According to the Urology Care Foundation (http://​www.​urologyhealth.​org/), as many as 1 in 3 adults experience bladder control issues. The statistics show that over 80% of those experiencing UI are women and the majority of cases are related to pregnancy and childbirth. The rise in prevalence can also be traced to the growing health conditions of obesity and diabetes, and the aging process.

The actual prevalence of absorbent product use for UI and FI is not known. In the acute care setting, hospital staff, particularly nurses, tend to use incontinence all-in-one briefs in patients whose condition may not necessarily require such a bladder management approach [3, 4]. Zisberg [5] conducted a study in five medical acute-care units (900 beds) in a teaching hospital in Israel to identify the incidence of in-hospital incontinence adult brief use, as compared to other products (e.g., urinals, bedside commodes, self-toileting). Fourteen percent (65/465) of older adults admitted to these units (66% females, 34% males) were provided incontinence briefs upon admission, despite the fact that all study participants reported that they were able to control their bladder. Commodes and urinals (38/465) were rarely used by female patients (30% females versus 70% males). Mobility, or lack thereof, was a predictor of incontinence all-in-one brief use.

The demand for products for adult incontinence products in the US is forecasted to rise over 48% through 2020, while baby diaper sales will only grow roughly 2.6% to 3% during the same time period (Bloomberg Businessweek ) (see Chart 6.2).

An absorbent product for incontinence should be chosen for or by the individual based on the quantity of urine leakage, the style, and the user’s ability to apply the product. Absorbent properties and capabilities should be considered. The right absorbency level should be chosen based on the individual’s needs, to ensure that skin exposure to urine and feces is minimized . Table 6.1 shows types of bodyworn absorbent products available for incontinence care noting absorbency. These product categories vary by their intended audience, functional design, and their overall capacity for protection [6]. As previously mentioned, there are two main types of absorbent products: reusable and disposable.

Reusable or woven (washable) products are composed primarily of absorbent natural and synthetic fabrics; therefore, they do not have the technological ability to keep wetness from the skin’s surface or are they able to absorb multiple voids or incontinence episodes. These products are made from absorbent woven materials that can be laundered and re-utilized several times [7] (see Fig. 6.2). Many are homemade, made by the patient and/or caregiver and may include terry cloth (e.g. washcloth), safety pins, and plastic or vinyl pant). Although washable absorbent products are increasingly viewed as being environmentally friendly, a 2008 United Kingdom report on baby diapers (called “nappies”) concluded that there was no significant difference in environmental impact between disposables and home or commercial laundered products, although the types of impacts did vary [8]. Typically, the average child used disposable diapers for an average of only two and a half years. Adults with UI tend to use these products for a longer period of time.

Common designs for these products include all-in-one briefs, or diaper-style products that have an integrated absorbent pad and fit close to the body to absorb leakage (see Fig. 6.3). There are also underpad styles that resemble a sheet or pad and rest on a support surface such as a chair (chair pad) or bed (bedpad) to provide protection and absorption. A waterproof backing on one side protects the support surface from wetness and odors.

The performance of most reusable products for incontinence is generally poor, particularly for preventing overflow leakage, when compared to disposable products. The materials composing these products are not effective in wicking moisture (pulling fluid away from the skin) and, therefore, are not indicated for multiple voids or incontinent episodes. They must be changed often, especially after a void or incontinent episode or there is a risk that moisture will sit against the skin. Their inability to effectively wick moisture away from the skin can impair skin health if not closely monitored [9]. When an individual’s skin is left with an underpad resting under the body open to air, the urine and feces are not properly contained. Without the wicking action of a close-fitting absorbent product, positioned close to the perineum, urine leakage may run into the folds of the skin. Prolonged exposure to urine and feces in the skin creases, and on perineal surfaces, can lead to discomfort, skin irritation, maceration, and eventual skin breakdown. Also, when considering the use of an underpad for sole use (e.g., without a bodyworn product) the patient will need to be naked below the waist, so consultation and patient approval should be obtained [10] to help uphold their individualized choice and dignity. Reusable products are not recommended for persons with FI because of stool staining in the materials.

