Management of Skin Damage Associated with Fecal and Dual Incontinence

  • Mikel Gray
  • Donna Z. BlissEmail author
  • Sheila Howes Trammel


The skin problems of dermatitis and pressure injury are common sequelae of fecal incontinence. The advanced practice nurse prevents and treats these problems while managing fecal incontinence. This chapter describes the manifestations of incontinence-associated dermatitis and pressure injury and how to make a differential diagnosis and assess their severity. It explains the association of incontinence to pressure injury along with other risk factors. The chapter summarizes the interventions used for prevention and treatment of both skin problems highlighting the expected outcomes for the advanced practice nurse to evaluate.


  1. 1.
    Bliss DZ, Funk T, Jacobson M, Savik K. Incidence and characteristics of incontinence associated dermatitis in community-living individuals with fecal incontinence. J Wound Ostomy Cont Nurs. 2015;42:525–30.CrossRefGoogle Scholar
  2. 2.
    Gray M, Giuliano KK. Incontinence associated dermatitis and immobility as pressure injury risk factors: a multisite epidemiologic analysis. J Wound Ostomy Cont Nurs. 2017;45(1):63–7.Google Scholar
  3. 3.
    Lachenbruch C, Ribble D, Emmons K, VanGilder C. Pressure ulcer risk in the incontinent patient: analysis of incontinence and hospital-acquired pressure ulcers from the International Pressure Ulcer Prevalence Survey. J Wound Ostomy Cont Nurs. 2016;43(3):235–41.CrossRefGoogle Scholar
  4. 4.
    Beeckman D, Van Lancker A, Van Hecke A, Verhaeghe S. A systematic review and meta-analysis of incontinence-associated dermatitis, incontinence, and moisture as risk factors for pressure ulcer development. Res Nurs Health. 2014;37(3):204–18.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Bliss DZ, Savik K, Harms S, Fan Q, Wyman JF. Prevalence and correlates of perineal dermatitis in nursing home residents. Nurs Res. 2006;55(4):243–51.CrossRefPubMedGoogle Scholar
  6. 6.
    Gray M, Beeckman D, Bliss DZ, Fader M, Logan S, Junkin J, et al. Incontinence-associated dermatitis: a comprehensive review and update. J Wound Ostomy Cont Nurs. 2012;39(1):61–74.CrossRefGoogle Scholar
  7. 7.
    Gray M, Black JM, Baharestani MM, Bliss DZ, Colwell JC, Goldberg M, et al. Moisture-associated skin damage: overview and pathophysiology. J Wound Ostomy Cont Nurs. 2011;38(3):233–41.CrossRefGoogle Scholar
  8. 8.
    National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: Quick reference guide. Emily Haesler, editor. Cambridge Media, Perth, Australia; 2014.
  9. 9.
    Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised national pressure ulcer advisory panel pressure injury staging system: revised pressure injury staging system. J Wound Ostomy Cont Nurs. 2016;43(6):585–97.CrossRefGoogle Scholar
  10. 10.
    Black JM, Gray M, Bliss DZ, Kennedy-Evans KL, Logan S, Baharestani MM, et al. MASD part 2: incontinence-associated dermatitis and intertriginous dermatitis: a consensus. J Wound Ostomy Cont Nurs. 2011;38(4):359–70.CrossRefGoogle Scholar
  11. 11.
    Bliss DZ, Zehrer C, Savik K, Smith G, Hedblom E. An economic evaluation of four skin damage prevention regimens in nursing home residents with incontinence: economics of skin damage prevention. J Wound Ostomy Cont Nurs. 2007;34(2):143–52.CrossRefGoogle Scholar
  12. 12.
    Bliss DZ, Zehrer C, Savik K, Thayer D, Smith G. Incontinence-associated skin damage in nursing home residents: a secondary analysis of a prospective, multicenter study. Ostomy Wound Manage. 2006;52(12):46–55.Google Scholar
  13. 13.
    Brown DS, Sears M. Perineal dermatitis: a conceptual framework. Ostomy Wound Manage. 1993;39(7):20–2. 4-5PubMedGoogle Scholar
  14. 14.
    Gray M, Bliss DZ, Doughty DB, Ermer-Seltun J, Kennedy-Evans KL, Palmer MH. Incontinence-associated dermatitis: a consensus. J Wound Ostomy Cont Nurs. 2007;34(1):45–54.CrossRefGoogle Scholar
  15. 15.
