Q: Please could you briefly explain your role, involvement, and experience as it relates to incontinence?
Anna Rajala, Postdoctoral Research Fellow, Tampere University (AR): I am currently conducting a three-year postdoctoral research project on politics of faeces, and some of my areas of interest include bowel health, public toilets, and of course anal incontinence. I have a background in physiotherapy and having worked with various people with bowel and bladder dysfunction, I wanted to use my postgraduate and doctoral training in philosophy, politics, and economics to do some good and to make incontinence, and especially faeces, to matter as a serious topic for political and sociological investigation.
Benjamin Metcalfe, Associate Professor and Head of Department - Electronic & Electrical Engineering, University of Bath (BM): I am an academic and a biomedical engineer based at the University of Bath, and my interest is in the research and development of novel technologies to support those living with all forms of neurological injury or disease. My expertise primarily relates to neural interfaces and implantable devices, and for some years I have been working on incontinence – my group have performed fundamental research that has enabled us to “sense” bladder activity by recording the electrical signals within the sacral roots. We have also developed new stimulation paradigms that aim to improve control of the bladder. Our long-term vision is to develop intelligent “closed-loop” technologies that enable concurrent sensing and modulation of bladder activity.
Chris Bray, Lead Design Engineer, Welland Medical Limited (CB): As a Lead Design engineer within R&D, my job is essentially to gather and distil insights, and convert that into a product that solves a problem, that can serve a broad community and be feasible in a very cost sensitive market – in this case, Stoma Care.
Davina Richardson, Children’s Nurse Specialist, Bladder and Bowel UK Team, Disabled Living (DR): I am a paediatric nurse who specialised in children’s bladder and bowel health 17 years ago, when I set up and then ran a community-based service for children with functional bladder and bowel conditions within the NHS. I joined the team at the national charity Bladder & Bowel UK 8 years ago.
Bladder & Bowel UK have a wide remit that includes providing information to the public, training for professionals, are involved in research projects, support product development, and work to reduce the taboos that surround bladder and bowel health issues.
I am the paediatric advisor to the executive of the Association for Continence Professionals, am co-chair for the Paediatric Continence Forum, and sit on other national groups. I have been a co-applicant on research related to children’s bladder and bowel health and have been an author on several pieces of national guidance, including the Guidance for Provision of Continence Containment Products to Children and Young People.
Kate Tomlinson, Lecturer in Tribology, Department of Mechanical Engineering, University of Sheffield (KT): Working in tribology I have been involved in projects in which the friction mechanisms at the interface of skin and continence products has been measured. The friction at the interface has been shown to be affected by the sliding direction, the hydration of the incontinence pad and if a barrier treatment is used. We have found that the sliding direction effects the coefficient of friction in the contact as a higher shear force is required to overcome adhesive forces at the interface when tension has been applied to the skin in the opposing direction. Considering the direction of motion is comparable to moving from sitting to standing or movement whilst sitting or lying down and is highly relevant to the consideration of the incontinence pad-skin interface.
Margot Damaser, Senior Rehabilitation Career Scientist, Louis Stokes Cleveland Department of Veterans Affairs, USA (MD):I have a PhD in Bioengineering and lead 2 research labs within major hospitals in Cleveland, OH USA. My role is the lead the research team to develop new methods of diagnosing and treating incontinence. I collaborate very closely with Urologists, Gynecologists, nurses, physical therapists and provide their feedback to the research engineers, graduate students and postdoctoral fellows in the laboratory. At the Cleveland Veterans Hospital I am Deputy Director of the Advanced Platform Technology Center and facilitate development of novel technologies and their application to treat the problems of veterans. Our current focus is on developing wireless technology for home monitoring and treatment of chronic conditions, including incontinence, to provide better care and rehabilitation of Veteran patients.
Oliver Baker and Louise Etherington, Physiotherapists, Birmingham Community Healthcare NHS Foundation Trust (OB and LE): We are physiotherapists who conducted a retrospective analysis as part of a collaboration between the University of Birmingham and Birmingham Community Healthcare NHS Foundation Trust. The research undertaken at the West Midlands Rehabilitation Centre involves the use of abdominal functional electrical stimulation (FES) as an innovative intervention for chronic constipation in individuals with neurological conditions. Our partnership enables this pioneering work to be analysed and reported on for wider dissemination. The project is overseen by Consultant Physiotherapist and FES specialist, Christine Singleton and her colleague Carla Peace. They will also be attending the conference with us. It may seem conflicting that we are presenting research into the treatment of constipation at a conference about incontinence, but for many individuals, constipation is a primary cause of faecal incontinence.
