Health Care for Women International

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Personal hygiene in external genitalia of healthy

and hospitalized elderly women

Marianne E. Lindell R.N.M, U.D. & Henny M. Olsson Ph.D., R.N.M., U.D.

To cite this article: Marianne E. Lindell R.N.M, U.D. & Henny M. Olsson Ph.D., R.N.M., U.D.
(1990) Personal hygiene in external genitalia of healthy and hospitalized elderly women, Health
Care for Women International, 11:2, 151-158, DOI: 10.1080/07399339009515885

To link to this article: http://dx.doi.org/10.1080/07399339009515885

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 PERSONAL HYGIENE IN EXTERNAL GENITALIA
OF HEALTHY
AND HOSPITALIZED ELDERLY WOMEN

Marianne E. Lindell, R.N.M, U.D.,

and Henny M. Olsson, Ph.D., R.N.M., U.D.
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A comparative study of the personal hygiene of two groups of el-

derly women was carried out in Örebro, Sweden. The investigation
group consisted of 28 women who were hospitalized in long-term
care wards and the comparison group consisted of 35 healthy
women. The results show that a remainder of soap in the genitalia
may be one factor contributing to elderly hospitalized women's dis-
comfort. Caregivers should be educated in how to assist elderly
hospitalized women with their personal hygiene.

A comparative study of the personal hygiene in two groups of elderly

women was carried out in Örebro, Sweden. Proper personal hygiene
should be based on individual need. A soap with a low acid content
should be used, and care should be taken to rinse the soap off thor-
oughly.
Henderson's (1972) basic principles of nursing care were used in
support of this study. Basic nursing care may be defined from human
needs, as can all welfare services. An analysis of appropriate nursing
care must, therefore, be based on a definition of the nurse's function that
is acceptable to all concerned. Henderson held that the unique function
of the nurse is to assist the individual, sick or well, in the performance
of those activities contributing to health or its recovery (or to peaceful
death) that the individual would perform unaided if he or she had the
necessary strength, will, or knowledge. Furthermore, the nurse should
provide this assistance in such a way as to help the individual gain
independence as rapidly as possible. Henderson presented 14 compo-
nents of nursing care.
In the present study, the comparison group consisted of 35 healthy
women aged 70-86. The investigation group consisted of 28 women aged
66-96 who were hospitalized in long-term care wards and who received
help with their personal hygiene. The results show that remains of soap in

Health Care for Women International, 11:151-158, 1990

Copyright © 1990 by Hemisphere Publishing Corporation 151
 152 M. E. Lindel! and H. M. OIsson

the external genitalia may be one factor contributing to elderly hospital-

ized women's discomfort. The caregivers' lack of knowledge about nor-
mal physical aging in the female external genitalia prevents them from
applying the eighth component of Henderson's nursing theory.

THEORETICAL BACKGROUND
Henderson's Nursing Theory

Henderson (1972) presented 14 components of nursing care. Compo-

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nent number eight describes how the caregiver should help the patient
carry out personal hygiene and protect the integrity of the skin. Further-
more, Henderson said that the caregiver should get to know the patient
well and act as her advocate.
When the patient is not capable of carrying out her daily activities,
the nurse should assist her. Although all people have similar needs, each
individual satisfies these needs in a uniquely personal way. For personal
hygiene, each patient should be provided with the facilities, equipment,
and assistance that she needs. Although concepts of cleanliness vary, the
patient should not have to lower her standards because she is ill.

Physiological Aging

Estrogen is one of the female hormones that, in an environment of

low acidity, functions to protect women against infections of the external
genitalia. The aging process in the genital area is directly affected by
estrogen. Low estrogen levels contribute to fragility of the vaginal mu-
cous membrane. This can result in experiences of genital discomfort
such as dryness, soreness, burning, itching, and genital discharge. Ex-
cessive washing with soap and water may contribute to a partial reduc-
tion in the effectiveness of the body's normal defenses. Low estrogen
production also increases the risks of urinary tract infections (Furuhjelm
1980, 1982; van Schoultz, 1985).

Knowledge about Personal Hygiene

The education of caregivers in regard to female hygiene is generally

focused on adults in their childbearing years and on children. Related
skills are learned and applied within the framework of diagnosis and
planning care. Aging is usually not stressed in care plans. Caregivers
consequently tend to underestimate or misunderstand the processes of
aging. Most of the caregivers in this study were 20 to 30 years old.
To a large extent, caregivers draw on their own experience with hy-
giene when working with their elderly patients, which may not be ap-
propriate. For example, younger women conduct most of their personal
 Personal Hygiene in Healthy and Hospitalized Elderly Women 153

hygiene in the shower, where soap rinses off easily. Elderly female pa-
tients, by contrast, usually get assistance with their personal hygiene by
use of a bed bath. In the area of personal hygiene, proper care requires
the knowledge of both biological and behavioral sciences. Caregivers
must have this knowledge in order to carry out their role as patient
advocate. Inadequate routines for carrying out the personal hygiene of
elderly chronically ill female patients have been pointed out by caregiv-
ers. They have also noticed that these patients suffer from vulvovaginal
problems such as fragile mucous membranes and infections. Healthy
elderly women who attend to their own personal hygiene do not have
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these problems to the same extent as do elderly sick women.

