Urinary incontinence (UI) is a common condition in the UK. A conservative estimate indicates that 5–10% of the UK population (around 7 million people) have UI (Incontinence UK, 2019). The International Continence Society (ICS) (2023) defines UI as the ‘complaint of involuntary loss of urine’. The incidence of UI varies with age and sex: overall, UI affects roughly twice as many women as men, but in older groups men predominate (Incontinence UK, 2019; Yates, 2021). It is estimated that more than 10% of men aged over 65 years experience some degree of UI (Incontinence UK, 2019).
Public information on managing UI from public health services and the wider media is more often aimed at women than men (Stenzelius, 2005; Helfand et al, 2018; Nursing Times, 2019). The National Institute for Health and Care Excellence (NICE) (2015; 2021) has published specific guidance for the management of UI in women, but guidance for male UI is included in its more general guidance on the management of lower urinary tract symptoms.
An analysis of sex differences in the understanding and treatment of UI found that men are likely to experience higher barriers to accessing care for UI and that there is a need for education about its diagnosis and management (Yates, 2021).
Background
UI can be caused by alteration to the bladder, lower urinary tract or pelvis due to surgery (such as prostatectomy), neurological conditions (such as Parkinson's disease, dementia or multiple sclerosis), infections in the lower urinary tract, obstructions (such as those caused by tumours, urological stones, constipation or an enlarged prostate), overactive bladder and certain medications (NICE, 2015).
Understanding the cause of UI is essential to determine the most appropriate management strategy (NICE, 2015). According to NICE (2015), all patients presenting with UI should receive practical and psychological support to manage their condition. Management may involve a combination of lifestyle changes, exercises, pharmacotherapy and surgical procedures, as well as products containment, including incontinence pads. The choice of containment product should be made in consultation with the patient and based on their individual needs and circumstances.
Incontinence pads are available in a range of shapes, sizes and absorbencies. Incontinence pads can be differently designed to fit closely to either the female or male anatomy to provide maximum absorption. Pads specifically designed for the female form may have a figure-of-eight shape, similar to that of a sanitary towel, and fit front-to-back, with a thicker absorbent zone. In contrast, pads specifically designed for the male form may have a triangular cup shape and fit at the front, with a more absorbent zone at the front.
However, pads designed for the female anatomy are much more widely available, and not all manufacturers tailor their containment products to the male anatomy (Yates, 2021). Consequently, in the author's experience, female pads are often marketed as unisex and are widely prescribed for and purchased by men. These unisex/female pads are intended to fit to the female anatomy, and male users must position them further forward in their underwear to absorb leaking urine. Mispositioning the pad in this way makes it more noticeable under clothing and may also mean it is less secure to fix, with a risk of leakage.
NICE has neither made a recommendation about desirable attributes for male incontinence pads nor indicated that sex-specific pads would be advisable (NICE, 2015). However, a consensus study recommended that ‘shaped pads for men are the preferred option for dignity, mental health and ergonomic reasons’ (Orme et al, 2022), and recent guidelines state that ‘men and women must be treated equally in relation to absorbencies (of pads) and product range available’ (Association for Continence Advice (ACA) et al, 2021).
A recent clinical audit-based study by Broom (2022) showed high satisfaction with pads designed for the male anatomy among men with UI, secondary to a radical prostatectomy. Participants considered these anatomically specific pads to be easy to use, discreet to wear and effective at preventing leaks, offering them valuable reassurance and greater confidence that they could return to work, exercise and social activity without worry (Broom, 2022).
Aim
Following on from Broom (2022), this article presents a clinical audit-based study aiming to compare female/unisex and male incontinence pads in terms of male users' satisfaction with aspects of fit, comfort and reliability, as well as health and wellness.