Q: What are the main challenges in the quest to better manage and treat incontinence and to support caregivers?
AR: One of the major barriers for seeking care is taboo and the fear of stigma. A more open discussion culture would help to manage and treat incontinence more effectively because that might help people to deal with the unnecessary shame they might feel. I would also like to emphasize that people living with incontinence should not feel forced into taking about the most private things in their lives however much that might help the wider cause of open conversation culture about urine and faeces. They should not have to feel like it is an obligation to turn their bowels or bladder into political health activism. Rather, I think it is up to all of us, whether continent of not, to create that openness that might help all people to talk about urine and faeces as the most natural physiological processes of our bodies.
BM: My focus has been on the restoration of bladder control for people with spinal cord injury, and it is important to understand that no two spinal cord injuries are the same. The nerves that innervate the bladder are located near the base of the spine, so although injury may occur at diverse levels, it almost always leads to some loss of bladder function. Identifying the best treatment for an individual is complex and must take account of their lifestyle and support networks as well as the potential benefits of an intervention. Ironically, a significant challenge is raising awareness of incontinence within the research community – even though it effects most people with spinal cord injury and can be a major factor in limiting quality of life, it is easily a “hidden” disability.
CB: Our products, though relatively simple, have to serve needs of two different customers: each with their own needs, priorities and requirements. That is, both the patient and the caregiver. There is a good deal of autonomy in the Stoma community, especially once one’s life with a stoma becomes more established. For those people, discretion and comfort is very high on the list of priorities. But for every Ostomate that is able to lead a relatively uninhibited life, there is another who requires much more direct contact and care from their stoma nurse, particularly in the post operative stages of their recovery.
DR: The main challenges remain the taboos associated with bladder and bowel issues and the wide-held belief that incontinence and a normal part of aging, that has to be endured. Assumptions that incontinence does not occur in certain demographic groups, including children or young people remain widespread, which produce barriers to treatment and provision of support.
Issues are compounded for children and young people both by beliefs that issues are behavioural or a direct result of disability or developmental differences as well as by changes in culture and practice with respect to toilet training. There is increasing research that later toilet training is associated with increased likelihood of incontinence at primary age.
KT: For sufferers of urinary incontinence, friction between continence products and skin is believed to be a contributor to Incontinence Associated Dermatitis (IAD), along with chronic exposure to urine. Symptoms of IAD range from erythema to lesions, severity varies as individuals will have a unique tribosystem due to length of exposure and properties of the incontinence product in contact. This variation of loading systems that occur in day-to-day life make determining an optimal tribosystem complex. A deeper understanding of the friction mechanisms involved at the skin-pad interface will aid the development of product design to reduce discomfort to those managing incontinence.
MD: Detailed phenotyping or being able to classify incontinence into physiologically based subtypes, to enable personalized medicine and development of more precise therapies is a current challenge. Currently incontinence is classified into a few basic types of overactive bladder, underactive bladder, mixed incontinence, and stress incontinence, which are based on observations, patient reporting, and rudimentary diagnostic procedures. To better manage and treat incontinence we need to know if the problem is in the bladder, the urethra, the nervous system, the pelvic floor, or a combination. Then we could develop therapies to precisely treat the exact problem. To do this we need better diagnostic methods that can measure function of the lower urinary tract and pelvic floor when the incontinence episodes occur as well as improved imaging methods and other diagnostic techniques.
OB and LE: Symptoms such as constipation and incontinence hinder social participation and increase psychological distress and isolation. Current management strategies use an individualised bowel care regime, which is usually comprised of conservative interventions such as laxatives, dietary changes, and enemas, to name just a few. This may pose a challenge in itself as the delivery of a bowel management program can be costly, time sensitive and involve other healthcare professionals and is not always reliable. To make matters worse, there is currently no evidence-based clinical pathway to manage bowel dysfunction due to a lack of methodologically rigorous studies supporting the efficacy of interventions that are frequently used today. Consequently, this imposes a significant task of trial and error on patients and caregivers trying to optimise control over bowel movements. It is therefore not surprising that treatment satisfaction remains low thus highlighting the need for increased research interest and investment into the development of new strategies.