Related Studies

We did not find any literature on this specific subject. Articles that
touch on this area are concerned with the self-care of healthy younger
women and the occurrence of urogenital and vulvovaginal symptoms. In
a study of 31 patients with dysuria, Ravnskov (1984) showed that the
pain was not caused by urinary infection but by irritation of the urethra,
which resulted from soap that was not rinsed off properly. In a study by
Heidrich, Berg, and Bergman (1984), women (mean age 32 years) had
similar rates of vaginal problems whether they wore panty hose or not,
but vaginitis caused by a yeast organism was about three times more
common among women who wore panty hose. Tight clothing can pre-
dispose wearers to candidiasis (Elgebe, 1982). A number of health
habits and behaviors are cited in medical and nursing textbooks as po-
tential causes of urinary tract infections in women (Foxman & Fre-
drichs, 1985).
We hypothesized that insufficient knowledge concerning the normal
physiological processes of aging prevents caregivers from applying the
eighth component of Henderson's nursing theory.

STUDY SAMPLE AND METHOD

The study consisted of an investigation group of women hospitalized

for long-term care and a comparison group of healthy elderly women in
Örebro, Sweden. The investigation group of 28 patients was selected
from six wards in four different institutions (Group 1). The comparison
group of 35 healthy elderly women was selected from social groups in
the community (Group 2).
All participants lived in the same geographic region. According to the
selection criteria, Group 1 consisted of elderly chronically ill women on
long-term care wards, who had identified symptoms of vaginal discom-
fort, such as erythematous mucous membranes, vaginal discharge,
 154 M. E. Lindell and H. M. Olsson

coated mucous membranes, ulceration/scratches, and eroded skin.

Group 2 consisted of women who were healthy in that they were not
permanently hospitalized. We had no further information concerning
their health.
The methods of study included reading case records, documenting
customary care routines, making observations, conducting interviews,
and administering a questionnaire. Case records from the previous 6
months were used to document incidences of urinary tract infections,
genital discomfort, and treatment with antibiotics and/or female hor-
mones. Existing routines of care and individualized care plans dealing
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with personal hygiene were noted.

The external genital organs were examined to note the appearance of
mucous membranes and to determine the presence of discharge, infec-
tion, yeast vaginitis, ulcers, or lacerations from scratching.
The interview contained variables concerning experiences of burning,
itching, and pain in the genital area. A questionnaire administered to the
comparison group contained the same variables as those in the interview
used with the patients.

Data Collection and Analysis

Group 1: The caregivers determined the patients who had genital

discomfort or symptoms from the external genital area and who would
participate in the study. We began our data collection with an interview
with the patient. We then conducted a visual examination of the patient's
external genital area. The case records were read, and the routines of
care were documented on the same day.
Group 2: The women in the comparison group were informed about
the study at a social gathering. They were told that the questionnaire
should be mailed back to the investigator within 10 days.

Participants

Group 1: The mean age of the patients was 83.9 years (range 66-96
years). The mean weight was 53.7 kg (range 33.2-78 kg) and the mean
height was 150 cm (range 147-174 cm). Of the 28 patients, 11 (39%)
were judged to be mentally oriented, and 17 (61 %) were judged to be
partially or completely disoriented. Two patients (7%) were continent.
Six patients (21 %) had physical mobility of their lower limbs, and the
others used wheel chairs or were bedridden. At the time of the study, the
mean length of hospitalization was 2.5 months (range 1 month to 9
years, 4 months).
Group 2: The comparison group consisted of 35 healthy women liv-
 Personal Hygiene in Healthy and Hospitalized Elderly Women 155

ing on their own. The mean age was 76.11 years (range 70-88 years),
the mean weight was 63.6 kg (range 47-78 kg), and the mean height
was 163 cm (range 150-170 cm).

RESULTS

In Group 1, 25 patients (89%) had vulvovaginal signs and symptoms

(see Table 1).
The most frequent symptom was erythematous mucous membranes.
Twenty-two patients (79%) had erythematous mucous membranes,
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which were localized at the introitus vaginae, the labia, and the external
urethral orifice. Twelve patients had other vulvovaginal symptoms in
addition to erythematous mucous membranes. Eleven of these patients
were incontinent of urine.
Eleven patients (39%) had been or were currently being treated for
pruritus with estrogen or other medication. (Four of these patients had
diabetes mellitus.) Because more than half of the patients were judged to
be mentally unclear, it was not possible to document whether they expe-
rienced external genital discomfort.
In Group 2, 7 women (20%) had experienced discomfort from pruritus
in the external genital area. The most frequent symptom was dry mucous
membranes. Four women had consulted a doctor and two had no symp-
toms after treatment. The discomfort was experienced as mild.
In the investigation group, all patients received help with their per-
sonal hygiene. All wards used soap and water for morning care, which
was carried out with the patients in their beds. Two wards also used a
common type of soap with a high acidity and water for evening care.
The patients received showers once a week on all wards except one,
where showers were given once every two weeks. Some nursing teams
had problems following individualized care plans for personal hygiene.
In the comparison group, most of the women had three to four showers
a week. More than 50% of the women used soap and water for their
personal hygiene five to eight times a week. Figure 1 shows the number
of times per week that the women used soap for personal hygiene.