    Rohwer K, Bliss DZ, Savik K. Incontinence-associated dermatitis in community-dwelling individuals with fecal incontinence. J Wound Ostomy Cont Nurs. 2013;40(2):181–4.CrossRefGoogle Scholar
  16. 16.
    Brown DS. Perineal dermatitis risk factors: clinical validation of a conceptual framework. Ostomy Wound Manage. 1995;41(10):46. -8, 50, 2-3PubMedGoogle Scholar
  17. 17.
    Bliss DZ, Mathiason MA, Gurvich O, Savik K, Eberly LE, Fisher J, et al. Incidence and predictors of incontinence-associated skin damage in nursing home residents with new-onset incontinence. J Wound Ostomy Cont Nurs. 2017;44(2):165–71.CrossRefGoogle Scholar
  18. 18.
    Bliss DZ, Bland P, Wiltzen K, Gannon A, Wilhelms A, Mathiason MA, et al. Incontinence briefs containing curly fiber lower (acidify) skin pH of older nursing home residents reducing risk for incontinence associated skin damage. J Wound Ostomy Cont Nurs. 2017;44(5):475–80.CrossRefGoogle Scholar
  19. 19.
    Kottner J, Surber C. Skin care in nursing: a critical discussion of nursing practice and research. Int J Nurs Stud. 2016;61:20–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Bliss DZ. Incontinence-associated dermatitis in critically ill adults: time to development, severity, and risk factors. J Wound Ostomy Cont Nurs. 2011;38(4):433–45.CrossRefGoogle Scholar
  21. 21.
    Arnold-Long M, Reed LA, Dunning K, Ying J. Incontinence-associated dermatitis in a long-term acute care facility. J Wound Ostomy Cont Nurs. 2012;39(3):318–27.CrossRefGoogle Scholar
  22. 22.
    Edwards L, Lynch PJ. Genital dermatology atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.Google Scholar
  23. 23.
    Beeckman D, Campbell J, Campbell K, Chimentao D, Coyer F, Domansky R, et al. Proceedings of the Global IAD Expert Panel-Incontinence associated dermatitis: Moving prevention forward. London: Wounds International; 2015. www. Scholar
  24. 24.
    Junkin J, Selekof JL. Prevalence of incontinence and associated skin injury in the acute care inpatient. J Wound Ostomy Cont Nurs. 2007;34(3):260–9.CrossRefGoogle Scholar
  25. 25.
    Kelechi TJ, Arndt JV, Dove A. Review of pressure ulcer risk assessment scales. J Wound Ostomy Cont Nurs. 2013;40(3):232–6.CrossRefGoogle Scholar
  26. 26.
    Borchert K, Bliss DZ, Savik K, Radosevich DM. The incontinence-associated dermatitis and its severity instrument: development and validation. J Wound Ostomy Cont Nurs. 2010;37(5):527–35.CrossRefGoogle Scholar
  27. 27.
    Bliss DZ, Hurlow J, Cefalu J, Mahlum L, Borchert K, Savik K. Refinement of an instrument for assessing incontinent-associated dermatitis and its severity for use with darker-toned skin. J Wound Ostomy Cont Nurs. 2014;41(4):365–70.CrossRefGoogle Scholar
  28. 28.
    Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, et al. Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Dis Colon Rectum. 1999;42(12):1525–32.CrossRefPubMedGoogle Scholar
  29. 29.
    Bliss DZ, Hurlow J, Cefalu JE, Gurvich OV, Wiltzen KR, Gannon A, et al. Validity and reliability of the Incontinence Associated Skin Damage Severity Instrument.D.2. when used by hospital and nursing home nursing staff. Abstract accepted for presenation at Wound Ostomy and Continence Nurses Society conference; 2018.Google Scholar
  30. 30.
    Doughty D, Junkin J, Kurz P, Selekof J, Gray M, Fader M, et al. Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, and current challenges. J Wound Ostomy Cont Nurs. 2012;39(3):244–7.Google Scholar
  31. 31.
    Whiteley I, Sinclair G, Lyons AM, Riccardi R. A retrospective review of outcomes using a fecal management system in acute care patients. Ostomy Wound Manage. 2014;60(12):37–43.PubMedGoogle Scholar
  32. 32.
    Powers J, Bliss DZ. Product options for faecal incontinence management in acute care. J World Council Enterostomal Ther. 2012;32(1):20–3.Google Scholar
  33. 33.
