The silver-haired actor Harry Van Gorkum — who once starred in Friends as Monica’s British ‘soulmate’ Don — stands in a luxury apartment in his underwear and looks confidently at the camera. ‘Now we’re comfortable, let’s talk urine leakage,’ he says, holding up an incontinence pad for men which he promises ‘slips discreetly into my underwear’. Not so long ago it would have been unthinkable to see this on prime-time TV. But while it’s undeniable that advertising like this is helping open up conversations around incontinence, critics warn that this kind of marketing also exploits people’s embarrassment — encouraging them to buy products to soak up leaks instead of seeking medical help for an often treatable problem. Meanwhile, there are concerns that people in hospital or care homes, particularly older patients, are falling victim to a ‘pad culture’, which means that, even if they are not incontinent, they are put in nappies (and then left in them for hours). Incontinence affects more than one in five people in the UK and demand for products to treat it is soaring. From ‘adult nappies’ which, like baby nappies, come as pull-on pants or wraparound pads with sticky tabs; to washable, reusable pants; or stick-on pads and liners worn inside underwear, sales increased by 13.2 per cent in the year to March. Last year we spent a staggering £234 million on these products, according to market data analyst Kantar, with around 1.16 billion individual items sold — that’s equivalent to 37 incontinence products bought every second. The UK is far from alone: customers in the U.S. account for about a third of global spending on incontinence products, European countries for another quarter — but sales are growing most rapidly in Asia, particularly in China, India, South Korea, Taiwan and Japan. Indeed, the Japanese manufacturer Oji Holdings has recently announced that it is switching from making baby to adult nappies because of changing demand. Arguably, it’s a financially savvy move, too, because manufacturers can charge more for larger adult products. In Tesco, a packet of 12 medium Tena adult nappy pants costs £8.55 (71p per nappy) — baby nappies were less than a third of the price, with a pack of 64 size five Pampers nappy pants costing £14 (22p per nappy). What’s behind rising demand? Clever advertising may be driving sales (more on that later) but experts believe that failings in care are also fuelling the rise — with too many people ending up in nappies for treatable problems. Incontinence is not an illness but a symptom of other health problems, such as damage to the bladder and bowel or the pelvic floor muscles that support them. It can also be caused by neurological disorders such as Parkinson’s disease or multiple sclerosis, and the side-effects of certain medications, including HRT (hormone replacement therapy) and some antidepressants. Research suggests that around one in three women in the UK experiences some form of leaks (often owing to damage sustained during pregnancy and childbirth); menopause can also trigger or aggravate symptoms, as hormonal changes reduce the elasticity and strength of the pelvic floor. In men, incontinence becomes more common in later life — around one in ten over 65 experiences leaks, typically as the result of an enlarged prostate or treatment for prostate cancer. Obesity is another risk factor — excess weight and body fat put pressure on the bladder and its supporting muscles; so, too, is getting older. Although incontinence affects all ages, it’s far more common in older people, and one of the most common reasons for them being admitted into care or nursing homes. The NHS says approximately a third of care home residents and two-thirds of nursing home residents experience urinary and/or faecal incontinence. But NHS England is clear — incontinence is usually treatable. The health service already spends around £80 million a year on incontinence pants and pads (or ‘containment products’, as it calls them) but says their use should be kept to a minimum and ‘treatment [of incontinence] must always be the preferred option’. Under NHS guidelines, people experiencing incontinence should be assessed by specialist staff to rule out any serious underlying problems and/or have a medication review with a GP. Once a cause is established, conservative treatments for both men and women include dietary advice (for example, avoiding caffeine, alcohol and artificial sweeteners which can irritate the bladder, and increasing fibre intake for healthy bowels) and pelvic floor muscle exercises and/or bladder retraining, to teach patients how to wait longer between loo visits. If these don’t work, patients are meant to be referred to a specialist and may be given medication (to improve muscle tone or alter the body’s signals about when to urinate) or