Method
Participants were recruited from men in Norfolk who were: receiving care for UI in a community setting via Norfolk and Suffolk NHS Foundation Trust; personally responsible for changing pads, skin care and managing other day-to-day incontinence needs; and using a female/unisex pad designed primarily for the female anatomy (TENA Comfort Mini Super, Essity). The pad manufacturer Essity approached 150 of these men by email or letter and invited them to try switching to a male pad designed for the male anatomy (TENA Men, Essity) and answer questions about their experience. These two incontinence pads both come in a range of absorbency levels and have broadly similar features (Table 1). However, they differ in shape and thickness to provide maximum absorbency where it is most needed for the respective anatomy (Figure 1). Participants who consented and trialled the new pad for at least 4 weeks were included in the audit.
Table 1. Features common to female/unisex and male incontinence pads
| Feature | Benefit |
|---|---|
| Absorbent core | Highly absorbent central core locks in urine, preventing leaks and leaving the surface next to the skin dry |
| Different absorbencies | Different absorbency levels available to meet different needs in different circumstances |
| Discrete design | Thin and discrete shape is not visible under clothes |
| Skin-friendly surface | Dermatologically tested surface material prevents skin irritation |
| Odour control | Material used in the absorbent core reduces growth of odorous ammonia-producing bacteria |
| Adhesive strip | Adhesive strip holds pad in place for use with close-fitting underwear |
The audit was undertaken in March and April 2023 and was based on an anonymous online survey devised by Essity and hosted on Microsoft Forms. Patients were first asked for background and demographic information and presented with multiple-choice questions about their previous use of female/unisex and male pads. Participants were then asked to score levels of satisfaction with each pad in terms of overall suitability meet incontinence needs, as well as specific aspects of wear and user experience, such as ease of use, comfort, reliability and their confidence, health and wellbeing. Satisfaction was measured with Likert scales of 1–10 for overall satisfaction and 1–5 for specific aspects. The same questions were asked about both pads; however, with regard to the female/unisex pad, 1 represented ‘very dissatisfied’ and the highest score represented ‘very satisfied’, while with regard to the male pad, 1 represented ‘much worse’ and the highest score represented ‘much better’. Participants also had the opportunity to provide free-text responses regarding dissatisfaction with any of the criteria in the multiple-choice questions, what they liked most about each pad and if there was anything they would change about those pads.
Essity were responsible for collecting the information submitted by participants. All responses were entered automatically into an Excel spreadsheet. The numbers of participants selecting a particular response to a question was converted to a simple percentage of all participants answering that question. No statistical analysis was attempted.
Ethics
The local NHS trust consented for patients to be approached concerning participation in this audit. All participants received an information letter regarding the study. People who completed the anonymous survey were deemed to have consented to participation in the audit. Participants' postal and email addresses were on record with Essity, as they were all existing customers of its home delivery service. A separate General Data Protection Regulation (GDPR) statement was not used, as the results provided no patient identifiable data and would not be used for any marketing purposes. Finally, there were no clinical interventions, so ethics committee approval was not required.
Results
Background and demographics
In total, 18 men completed the questionnaire. Of these, two provided answers to questions about the female/unisex pad but not about the male pad. The questionnaire did not include questions about the participants' ages or about the cause of their UI.
All participants completed the questionnaire on their own behalf. Of the participants, 14 reported that they partially or fully took care of their own continence needs (changing pads, skin care, etc), while the others provided no information. While 16 participants were retired, one was unable to work due to disability and one was in part-time work.
All but one participant also used the TENA Comfort Mini at night; the other participant preferred to use TENA Pant at night. The most common underwear used to secure the product was close-fitting underpants (n=11), followed by loose-fitting boxer shorts (n=4), net fixation pants (n=2) and fixation pants (n=1).
Satisfaction with female/unisex pads and male pads
Participants were generally satisfied with both pads (Figure 2). Mean satisfaction scores for overall suitability (maximum score of 10) increased from 7.3 to 9.3 after switching (female/unisex pad: mode was 7, range was 1–10, n=18; male pad mode was 10, range was 5–10, n=16).