    Pittman J, Beeson T, Terry C, Kessler W, Kirk L. Methods of bowel management in critical care: a randomized controlled trial. J Wound Ostomy Cont Nurs. 2012;39(6):633–9.CrossRefGoogle Scholar
  34. 34.
    Benoit RA Jr, Watts C. The effect of a pressure ulcer prevention program and the bowel management system in reducing pressure ulcer prevalence in an ICU setting. J Wound Ostomy Cont Nurs. 2007;34(2):163–75.CrossRefGoogle Scholar
  35. 35.
    Sammon MA, Montague M, Frame F, Guzman D, Bena JF, Palascak A, et al. Randomized controlled study of the effects of 2 fecal management systems on incidence of anal erosion. J Wound Ostomy Cont Nurs. 2015;42(3):279–86.CrossRefGoogle Scholar
  36. 36.
    Marchetti F, Corallo JP Jr, Ritter J, Sands LR. Retention cuff pressure study of 3 indwelling stool management systems: randomized study of 10 healthy subjects. J Wound Ostomy Cont Nurs. 2011;38(5):569–73.CrossRefGoogle Scholar
  37. 37.
    Monge FJC, Angorrilla IÁ, Aguado ES, Ruiz FR. Rectal ulceration due to using the Fexi-Seal fecal management system: a case report. Rev Esc Enferm USP. 2011;45(5):1256–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Sparks D, Chase D, Heaton B, Coughlin L, Metha J. Rectal trauma and associated hemorrhage with the use of the ConvaTec Flexi-Seal fecal management system: report of 3 cases. Dis Colon Rectum. 2010;53(3):346–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Bright E, Fishwick G, Berry D, Thomas M. Indwelling bowel management system as a cause of life-threatening rectal bleeding. Case Rep Gastroenterol. 2008;2(3):351–5.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Mulhall AM, Jindal SK. Massive gastrointestinal hemorrhage as a complication of the Flexi-Seal fecal management system. Am J Crit Care. 2013;22(6):537–43.CrossRefPubMedGoogle Scholar
  41. 41.
    Page BP, Boyce SA, Deans C, Camilleri-Brennan J. Significant rectal bleeding as a complication of a fecal collecting device: report of a case. Dis Colon Rectum. 2008;51(9):1427–9.CrossRefPubMedGoogle Scholar
  42. 42.
    Denat Y, Khorshid L. The effect of 2 different care products on incontinence-associated dermatitis in patients with fecal incontinence. J Wound Ostomy Cont Nurs. 2011;38(2):171–6.CrossRefGoogle Scholar
  43. 43.
    Palmieri B, Benuzzi G, Bellini N. The anal bag: a modern approach to fecal incontinence management. Ostomy Wound Manage. 2005;51(12):44–52.PubMedGoogle Scholar
  44. 44.
    Zhou X-L, He Z, Chen Y-H, Zuo L-E. Effect of a 1-piece drainable pouch on incontinence-associated dermatitis in intensive care unit patients with fecal incontinence: a comparison cohort study. J Wound Ostomy Cont Nurs. 2017;44(6):568–71.CrossRefGoogle Scholar
  45. 45.
    Bliss DZ, Lewis J, Hasselman K, Savik K, Lowry A, Whitebird R. Use and evaluation of disposable absorbent products for managing fecal incontinence by community-living people. J Wound Ostomy Cont Nurs. 2011;38(3):289–97.CrossRefGoogle Scholar
  46. 46.
    Palese A, Regattin L, Venuti F, Innocenti A, Benaglio C, Cunico L, et al. Incontinence pad use in patients admitted to medical wards: an Italian multicenter prospective cohort study. J Wound Ostomy Cont Nurs. 2007;34(6):649–54.CrossRefGoogle Scholar
  47. 47.
    Fader M, Cottenden A, Brooks R. The CPE network: creating an evidence base for continence product selection. J Wound Ostomy Cont Nurs. 2001;28(2):106–12.Google Scholar
  48. 48.
    Fader M, Bliss DZ, Cottenden A, Moore K, Norton C. Continence products: research priorities to improve the lives of people with urinary and/or fecal leakage. NeurourolUrodyn. 2010;29(4):640–4.Google Scholar
  49. 49.
