Managing Urinary Incontinence in Dementia Patients: External Collection Devices and Absorbent Products - Diane Newman

May 7, 2024

Diane Newman addresses the complexities of managing urinary incontinence in bedbound or non-mobile individuals, particularly within the elderly population. Highlighting that a complete cure is often not feasible, she focuses on management strategies to enhance quality of life. Dr. Newman introduces various external collection devices, such as condom catheters for men, which minimize infection risks and skin issues compared to internal catheters. She also discusses the use of absorbent products and newer vacuum-assisted devices that offer a non-invasive solution, continuously drawing urine away from the body to prevent discomfort and skin breakdown. Emphasizing the importance of proper application and maintenance, Dr. Newman provides practical advice and resources to caregivers and healthcare professionals to better support those living with incontinence.


Diane K. Newman, DNP, ANP-BC, BCB-PMD, FAAN, Adjunct Professor of Urology in Surgery, Perelman School of Medicine, University of Pennsylvania, and Former Co-Director of the Penn Center for Continence and Pelvic Health, Philadelphia, PA

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Diane Newman: What I was asked is, again, to go over a lot about how you manage your own leakage. You may say, "Well, Diane, those are all really good things, but my person doesn't really get out of bed." They can't walk to the bathroom, so how do they manage? I love this slide because it's Cat in the Hat, because we have so many different things to deal with. And I want to go through some things here that maybe can help you manage. With the aging population we have in the world, we're really not going to cure everybody. We're probably going to have to manage it, and there are a lot of issues around management and what's the best thing to do? And I want to share with you some different ideas and things, and give you some education about absorbing products.

I want to start with external collection devices. Now, I hope you're not... We're going to see some slides like this. I hope you're not upset with me showing some anatomy in those slides, but these are patients I deal with every day. External collection devices, there are several. We start with what we call condom catheters for men, and these go back years and years. These are like condoms we use for contraception, but they have a hole at the end because we hook it to a drainage bag. These work. There are a lot of different ones I'm going to show you. These, there's a lot of different technology now with men. They do go over the penis. They have much fewer problems with infections because they're external to the body. They're not internal. I'm not going to talk about internal catheters, a Foley catheter. If you have questions about that, I'll answer, but we tend not to want to use those with incontinence. We want to use external products. They can cause skin problems on the penis, so that's a concern.

But these do work, okay? So that's why I want to start with these. These are all different kinds they have. There are lots of these products out there. The McGuire up there is a reusable product. It's an old product, but it does work. The Liberty Pouch, you may have seen this advertised on TV. This just goes over the tip of the penis and is hooked to a bag; it's like a butterfly that goes over, does have adhesive. The Alpha Dry on the left there is for someone who doesn't have a lot of incontinence. I actually have men who golf use these. And then we have the silicone or the two-piece systems that roll over. Again, the penis that work. You see the different colors there of the silicone catheter because we do measure the individual to make sure they have the right size.

I actually have a handout on this if you want it on how to apply one. I have a lot of patient education that I give to people because you can tell I used to talk very fast, and we are not going to have enough time to explain some of this, so I give them handouts to take home and try. You have to measure the size of the penis, the circumference, to make sure you get the right size. And companies do have, believe it or not, sizing things for you. So there are ways that you, you know. But these do fit. They do have to be removed every 24 hours. These do not stay on for days. You do not want to keep them on with tape because you can cause skin problems, but they work very well. I have individuals that during the day will go to the bathroom, but at night wear one of these. That's totally appropriate. Okay, it's hooked to a bag, then they can sleep through the night.

But there's one thing that you want. You want to make sure the area is dry, no hair, so you're not pulling the hair. So again, there are certain things as far as applying these. But I want to stress to you that these do work, and people have successfully used them. Sometimes I have men, fathers that don't want their daughters to apply it, but I do teach daughters, I teach sons, and I also teach the wives to do this. I've also taught nursing aides to apply these, so these can work.

Another product is actually an external pouch. It looks like an ostomy pouch. It's actually by the same company, Hollister, that makes ostomies. The middle picture is actually a home care patient. For about 15 years, I did home care visits in the county of Philadelphia, through actually, our lottery fund support, where we were managing frail elders in the city of Philadelphia. And I saw a lot of individuals who had dementia, and this was a woman who really was bedbound non-responsive. And her husband was in his 80s, and the act of caring for her was killing him, literally. We call it caregiver burden.

