As a Geriatric nurse with over 14 years of experience, I have learned many tips and tricks for managing incontinence and have also seen what caregivers get wrong. Navigating incontinence can be difficult and stress-inducing, but with the right knowledge and products, things can improve.
The number of people with incontinence increases with age and is higher in women; over 40% of women aged 70 and older report incontinence. Incontinence is something people shy away from discussing and often struggle with on their own. An estimated 40% of people living with incontinence have not even reported it to their healthcare provider.
Caregivers play a critical role in managing incontinence as they may be the first to notice when the house smells like urine or when an older adult starts avoiding activities due to concerns about leaking, or lack of access to a restroom.
Common Mistakes I See When Dealing With Incontinence
One of the most common phone calls I receive as a nurse is caregiver concerns about managing incontinence. Leaking, skin concerns, overnight wetness, you name it, I've heard it. Managing incontinence is definitely not a one-size-fits-all approach, but we can start by looking at common mistakes that are made.
Using the Wrong Product
With the assortment of different incontinence products available on the market, it’s no surprise that people end up selecting the wrong one for their needs. It’s not until a product fails that caregivers realize using the wrong products can lead to leaks, discomfort, and frustration. It’s not uncommon for people to use a pad, booster, or insert as the first-line product type. It feels less like a diaper, and for many, comes with less associated stigma. However, pads are only meant to protect against occasional light leakage, not full-bladder incontinence.
For example, I had a patient come into the clinic complaining of frequent urine leaks despite using “heavy-duty” pads. This patient experienced what we call full bladder loss, which means the entire amount of urine in their bladder would empty at once with little to no warning. Many booster pads, even high-absorbency ones, can only hold small amounts of urine and may not absorb a full bladder loss quickly enough to prevent a leak, though some higher-capacity pad products can handle larger volumes. I suggested switching this patient to a high-absorbency pull-up-style product that could accommodate full bladder loss. They were still able to change and manage the product themselves, and it was discreet beneath their clothing.
Picking the right product is a lot easier when you have some knowledge about the different types. The most common products available are booster pads (placed inside regular underwear), pull-up-style disposable underwear, or briefs (which have tabs on the sides, like a traditional diaper).
- Liners, or incontinence pads, are the best choice for occasional incontinence episodes where only a small amount of urine is present. They provide reassurance for occasional episodes of incontinence, but typically cannot contain large amounts.
- Booster Pads are a type of product that must be used with pull-up style incontinence underwear or tabbed briefs. It has a flow-through design, so liquid eventually drips out the bottom when it is saturated. The Booster Pad itself has an absorbent core, so it is designed to capture and hold urine in addition to the outer protective layer; adding more capacity.
- Pull-up style underwear is well-suited for people who are still using the bathroom and can stand up and sit down independently or with some assistance. However, pull-ups can be difficult to change if the person wearing them cannot assist with the process. These products typically come in an absorbency range of light to heavy.
- The last choice is a brief with adjustable tabs on the sides and is better suited for people who spend most of their time in bed, experience full-bladder incontinence, or need to adjust the fit around the legs if a standard leg band on a pull-up does not provide a good fit. Incontinence pads are often used together with the tabbed brief. A caregiver can more easily change briefs by rolling the person side to side, without having them stand or move/shift their lower body to have the product put on or removed.
Many people need different products throughout the day; some may be ok with a pad during the day but need a pull-up at night. You also need to consider different products based on the activities you are doing. If you are active and putting more strain on your pelvic floor, you may also need to choose a higher-absorbency product.
Layering Products
It is a common misconception that adding more products on top of each other will increase absorbency. Most incontinence products are designed with a backing that aims to prevent leakage, so when you layer two products together, if the first product overflows, it won’t go through the backing; it will go over the edges and bypass the layer below.
I’ve seen product layering quite frequently throughout my career with people assuming that more is better and that layered products will stop leaks. When explaining that this is not a solution, I will even demonstrate what happens when products are layered. Imagine two incontinence pads stacked on top of each other. The bottom of the first pad has a plastic, adhesive layer, and it is stuck to the top of the absorbent side of the other pad. If you pour water onto the top pad, it will fill the first pad and then will eventually start leaking over the sides, ultimately bypassing the pad below. The backing on the pad is designed to prevent moisture from passing through, so water or urine will not reach the other pad. The bottom pad is there just to create friction, shear, and heat against the skin that can be damaging.
If you are experiencing leaks with pads, switching to pull-up style underwear can often fix the problem. A pull-up has the same absorbency technology as a pad, except it is spread out across the product. This means there is a much larger capacity for absorption due to the increased surface area. The same goes if you are experiencing leaks with a pull-up; trying a brief provides additional absorbency and a more customized fit.
In one instance, I was working with a caregiver in a long-term care facility. The resident was constantly leaking through their products, and they were starting to have issues with skin damage. When I went to meet with the caregiver, I discovered they were using a pad, inside of a pull-up, with a tabbed brief on top. When the resident voided, the urine filled the pad, overflowed, and then spread to the front and back of the pull-up, meaning the urine was not able to be absorbed into the middle, largest area of absorbency. The brief on top was then trapping all of the moisture and heat directly against their skin. I recommended switching to a heavy or overnight-absorbency brief only, which would provide the best protection against leaks while also reducing moisture and friction. This allowed the residents' skin to heal and significantly reduced the number of leaks they experienced.