Q: What are the biggest developments for the treatment and management for incontinence that have occurred since the previous conference in 2021?
AR: AI did not attend the previous conference, but I’m delighted to see faecal topics represented in the 2023 conference. I’m also delighted to see topics concerning humanitarian crises represented. Incontinence does not disappear when a disaster strikes.
BM: In my field specifically, we have made real advancements in our ability to develop computational models that encompass not just the neuroanatomy but also the electromagnetic properties of various tissues. The result is that now we can model, in one simulation environment, the soft tissue and bone, the stimulation and recording electrodes, and the neurons themselves. We have also made advances in our ability to record bladder activity from the sacral roots, thus paving the way for closed-loop interfaces in the future.
CB: The fundamentals of how a Stoma is managed has not changed greatly, but what we have seen change is the emotional packaging around it. As with many aspects of life, social media has significantly impacted and the reach and spread of information for those living with a stoma. There is more conversation, more awareness, more choice. We as designers, engineers and manufacturers need to listen to this, and allow it to shape out product development.
DR: In my field there is new evidence, about the role of absorbent disposable continence products in the management of bedwetting, there is a new NHS England pathway for treating constipation and soiling in children, an International Children’s Continence Society standardization document on ‘Neurodevelopmental disorders and incontinence in children and adolescents: Attention-deficit/hyperactivity disorder, autism spectrum disorder and intellectual disability’, a new pathway that will be published soon by Bladder & Bowel UK for the use of rectal irrigation in children and a new guidance document, also due publication on toilet training that is a joint initiative between Bladder & Bowel UK and Down Syndrome UK.
KT: Since the previous conference there has been development in the understanding of barrier creams and sprays in reducing friction at the skin-pad interface in both wet and dry conditions. The findings of the study showed that 3M™ Cavilon™ Barrier cream was the most efficient treatment to prevent higher friction coefficients, as well as minimising surface and subsurface shear. Additionally, it was suggested that the predictable skin response that 3M™ Cavilon™ Barrier cream produces is ideal in terms of treating medical conditions because a prescriber or advisor can be confident about the skin response for most people.
MD: Advances in electrical stimulation methods for incontinence have enabled more patients to obtain effective therapy. In addition, the first use of a wireless catheter-free system to measure bladder pressure during ambulation in women was recently published suggesting we will be able to improve phenotyping of incontinence patients in the near future.
OB and LE: The use of neuromodulation devices in medicine isn’t novel, but there has been an explosive increase in their use in recent years due to their continual uptake across multiple healthcare specialties to treat various disorders. To put this in the context of constipation and incontinence, there is a great deal of research dating back decades that demonstrates the effectiveness of sacral nerve root stimulation in improving bladder and bowel control. However, this requires the surgical implantation of electrodes, and as is often the case with invasive interventions, there is an increased monetary cost and risk of complications. Consequently, there has been mounting interest in safe, low-cost alternatives such as less invasive transcutaneous neuromodulation therapies. While the research into the stimulation of the abdominal muscles using functional electrical stimulation is still in its infancy, it does however show great promise, and we welcome the opportunity to tell you more about it at Incontinence: The Engineering Challenge XIV.
Q: What specific topics or new developments are you hoping will be addressed at the forthcoming 2023 conference?
AR: The world is acutely feeling the impacts of humanitarian crises across the globe. Therefore, I think it is imperative to pay full attention to how people living with incontinence are impacted by war, conflict, environmental crises, discrimination, and poverty. While incontinence is a health issue, treating it as a mere health issue is highly problematic. People living with incontinence live in societies, and therefore lived experiences of people in different societal settings are extremely important.
BM: I am really excited to learn more about how we can raise the profile of incontinence engineering, ensuring that the UK community continues to grow and does so with patient benefit being front and centre. As an academic my field of vision can be quite narrow, so I am also looking forward to learning about other approaches to bladder and bowel control, with which I am less familiar. As a first-time attendee, I am also looking forward to networking with other researchers in this area.
CB: Di-stigmatisation seems to be an important stage in how we approach topics surround toilet behaviour. It’s certainly been a powerful shift in in Stoma care. We live in an age where information about everything is available, all of the time. And there is a growing willingness to discuss things, particularly on social media platforms. Mental health is high on societies agenda in 2023, and it gives engineers both the challenge and the opportunity to see how this openness can drive innovation.