DISCUSSION

The results indicate that caregivers either have inadequate knowledge

or do not use their knowledge regarding the importance of correctly
administered personal hygiene for elderly women. These chronically ill
elderly women often have a severely reduced mental ability (senile de-
mentia), reduced physical mobility of their lower limbs, and urinary
incontinence. It appears that care is primarily directed toward problems
 VI
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Table 1. Frequency of macroscopically observed vulvovaginal signs and symptoms

Erythematous Vaginal Coated Ulcération, No observed

Number of symptoms mucous membranes discharge mucous membranes scratches Eroded skin Other symptoms

2 1 1
3 3
5 4
4 3
6 6 2
5 5 1
Note: n - 25.
 Personal Hygiene in Healthy and Hospitalized Elderly Women 157

Number of women
|| I.I 15 comparison group

investigation group
30
28
25
20
ie
15 WT
i;
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10
3
7 |^ 4
5 f"
0 fí
t
1 1 í
1
i
0 | í 0 Number of times/
i
1° 1 j 1 week that soap
1-3 1
4-7 >8 is used.

Mann-Whitney test significant difference at 0.01 level.

Figure 1. The number of times per week that the subjects used soap for
their personal hygiene.

that are visible and obvious. In regard to symptoms in the female genita-
lia, this study indicates that urinary incontinence is a central focus of
care. Chronically ill women on long-term care wards wear an absorbent
sanitary diaper and a pair of elastic netlike yarn panties to keep the
diaper in place. On top of this, these women often wear thick cotton
briefs and nylon tights. All this, combined with the moisture in the
external genital area, probably constitutes a perfect environment for
bacterial growth and skin breakdown.
To provide the proper care, caregivers must know that the urogenital
mucous membranes of elderly chronically ill women are normally
atrophie and are easily damaged by pressure and acidity in the genital
area.
A search of the literature has revealed a lack of attention to female
personal hygiene. Studies have generally focused on younger (fertile)
women. Wearing tight underwear carries an increased risk of contract-
ing Candida albicans (Elgebe & Elgebe 1983). We found that the care-
givers did not fulfill the eighth component of Henderson's (1972) theory,
which has to do with helping the patient protect the integrity of the skin.
One cause of the patient's genital discomfort can be that the caregivers
do not pay sufficient attention to the importance of individual care.
Another cause of the patient's genital discomfort can be the caregivers'
 158 M. E. Lindell and H. M. OIsson

attitude that the genital area of elderly women is unimportant. This

attitude may exist because the genital discomfort of elderly women, in
particular, is not talked about and their personal hygiene is not empha-
sized in the literature as being an important aspect of care.

CONCLUSION

The caregivers in our study did not fulfill the eighth component of
Henderson's theory, which is to help the patient carry out her personal
hygiene and protect the integrity of her skin. Administering personal
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care is one of the main responsibilities of nurses. Proper personal care

of elderly chronically ill women should not require a medical order.
Caregivers should be educated about the physiological function in the
vaginal mucous membrane. They should be taught that remains of soap
in the female genitalia may cause damage to the tissue and discomfort
for the woman and that, if the soap cannot be rinsed out thoroughly, it is
best to use water alone most of the time.

REFERENCES

Elgebe, I. A. (1982). A preliminary study on dressing patterns and incidence of

candidiasis. American Journal of Public Health 72, (2), 176-177.
Elgebe, I. A., & Elgebe, I. (1983). Quantitative relationships of Candida albicans
infections and dressing in Nigerian women. American Journal of Public Health 73,
(4), 450-452.
Foxman, B., & Fredrichs, R. B. (1985). Epidemiology of urinary tract infection: n .
Diet, clothing and urination habits. American Journal of Public Health 75, (11),
1314-1317.
Furuhjelm, M. (1980). Gynekologi för kvinnor over fyrtio. [Gynecology for women
above the age of forty]. Stockholm, Sweden: Raben & Sjögren.
Furuhjelm, M. (1982). Inverkan av östrogent hormon på urinvägarna hos kvinnan. [The
effects of estrogen on the female urinary tract.] Läkartidningen, 79, 1800-1801.
Heidrich, F. E., Berg, A. O., & Bergman, J. (1984). Clothing factors and vaginitis. The
Journal of Family Practice, 19, (4), 491-494.
Henderson, V. (1972). Basic Principles of Nursing Care. New York: International
Council Nurses.
Ravnskov, U. (1984, May 5). Soap is the major cause of dysuria. The Lancet, 1027.
van Schoultz, B. (1985). Substitutionsterapi med östrogen inom geriatriken.
[Substitution therapy with estrogen in geriatric care]. A. Svanborg, D. Mellström, &
L. Wilhelmsson, eds. (pp. 43-47). Göteborg: Organon.