offered surgery, such as procedures to support the bladder. ‘Containment products can offer security and comfort, helping people continue with their normal daily activities. However, they are costly [a month’s supply of incontinence pants from the supermarket costs around £87], can affect a person’s dignity and do not offer a long-term solution unless the person has not responded to other treatments,’ the guidance adds. It is important that men with symptoms seek treatment as soon as possible because incontinence can be a sign of an underlying health problem, such as an enlarged prostate, says Hamid Abboudi, a consultant urological surgeon at Imperial College Healthcare NHS Trust and founder of londonandsurrey urology.com. ‘If you notice any changes to your urine flow, you should see a doctor,’ he adds. ‘If you leave it too long, it can be much harder to treat and can cause lasting damage to the bladder or kidneys.’ With women, most cases of incontinence are related to pelvic floor damage and are usually treatable, says Tina Mason, a specialist pelvic physiotherapist at the private Women’s Health Brighton clinic. ‘The pelvic floor muscles are like any other muscles in the body,’ she says. ‘If you injured your leg, you wouldn’t just drag it around behind you. It should be the same with your pelvic floor. ‘It’s always good to get these things sorted earlier rather than later, but even when you are into your 70s and 80s, a physio can give you tailored exercises to improve or stop incontinence symptoms. It is never too late.’ If symptoms worsen because of changes around menopause, as well as pelvic floor exercises, oestrogen hormone creams and vaginal moisturisers can improve tissue elasticity, she adds. A ‘pad-happy’ hospital culture The Royal College of Nursing (RCN) says giving more people access to pelvic floor and bladder-training programmes would improve their quality of life and save the NHS money on incontinence products and hospital admissions. But, instead, older patients in particular are being pushed into using adult nappies. A 2022 report by the National Institute for Health and Care Research (NIHR) highlights the focus on ‘containment’ instead of treatment in both hospital and community care settings, as well as a lack of staff training on incontinence. Other research in 2022 identified an endemic ‘pad culture’ in hospitals, where older people — particularly those with dementia — were routinely given wraparound nappy-style pads ‘regardless of independence, mobility, capacity and functionality’, in order to reduce the number of ‘interruptions’ to staff. In the study, led by Professor Katie Featherstone, a medical sociologist at the University of West London, researchers observed six geriatric wards in hospitals in England and Wales for 180 days. They found that nurses and healthcare assistants who felt under huge pressure to get through their daily care tasks on time regularly ‘deprioritised’ incontinence care and would leave patients sitting in unchanged pads ‘until the timetable allowed’. Healthcare staff felt it would take ‘too long’ to encourage patients to go to the loo, or support them to walk there. Instead, fears that patients could fall meant many were ‘generally discouraged and often forbidden’ from going to the loo independently and told to use incontinence pads. Professor Featherstone and her team said such ‘pad cultures’ were not caused by ‘a malicious act or poor care on the part of ward staff’, but were felt necessary in order for staff to keep up with the pace of the timetabled rounds of routine tasks they had to carry out. Ironically, researchers noted the pads regularly leaked, smelled and caused skin damage — such as nappy rashes and sores — creating extra work for staff. And incontinent patients who were put in bulky pads ‘just in case’ found it more difficult to walk to the bathroom, so ended up needing more support. The authors warned that there seemed to be ‘little recognition’ among staff of the distress having to use pads or sitting in soiled pads caused patients — and that often this distress was written off as part of their dementia. Another study, at the University of the West of England in Bristol in 2021, found a similar ‘over-reliance’ by NHS hospital staff on using wraparound nappy pads for older patients. ‘Interviewees [spoke] of pads being provided as a matter of course, without first determining need, suitability, benefit or risk. This convention was summed up by one staff nurse when admitting: “We tend to get pad happy,” ’ the researchers reported in the journal BMJ Open Quality. In a 2021 statement on the issue, the RCN described poor incontinence care as ‘distressing and degrading for individuals’, as well as costing the NHS through increased risk of infections, pressure ulcers and falls. Similar