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Clinical Practice Keywords Incontinence/

Sustainability/Products
Discussion
Continence This article has been
double-blind peer reviewed

In this article...
● T
 ypes of continence product available and their advantages and disadvantages
● Why a single-use culture currently exists and how this can be addressed
● Why a ‘mix and match’ approach may be best for most product users

Sustainability 2: are sustainable

continence products a realistic option?
Key points
Authors Margaret Macaulay is senior research fellow, Sandra Wilks is lecturer in
There are medical microbiology, Catherine Murphy is senior research fellow and Mandy Fader is
advantages and professor of continence technology at School of Health Sciences, University of
disadvantages of Southampton; Bill Gillespie is chief executive at Wessex Academic Health Science
both reusable Network, and Alan Cottenden is emeritus professor of continence technology at
and single-use Medical Physics and Bioengineering, University College London.
continence products
Abstract Incontinence management currently depends largely on single-use
Evidence shows products. Reusable products exist but are less developed and less widely used. There
that some reusable are advantages and disadvantages to both types of products. Some evidence exists
products can be to support the use of reusable products instead of, or as well as, single-use ones.
effective alternatives Currently it is likely that some use of reusable products, in a mix with single-use
to single-use ones products, is the best route to more sustainable product provision. This article
discusses the evidence for, and barriers to, the use of reuseable products, and
A ‘mix and match’ suggestions to promote it. Part 3 of this series (p38) discusses how nurses can reduce
approach of both the environmental impact of inhalers.
types of product
may be the best Citation Macaulay M et al (2020) Are sustainable continence products an aspiration
option for many or a current option? Nursing Times [online]; 116: 9, 32-37.
people

S
There are barriers to ustainable healthcare is a major
the use of reusable goal both worldwide and for the
products, which NHS, where single-use products
should be addressed are a key contributor to plastic
waste (Sustainable Development Unit,
Investment in new 2020). Incontinence management is
reusable designs heavily dependent on single-use products
and materials is – mainly plastic-backed disposable pads
needed to improve and other products containing non-biode-
their acceptability gradable plastics, such as urinary drainage
and effectiveness sheaths and catheters. These containment
products are essential for people with
intractable incontinence: their dignity,
quality of life, independence and physical
health depend on them (Cottenden et al,
2017). The number of single-use conti-
nence products used per annum is hard to
estimate, but it is a large and growing
market estimated to be worth US$12.9bn
(£10.3bn) across 41 countries in 2018 and is
expected to increase to US$15.8bn (£12.6bn)
by 2026 (Absolute Reports, 2020).
NHS Inform (2020) estimates that three
million to six million people in the UK
experience urinary incontinence and that
demand for continence products is likely
to rise because risk factors for inconti-
nence are increasing. Risk factors include
advancing age, lifestyle factors, dementia,
complex comorbidities and obesity.
The three Rs: reduce, reuse,
recycle
With origins in the American ‘Earth move-
ment’ of the early 1970s, the three Rs are
often used as a framework to consider
ways of reducing waste. They are now part
of day-to-day environmental language:
“reduce the amount of waste created,
reuse items that could have a future pur-
pose and recycle whenever possible”
(Recycle Nation, 2015). In continence care,
reducing or curing incontinence is the
most desirable goal; assessment

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Clinical Practice
Discussion

Table 1. Categorisation of continence products: single-use or reusable

Typical lifespan of single-use products/devices* (manufacturer’s instructions for use vary)
Multiple products/ 12-24 hours 24 hours 7 days 1 month 3 months
devices per day
● Disposable ● Internal vaginal ●U  rinary sheaths ● Catheter valves ● Short-term ● Long-term
absorbent pads devices ● Body-worn ● Drainable indwelling indwelling
(body-worn pads retracted penile urine-collection catheters catheters
and under-pads devices bags
for bed/chair) ● Non-drainable
● Intermittent urine-collection
catheters bags
● Internal vaginal
devices
●A  nal plugs and
inserts
●B  ody-worn faecal
collectors

Typical lifespan of reusable products/devices** (manufacturer’s instructions for use vary)

