elderly patients with urinary
retention but is also a treatment in long-term facilities. The use of ommending CIC. Considerations
for overflow UI secondary to ure- long-term antibiotics in people include (a) the physical ability of
thral obstruction. regularly using CIC is not neces- the person who will perform the
Sterile technique is used for sary because such long-term use catheterization; (b) the willing-
intermittent catheterization in is associated with the presence of ness and self-discipline of both
acute care facilities because of resistant bacterial strains. But, if patient and caregiver; (c) pres-
the high risk of nosocomial infec- an infection occurs, it should be ences of leg spasms and/or
tions. However, there is very lit- treated. decreased flexibility or balance;
tle data about the safest method Age is not a deterrent to rec- (d) decreased finger/hand dexter-
 Figure 16A. ity, intentional tremors, and poor Figure 17A.
Catheter Holder eyesight of person performing Self-Contained System with
the catheterization; (e) decreased PVC Catheter
perineal sensation; and (f) obesi- (Self-Cath)
ty that prevents adequate visual-
ization of the urinary meatus in
the female patient. Aids such as a
catheter holder can be helpful in
patients with decreased finger
and/or hand dexterity or grip (see
Figure 16A).
There are two main designs
of intermittent catheter: those
that have a hydrophilic coating Photo courtesy of Mentor.
(which becomes slippery when
immersed in water to aid inser-
tion) (see Figures 16A, B, & C)
Photo courtesy of Astra Tech. and those with no coating (see Figure 17B.
Figures 15A, B, & C). There may Self-Contained System
be large differences in the slip- (Self-Cath) with Gloves
Figure 16B. periness of the coatings, with and Lubricant
Hydrophilic Catheter some catheters showing a
(SpeediCath) marked propensity to “stick” to
the wall of the urethra on
removal (Fader et al., 2001a).
However, to date there has been
no evaluation comparing coated
and noncoated catheters. The
clinician who instructs the
patient usually makes the
catheter choice. Red rubber
catheters are more flexible and Photo courtesy of Hollister.
some elderly patients find them
more difficult to insert. The pre-
ferred catheters used for CIC are
clear and made of plastic materi-
al. Polyvinyl chloride (PVC) are Figure 17C.
the most common as they are Self-Contained System with
flexible but firm, require lubrica- Hydrophilic Catheter
tion, and are usually reused for
up to 1 week (see Figure 15A).
Photo courtesy of Coloplast. Prelubricated hydrophilic cathe-
ters are coated with a substance
that absorbs water and binds it to
Figure 16C. the catheter surface (see Figures
Hydrophilic Catheter (Lofric) 16A, B, & C). Prior to insertion
this catheter is immersed in
water. This extremely slippery
layer of water stays on the
catheter during insertion and
withdrawal. This type may be
indicated for patients who expe-
rience particular discomfort dur-
ing catheterization or have diffi-
culty with other types of
catheters (Diokno, Mitchell,
Nash, & Kimbrough, 1995). Self-
Photo courtesy of Astra Tech. contained systems are closed sys- Photo courtesy of Astra Tech.
 Figure 18. Figure 19. Figure 20.
Self-Contained Coudé Olive Tip PVC Catheter Coudé Tip PVC Catheter
Pre-Lubricated System

Photo courtesy of Mentor. Photo courtesy of Mentor.

Figure 21.
Entry Points for Introduction of Microorganisms

Photo courtesy of Coloplast.

