Prevention and Treatment of Perineal Skin Breakdown Due to Incontinence

Author(s): 
Denise Nix, RN, MS, CWOCN

Pathology and Risk Factors of Perineal Skin Breakdown

Perineal skin breakdown secondary to incontinence can range in severity and may present as one or all of the following symptoms: erythema, swelling, oozing, vesiculation, crusting, and scaling in the groin, perineum, and buttocks region.1

Multiple potentially harmful variables work together to cause perineal skin breakdown. Moisture from incontinence alters the skin’s protective pH and increases the permeability of the stratum corneum. An intense irritant such as feces contains bacteria that can permeate the stratum corneum, allowing for secondary infections. The need for frequent cleansing can lead to further pH changes and damage from friction.1,2 In addition to exposure to urine and feces, intensity of irritant, duration of exposure, and factors that cause diarrhea are potential threats to perineal skin integrity.3

Significance

In long-term care, the prevalence of incontinence has been reported to be as high as 46.4% for urinary incontinence, 29.5% fecal incontinence, and 25.6% for combination urinary and fecal incontinence.4 In hospitalized elderly, fecal incontinence is estimated to affect 16% to 66%.1 Even though painful and preventable, perineal skin damage occurs in as many as 33% of hospitalized adults and 41% of adults in long-term care.5,6

Perineal skin damage may progress rapidly to ulceration and secondary infection, including bacterial (staphylococcus) and yeast (Candida albicans) infections that increase discomfort and treatment costs.7 Additional significant problems associated with perineal skin damage include pressure ulcer development, pain, and compromised quality of life (QOL).8

Incontinence, perineal skin breakdown, and pressure ulcer development are linked.5,9–11 Maklebust and Magnan9 reported that 56.7% of patients with pressure ulcers had fecal incontinence and were 22 times more likely to have pressure ulcers than patients without fecal incontinence. Studies have shown that when a comprehensive preventive skin care program includes appropriate perineal skin care, incidence of sacral/buttock pressure ulcers is significantly reduced.5,10,12

Regulatory entities such as the Joint Commission for Accreditation of Health Care Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS) recognize skin breakdown as a key indicator for quality care.13–15 Federal and state survey agencies use “tags” F-314 and F-315 of the CMS Guidance to Surveyors for Long-Term Care Facilities to assess the quality of pressure ulcer and incontinence care provided to residents in long-term care facilities. Inherent to these documents is the expectation that appropriate interventions will be implemented for patients with incontinence. For example, F-314 identifies moisture from incontinence as one of the risk factors that must be minimized to prevent pressure ulcers.14 F-315 guides surveyor evaluation of efforts regarding appropriate cleansing, rinsing, drying, and protective moisture barrier application to prevent skin breakdown from incontinence.15

Plan of Care

The plan of care must be individualized for the patient with incontinence and should include the following components:

  • assessment and management of incontinence etiology

  • perineal skin and risk assessment

  • gentle cleansing and moisturization

  • application of skin barriers

  • use of containment devices if indicated.

References: 

1. Brown DS, Sears M. Perineal dermatitis: a conceptual framework. Ostomy Wound Manage. 1993;39:2–26.
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3. Nix DH. Validity and reliability of the Perineal Assessment Tool. Ostomy Wound Manage. 2002;48(2):43–46,48–49.
4. Sgadari A,Topinkova E, Bjornson J, Bernabei R. Urinary incontinence in nursing home residents: a cross-national comparison. Age Ageing. 1997;26(suppl 2):49–54.
5. Lyder C, Clemes-Lowrance C, Davis A, Sullivan L, Zucker A. A structured skin care regimen to prevent perineal dermatitis in the elderly. J ET Nurs. 1992;12:12–16.
6. Lyder CH. Perineal dermatitis in the elderly. A critical review of the literature. J Gerontol Nurs. 1997:23(12):5–10.
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11. Wound, Ostomy and Continence Nurses Society. Guideline for Management of Pressure Ulcers. WOCN Clinical Practice Guideline Series #2. Glenview Ill: WOCN Society;2003.
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13. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH). JCAHO 1999. Available at: www.jcaho.org/standard/pm_mpfrm.html and www.jcaho.org. Accessed February 21, 2006.
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17. Donovan A, Ratliff C, Gray M. Perineal skin care for the incontinent patient. Adv Skin Wound Care. 2002;15(4):170–175.
18. Nix D. Prevention and treatment of perineal skin breakdown. In: Milne C, Corbett L, Dubuc D, eds. Wound, Ostomy, and Continence Nursing Secrets. Philadelphia, Pa: Hanley & Belfus, Inc.:2002:373–377.
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20. Kim J, Shim M, Choi B, et al. Clinical application of continent anal plug in bedridden patients with intractable diarrhea. Dis Colon Rectum. 2001;44:1162–1167.
21. Newman DK, Fader M, Bliss DZ. Managing incontinence using technology, devices and products. Nurs Res. 2004;53(6 suppl):42–48.



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