DR: I am hopeful that issues around sustainability will feature, particularly in respect to the use of disposable and washable products to contain incontinence (nappies, pants and pads), catheters and rectal irrigation equipment.
I am also particularly interested to hear whether there is any innovation around maintaining skin health for all ages and reducing moisture associated lesions and whether there is any innovation for those whose incontinence is related to neuropathic bladder and bowel (incontinence because of damage to the nerve supply to the bladder and bowel).
KT: I am hoping that the conference will be a great opportunity to hear from clinicians and patients and gain an insight of the day-to-day concerns that users of continence products are facing. The challenges facing those in nursing homes and young patients will clearly be different and understanding the differences in typical movements of users and frequency of product replacement will inform the test conditions relevant to further research.
MD: I am interested in sustainability and pleased to see that sustainability in incontinence technology will be addressed at the forthcoming 2023 conference. One has to think of sustainability as a two-way street. Most evident is that to create a sustainable economy we need to reduce waste and carbon fuel consumption to reduce the impact of our practices on the environment. However, the impact of unsustainable practices on the individual also needs to be considered, such as impact of coatings and synthetic materials in absorbent pads on the skin. I look forward to interesting discussions at the 2023 conference.
OB and LE: It probably comes as no surprise, but we are very excited for the presentations focusing on the use of neuromodulation therapies in the treatment of bladder and bowel dysfunction, of which there are several. We are particularly interested in Tamsyn Street from Salisbury NHS Foundation Trust, who has also realised the potential behind abdominal functional electrical stimulation as a bowel management strategy and will be emphasising its efficacy in those with spinal cord injury.
Q: Why do you think it is important for engineers, scientists, clinicians, industry, researchers, commercial designers/producers and product users to come together to discuss these topics and new developments?
AR: As the world stands today, we need collaboration, and we need to start listening to each other. The only way to do good and to have a positive impact is to come together.
BM: Achieving demonstrable patient benefit is simply not possible if we work in isolation, the complexities of incontinence coupled with the ever-changing regulatory environment for medical devices simply necessitates truly inter-disciplinary research and development. The UK has been a leader in incontinence engineering for some time and we must work together as a broad community to ensure that we retain this strong position and maximise impact. Involving product users and patients is an absolute must if we are to understand the real-world challenges that should drive our research.
CB: Having never attended this event before, I’m not sure precisely what to expect. But any forum that pulls together people with different experiences, different problems to solve, and different solutions to explore can only be good thing in the pursuit of innovation.
DR: Each discipline considers the issues around incontinence from a different perspective, which gives an opportunity for more holistic and innovative approaches, that have the capacity to improve the lives of those affected by incontinence. Furthermore, a global perspective of the issues, treatment and management for incontinence throughout the life course can be considered from a broad base.
The meeting of those with different roles in research and development of products with product users is an ideal opportunity to spark innovation, revolution in practice and to progress towards solutions that are cost effective, improve quality of life for those that need them, while being mindful of environmental impacts and issues of supply.
KT: Bringing together such a wide range of people involved in a multidisciplinary area is highly beneficial for being able to address a real-world problem. Through active listening to clinicians and product users we can ensure that future product design is user centred. The combination of engineers, scientists and researchers with commercial producers and industry enables an opportunity for knowledge transfer and continuous improvement. Shared resources and data can accelerate innovation which is clearly important when it can be used to improve quality of life for the patient.
MD: People from different perspectives bring different views to the challenge that is incontinence. Thus, we need a diversity of views and opinions to solve the challenges. We need to hear everyone’s opinion and, while that is possible offline and remotely, it is most efficient and most creative when this highly multidisciplinary group gathers together in person.
OB and LE: It is of great importance for different persons from across the entire industry to attend events such as Incontinence: The Engineering Challenge XIV because not only do they provide excellent professional networking opportunities with like-minded individuals but also a chance to hear more about some of the innovative research that is taking place in a field of medicine that is of shared interest to us all.
Incontinence: The Engineering Challenge XIV will be taking place on 29-30 November 2023 at the Watershed in Bristol.
join the 14th biennial Incontinence: The Engineering Challenge conference to hear presentations addressing the following topics:
- Exploration – improving sustainability for incontinence technology
- Incontinence and skin health
- Urinary indwelling and intermittent catheter developments
- Incontinence technology in low resource settings
- Bowel and bladder in spinal cord injury
View the full two-day conference programme and book your place at www.imeche.org/incontinence.