tems that provide sterile catheter-

ization and are 100% latex-free,
prelubricated hydrophilic or
PVC catheters. The catheter pass-
es through a special guide mech-
anism at the top of the pocket
(see Figures 17A, B, C, & 18).
This guide provides two main
benefits: it keeps the catheter
straight as it is advanced and,
when squeezed, it prevents the
catheter from slipping during
insertion. Once inserted the
urine drains into the bag. The use
of this system may decrease
Graphic courtesy of Diane Newman.
chances of infection. In patients
who have bacterial, nonspecific
urethritis, a catheter that con-
tains a coating of antibacterial elderly man to advance the (for women) or 12 inches (for
agent (for example, nitrofura- catheter past the prostate gland men).
zone) in the outer layer to pro- (see Figure 20). Both of these The catheterization schedule
duce local antibacterial activity types of catheters have “blue line should be based on the urine vol-
may be indicated. guide strips” to help patients ume. As a general rule, bladder
Catheter tip configuration is maintain correct position for volume should not exceed 400 to
also important when choosing a insertion — curved tip is pointed 500 mls. When starting CIC,
catheter for CIC. An olive, Coudé up to the head. An additional patients and/or caregivers should
or curved-tip catheter may help a consideration when teaching an record the amount of urine drained
woman in identifying her urethra elderly patient how to perform from the bladder. If the patient
(see Figure 19). Using a Coudé tip catheterization is the catheter voids, catheterization should
catheter can make it easier for an length which is either 5 inches always be performed after voiding.
 Figure 22.
Anchor or Securement Strap
Photo courtesy of Dale Medical
Products, Inc.
Figure 23.
Self-Adhesive
External Catheters
Photo courtesy of Mentor.
Based on a person’s average out-
put, catheterization is usually done
three to four times during the day.
External Compression
Devices
An external compression
device or penile clamp can be
used in men with UI. The device
provides external urethral com-
pression to create outlet resis-
tance high enough to prevent
urine leakage secondary to stress
urinary incontinence (SUI).
Often men will use these clamps
after prostate cancer surgery to
stop SUI or to prevent continu-
ous urine leakage in elderly male
Figure 24A.
Latex External Catheter (2-
Piece) with Adhesive Strip
Photo courtesy of Coloplast.
Figure 24B.
Reusable External
Catheter System
Photo courtesy of Arcus Medical.
Figure 24C.
External Condom Catheter
Photo courtesy of BioDerm.
patients. Usually the clamp is
placed halfway down the shaft of
the penis and then tightened to
compress the urethra. The inside
of the available clamps have a
flexible, soft part made of soft
foam that conforms to fit the
penis. When closed, it should
pinch off the urine flow without
discomfort. A penile clamp
should be used with caution and
is only appropriate in men who
have penile sensation, good man-
ual dexterity, and will comply
with proper care and use of the
product. Usually the clamp
should be released every 2 hours
to promote circulation. Skin
breakdown secondary to con-
striction, swelling, and urethral
strictures can occur inside of the
urethra if a clamp is left in place
too long (Moore et al., 2004).
Skin Care Products
The skin of elderly persons is
more fragile than younger persons.
Skin care is integral to the use of
most incontinence devices and
products. Potential sources of
excessive moisture on the skin
include:
• Urinary incontinence.
• Fecal incontinence.
• Frequent washes.
• Nonabsorbent and/or poorly
ventilated padding on the
skin.
• Skin occlusion.
 A skin care program should
include skin assessment of the
buttocks, coccyx, rectal area,
scrotum/perineum, and upper
thighs. Skin breakdown and ery-
thema are directly related to
exposure to urine and feces
(Scardillo & Aronovitch, 1999).
Normally the skin is slightly
acidic which helps prevent the
invasion of bacteria, yeast, and
fungus. This is often referred to
as the “protective acid mantle” of
the skin. Further, the presence of
excessive skin surface moisture
can contribute to growth of bacte-
ria that can lead to skin break-
down and infection. When com-
bined with changes in skin pH
(into the alkaline range), the
effect can be particularly devas-
tating, promoting the loss of nor-
mal skin integrity in the person
whose skin is already compro-
mised by exposure to urine and
feces.
When skin is subject to mois-
ture from urine in combination
with fecal matter, further skin
trauma results. Prolonged expo-
sure to urine and feces, moisture,
and friction combine to macer-
ate, abrade, and blister the skin
over the buttocks and sacrum.
Prolonged perineal exposure to
wetness and increased tempera-
ture can result in the growth of
microorganisms such as Candida
albicans, resulting in candidiasis
or yeast dermatitis. All of these
factors work in concert to cause
skin irritation, breakdown, and
further skin problems. Friction
can cause skin abrasion. Wet skin
is more easily abraded by move-
ment of skin against an object
such as cloth and plastic in leg
gathers and tape fasteners on
adult briefs. Tape cuts are com-
monly seen in obese, elderly
patients who are wearing a tight-
fitting adult brief.
Proper use of soaps, skin
products, topical antimicrobials,
and gentle pH balanced
cleansers; appropriate barrier
products; and effective use of
better quality and appropriate
absorbent, incontinence prod-
ucts are all important in skin care
management. Washing with regu-
lar soap and water is harmful to
some patients with associated
problems such as dry skin, con-
tact dermatitis, and eczema
(Newman, Wallace, & Wallace,
2001). As frequent washing with
soap and water can dehydrate the
skin, the use of a perineal rinse
may be indicated in certain
elderly patients.
Perineal cleansers are more
skin-friendly than most bar soaps
because they are convenient,
time saving, and effectively
remove the urine and/or feces
without patient discomfort.
These skin cleansers can help
emulsify and loosen stool and
urine to cleanse the skin.
Additionally, no-rinse perineal
cleansers are pH balanced for the
skin, whereas bar soaps are
almost always in the alkaline
range. Some perineal cleansers
are also formulated with topical
antimicrobials that may decrease
the bacteria on the skin.
Fragrances, alcohol, and alkaline
agents should be avoided when
picking a cleanser.
The use of disposable wipes
or wash clothes rather than toilet
tissue may be more beneficial to
the perineal skin of an older
patient. These cleansers are also
gentler to the skin than those
used in bar soaps. Moisturizers
preserve the moisture in the skin
by either sealing in existing
moisture or adding moisture to
the skin. Moisturizers include
creams, lotions, or pastes. Barrier
products protect the skin from
contact with moisture and
decrease friction from absorbent
products. However, if the skin
barrier product is easily removed
with water during cleansing,
than it is not likely to promote a
durable barrier to urine and
feces. Paste is created by adding
powder to an ointment. Paste
does not need to be removed
each time an area is washed.
Topical antifungal agents are
available in ointment, powders,
and creams. Some topical anti-
fungals with anti-candidal activity
are available as over-the-counter
products (such as clotrimazole
and miconazole). Topical antifun-
gal cream should be applied after
each incontinence episode and
continued until the erythema is
completely resolved. Do not use
other barrier products when
using antifungals.
Careful and close attention to
skin care reduces the occurrence
of skin breakdown in elderly
patients whose urine leakage is
being managed by devices and
products (Scardillo & Aronovitch,
1999). It is important for the care-
giver to carefully select the appro-
priate absorbent product, prefer-
ably one that minimizes the possi-
bility of dermatitis. It has been
shown that products designed to
absorb moisture and present a
quick-drying surface to the skin
keep the skin drier and are asso-
ciated with a significantly lower
incidence of skin rashes than
cloth products.
Summary
With the increasing preva-
lence of UI in elderly patients,
urology nurses should be famil-
iar with products and devices
that can contain or collect urine
because there is very little evi-
dence-based clinical research on
management of these products.
Nurses are in a difficult position
when caring for these patients on
a long-term basis. Continuing
education on the current applica-
tion is imperative. The National
Association for Continence pro-
vides a Web site for additional prod-
uct information (www.nafc.org) and
a reference guide that is an excellent
resource for product information.
Their new publication, Discoveries,
provides information about ad-
vances in products for inconti-
nence. •
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 UNJ J409