Disposable or non-woven products contain levels of pulp-derived fluff and SAPs to wick urine into the product for containment, minimizing wetness against the skin thus allowing for the absorbency of multiple voids or UI episodes into the product while keeping the skin surface dry. The basic technology of disposable absorbent products for incontinence derives from baby diapers [11, 12], with design and additional features specifically developed and adapted for the needs of adults. The fluid absorption capacity of these products reflects the larger urinary volumes of adults. Distinct features, such as the outer cover materials, are selected to avoid rustling noises. The anatomical product shapes, for example, are also designed for the optimal fit and comfort of adults wearers [13, 14].

Although features vary depending on the quality and intended product use, certain standards are common to most products. These include products manufactured to be latex-free so as to minimize or avoid any potential skin sensitivities . All disposable products contain a moisture-proof lining that prevents liquid from escaping the product. In the past, products have offered only a plastic backsheet that was mostly uncomfortable for the wearer and potentially embarrassing. The products could rustle and emit noise as the person moved normally. Today, many products feature a soft, textile-like waterproof backsheet that is much more comfortable and feels more like a normal garment. Wearers prefer the cloth-like backsheet, which makes the product noiseless and helps promote wearer dignity and privacy.

The use of SAP technology is also now a standard in absorbent product technology ; however, the amount of SAP granules utilized in the product will vary depending on the quality of the product manufacturing, and the intended product. Most incontinence experts recommend the use of products containing SAP because, when utilized properly, this technology may have a significant impact in preventing complications such as incontinence-associated dermatitis (IAD) and subsequent development of pressure injury (see Chap. 8). Most of the current high-quality products on the market (e.g., Abena^®, Attends^®, TENA^®) are designed to be skin-friendly. This means they provide a surface area against the individual‘s perineum that collects and transmits moisture from the acquisition layer to the inner core of the product that contains the SAP, which locks in the moisture. Absorbent cores that contain SAP will be more effective and contain more urine than a core containing just fluff pulp to absorb moisture.

Well-engineered, innovative absorbent products for moderate to heavy incontinence have two layers to properly function and will contain both bladder leakage and stool. These products have a surface area (generally an acquisition layer) that absorbs and collects the urine, drawing urine in and transmitting it to the lower SAP inner core. The layer closest to the skin is designed to wick moisture and disperse the urine along the inner absorbent layer, to maintain a surface that is as dry as possible against the skin. Four minutes after an incontinence episode, 80% of the inner core of SAP will be dry, though it takes an additional four minutes to reach equilibrium. The inner core promotes urine distribution throughout the entire product, facilitating absorption capacity while functioning to prevent urine leakage and odor. In addition to facilitating absorption capacity, this inner core allows the urine to spread throughout the entire layer, locking it into superabsorbent granules as a gel. The product’s design features a combination of absorbent cores or layers which work in tandem to provide the total absorptive capacity for the product. Newer products may have a third layer, called the superabsorbent layer (see Fig. 6.4).

The amount of SAP and fluff utilized in a product will determine the total capacity that it can absorb. Higher quality product lines will generally contain more absorbent materials overall. The industry standard measure of a product’s total performance when fully saturated is termed the ISO Absorbency Rothwell method . Additional product parameters that indicate the performance of a product include the absorption speed, absorption under direct pressure, and re-wet testing. The combination of all performance factors will determine the most effective product.

The absorption speed of a product is known as its acquisition speed and is often measured in tandem with the testing for re-wet. Re-wet represents how dry a product will stay during normal use, or how wet the surface of the product will stay when subjected to pressure (i.e., the pressure of the body during normal wear against the product surface). Because fluid and wetness against the skin is negative for wearers and for skin health, an effective product design in tandem with the strategic use of SAP can influence the feeling of dryness against the skin and, in turn, user satisfaction. Re-wet values determined in a laboratory will not be the same as the values determined in use, due to the natural factors of product compression and handling during actual use. The temperature of the fluid and of the individual will also affect the absorption rate and re-wet performance.

Full product performance is truly determined by the perceptions and feeling of dryness and comfort by the individual wearer and/or individual utilizing the product for incontinence protection. When evaluating absorbent product materials for quality and performance, the accumulative array of features and construction should be considered, rather than claimed absorbent capacity. Higher-quality products will not only contain quality materials and claim a high absorbent capacity, but will also be constructed to fit comfortably against the body and offer additional features that work in combination for improved performance and wearer comfort. These features include areas of SAP concentration, also known as zoned SAP , placed strategically in the product core to improve acquisition speed, re-wet performance, and odor control. Other features that help effectively contain leakage include longitudinal leg cuffs and elastics (see Fig. 6.5) that hug the curves of the body and act as additional guards against leakage. It is important to check the construction of the leg cuffs to ensure their viability and effective functioning while remaining comfortable.

