The urethra in women lies just beneath the clitoris, and above the vaginal opening. Urinary incontinence, the involuntary loss of urine, can occur with activities such as exercise, sex, coughing, sneezing, and laughing, and can also occur with uncontrolled urge to urinate/overactive bladder. Sometimes it can be just a drop or two, requiring no more than a change of underwear, but in some women, it can be significant, leading to use of liners or pads. The pads, whether dry or wet with urine, can themselves irritate sensitive vaginal and perineal (the area between the vagina and anus) skin. Simple urine contact with vaginal and perineal skin, when chronic, can lead to dermatitis, skin irritation and infection.
How does this happen?
The opening of the vagina, the labia majora, and perineum can become red and inflamed. Women will complain of a “burning sensation down there”. I encounter this complaint frequently in my female patient population. This non-specific description can often be misunderstood for burning with urination (or a urinary tract infection), leading to a reflexive prescription of antibiotics. If vaginal dermatitis exists, direct urine contact on these areas will lead to a burning sensation, that is, a burning sensation after urination. The physician should be careful to elicit the correct problem here: is there burning with urination/dysuria (which may be a UTI), or is there vaginal skin burning? The treatments of course are much different.
Think of a baby’s red bottom which after prolonged contact with a wet diaper, becomes irritated and very painful. This is how I describe this problem to my patients, as it’s a common scenario all mothers have dealt with. Balmex and Desitin to the rescue, usually. However, in adults, the treatment goal is not only to soothe and heal the skin, but to stop the incontinence and urine contact in the first place.
Constant moisture to the skin alters the skin’s pH and natural protective barrier, allowing this barrier to break down, becoming more permeable to bacteria. Despite best hygiene efforts in women, the perineum and vagina are areas where fecal bacteria can live, and most of the time, cause no problems. When the skin barrier is compromised, these bacteria can invade the skin leading to secondary infections. This then leads to frequent itching and wiping of this area, often vigorously, further causing local trauma to the delicate skin.
The skin can become red, swollen, crusty, develop scales or pimples, and cracks. This can occur around the anus, the perineum, and around the vagina/labia. If left untreated or ignored, bleeding and painful ulcers can develop. Staph and yeast infections can easily thrive in this environment. For those taking care of elderly family members, this may be an overlooked area either due to patient or caretaker embarrassment to either report it, or to examine this area on a routine basis. Moreover, if stool contamination occurs or if stool hygiene is poor, it clearly makes a bad situation worse.
Good skin care is always important, but again, treating the underlying urinary incontinence is more important. Pain and irritation of the perineum and vagina can become significant daily issues. It may impact very heavily on self-image, sexual relationships, overall health image, and exercise and care routines. Pad usage can in many cases exacerbate the already irritated skin by constant contact especially if not changed promptly.
Not to be neglected, the irritation can spread to the inner thighs, buttocks and lower abdominal skin folds.
What do you do then?
A thorough exam is necessary to evaluate all the “hidden areas” most people cannot reach or cannot directly see. Often anti-fungals and antibiotics are necessary to help eradicate infections. Topical barriers such as pastes or lotions help shield the skin from urine and/or stool contact. Pastes are better when diarrhea is involved.
Gentle skin cleaning is important. After each incontinence episode, the skin should be cleaned, the pad changed, and a barrier applied, if needed. Hand soap should be avoided because it can dry out the skin. Cleansers can be either liquid, foam, oil-based or towelettes. Mineral oil, and lanolin can replace the natural skin oils lost from urine contact, skin irritation and frequent wiping.
Skin barriers that contain lanolin, zinc oxide, petroleum, and dimethicone can all block the skin from moisture and irritants. Ointments are oil-based and can last longer than creams, which are water based. If any barrier stings the skin on contact, it should be avoided. Absorptive pads and undergarments that draw moisture away from the skin are preferred, not ones that trap the urine against the skin.
Lastly, treat the incontinence!