And she was really non-responsive, so he was putting on absorbent products, but he would have to change them every several hours. So he had a wonderful nursing aid in there helping him during day hours, and I taught her how to apply this pouch. So that relieved him of that burden for several hours of the day. So these pouches work. Okay, they do. They're easier in men because the penis can go in that hole we cut. The retracted penis pouch, we cut that in and then it adheres against the pubic area. And for women, they go outside the labia, so they can leak over time if you leave them on too long. These are usually changed every 24 hours. But these can work.

I want to talk to you about the newest, really technology that is out there and these are called vacuum-assisted devices. So they're urine collection devices that you suction. You may have heard the term PurWick, which was actually Bard, which is a catheter company that was bought by BD, which is our needle company. We use BD needles everywhere. And this concept though, now you have many companies that have these products, but I am really excited about this because this has only been in the past few years that we have had them available. They're different. Each one is a little different.

They started out for women, but we now have them for men. And basically for women, they either go up against that opening to the urethra, or they go over the labia, and then there's tubing that's hooked to suction. And the suction is low suction. You don't want it too high. And it literally continually pulls the urine away from the patient. I think these can be a really great product. I've had individuals, I use them, again, during the night when someone, you don't want them to be woken up, or you don't want to disturb them, or you want them to get that sleep. Because you know that especially someone who has confusion or dementia, if you wake them up at night, they can't function during the day. They become very combative and they may get very angry. So you want them to get those good sleep hours. And this is one way to use this product at night.

Usually, each one of these products should be changed every day, but I'm now seeing that some have actually started use in hospitals, but now they're used in home care, is using them over two days. They can stay in place. So really, the Sage product, actually, and actually the Contour product, actually has adhesive where it will stay. They adhere that to the pubic bone, and it actually will stay there. And so a patient can sit in a chair. You, the person, can sit in the chair, walk around, and that type of thing.

I'm showing you the Sage product because I had a good slide on that. But this kind of shows you where they're placed, okay? And then they're hooked to tubing and then to a suction apparatus. Similar to what you would see for suction in a hospital. So you can see how they're worn. So, kind of give you that orientation of where you would put this device.

They do not go in the body, so we call them non-invasive. So the chances of infection are lower. We have them for men and women who can use them in your home. Again, that low pressure sucks, wicks that urine away from the body. We're using it in the hospitals for accurate I & O. And again, it's a really great option, either then for use as opposed to an internal Foley or internal catheter, which you may have some experience with. So this is actually a better product for someone who has incontinence. Now remember, if that person is not emptying their bladder and they have something we call retention, we would not use this product. We'd use something different.

You can use it again, side-lying, sitting position. You want to make sure it's positioned correctly. And there are other things around these suction products or vacuum products.

Now, I want to talk about absorbent incontinence products. I want to spend a little bit of time because this tends to be what we are going to use. These are incontinence products. You may see them in CVS and retail. They're usually a whole aisle of incontinence. We do have disposable versus reusable. So there are reusable products you can buy mostly online. You do have to change them.

I like to show this slide because this is huge growth. This is a billion-dollar business. And we're now having much more growth in adults than in children. An adult diaper in 2020 was the number one healthcare product sold in this country. Not a baby diaper, an adult diaper, which we call briefs, adult briefs. So these are very much a big part. And that's why you see ads everywhere, and why you see, of course, the ads on TV.

We do have products that are better for nighttime because they have more absorption. We have pads, which are better for small amounts of incontinence, so for that person who may have stress incontinence. You need to know the severity of the incontinence when you choose your products.

Gender. There are differences between men and women, and there are gender-specific products. There are larger size products. So depending on if you have someone who maybe has a large weight, you want to give them maybe what we call a larger size product. Dexterity. Can they remove the product if you're really trying to promote them going to the bathroom to pee? And of course, the cost is also, these can be very expensive.

There are practical problems. I've tried so many, this is what I've had for my patients. I've tried so many incontinence products. When I finally found something that works, I kept trying and trying, it was many months. No one tells you which product is good. People do double. We call it double padding. If they have fecal incontinence as well as urine, say loose stool as well as urine. And what we find, and I have to tell you, being in urology, a lot of providers do not have this discussion with their patients. Because I hate to tell you, a lot of doctors are not aware of products, even urologists, even nurses. Nurse practitioners are not aware of them.

So this is sometimes what I find with family members. I actually get consults that just families come in and say, "Well, how can I manage this? You need to help me, which is the best product to use for my mother, my daughter, my husband?"