When specific aspects of the two products were considered (Figure 3), satisfaction scores (maximum score of 5) increased after the change in product in all but one domain. The greatest increases in score were for physical coverage of genital area (1.5 points), ability to hold urine without leaks (1.4 points) and level of comfort when wet (1.3 points). Satisfaction with the products' ability to contain unpleasant odours decreased from 3.9 (range 1–5) to 3.7 (3–5), a difference of -0.2 points.
Analysis of the individual responses suggested that level of satisfaction was related to the type of underwear used to hold the continence pad in place.
Similarly, satisfaction scores for aspects of health and wellbeing generally increased when the product was changed (Figure 4). The greatest increase in satisfaction score was in the exercise domain, from 3.4 to 4.7 (1.3 points).
The proportion of participants who were fully independent in everyday health and wellbeing increased from 71% (n=12/17) to 100% (n=16/16). While 44% (n=8/18) of participants wanted to change something about the female/unisex pad, only 19% (n=3/16) wanted any changes with the male pad. All but one user of the male pad, 94% (n=15/16), reported that they would like to continue using it (Figure 5).
Qualitative feedback
Free-text comments were provided by 14 participants. For both pads, positive features focused mainly on comfort, ease of use and reliability (Box 1 and Box 4). Several participants remarked on the anatomic fit of the male pad.
Box 1.Positive features of female/unisex pad (n=10)
- ‘Best to date’
- ‘Comfortable’
- ‘Does job OK’
- ‘Ease of application’
- ‘Easy to fit to underwear, and I feel confident that the pad will stay in place’
- ‘Good capacity and able to absorb fast’
- ‘I know I'll be safe if I'm out; without these I wouldn't leave the house’
- ‘Nice and thick, not narrow’
- ‘Their size’
- ‘They enable me to keep going; without them I would have real difficulties’
Box 2.Reasons for dissatisfaction with female/unisex pad (n=8)
- ‘Doesn't help pressure sores and irritates it’
- ‘Due to the ill fitting of the pads, they usually leak if I lose bladder control during the night’
- ‘I can't think of anything that I do like about them; I wear them because I need protection’
- ‘I don't like them at all – they do not fit me properly, as they are not shaped for a man's contour – I find it difficult to fit to my underwear and to get them in the correct position’
- ‘Need change more frequently’
- ‘Physical coverage could be a lot better’
- ‘They work but not very well’
- ‘Sometimes (don't) feel wide enough at top front’
Box 3.Suggested changes to female/unisex pad (n=8)
- ‘A thinner pad that covers the front of the pants rather than having that bulky piece between the top of my legs’
- ‘As above comments’
- ‘Both’
- ‘Greater absorbency and more infrequent changes’
- ‘Make it shorter’
- ‘More shaped, thicker’
- ‘Shaped to men's need’
- ‘Stop going out in case he leaks—embarrassing’
- ‘Too bulky, too long’
Box 4.Positive features of male pad (n=14)
- ‘Comfortable, easier to wear’
- ‘Comfortable, easy to fit’
- ‘Comfortable, less like a double-decker bus, easier to use’
- ‘Far better product and designed for men’
- ‘Felt more confident going out and socialising’
- ‘Great design, less bulky’
- ‘I feel happy and confident about going out and people not seeing the pad’
- ‘I thought they were great; I can now take one out with me in my pocket—a lot more comfortable’
- ‘I would like to stay on this product. It has given me the confidence to go back to the gym, even in my 70s. I feel protected. I like the shape—fits where I need it. I used a glass of water to compare the two products, and I felt the Men product was far superior’
- ‘Softer texture, more discreet, a lot more comfortable’
- ‘Superior design, better material—I liked that they were individually packaged and really liked how it was anatomically shaped’
- ‘The increase of self-confidence to go out and about, easier to change—really happy with the pad, more than the old ones’
- ‘The shape—much more comfortable fit’
- ‘Very comfortable, fits well’
Suggested design changes for both pads again focussed on comfort and reliability (Box 3 and Box 6): two participants suggested the male incontinence pad should be longer and one participant had found the tape insufficiently sticky.