    Fader M, Cottenden AM, Getliffe K. Absorbent products for moderate-heavy urinary and/or faecal incontinence in women and men. Cochrane Database Syst Rev. 2008.
  50. 50.
    Bliss DZ, Savik K. Use of an absorbent dressing specifically for fecal incontinence. J Wound Ostomy Cont Nurs. 2008;35(2):221–8.CrossRefGoogle Scholar
  51. 51.
    Zehrer CL, Newman DK, Grove GL, Lutz JB. Assessment of diaper-clogging potential of petrolatum moisture barriers. Ostomy Wound Manage. 2005;51(12):54–8.PubMedGoogle Scholar
  52. 52.
    Dykes P, Bradbury S. Incontinence pad absorption and skin barrier creams: a non-patient study. Br J Nurs. 2016;25(22):1244–8.CrossRefPubMedGoogle Scholar
  53. 53.
    Rolnick SJ, Bliss DZ, Jackson JM. Healthcare providers’ perspectives for promoting communication with family caregivers and patients with dementia about incontinence and skin damage. Ostomy Wound Manage. 2013;59(4):62–7.PubMedCentralPubMedGoogle Scholar
  54. 54.
    Continence Product Advisor. International Continence Society, International Consultation on Incontinence, University College London, University of Southampton;
  55. 55.
    Beeckman D, Van Damme N, Schoonhoven L, Van Lancker A, Kottner J, Beele H, et al. Interventions for preventing and treating incontinence-associated dermatitis in adults. Cochrane Database Syst Rev. 2016;11:CD011627.PubMedGoogle Scholar
  56. 56.
    Park KH, Kim KS. Effect of a structured skin care regimen on patients with fecal incontinence: a comparison cohort study. J Wound Ostomy Cont Nurs. 2014;41(2):161–7.CrossRefGoogle Scholar
  57. 57.
    Gray M. Optimal management of incontinence-associated dermatitis in the elderly. Am J Clin Dermatol. 2010;11(3):201–10.CrossRefPubMedGoogle Scholar
  58. 58.
    Abbas S, Goldberg JW, Massaro M. Personal cleanser technology and clinical performance. Dermatol Ther. 2004;17(s1):35–42.CrossRefPubMedGoogle Scholar
  59. 59.
    Ali SM, Yosipovitch G. Skin pH: from basic science to basic skin care. Acta Derm Venereol. 2013;93(3):261–9.CrossRefPubMedGoogle Scholar
  60. 60.
    Rönner A-C, Berland CR, Runeman B, Kaijser B. The hygienic effectiveness of 2 different skin cleansing procedures. J Wound Ostomy Cont Nurs. 2010;37(3):260.CrossRefGoogle Scholar
  61. 61.
    Voegeli D. The effect of washing and drying practices on skin barrier function. J Wound Ostomy Cont Nurs. 2008;35(1):84–90.CrossRefGoogle Scholar
  62. 62.
    Aboud A, Khachemoune A. Vaseline: a historical perspective. Dermatol Nurs. 2009;21(3):143–4.PubMedGoogle Scholar
  63. 63.
    Draelos ZD. Active agents in common skin care products. Plast Reconstr Surg. 2010;125(2):719–24.CrossRefPubMedGoogle Scholar
  64. 64.
    O’Connor S, Murphy S. Chronic venous leg ulcers: is topical zinc the answer? A review of the literature. Adv Skin Wound Care. 2014;27(1):35–44.Google Scholar
  65. 65.
    Hoggarth A, Waring M, Alexander J, Greenwood A, Callaghan T. A controlled, three-part trial to investigate the barrier function and skin hydration properties of six skin protectants. Ostomy Wound Manage. 2005;51(12):30–42.PubMedGoogle Scholar
  66. 66.
    Corazza M, Minghetti S, Bianchi A, Virgili A, Borghi A. Barrier creams: facts and controversies. Dermatitis. 2014;25(6):327–33.CrossRefPubMedGoogle Scholar
  67. 67.
    Beeckman D, Verhaeghe S, Defloor T, Schoonhoven L, Vanderwee K. A 3-in-1 perineal care washcloth impregnated with dimethicone 3% versus water and pH neutral soap to prevent and treat incontinence-associated dermatitis: a randomized, controlled clinical trial. J Wound Ostomy Cont Nurs. 2011;38(6):627–34.CrossRefGoogle Scholar
  68. 68.