The Wrong Size or Fit
Sizing and fit of products may be one of the most common mistakes I see. Our bodies do not come in a one-size-fits-all shape, and neither do incontinence products. People tend to assume a larger size will increase absorbency, but this can actually lead to even more leaks because when incontinence products are too big or too small they’re likely to cause gaps around the legs or waist. It is essential to find the correct fit for each individual; otherwise, leaks are almost guaranteed.
A common scenario I run into is a patient telling me they were leaking through their pull-up at night, so they decided to try the next size up. They are frustrated because they are now experiencing even more leakage than before. The first thing I do is measure them using the size guide for whichever brand or product they are using. This will include a waist or hip measurement (measure the widest point where the product will sit, the same place they wear their underwear). Some products will also have a leg band measurement, which is the measurement around the upper leg.
If the measurement falls between sizes, you may need to use some judgment about whether to go up or down. Things I would consider are whether their weight is stable (losing or gaining) and whether they have issues with clothing fitting around their thighs (too big or too small), which can help gauge which direction to go with sizing. Often, brands carry gender-neutral sizing options but also have products more specifically targeted to men and women that offer more accurate sizing.
In the case above, where the patient upsized their product, we found that even the first size they were using was too large and once they sized down, they stopped having leaks at night.
Timing
Another common mistake I see is trying to avoid mid-day changes. Incontinence products are only designed to hold a certain amount of fluid - even those with the highest absorbency. There are numerous variables that cannot always be accounted for, so the products will need to be changed at various frequencies throughout the day. Factors such as activity level, sitting vs. standing, and fluid intake can all affect when a product becomes saturated.
I remember a patient who wanted to be more active, spend time with their grandchildren, and not feel stuck at home all day. She was using booster pads for occasional leaks due to stress incontinence. Stress incontinence occurs when increased movement, laughing, sneezing, or coughing causes urine leakage without complete bladder emptying. Booster pads worked for her at home because she could change them out whenever they became wet, preventing urine from getting on her clothes. Booster pads were also what her daughter was buying for her and what she had available at home.
We were able to talk through a toileting plan that included her using the restroom every 2 hours when she was not at home to help with complete bladder emptying. This helped reduce the amount of urine that leaked and allowed her to avoid changing her pad as often. I was also able to help her daughter with product selection, as she was overwhelmed with what to buy and didn't want her mom to be embarrassed by wearing “diapers”. By educating them both on how different products help in different situations, her mom was able to be more active and enjoy spending time with family.
If a timed toileting plan is not an option, the next solution is to wear a higher-absorbency product, such as a pull-up, when not at home. Ideally, incontinence products should be checked every 2 hours during the day and changed whenever they are wet. This helps prevent leaks and protects the skin. Urine and other bodily fluids sitting against the skin can cause maceration, which is when fluid is absorbed into the skin, making it soft and fragile.
Placement of Incontinence Products
Once you’ve figured out the right product for the right situation, knowing where to place or wear them is also key. Pull-up-style underwear should sit at what we call the “underwear line”. This means the waistband fits comfortably around your hips or waist, and the leg bands encircle your upper thighs, resting at the crease between your buttocks and groin and your upper leg. The waistband should be form-fitting but not tight; it should not have gaping or be so tight as to cause indentations on the skin. The same applies to the leg bands; they should fit close to the skin without gaps, but should not dig into the skin or leave red marks.
When using booster pads placement goes a long way. Men need a pad placed towards the front, whereas women need it placed in the middle of their underwear. This is due to the differences in anatomy and where urine leaves the body. Pads that are too bulky or shifted out of place by clothing can also reduce their effectiveness.
Additional Products to Consider
Sometimes, additional products may be needed to help manage incontinence. These can include washable or disposable bed and chair pads. It is important to remember that bed and chair pads can increase friction and heat on the skin, so they should not be double-layered and should be kept flat and wrinkle-free.
I also recommend buying a waterproof, washable mattress cover if not using a hospital-style mattress enclosed in waterproof material. Just make sure to keep breathable fabric close to the skin and avoid lying or sitting directly on any plastic or non-breathable surface, as this can lead to skin damage.
Fluid Management
Managing fluid intake is often a controversial topic. Drinking enough fluids throughout the day is essential to health and hydration, but it can also increase episodes of incontinence. It can help to limit fluids a few hours before bed, but only if you consume enough fluids during the day to prevent dehydration. My nurse’s tip is to reduce or avoid bladder irritants such as caffeine, carbonated beverages, and alcohol. This does not mean you need to avoid these types of beverages entirely, just be mindful of when you have them, knowing they can increase how much and how often you need to urinate.
Skin Care
Barrier creams are used to create a barrier between the skin and moisture produced by urine, sweat, and other bodily fluids. These creams are applied in a thick layer over areas of the skin that come in contact with moisture. I always tell caregivers it should be a similar consistency to frosting a cake; you want enough cream so it doesn't pull on the skin underneath, just as you don't want to tear the cake with too little frosting. You should also never scrub to remove barrier cream, as it can damage the skin. It should be gently cleansed with soap and water or gentle wipes.
Areas of the skin that come into contact with urine should be cleaned every time an incontinence product is changed. Taking showers or baths frequently throughout the day is usually not possible, so using wipes or foam cleansers formulated for the skin is the best option. If you notice any reddened or open areas of skin, it is important to notify a medical provider as soon as possible to prevent infection and further skin damage.
Final Thoughts
The goal of incontinence management is to help ensure daily life can continue without disruption while also protecting the skin. By avoiding common mistakes and taking the time to find the right products, caregivers can have a positive impact on incontinence management.