I like this slide because it kind of gives you the categories. We have light to moderate products. So someone who's not losing a lot of urine. Those are like the panty liners, or pads, perineal pads, or guards for men. So that's someone. They may hold up to maybe about 200 ccs. With someone who has moderate to heavy urine loss, we have the protective underwear or the adult briefs. I have to tell you that the protective underwear for someone with memory loss is a really good product because it mimics underwear, right? So if they're confused and you understand, "Oh, I have underwear on, I can pull them out." Or it's hard maybe for a guy to pull his penis out of the protective underwear. But it's more of the concept of the cloth or the brief.

One of the stories I tell all the time happened to me years ago in my home care practice. And it was an older gentleman who had significant dementia, cared for by his wife. But she would take him to the bathroom, and she found that for a while that really worked. But then she said he started to be wet when she got him to the toilet, and he was in an adult brief. And I said to her, "Let's move him to an underwear type of product." Do you know that his incontinence decreased by 50%? She was shocked by it. He was equating the diaper with childhood, so he just peed in the diaper, in the brief. He also couldn't get it off because it had maybe the sticky kind of, or Velcro at the end. But the underwear he understood, he had underwear on. He went to the bathroom and urinated most of the time. So I know that sounds simple, but sometimes it is that simple that you can make a change and really help their incontinence.

This is kind of what we see nowadays. I mean, I'm just so surprised when I have individuals like the woman up there, that picture, I thought she had underwear on. They've become so normalized, haven't they? In men, we now have black protective underwear, because briefs tend to be darker colors. Or we have that gray and white, so it's more masculine. On that middle one, you may think that's a cloth product, but it's not. So we do have some really different types of products out there to think about, "What's the best product for the individual I'm caring for?"

I put up this one because I want to stress to you that we do have products that really contain a lot, and I want to talk to you a little bit about the technology around products.

I have three daughters and they're seven years apart. And when my youngest one, Emily, was an infant, my older daughters would say, "Mommy, Mommy, Emily's wet and daddy won't change her." And my husband used to say, "Well, I put my finger in the diaper, Diane, and it's dry." But if you would take off Emily's clothes, the diaper looked like it was going to burst. What we've done is, we've put in these products a polymer, like that's in the kitty litter. You know the scoop-away where the kitty pees and it clumps? Well, that polymer is in the middle of the products. The better products now. Not all the products have this, but the better products. So what happens when someone's incontinent, the urine is pulled into this middle gel, so against their skin, they are dry. And that's what's really changed in technology. And that's the difference between swimmers' products for kids as well, that they put in the pools. Because it clumps it together so that it's not going out into the pool type of thing.

The product at night can hold up to 1500 ccs, that's a lot of urine. And there are products that Tana has that is a major overnight pad, if you go on their website, and then a mesh panty holds it in place. So there are different products depending on what you want to do. And you really, to understand these important if you want to have the best product for the individual.

Now, I'm almost done with my lecture here, and I want to leave some time for questions, but there are also urinals. And I know that for women, we're seeing better urinals that cup. You know where I find and where my patients find a lot of their products, is in camping catalogs. Because when you go camping or whatever, you got to pee. And women, men can go, I hate to... You know. Men go on the side of the road, they go in the woods, but us women don't. So they actually have products that kind of cup against your perineum to pee. That may be an option.

We have rehab urinals. You see that top urinal there on the left has a cup that a woman could use. Urinals can be helpful, especially in a guy at night that maybe can get up, sit on the side of the bed, pee, and then put it next to the bed or on the floor. And that may be an option, because you're worried about them falling. So I just want to stress to you, we call these total assistive kind of devices. This may be an option in someone you're caring for.

Now, a couple of things. I want to talk about bathing, because I know that was a question. Bathing is important. It's important to get rid of the urine. I always say to people, "You don't have to bathe someone after each incontinent episode, but you want to bathe and get that urine away." If they're in a pad and they have a stool accident, okay? You want to apply moisturizer. And there's also what we call skin protectives, you can buy these at CVS, that actually should be put on the skin so that there's no breakdown if you have someone where all you're using is an incontinence product.

Bathing, we prefer no-rinse cleansers. You can buy those, again, in any retail store. As opposed to soap and water, they're more what we call pH balanced, so they don't break down the skin. But Dove soap is okay, but be careful about what kind of soap that you use. You want to moisturize. I'm showing Sween cream. You can buy this at a drugstore online. I love Sween cream. It's a very nice moisturizer. Anything that has aloe in it is good. You want to keep that skin healthy. As we age, that skin is not as moisturized. We lose that fluid in the skin. So you want to add back that moisture product.