The use of SAP in adult incontinence products began in the 1970s. This petroleum-derived material is impregnated into the product core as a granule that swells as it absorbs and locks in moisture (see Fig. 6.6). Current SAP technology allows for very effective absorption. Presently, SAP granules can absorb up to 70 times their original weight in urine and swell to an average particle size of 1–2 mm.

When designing the absorbent products, manufacturers decide where to position the SAP within the absorbent core for effective wicking of moisture and product performance. The SAP is concentrated in what is known as the “strike zone” in the product , which denotes where the void is likely to immediately reach the product as it leaves the body (see Fig. 6.7). Depending on the product and its intended user, manufacturers will develop targeted zones with areas of more concentrated SAP granules to help facilitate rapid absorption. For example, products intended for men will have their strike zone positioned to specifically work with the needs and natural voiding function of the male anatomy and will be positioned more in the front of the product. The strike zone for women will relate to female anatomy and be targeted to ensure comfort and quick absorption. The outside of the product will usually have a “wetness indicator” that changes color as urine transmits through the different layers (see Figs. 6.7 and 6.8). Besides the SAP , the pulp fibers within the product function to help to spread liquid quickly and efficiently around the entire absorbent core, for even absorption and more wearer comfort.

In higher-quality products, additional features are added to help minimize the risk of leakage , while promoting wearer comfort. Some products feature a top “acquisition” layer against the skin that facilitates more rapid absorption, while providing a dry surface against the skin. Other useful features include leg cuffs that fit into the groin area, helping to provide a comfortable and efficient barrier against leaking (see Fig. 6.5). These leg cuffs feature elastic that can help provide a more comfortable, secure fit against the body.

In addition to leakage protection, odor control is one of the most valued features for disposable bodyworn products. No matter how long the product is worn, the individual should feel comfortable, confident, and odor-free. If the products are worn for several hours or extended periods of time, and contain multiple voids, it is even more critical for the product to effectively control odor. Manufacturers employ varying systems in the designs of their products to promote superior odor control and wearer confidence. New odor neutralizing technology continues to be developed [16]. While the natural acidic level of the SAP material naturally makes it effective in controlling odors related to UI, other elements may be added to minimize odor and support wearer confidence.

Having an effective body-close fit is key for ensuring product performance, leakage protection and odor control. The most important consideration for the wearer is choosing the correct size. The wearer then must ensure that the product is applied properly to support a close fit. With pad products, correct application of the product in the undergarment is key. In all-in-one brief products, the ability to refasten and reposition the product closures without ripping or damaging the product is an important feature that ensures the product fits securely and functions properly. Refastenable tabs with Velcro™-like hook closures are seen as most effective in promoting ease of utilization (see Fig. 6.9) and application. Plastic-backed products are still common, but to help maximize skin comfort and health, the preferred high quality absorbent product designs feature a cloth-like backsheet. In addition to being more comfortable for the wearer due to the textile feel, this material is also known to allow for more “breathability,” i.e., air flow against the skin. It is important to note that the use and claim of “breathable side panels” in all-in-one brief and diaper-style products has been widely promoted in the industry, but is misunderstood or misrepresented. Therefore, it is important to ask exactly where the product is considered breathable, and to check the construction of the material in any area designated as “breathable,” to ensure that actual skin benefits can be realized by the wearer. Only a small number of advanced products exist that employ a truly breathable backsheet in their products (i.e., the Abena^® brand as shown in Fig. 6.8 is one example) with microporous openings that allow water vapor to pass to the outside of the product and offer air permeability while still effectively locking in moisture and odors. Comfort and skin health as it relates to breathability in products is directly related to air permeability and the water vapor transmission rate. Thus, breathability is valuable in promoting the highest levels of comfort and dignity for the wearer.

Absorbent disposable products for incontinence feature a variety of designs, sizes, absorbency levels, and functional attributes to meet the needs of the wearer and to maintain the highest possible quality of life.