24 hours 28 days 1 month plus
Emteva intermittent catheter Cliny intermittent catheter (not available in ● Washable absorbent pads (body-worn
the UK) pads and under-pads for bed/chair) and
pull-on pads
● Body-worn urinals
● Penile compression devices
● Metal intermittent catheters
● Hand-held urinals and toileting devices
● Internal vaginal devices
* Used once then thrown away. **Used repeatedly when cleaned between uses.
For all products/devices, lifespan varies according to the manufacturer’s instructions for use and local licensing regulations.

interventions to prevent and reduce incon-
tinence should, therefore, be the highest
priority. Appropriate reassessment of indi-
viduals’ continence product requirements,
using validated tools where available
(Yearwood-Martin et al, 2018), can help
reduce the number of products used,
avoiding over-supply and product waste.
Fewer highly absorbent pads of the most
appropriate design may be more effective
than several less-absorbent or less-effec-
tive ones. The potential for recycling
products is currently very limited. Conti-
nence products typically utilise non-bio-
degradable plastics, superabsorbent poly-
mers and other materials that make them
unsuitable for recycling.
Reusable products have existed for a
long time but have limited uptake com-
pared with single-use options. Continence
products are needed while users are waiting
for treatment to take effect and when it fails
or is unsuitable, and there is potential for
the number of single-use products used to
be reduced by substituting reusable vari-
ants where available and acceptable.
Drawing on the available product evi-
dence, this article will focus on the use of
reusable products as a strategy for more
sustainable incontinence management,
asking whether it is a feasible option. It
will address:
l T he advantages and disadvantages of
Fig 1. Single-use symbol
single-use and reusable products;
l W
 hether the lifespan of all single-use
and reusable products is equal;
l T
 he evidence that shows reusable
options are effective or acceptable;
l W
 hether, given the limitations of both
types of product, a mixed approach is
the best way forward.
Categorisation of continence
products
Continence products are usually catego-
rised by design, for example, products
might be categorised as pads, male devices
or catheters. In terms of sustainability,
they can be categorised as either single-use
(disposable, used once then thrown away)
or reusable (used multiple times by the
same person then thrown away). In addi-
tion, the lifespan of single-use and reus-
able products varies (Table 1).
Most commonly used continence prod-
ucts are single-use. This means they are
licensed only to be used once then dis-
carded, as indicated by the symbol
showing a crossed-out two (Fig 1) on their
packaging. Whether a product is for
single- or multi-use is regulated by its
license for use. The European Union (2017)
directive requires that products which are
intended or designed for reuse must be
provided with cleaning instructions that
restore the product to its original state.
Advantages and disadvantages
of reusable and single-use
continence products
There are some generic advantages and dis-
advantages of both types of product, which
are not design-specific (Table 2). These fac-
tors can strongly influence product choice:
someone may find a product very effective
at containing their incontinence but unac-
ceptable in its reusability, for example, due
to an unwillingness to clean it or a lack of
suitable washing facilities.
It is evident from Table 2 that the disad-
vantages of reusable products are likely to
make their wholesale use unsuitable for
most people, even if they are as effective as

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Clinical Practice
Discussion

Table 2. Advantages and disadvantages of single-use and reusable products

Reusable products/devices Single-use products/devices
Advantages Disadvantages Advantages Disadvantages
GENERAL
Waste Fewer products to throw Energy, water and More products to throw
away detergents required for away
cleaning
Energy Fewer products Energy required for More products produced
produced washing machines/
dryers
Cost Cost per use diminishes Relatively high capital Unit cost relatively low, Cost is repeated for each
with increasing use, outlay, so trial and error so trial and error is use and does not
therefore, cost-effective is more expensive inexpensive diminish over time
if used multiple times
Quality Potential for high-quality Potential for quality of
products less limited products to be limited
by cost by cost
INDIVIDUAL
Cleaning burden ● Cleaning may be too Always in a state ready
burdensome for the for use, with little
user/carer preparation required and
● A washing machine/ no need for cleaning
dryer may be needed after use
● May be unsuitable in
institutional settings
where individual
laundry of personal
items is limited
Infection prevention Some product types Sterility perceived to be
perceived to cause essential to avoid some
infection, for example, product types causing
reusable catheters infection, for example,
causing urinary tract single-use catheters
infections
Running out Product can be reused, ● Fear of running out
so reduced likelihood of ● Potential lack of
running out access to products
Lifestyle Need to carry used Need to dispose of used
(soiled) products when products in public places
out
Storage Fewer products, Large quantities of
therefore, less storage products to be stored
required