This test may be copied for use by others. Objectives

This educational activity is designed for
nurses and other health care professionals
COMPLETE THE FOLLOWING: who care for, evaluate, and educate patients
regarding continence products and devices
Name: ______________________________________________________________ for the elderly. For those wishing to obtain CE
credit, an evaluation follows. After studying
Address: ____________________________________________________________ the information presented in this offering,
you will be able to:
City: ___________________________State: _______________Zip:____________
1. Define absorbent products and toilet
Preferred telephone: (Home)_________________ (Work)__________________ substitutes.
2. Describe the types of catheters and
SUNA Member Expiration Date: ______________________________________ catheter systems.
3. Discuss intermittent catheterization.
4. Describe key components of a skin care
Registration fee: SUNA Member: $12.00 program.
Nonmember: $20.00

Posttest Instructions

Answer Form: 1. To receive continuing education credit for

individual study after reading the article,
1. Name one new detail (item, issue, or phenomenon) that you complete the answer/evaluation form to
learned by completing this activity. the left.
______________________________________________________________ 2. Detach and send the answer/evaluation
______________________________________________________________ form along with a check or money order
payable to SUNA to Urologic Nursing, CE
______________________________________________________________
Series, East Holly Avenue Box 56, Pitman,
NJ 08071–0056.
2. How will you apply the information from this learning activity to
3. Test returns must be postmarked by
your practice? August 31, 2006. Upon completion of the
a. Patient education. answer/evaluation form, a certificate for
2.8 contact hour(s) will be awarded and
b. Staff education. sent to you.
c. Improve my patient care.
d. In my educational course work.
e. Other: Please describe.______________________________________
This activity has been provided by the Society of
______________________________________________________________ Urologic Nurses and Associates, which is
accredited as a provider of continuing nursing
education by the American Nurses' Cre-
dentialing Center's Commission on Accre-
Strongly Strongly ditation (ANCC-COA). SUNA is a provider
Evaluation disagree agree approved by the California Board of Registered
The offering met the stated objectives. Nurses, provider number CEP 05556. Licenses
in the state of CA must retain this certificate for
1. Define absorbent products and toilet substitutes. 1 2 3 4 5
four years after the CE activity is completed.
2. Describe the types of catheters and catheter
systems. 1 2 3 4 5
3. Discuss intermittent catheterization. 1 2 3 4 5
4. Describe key components of a skin care program. 1 2 3 4 5
5. The material was new for me. 1 2 3 4 5
6. Time required to complete reading assignment and posttest:______Minutes
This article was reviewed and formatted for
Comments contact hour credit by Sally S. Russell, MN,
________________________________________________________________________ CMSRN, SUNA Education Director; and Jane
Hokanson Hawks, DNSc, RN, BC, Editor.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

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