Box 5.Reasons for dissatisfaction with male pad (n=1)‘I've got used to using my old pads and prefer them’
Box 6.Suggested changes to male pad (n=3)‘Just a bit bigger would be nice’‘Just fractionally longer’‘The sticky on the back needs to be stronger’
Reasons for dissatisfaction with the female/unisex pad included different aspects of the poor fit of the product (Box 2). Only one participant expressed dissatisfaction with the TENA Men pad (Box 5).
Discussion
Participants reported increased levels of satisfaction, comfort and dryness after switching from a unisex/female pad to a male pad. The analysis indicates that switching pads had an additional positive impact on participants' sense of health and wellbeing. This was most notable in participants' increased willingness to engage in exercise, social and work activities.
Comparing attitudes before and after the switch saw a 30% increase in sense of independence in everyday health and wellbeing. No participant required more from their pad in order to improve health and wellbeing, and a large majority wished to continue using the male pad.
It is notable that satisfaction scores for odour containment were higher with the female/unisex pad compared to the male pad; however, the difference was quite small, and no participant mentioned it as a reason for dissatisfaction in the free-text comments. Some participants would have liked the male pad to be bigger.
Participants' free-text comments suggested that receiving the correct containment product for their individual needs had a positive effect on their physical health and mental wellbeing. For health professionals caring for people with UI, this should highlight the importance of personalised product choice.
The NHS spends around £800 million per year on continence care, around 10% of which is spent on procuring containment products (NHS England, 2018). Providing the right product for the right individual can be cost-effective, as reducing leaks and improving patient health and wellbeing reduces the financial burden of care.
The results of this study should encourage health professionals to challenge the persistent traditional use of female/unisex pads for male as well as female patients. Instead, men should be offered the opportunity to use products designed for their anatomy that may better suit their needs.
Health professionals may also find that engaging with the specific experiences of men living with UI has an impact on the care they give. This may involve exploring the social context of incontinence, which men and women experience differently, and affects how they report and deal with comparable problems. Examples include the impact of post-prostatectomy incontinence (Singla and Singla, 2014). Information and resources on this topic are available from charities such as Prostate Cancer UK (2023).
Limitations
There are some limitations to this analysis. In particular, the number of participants is very small (18 responders from 150 who were approached) and they were self-selected. It is possible that response rates could have been increased with incentives or email reminders. Furthermore, only people who had access to, and were sufficiently comfortable with using the internet were able to take part in the study. It is also possible that the regional sample population may limit the transferability of the results to other areas.
There were a couple of issues with the questionnaire. A confusingly worded question about numbers of GP visits elicited responses that suggested that participants did not understand the purpose of the question, and so, these were not included in the results. Some free-text responses expressing negative feedback were entered under the question asking for positive feedback. For the purposes of this paper, these responses were relocated to the more relevant box, but this again suggests that the wording of some questions was unclear to participants.
Conclusions
This clinical audit-based study confirmed that sex-specific fit is an important factor in the acceptability of an incontinence pad for men with UI. It showed that wearing pads specifically designed for the male anatomy provides men with a greater sense of comfort and confidence. Moreover, the results suggest that these pads are better able to hold urine without leaks in male patients. Fewer leaks should reduce the overall number of pads prescribed, as well as minimise the occurence of leak-related complications, representing potential savings in time and costs for the NHS.
Key points
- Urinary incontinence is a common and impactful condition
- Despite the availability of incontinence pads specifically designed for the male form, many men use pads designed to fit the female anatomy
- Sex-specific fit is an important factor in the acceptability of an incontinence pad for men with urinary incontinence
- Wearing pads specifically designed for the male anatomy provides men with a greater sense of comfort and confidence
CPD reflective questions
- How can the impact of urinary incontinence be measured?
- What are the advantages of incontinence pads specifically designed for the male form?
- Why might many men be using pads designed to fit the female anatomy?
- How can men with urinary incontinence be provided with a greater sense of comfort and confidence?