– or more effective than – single-use prod-
ucts. It is also evident that some of the dis-
advantages of single-use products may be
offset by the use of reusable versions. This
raises the question of which reusable prod-
ucts are sufficiently effective to be able to
replace the use of some single-use products.
What is the evidence for reusable
products over single-use products
for specific product designs?
Although there is evidence that users are
concerned about the quantity of waste
they generate (Avery et al, 2018), single-use
products – particularly body-worn
(plastic-backed), disposable pads – are
highly effective. However, there is evi-
dence in different product categories and
for different patient groups that reusable
alternatives can also be effective and
acceptable (Table 3).
Although limited for reusable conti-
nence products, there is evidence to show
that, for some people, circumstances and
product designs, reusable variants may
not only be effective but preferred by users
to single-use options. This provides an
opportunity to either avoid single-use
products entirely or, more realistically,
reduce the quantity used by combining
single-use and reusable versions.
Mix and match
Most studies of continence products show
that one product type does not suit an indi-
vidual at all times, and the concept of a
‘mix and match’ of products has been
shown to be preferred by both women
(Fader et al, 2008) and men (Macaulay et al,
2015). This term refers to using different
products:
l A t specific times of the day or night;
l F or specific activities;
l F or other preferences.
It does not refer to the simultaneous
use of different products, for example,
using a disposable, plastic-backed pad
inside a pantegral (washable pants with an
integral pad).
The ‘mix and match’ approach requires
users to be offered, and encouraged to con-
sider using, more than one product variant
or design, including both reusable and
single-use products. Although the
approach is most suitable for men – for
whom there is a more diverse range of
products available – women have some
similar options, as shown in Table 3.
Addressing barriers to more
sustainable approaches
Using available evidence, we have suggested
ways in which reusable products can be used

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Clinical Practice
Discussion

Table 3. Reusable alternatives that have the potential to reduce use of single-use products
Table 3.1. Body-worn containment products and male devices
Type and Typical Reusable (and Potential for Guidance and evidence
degree of single-use longer-lasting) use (either on
incontinence product used option its own of in a
mix of
products)
Women with Small Washable pants Recommended Can be effective and acceptable for women with very
light or very disposable with integral light leakage, for example, used alone when at home or
light urinary pads pad combined with disposable pads when away from home
incontinence (pantegrals) (Fader et al, 2008)
(UI) Washable pads Not When tested they were lowly rated (Fader et al, 2008)
recommended
Internal vaginal Consider Can be used intermittently for specific activities and/or
devices daytime use, but many women find them unacceptable or
derive only limited benefit. They require a degree of manual
dexterity for insertion and removal (Cottenden et al, 2017;
Lipp et al, 2014)
Women with Single-use large Different Consider May be effective, but generally unacceptable for women at all
moderate or disposable designs of times, particularly due to appearance and lack of discreetness
heavy UI pads/pull-on purpose-made (Fader et al, 2008)
pads/all-in-ones all-in-ones or
(wraparounds) traditional
cotton-
towelling pads
and waterproof
pants
Men with light Single-use small Washable Recommended Can be effective and acceptable for men with very light
or very light UI pads/male pantegrals leakage, for example, used alone when at home or combined
pads/pouches with disposable pads when away from home (Fader et al,
2008). Particularly suitable for active men as they are more
secure than pads (Fader et al, 2006)
Washable male Not No evidence, but likely to be rated lowly as they were for
pads recommended women
Urinary Consider A discreet, acceptable alternative to pads, particularly when
drainage sheath containment is required over long periods and changing a
plus catheter pad would be difficult, for example, when playing golf
valve or (Macaulay et al, 2015; Chartier-Kastler et al, 2011) or when
collection bag seated, such as wheelchair use. Less suitable if there is skin
damage around the penis, the penis is retracted or urinary
tract infection is a problem (Macaulay et al, 2015)
Body-worn Consider May be an acceptable alternative for standing activities where
urinal with tap there is a preference for a device that does not require glue
or collection (from a sheath) on the skin. Less suitable when seated or
bag lying down (Macaulay et al, 2015)
Penile compres- Consider May be useful as part of a mix of the above devices when
sion devices secure leakage prevention is needed for short, vigorous
activities, such as dancing or swimming. Not suitable when
memory, genital sensation, urge to void or manual dexterity
is poor or penile skin is damaged (Macaulay et al, 2015; Moore
et al, 2004)
Men with Single-use large Washable Consider The most absorbent of the washable products for moderate
moderate or disposable purpose-made or heavy UI have been found to be more absorbent than their
heavy UI pads/pull-on or traditional disposable equivalents (Fader et al, 2008). Effective for men
pads/all-in-ones cotton- at night when their UI is particularly heavy, and absorbency is
(wraparounds) towelling pads needed over the hips if they are lying on their side. Very bulky
and waterproof and less acceptable when discreetness is a priority (Fader et
pants al, 2008)
Other products Recommended As for ‘Men with light or very light urinary incontinence’ – see
(sheath/ above
body-worn
urinal/clamp)
Faecal Single-use Anal plugs or Consider May be useful for preventing or reducing faecal incontinence,
incontinence disposable inserts but can be difficult to tolerate (Deutekom and Dobben, 2015)
pads

