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t's so easy to lapse into a routine when it comes to the subject of incontinence--forgetting reminders to the staff about timed toileting, reordering last week's re-stock levels of absorbents, remembering but postponing that discussion about medications with the consultant pharmacist. So much is happening in the field of incontinence that extended care administrators, nursing supervisors, and nurse specialists can ill afford to operate by rote. Let's revisit briefly those categories of intervention, both treatment and management, to see where we can revitalize the routine with intelligence and goal setting.

Treatment
       Behavioral. Plenty has changed recently for Medicare beneficiaries. In the last two years, board members of the National Association For Continence (NAFC) have shepherded a leadership role in successfully securing significantly broader coverage from Medicare for biofeedback therapy for the treatment of incontinence. Specifically, the coverage manual was amended in October, 2000, so biofeedback therapy is covered for the treatment of stress and/or urge incontinence in patients who failed a documented trial of pelvic muscle exercise training or who are unable to perform pelvic muscle exercises. It remains the individual contractor's decision whether or not to cover biofeedback as an initial treatment modality.
       Is your facility or agency aligned with a qualified physical therapist? Is your facility's medical director in touch with a specialist in continence care, such as an urologist or urogynecologist, who can perform the urodynamics testing to refine a diagnosis and thus appropriately prescribe biofeedback therapy? While there may be limited upside benefit for the elderly in pelvic floor rehabilitation therapy, there remains a window for improvement for those individuals who are not otherwise candidates for surgery for a variety of reasons.
       Medications. Pharmacology represents a rapidly expanding frontier for treatment of incontinence. Recognizing that the elderly are less likely to be candidates for invasive surgery because of comorbidities, the pharmaceutical industry has aggressively pursued drugs for treating incontinence. Longer-acting and extended-release drugs have made brand names, such as Detrol LA (Pharmacia Corporation, Peapack, New Jersey) and Ditropan XL (Ortho-McNeil Pharmaceutical, Raritan, New Jersey), simpler to take on a daily basis for those with urge incontinence and frequency of urination. Within the coming year, we expect a similar drug to be on the market that utilizes a new delivery mechanism in the form of a patch so the side effects of dry mouth, for example, can be lessened. In less than two years, we anticipate FDA approval of still another drug that reduces the effect of symptoms of stress urinary incontinence. It may, as well, reduce symptoms of depression, given how it works on the neurological system of the body.
       Devices/surgery. There are new injectable materials with promising results for male and female stress urinary incontinence that warrant revisiting an urologist with questions. Ask for a comparison between Durasphere (Carbon Medical Technologies, Inc., St. Paul, Minnesota) carbon-coated beads and Contigen (C.R. Bard, Inc., Covington, Georgia) collagen protein. Elsewhere, surgical procedures for stress urinary incontinence today incorporate implantable devices, such as Gynecare's TVT material (Ethicon, a Johnson & Johnson Co., Somerville, New Jersey), to allow for minimally invasive surgery that has proven highly successful in women of all ages. As for men, many are still not aware that the artificial urinary sphincter is not only well proven, but it has returned and enhanced quality of life after radical prostatectomies for cancer.
       The point is medical technology and approaches are constantly and rapidly evolving. Just because a consumer was told a decade ago that major surgery was the only answer doesn't mean this is still true today. There is an ever-increasing array of answers and solutions. Many represent options that are combination therapy or the use of more than one approach concomitantly.

Management
       On the management front, the nonwovens industry hasn't stood still either in its product development efforts. In fact, the evolution of materials technology and its applications for adult incontinence is probably only in its infancy.
       SCA Incontinence Care (Eddystone, Pennsylvania) introduced the first extra-absorbent protective underwear for moderate to severe incontinence with extended care specifically in mind. There are now published, clinical studies extolling the value of not interrupting the sleep of the elderly and the benefit, therefore, of highly absorbent products for use at nighttime. Meanwhile, Kendall, a Tyco Healthcare Company (Mansfield, Massachusetts), has introduced an innovative hook and loop fastening system that functions like Velcro and allows closer sizing, better fit, and fewer unnecessary changes. This promises to be a real money saver as well as an improvement in skin protection.
       For women, pessaries for prolapse can also be an answer. Pessaries date back to the Egyptians, but they are undergoing a renewed level of interest as our population ages and seeks out nonsurgical solutions for management. Just because a pessary failed a decade ago doesn't mean the subject shouldn't be reinvestigated. New options in terms of shapes and sizes are increasingly available. It's especially important to seek out a healthcare professional with extensive knowledge and experience, however, in proper fitting.

Conclusion
       Whatever the calling and regardless of the facility, you must stay abreast of product developments in the field of incontinence so you don't grow comfortable with your care regimen. Recognize the critical interrelationships among skin care, nutritional care, incontinence care, and pressure ulcer care and prevention. They are all dangerously closely connected. Consult with the industry experts in each arena for their recommendations and build them into your own. For example, Ross Products Division of Abbott Laboratories (Columbus, Ohio) has a comprehensive prevention plan for pressure ulcer management that acknowledges and largely builds upon continence care programs and incontinence management, not just the nutritional supplements that it markets. Find and solicit these tools and put them into practice. There are many out there. But don't lapse into repetitive motions from the past. Many are evolving, many are new, and much is happening. Change can improve your life and your patients' lives.
       For more information, visit the National Association For Continence (NAFC) at www.nafc.org or call 1-800-BLADDER.