Incontinence and Protecting the Skin

Incontinence-associated dermatitis causes a range of signs and symptoms, and yet the potential impact of skin breakdown may lead to serious, even life-threatening consequences. Although patients of any functional status or within any treatment setting may be at risk for developing the condition. An article from Beeckman et al. in the British Journal of Nursing describes both the chemical and physical irritation of the skin that occurs when urine or feces remains in contact with the perineal skin. According to this article, urine and feces can cause an increase in the pH levels, and subsequently increase skin permeability, reduce barrier function, and increase the risk of bacterial colonization. Rubbing of the skin on clothing, pads or diapers, or surfaces such as a bed or chair creates friction and can further irritate the skin. The linked article focuses on the differentiation between incontinence-associated dermatitis (AID) and pressure ulcers, and is available for free, full access via the link above if you are interested in learning more about the concept.

If the skin dysfunction is limited to IAD, the pelvic rehabilitation provider may observe rash and erythema with possible skin breakdown, or infections such as candidiasis. Unless a therapist is trained in assessing for pressure ulcers, any new or worsened skin breakdown should be brought to the attention of a physician, nurse, or physician extender who is working with the patient. One of the challenges in perineal skin irritation is that the patient may not be able to easily observe the skin and report new onset or worsening of symptoms. In an outpatient setting, even when working with patients who do not have limited mobility or self-care skills, observing the perineal skin remains critical in documenting skin integrity, persistent issues, or a worsening of a condition. Because, as the authors of this study point out, care for skin ulcers and incontinence-associated dermatitis are different, early recognition and proper diagnosis aids in healing.

Following are some recommendations by Beeckman and colleagues for avoiding skin irritation in the presence of incontinence:

•A perineal cleanser should be used that has a pH range of 5.4-5.9
•Perineal skin should be cleaned quickly following an episode of fecal incontinence, whereas avoiding too-frequent skin washing with continual episodes of urinary incontinence is important
•Moisturizing the skin (with emolient-based rather than humectant-based moisturizer) is valuable in aiding healing and preventing further irritation
•Use a skin protectant to create a barrier between the skin and feces or urine
•Absorptive or containment products (catheter or stool diversion system) can further help keep irritants away from the skin surface

Ideally, issues of incontinence, topics covered at length in the Institute's introductory pelvic floor course series are treatable. Even in the case of refractory incontinence, patients should be made aware of appropriate treatment options and screening by appropriate medical providers can direct patients to proper diagnostic testing and referrals. Because pelvic rehabilitation providers may be the first to notice skin breakdown or risk for infections, recognizing our role in patient education and referral to proper providers remains essential.