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Clinical Practice For more articles

on continence care, go to
Discussion nursingtimes.net/continence

Table 3.2. Under-pads

Single-use Reusable Potential for Guidance and evidence
product option use
Disposable bed Washable bed Consider Useful alternative to body-worn products but the user should be naked below
pads pads the waist, which is unacceptable to some people. Pads with tuck-in flaps can
stay in place better (Cottenden et al, 2017)
Disposable Washable chair Consider No published evidence. The presence of a chair pad denotes the user as having
chair pads pads a leakage problem. Should only be used as a back-up to a body-worn product
(Cottenden et al, 2017)
Table 3.3. Intermittent catheters
Single-use Reusable Potential for Guidance and evidence
product option use
PVC/silicone Cornstarch* Consider No published evidence for cornstarch, reusable intermittent catheters**
intermittent
catheters
Silicone CE-marked but No published evidence for silicone, reusable intermittent catheters**
not available in
the UK
Stainless steel* Consider No published evidence for stainless steel, intermittent catheters**
*Rigid catheters for women only; **Qualitative data from users suggest that single-use and reusable catheters have different advantages and
disadvantages (Avery et al, 2018).
Table 3.4. Devices to aid toileting (and avoid the need for containment products)
Single-use Reusable Potential for Guidance and evidence
product option use
Disposable Reusable Recommended ● Women: suitable when users can stand, crouch or move to the edge of a
hand-held hand-held chair or bed; less suitable when lying down or sitting back in a chair
urinals urinals (Macaulay et al, 2006; Fader et al, 1999).
● Men: suitable for users with reasonable hand control; less suitable when
unable to empty independently, and when balance or cognition are poor
(Vickerman, 2006)
Disposable bed Reusable Consider Only suitable when access to a toilet, commode or urinal is not possible
pans bedpans (Fader, 2002)
Disposable Commodes Consider Only suitable when access to a toilet is not possible. For users in hospital, a
inserts for shower chair to the toilet may be preferable. Commodes can be unsafe
commodes (Fader et al, 2004)

