Genital hygiene is of particular importance to the health and well being of older women. The consequences of inadequate hygiene vary. Mild skin irritation and fungal or bacterial skin infections become more common in older people who have a diminished capacity to care for themselves. Atrophic vulvovaginitis is prevalent after menopause. Moreover, the risk of pressure ulcers and incontinence dermatitis can be significant when older women suffer impaired mobility and urinary or fecal incontinence. Health conditions linked to genital hygiene in older women are described in the following sections.
Intertrigo and vulvar folliculitis: Intertrigo is an inflammation of the genitocrural folds, the labia, and the perineum sometimes seen in older or morbidly obese women (176). It manifests with erythema and excessive moisture. Vulvar folliculitis presents as red, tender papules surrounding the hair follicles and may be associated with staphylococcal and streptococcal infection. Both conditions result from impaired ability to maintain adequate hygiene. Hygienic interventions and maintaining skin dryness are indicated treatments.
Tinea: Tinea is a fungal infection of the feet, nails, and vulvar skin folds. Though a rare condition, its prevalence rises in older women because of diminished cellular immune responses (177). The most characteristic presentation is a ring-shaped eruption with an actively advancing border and scaly, healing center. However, any pruritic, scaly eruption of the vulva is suspect: it should be scraped for microscopic examination and treated with antifungal therapy, if appropriate. Maintaining dry skin helps prevent this condition.
Incontinence dermatitis: Preventing and managing incontinence dermatitis are the principal hygiene challenges in people with severe incontinence. Incontinence dermatitis is sometimes referred to as perineal dermatitis, which is a broad term that encompasses inflammation and tissue damage to the vulva, perineum, perianal region, and buttocks. The condition creates much pain and discomfort in elderly sufferers.
Prevalence of incontinence. In North America and Europe, urinary incontinence is prevalent among people over the age of 65. A community-based survey of 1584 Caucasian and African American women in the United States aged 70 to 79, found a prevalence of 21% (178). Of these, 40% reported stress incontinence and 42% reported urge incontinence. The frequency of urinary incontinence was higher among Caucasian women (27%) than among African-American women (14%). Fifteen percent of Mexican American women aged 65 or older reported having urinary incontinence (179). A community-based survey of Italian women aged 65 or older found a 26% prevalence (180).
Pathogenesis of incontinence dermatitis. The etiology of incontinence dermatitis in elders (Fig. 3) is inferred from research on pediatric diaper
dermatitis. Elevated skin wetness, elevated pH, and the presence of fecal enzymes set the stage for skin damage. Hydrated skin is more susceptible to mechanical forces, whereas the elevated pH induced by urinary ammonia alters skin barrier function and activates fecal enzymes that compromise skin integrity. Moreover, several additional factors increase the risk of skin injury in older people (181,182). Skin atrophy makes the tissue inherently more fragile. Skin hydration following occlusion is significantly greater, and dissipated more slowly, in aged skin (183). Immobility increases the impact of mechanical forces; moving an immobile person across a chair or bed produces not only superficial friction but also generates shear forces in the underlying tissue because of pressure from the sacral bone (184). In those with impaired immune function, overgrowth of cutaneous pathogens or invasion of fecal bacteria is more likely to be a complication. Poor nutritional status can impede tissue recovery. Finally, impaired cognition can limit the person's ability to alert caregivers to incontinent episodes.
Incontinence dermatitis in older people begins with mild erythema of the skin, then progresses to an intense red appearance, often accompanied by blistering, erosion, and serous exudates. In darker skin, the initial inflammation reaction may be more difficult to detect. With urinary incontinence, dermatitis begins between the labial folds; dermatitis associated with fecal incontinence originates in the perianal area and progresses to the posterior aspect of the upper thighs. Secondary infection with Candida albicans causes erythematous, punctate vesicles that form a central confluence; satellite lesions may be visible on the border of the infection. Because of friction, vesicles may assume a macular appearance. The infected skin takes on a dark red color.
Hygiene measures. Examination and care of the genitalia should include gentle separation of the labia and exposure of the skin folds between the mons pubis and the inner aspect of the upper thigh. The buttocks should be separated and examined, as well as the crease between the buttocks and the posterior upper thigh. In women who are obese, skin folds of the lower abdomen must also be exposed and examined, particularly in women who are diabetic or immunocompromised (184).
Although no systematic trials exist on the impact of perineal hygiene on skin health, general guidelines have been developed for preventive care (184,185). The focus is on keeping the skin dry, maintaining a healthy skin pH, avoiding mechanical forces, and minimizing contact with urine and feces. The use of specially formulated perineal skin cleansers or disposable wipes is preferred over bar soap and a washcloth. The former avoid the high pH of most soap bars and the friction forces created by rubbing a washcloth against the skin (182). Powders are used to absorb excess moisture; cornstarch-based powders are sometimes favored because of the controversy regarding perineal talc. Moisture-barrier preparations are also employed. Superabsorbent incontinence pads or garments are used to absorb wetness and keep it away from the skin. Wet or soiled garments should be changed promptly.
Treatment of incontinence dermatitis. Prospective clinical trials are needed to study the effectiveness of preventive hygiene measures as well as the efficacy of therapeutic intervention. To our knowledge, the only published prospective study of preventive care was a preliminary trial of structured nursing intervention in 15 institutionalized patients with dementia (186). An equal number developed dermatitis (two in the structured care intervention group and three in the unstructured care group) regardless of whether cleansers, moisturizers, or moisture-barrier preparations were used. Dermatitis developed only in those with urofecal incontinence and followed more than four incontinent episodes in 24 hours. None of the patients was capable of informing caregivers of incontinent episodes. The small number of subjects and their poor mental health limit the conclusions that can be drawn from this study.
Case reports provide evidence for the effectiveness of barrier creams and hydrogel dressings in treating incontinence dermatitis (187,188). In one case report, applying a commercial barrier cream three times per day prevented dermatitis from postsurgical diarrhea (10-20 stools a day) during a one-month follow-up period (187). In another, a 68-year old woman, who presented with candidiasis secondary to urofecal incontinence and diarrhea, was treated with a regimen of skin cleansing followed by application of an antifungal powder and then a layer of barrier cream. Her dermatitis cleared within three days (187).
Case reports also support the efficacy of hydrogel dressings for treating excoriation (188). The first case involved a disabled woman with incontinence who suffered perianal excoriation unresponsive to a titanium-based barrier cream and paraffin wax. Resolution was achieved in three days by applying hydrogel every two hours and after every incontinent episode. Another case involved a man incontinent of urine who had perianal dermatitis and a sacral pressure ulcer. Application of hydrogel cream resulted in improvement after five days of treatment.
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