Moisture barriers are wonderful. Medline has a great one, Nutrashield. Think of moisture barrier products like Saran; I hate to use that term. But after you keep the skin wiped clean and you're worried about urine breaking down the skin during the day, or maybe you see some redness on someone's butt, if you put on a barrier product, it really keeps that area protected. These do work, and there are some nice ones out there. I'm showing one. They actually now have some silicone in them, so it really is a nice protective product.

But there are ointments. You don't want anything that occludes the skin. Zinc oxide people tend to do that, or they coat with powders. That may not be the best thing because it occludes the skin, preventing it from breathing. So I really work on products that are breathable.

If someone has a yeast infection, which we see in this area because of moisture, some of these products have a combination antifungal. So that may be something that you consider. Be careful about powders that coat the area, and paste; those may not be as good. And I'm just giving you some common ingredients in these products.

So that was kind of a really quick overview. I'm sorry that I spoke so fast, but you can see that I really have a lot of things I can share with you that you can do for someone who has dementia. Don't give up and don't think that, "Oh, there's nothing that can be done."

And I've written quite a few things on this. I have actually what I call my picture book where I show a lot of these products. If you're interested, you can go on Amazon and maybe pull out chapters on different things. And I also have a site on UROToday, where I talk about catheters and that. So there's a lot of things out there that you really can access for further information. And like I said, if you want, I can give you some of my handouts that you can give to some of the caregivers that may help them.

So thank you very much for having me. And if we have any questions, I think I have some time.

Julia Schafer: Thank you so much, Dr. Newman. I have a question, which is about the external catheters. Do you need a prescription for those, or can you just buy them anywhere?

Diane Newman: You can usually get these online. And if you go, the companies will help you. But if you get a prescription, Medicare pays for 30 of these a month. So that's a great question, Julia, because absorbent products are not paid for, except if they're on, say, the state program, we know that. Or if they're in a Medicare advantage will pay for some absorbent products. But Medicare does pay for external catheters for men. And like I said, 30 a month, so you have to change them every day. And I think you would need a prescription for that. But if you go online, the medical supply companies will help you get that prescription. So it's not that difficult.

The vacuum-assisted products were covered by Medicare for a period of time, but I think they stopped their coverage. But that may come into existence also. But yes, I'm sure coverage and cost is a big issue here.

I put my email there really, if you want to email me too, or if you go on the internet, you'll find me. I have no problem with answering or anything that you need. That's good.

Julia Schafer: I've started to think of incontinence as a disability, not unlike the crutches that I use that I'm not embarrassed to go out with. I broke my foot. So that's why I'm using crutches. But I'm not embarrassed to go outside without my crutches. And I think that we shouldn't be embarrassed about incontinence. And I'm wondering about, if you know anything about rules around asking for the bathroom. I know sometimes when I go into a place they'll say, "You can't use the bathroom unless you've paid for this.", or something like that. And I'm just wondering if you have any ideas on how to negotiate that for people?

Diane Newman: Oh, Julia, I could do a whole lecture on this. That's a lot of my research, about bathroom access. And actually, we're publishing quite a bit from one of the NIH consortiums I'm involved in. You're 100% right. There are a lot of issues around the bathroom.

Number one, men. And I just had breakfast the other day with a guy who has incontinence after his prostatectomy surgery for cancer. And he told me how he goes into the bathroom and he has a pad because he has incontinence, and he goes into a stall, and there's no place to throw the soiled pad away. And he's actually, he's from the United Kingdom. He is starting a thing with the UK government called Bins for Boys, that they are going to put bins in bathrooms. You know how us women have the bins in the stalls for our sanitary pads? They're going to start putting them in bathrooms for men.

But you're right, I think the bathroom issue is a big issue. We've done research in schools where we call it the gatekeeper. Where kids in schools now are asked, "You're getting up too often. What are you doing? You're taking your phone into the bathroom." We even heard from teenagers, young kids, 13, where they have a guard in the hallway saying, "Where are you going?" That's deterring voiding. So I think bathrooms are a big issue that... I always say, "Where do the homeless go pee?" That's a terrible thing to say, but seriously, you can't go into restaurants unless you're eating there. And in Europe, they actually have bathrooms on the street, which we don't have here in the US. But I think we're trying to publish this stuff because I think there has to be more public policy around the uses of bathrooms.

I think you're seeing more unisex bathrooms, right? So that now it's not just men and women, but it's a big issue. And for disabled individuals, can you get into the bathroom with a wheelchair? Can you get into the bathroom with a walker? Can someone get into a stall with someone to assist them maybe in taking down their clothes? Right, Julia? That's not the case in a lot of bathrooms.

So I don't know. We have to raise this awareness, but I know there's a lot of interest in this area.