“A more sustainable Where to get help

approach to continence
product provision currently
depends on a reduction in
use of single-use products,
use of longer-lasting
versions, and their
substitution with reusable
alternatives”
to reduce the use of single-use products.
There is potential to build on this strategy
through better understanding of the reasons
why reusable products are not more widely
used and how these can be addressed.
Table 4 sets out some of the areas in
which there are unknowns or other bar-
riers and suggests actions to address them.
In particular, there is a need for innovation
and new, effective designs of reusable
products together with systems for adop-
tion and implementation into the NHS,
such as using the Academic Health Sci-
ence Networks.
There are many designs and brands of dis-
posable and reusable products available and
discerning the most appropriate is not easy.
Some products are much more familiar to
health professionals and patients than others.
Easily accessible, user-centred information
is important for enabling effective product
selection. The Continence Product Advisor
(www.continenceproductadvisor.org) is a
not-for-profit website, independent of
industry sponsorship, which provides
impartial, comprehensive, evidence-based
information for product users and health-
care professionals. It contains an evidence-
based continence product decision aid,
which guides users to product types that
might suit them, based on their characteris-
tics, lifestyle and preferences. The website
also provides detailed information through:
l P  roduct pages (linked to the product
decision aid) with links to the websites
of relevant manufacturers;
l D  ownloadable PDFs explaining
product use, including laundering
reusable pads;
l V  ideos showing use of male devices and
3-6 million
QUICK
FACT
People in the UK who
experience urinary
incontinence
pads and cleaning of reusable catheters;
S
 pecific guidance for men with
l
post-prostatectomy incontinence.
Summary
A more sustainable approach to continence
product provision currently depends on a
reduction in use of single-use products,
use of longer-lasting versions, and their
substitution with reusable alternatives.
There are advantages and disadvan-
tages to both reusable and single-use prod-
ucts and a ‘mix and match’ approach is key.
For many people, the introduction of reus-
able products may be acceptable, but only
in combination with other single-use ver-
sions. Working towards strategies for sus-
tainability in continence care – such as
reduce, reuse, recycle – requires a thor-
ough understanding of the lifecycle of
products and associated processes. It is the

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Clinical Practice
Discussion

Table 4. Potential barriers to adoption of reusable continence products

Unknowns and other barriers Suggested actions
Continence Lack of effective, high-quality, reusable variants Industry investment in high-performance reusable or
products longer-lasting products, materials and designs with a
higher unit cost but potential for cost-effectiveness
Clinical evidence Lack of research evidence about effectiveness, ● More well-designed trials needed
user acceptability and impact on clinical outcomes ● More qualitative research needed to understand user
(such as infection) to inform their use needs and barriers to use of reusable products
Cleaning methods Lack of evidence-based and user-friendly methods Published, evidence-based guidance needed to allow
for cleaning regulatory bodies to license for reuse
Other user Lack of guidance for using products, for example, Co-designed, user-friendly guidance needed
processes storage and carrying
Environmental ● Lack of lifecycle analysis, including the relative ● Increased focus on materials, manufacturing and
impact environmental impact of cleaning (reprocessing) recycling processes
reusable products compared with waste from ● Multidisciplinary approach, including manufacturers,
single-use equivalents implementers (Academic Health Science Networks)
● Failure to achieve a circular economy, through a and users (clinical groups)
lack of recycling methods, leading to lost potential ● Used continence products need to be viewed as a
value in used products (waste) useful commodity
● Providers (product users) reimbursed for their
contribution
Stakeholder ● Clinicians’ and policymakers’ attitudes towards ● Utilisation of available research by clinicians seeking
attitudes reusable products vary to modify their practice and maintaining an open
● A single-use culture in healthcare, in which reuse mind to changes in practice
is considered to be outdated, burdensome and/or ● Working towards a change in approach in which the
unsafe (although there is evidence that this is single-use culture is questioned and reusable options
changing) are always considered

responsibility of us all, including product
manufacturers, policymakers, purchasing
agencies, prescribers, researchers, health
professionals and end users.
Over recent years, the focus has largely
been on development of single-use prod-
ucts. The evidence provided in this article
shows that reusable products can be an
effective and acceptable alternative,
making continence care more sustainable.
There is potential for reusable products to
be of a higher quality, but there is a need
for greater innovation and investment in
reusable materials and designs for conti-
nence care. NT
CONTINENCE PRODUCT ADVISOR
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