Urinary incontinence is a common symptom among women that has wide-ranging and often complex aetiology (Hunskaar et al, 2005). Although many will be incontinent as a result of altered bladder pathophysiology, other factors such as obesity, medication or mental illness can contribute or may even be the sole cause.
Immobility is widely accepted as a key factor associated with urinary incontinence (Fonda et al, 2005) and where a bladder problem coexists with immobility, the maintenance of continence can be difficult or impossible.
Healthcare professionals caring for incontinent people often resort to absorbent pads without considering that if reaching the toilet is the primary problem, finding an alternative method of toileting may be preferable. Urinals designed specifically for women can prevent incontinence occurring and provide a dignified and cost-effective solution. However, most healthcare professionals are unfamiliar with the wide range of products available (White, 1999).
There is very little literature available on this important and versatile product group. A few papers describe the designs that are available and assess their suitability (MacIntosh, 2001; Vickerman, 2003). In the sole published research study, Fader et al (1999) conducted a multicentre crossover project in which 37 women evaluated 13 female urinals available in the UK in 1997. All the urinals performed well for some subjects but their strength of performance varied according to the position in which they were used. In particular, most of the urinals worked well when the user was sitting on the edge of a chair or bed but less well when lying down. The more independent the user the more likely urinals would be rated highly, with those users in wheelchairs who were unable to move forward finding the urinals difficult to use.
What is a female urinal?
Female urinals are generally small, lightweight and made from moulded plastic or metal. The contact surface or ‘interface’ is anatomically shaped allowing the urinal to fit snugly against the woman’s body. Once urine has been passed into the urinal it is securely contained away from the body until a convenient time for disposal (Table 1).
Female urinals are designed for use in a range of positions, for example in a fixed position in a bed/chair/wheelchair, perching on the edge of a chair/bed, or standing. Several products have handles that can assist positioning. This is important as many people with mobility problems also have impaired manual dexterity. Some urinals are designed specifically for use outside the home and are portable and discreet while others can be connected to a large-volume urine drainage bag secured on a stand. This provides additional storage volume for multiple uses where assistance is not always available to empty the urinal.
Assessment of the patient
Although hand-held urinals have the potential to increase independence, they are not suitable for everyone and careful assessment is required. If non-specialist staff have difficulty making this assessment they should contact their continence nurse specialist and, if available, specialist occupational therapist. Urinal selection and the key design features to consider depend on the physical characteristics of the user and her lifestyle.
Table 2 provides points to consider in an assessment of a patient for a female urinal.
Unless a carer is available to assist, the woman will require sufficient manual dexterity to position the urinal correctly. This involves adjustment of clothing, abduction of thighs (although some urinals can be inserted with thighs closely positioned together), supporting the urinal in position during micturition, removing it without spillage and either emptying it or placing it securely until help is available. The ability of the hand to grip the body of the urinal or its handle will determine whether the patient is suitable for a hand-held urinal and the type of urinal. Handles can be modified to facilitate a limited grip in terms of handle bulk and friction, and may be extended if the woman has problems reaching forward to insert the urinal.
Hand and wrist strength is necessary to support the full urinal as it is removed from the body and lowered to its resting place or emptied without spillage. Spillage can be avoided by using urinals with a non-spill function, for example the Spil-pruf or Ursec. Alternatively, Vernagel (a superabsorbent polymer) is available in 8g sachets that, when placed in the urinal, will absorb and solidify the urine. A urinal that is connected to a drainage bag will allow the urinal to empty rendering it light and more manageable, for example the Bridge urinal.
Position for urinal use
The position in which the urinal is to be used should be considered, for example whether the patient will be:
- Flat in bed;
- On her side;
- In a wheelchair;
It is important to consider how agile the woman is in that position. For example, can a wheelchair user move towards the front of the chair or is she in a fixed position and unable to part her legs? Is she able to sit up in bed or move to the edge of the bed or is she in a fixed supine position? In practice, people often adopt a range of different positions throughout the day and this, coupled with an inability to adopt conventional positions as a result of neuromuscular and musculoskeletal conditions, means that finding a suitable urinal is often best addressed by trial and error. The body of the urinal must be lower than the urine entry point as urine flows downwards with gravity. Insertion of the urinal from the rear (with the body of the container behind the patient and sloping downwards) may provide a solution, particularly for patients lying on their side or back.
The urinals evaluated by Fader et al (1999) generally performed poorly when women were sitting back in a chair or in bed. The ability of a patient to adjust her position was found to increase the likelihood of being able to find a urinal that worked for them. However, gentle pressure on the body of the urinal when used in a chair may provide the necessary angle required for urine to drain into the container despite the backwards slope created by sitting on a soft surface (most chairs are manufactured with a backwards slope of about five degrees as an ergonomic requirement.