    Peterson KJ, Bliss DZ, Nelson C, Savik K. Practices of nurses and nursing assistants in preventing incontinence dermatitis in acutely/critically-ill patients. Am J Crit Care. 2006;15(3):333.Google Scholar
  69. 69.
    American Health Care Association. American Health Care Association 2012 staffing report. 2012.
  70. 70.
    Nursing Solutions Inc. National healthcare retention and RN staffing report. East Petersburg, PA; 2016.
  71. 71.
    VitalSims. Incontinence associated skin damage.
  72. 72.
    Boronat-Garrido X, Kottner J, Schmitz G, Lahmann N. Incontinence-associated dermatitis in nursing homes: prevalence, severity, and risk factors in residents with urinary and/or fecal incontinence. J Wound Ostomy Cont Nurs. 2016;43(6):630–5.CrossRefGoogle Scholar
  73. 73.
    Berlowitz D, Lukas VC, Parker V, Niederhauser A, Silver J, Logan C, et al. Preventing pressure ulcers in hospitals: a toolkit for improving quality of care. Rockville, MD: Agency for Healthcare Research and Quality; 2012. Google Scholar
  74. 74.
    Redelings MD, Lee NE, Sorvillo F. Pressure ulcers: more lethal than we thought? Adv Skin Wound Care. 2005;18(7):367–72.CrossRefPubMedGoogle Scholar
  75. 75.
    Russo CA, Steiner C, Spector W. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006: Statistical brief #64. 2008 Dec. In: Healthcare Cost and Utilization Project (HCUP) statistical briefs. Rockville, MD: Agency for Healthcare Research and Quality; 2006.
  76. 76.
    Voss AC, Bender SA, Ferguson ML, Sauer AC, Bennett RG, Hahn PW. Long-term care liability for pressure ulcers. J Am Geriatr Soc. 2005;53(9):1587–92.CrossRefPubMedGoogle Scholar
  77. 77.
    Lyder CH, Ayello EA. Pressure ulcers: A patient safety issue. In: Hughes R, editor. Patient safety and quality: an evidenced-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. Scholar
  78. 78.
  79. 79.
    Norton Pressure Sore Risk Assessment Scale Scoring System.
  80. 80.
    Posthauer ME. Nutrition: fuel for pressure ulcer prevention and healing. Nursing. 2014;44(12):67–9.CrossRefPubMedGoogle Scholar
  81. 81.
    Wound Ostomy & Continence Nurses Society. Guidelines for prevention and management of pressure ulcers (injuries). Mount Laurel, NJ: Wound Ostomy & Continence Nurses Society; 2016.Google Scholar
  82. 82.
    Allman RM. Pressure ulcers among the elderly. N Engl J Med. 1989;320(13):850–3.CrossRefPubMedGoogle Scholar
  83. 83.
    Andersen PH, Bucher AP, Saeed I, Lee PC, Davis JA, Maibach HI. Faecal enzymes: In vivo human skin irritation. Contact Dermatitis. 1994;30(3):152–8.CrossRefPubMedPubMedCentralGoogle Scholar
  84. 84.
    Braden B, Bergstrom N. A conceptual schema for the study of the etiology of pressure sores. Rehabil Nurs. 1987;12(1):8–12.CrossRefPubMedGoogle Scholar
  85. 85.
    National Pressure Ulcer Advisory Panel (NPUAP). NPUAP position statement on staging -2017 Clarifications. 2017 [1–6].
  86. 86.
    Leaper DJ, Schultz G, Carville K, Fletcher J, Swanson T, Drake R. Extending the TIME concept: What have we learned in the past 10 years? Int Wound J. 2012;9(s2):1–19.CrossRefPubMedGoogle Scholar
  87. 87.
    Dowsett C, Newton H. Wound bed preparation: TIME in practice. Wounds UK. 2005;1(3):58.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Mikel Gray
    • 1
    • 2
  • Donna Z. Bliss
    • 3
    Email author
  • Sheila Howes Trammel
    • 4
    • 5
  1. 1.Department of UrologyUniversity of Virginia School of MedicineCharlottesvilleUSA
  2. 2.Department of Acute and Specialty CareUniversity of Virginia School of NursingCharlottesvilleUSA
  3. 3.University of Minnesota School of NursingMinneapolisUSA
  4. 4.Hennepin County Medical CenterMinneapolisUSA
  5. 5.WEBWOC Nursing Education ProgramMinneapolisUSA

Personalised recommendations