issues can be seen in community care, says the NIHR. For patients like Thomas (his name has been changed), 92, this can have devastating effects on dignity and mental health. The retired writer is frail and bedbound after a fall at home six months ago. Local authority carers visit his London apartment for just 15 minutes four times a day, when they help him to wash, eat and take his medications. Thomas is not incontinent but because there is no one to help him walk the few metres from his bed to his bathroom between these short visits, he has to use a nappy. ‘I hate it, but what can I do?’ he says. Carers suggest that pads should be changed at least every four to six hours, or as soon as they are soiled, to reduce the risk of rashes and sores. Yet many patients like Thomas have no choice but to wait until their next care visit. If he has to use the nappy after his 6pm night-time visit, he has to wait until his next visit, at 8.30am, to be changed. Helen Walker, chief executive at Carers UK, says: ‘As councils struggle to meet social care demand, they will often advise unpaid carers to use incontinence pads rather than provide additional care.’ As cuts to local authority care provision mean fewer patients with mobility issues are provided with round-the-clock care, it seems inevitable that this will lead to more being made to use adult nappies. And, while patients with severe symptoms may be entitled to receive some pads on the NHS, supply is limited and styles are often bulky and uncomfortable. As Helen Walker says: ‘The pads provided are not always suitable, leaving many carers to purchase them privately. ‘Some then struggle to claim their purchase as a disability-related expense as their local authority may argue that pads are already provided by the NHS, even if they are unusable.’ A separate issue driving sales of adult incontinence products is long NHS waiting lists to see specialists: there are currently more than 400,000 people on the waiting list for urology in England alone, and patients are being forced to buy incontinence products while they wait for treatment. Women misled by marketing At the other end of the spectrum, middle-aged adults with mild symptoms are being targeted by marketing campaigns encouraging them to buy incontinence products, while there is little public information about available treatments. In Tena’s latest ad, for example, Harry Van Gorkum waves at his underwear in which he claims to be wearing a pad, saying: ‘You’d never know’, as a slogan tells men they can ‘keep control’ by using the product. The only reference to getting treatment is a line of small print underneath which states: ‘Do not hesitate to seek healthcare advice if you experience urine leakage.’ This, says Mr Abboudi, is ‘strange wording’. ‘The message should be: If you need a product like this, you need to see a doctor first to work out the cause,’ he says. ‘It’s not normal to be incontinent — it’s not a natural part of ageing and shouldn’t be portrayed in that way. ‘We already know from research that men tend to under-report symptoms and present to a doctor quite late, with potentially long-term consequences, such as kidney damage. ‘Men can feel incontinence is embarrassing but they also often don’t see it as an important problem, so they downplay it.’ In 2019, the RCN reported Tena to the advertising watchdog after it ran a similar ad for new mothers, which the nursing union claimed portrayed postnatal incontinence as ‘inevitable’ and implied that women should wear nappy pants, rather than informing them they could get treatment. A lthough the watchdog dismissed the complaint, Essity, which owns Tena, told Good Health it has consulted with the RCN on the wording of its adverts. As well as TV ads, some incontinence product companies use social media to target individuals based on their age, sex, interests and browsing history — and sell them products online which are delivered direct to their door. The ‘easier access and discreet purchasing options’ provided by online shopping is driving sales, particularly among younger customers in their 30s to 50s, according to market researcher Global Market Insights. In the UK last year, sales of liners for mild incontinence — which is more common among younger women — increased at a 40 per cent greater rate than for pants and pads, Kantar figures show. Normalising the use of products for mild symptoms risks discouraging women of all ages from seeking treatment, warns Tina Mason. ‘A lot of women tell me it’s “OK” because they only use a “thin” liner, for instance,’ she says. ‘But that’s not OK — you should still be able to go about your life, jump and exercise without having to use a pad. What you need is help to make sure your pelvic floor is functioning.’
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