Many of the urinals were successful with the patient sitting towards the edge of the chair or when standing or crouching. If the patient is able to stand and bear some of their own weight, consideration should be given to their balance, the need for a support, for example a frame, furniture or carer, and their ability to manage clothing and the hand-held urinal with one hand.
The compliance of the surface on which the woman is lying or sitting will play a part in determining which urinal works. If the woman is unable to lift herself it may be possible for a urinal to be inserted beneath her by compressing the mattress or chair cushion. Urinals that have a slim ‘insertion point’ may be easier to insert.
Clothing can impede insertion of the urinal and prevent its use. For women who do not wish to change the style of their clothes, discreet modifications can provide the answer, for example extended or newly inserted side openings, use of alternative fastenings such as Velcro and elastication of waistbands. Certain styles of clothes, such as long straight skirts, limit the options for urinal use. Multiple layers of clothes can make access difficult and alternative styles of underwear, such as camiknickers with crotch fastening, can help. Patients should be helped to work out the clothing styles and modifications that work best for them.
Where is the urinal to be used?
A hand-held urinal may be all some women require to become completely independent for their toileting needs. For others, however, a urinal may form part of a range of methods proving particularly useful in certain circumstances, for example in bed or away from home, at work or on holiday. Different types of urinal may be required for different circumstances, for example a more discreet urinal may be used when away from home but one with greater capacity for use at night.
Specialist functions of urinals
Certain key design features are available that make a urinal useful in particular circumstances. Some are designed for travelling and may be disposable (TravelJohn) or collapsible (UriBag F) for discreet use. A number of urinals are available that are already connected (or can be connected) to a drainage bag. The urinals themselves do not contain the urine but merely allow a secure conduit for it to pass into a drainage bag. The bags have a relatively large capacity and can provide storage for urine from multiple voids (Lady Funnel, Lady Jug). However, efficient drainage is gravity dependent so it is important that the urinal is positioned so that the exit port is at the lowest point in the urinal and that flow of urine through the tubing is unimpeded, for example by kinks.
Urinals can be obtained by mail order, over the counter from chemists or on prescription. Female urinals can provide an economic alternative to absorbent pads: a typical one-off cost of £10 for a urinal compared with a daily cost of around £1 for pads. However, purchasing a urinal without trying it out first can result in costly mistakes. Urinals can be tried over underwear or even outer clothing in the first instance and many continence nurse specialists and specialist occupational therapists will have at least a small range of urinals available for viewing and/or loan. A female urinal lending library has also been developed in one PCT (Vickerman, 2003).
Problems with conventional urinals
Although the conventional female urinals currently available will suit the needs of many people, they do have some limitations. In particular, urinals need to be emptied soon after they have been used to avoid the risk of spillage and odour and to ensure they are ready for subsequent voids. Urinals that are designed to be attached to drainage bags depend on gravity for emptying, which may be incomplete especially as some users will be sitting towards the back of a chair with a sloping surface.
A novel alternative
To overcome these challenges, a prototype device called a non-invasive continence management system or NICMS (Tinnion and Jowitt, 2000) has been designed that allows urine to be simultaneously voided into a small, slim-line urinal and evacuated from the urinal into a closed container. A vacuum is created in the container by a pump. This is used to draw urine rapidly into the container when a heat sensor in the urinal detects the presence of urine. Once the device has been set up and is in position either on the floor or the back of a wheelchair, it is ready for use.
Clinical evaluation of the device has demonstrated that it can work very well for women in a variety of circumstances, particularly wheelchair uses who are reasonably agile in their chairs, women who depend on carers for transfer to the toilet and for travel. However, further work is required to make the device more reliable and suitable for widespread use, for example it needs to be quieter, lighter and less bulky.
All the urinals described above require the woman to be aware of the need to void. An alternative, pad-shaped interface has been developed for use with the device which is intended to remain in place for extended periods for women who are unable to sense the need to void. This is currently undergoing clinical evaluation.
Female urinals can provide a very acceptable, safe and economic alternative to difficult journeys to the toilet or the use of absorbent products. They can benefit individuals with a range of mobility difficulties and, just as importantly, their carers.
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The NICMS consortium is led by the Brunel Institute for Bioengineering (UK) and includes Medical Device Management (UK); the Continence and Skin Technology Group, University College London (UK); KBOH (Netherlands); the Medical University of Lodz (Poland); Loewenstein Hospital (Israel); the Swedish Handicap Institute (Sweden); the Broca Hospital of APHP (France); and Loughborough University (UK). The project is currently funded by the European Commission’s Quality of Life Programme under Framework 5, key action 6.4 ‘Coping with the functional limitations of old age’.
Vernagel is available on FP10 from Vernacare (01204 384858).
Table 2 is reproduced with the permission of Joan MacIntosh and the article was produced with the support of Julie Vickerman.
This article has been double-blind peer-reviewed.
For related articles on this subject and links to relevant websites see www.nursingtimes.net.