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Penile sheaths: are they underused for managing urinary incontinence?

Helen Young and Pat O'Brien
Clinical Nurse
Specialists

Kate Dimelow
Specialist Continence Nurse

Mary Richardson and Karen Moss
Continence Nurses
for Western Cheshire and Halton PCTs

Male urinary incontinence is a common problem, causing discomfort, embarrassment and disruption to the everyday life of many thousands of men. It is irrespective of age and within the UK, it is estimated that one in 33 men aged 15 to 64 have incontinence problems, increasing to as many as one in 10 men aged 65 and over. Evidence suggests that many men do not admit to having a continence problem and therefore the statistics may not be 100% accurate.(1,2)
There are a number of treatment programmes for male sufferers of urinary incontinence, many of which can cure or improve symptoms, however for some men, a good containment system may be required to avoid the discomfort and embarrassment that is associated with urinary incontinence.(3) With new developments in sheath systems and more choice for the patient, a penile sheath may provide an ideal containment system either in the short or long term to manage their urinary incontinence.
A penile sheath is a soft, flexible sleeve that fits "snugly" over the penis and is available in many styles, sizes and materials. The sheath is then connected to a drainage bag for the collection of urine.
Research suggests that penile sheaths are not being used to their full potential in the management of male urinary incontinence and although there are many continence products available, penile sheaths only represent about £9.3 million (15%) of the market.(4) These statistics would suggest that penile sheaths are an underutilised containment device and therefore healthcare professionals need a better understanding of their role in continence management in clinical practice. Brodie suggests that lack of education and training is the biggest barrier to sheath usage.(5) One suggestion is that this may be attributed to the wide variety of sheaths available on the Drug Tariff in the UK.
In order to validate these statements our service decided to conduct a small audit on the use of penile sheaths in practice among local district nursing teams. The aim of the audit was to establish the number of male patients with urinary incontinence and of these patients, how many were managed with a sheath system, how many trained staff felt competent and confident to apply a sheath system and to advise patients/carers in sheath fitting and management (see Box 1). The results of the audit indicated that there was a competence/confidence deficit in terms of advising on and applying sheaths and therefore it is likely that sheaths are being underutilised.

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Assessment
Assessment of male urinary incontinence can be a sensitive task, (see Box 2) and it should be undertaken by a healthcare professional with appropriate education and training. There are different types of urinary incontinence and once identified, individual treatment pathways can be commenced. Urinalysis should be carried out to identify any abnormalities which may be contributing to their incontinence. It may be possible to resolve any further underlying contributory factors such as constipation and medication that can impact on the patient's incontinence, clothing issues and toilet access, etc.

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Treatment programmes that can be implemented may include drug therapy, pelvic floor exercises, bladder retraining, drinking programmes, and the use of environmental toileting aids, eg, urinals and funnels etc. For some male patients with urinary incontinence, treatment programmes may improve the situation but not provide a cure.
Penile sheaths are a viable alternative to disposable products, indwelling and intermittent catheterisation, particularly after any other underlying cause has been excluded by primary and secondary healthcare professionals. Their potential has also been recognised within the influential epic guidelines for the prevention of healthcare-associated infections in primary and community care.(7)
There are a number of practical considerations before, during and following the application of a penile sheath as penile sheaths are made from a variety of materials. Each patient should be assessed for suitability and any known allergies to the materials in the sheath, eg, latex and silicone should be identified.
As sheaths are appropriate for male patients with moderate or heavy urinary incontinence, the advantages of using a penile sheath system include reliability and comfort, and as the procedure is noninvasive, it is easily taught, facilitating self-care, and thereby maintaining both the patient's independence and dignity.
Pomfret highlights that if a patient is unable to fit their own sheath, then with their consent and appropriate training, carers such as the patient's partner, relatives and carers in residential and nursing homes can apply the sheaths.(8) This avoids reliance on healthcare professionals and maximises the user's independence.
Limiting factors to a sheath being successful include motivation, body image, ability to apply a sheath or co-operation of partner/carer, skin sensitivity/allergies to any of the sheath materials, and sexual activity. Patients should not be confused or likely to pull the sheath off due to the risk of skin trauma.9
There are also two main reasons why a sheath does not remain in place: wrong size or penile retraction, or sometimes a combination of both.

The penile sheath in practice

  • The diameter/girth of the penis should be measured to make sure the correct size of sheath is used. Sizing kits or measuring guides are available from most manufacturers to ensure a correct fit, thereby reducing the risk of leakage and detachment. The penis should be measured in a flaccid state and the penile shaft must be at least 2 cm in length to ensure successful fixation.
  • Whether a one-piece or two-piece penile sheath is used, it needs to be big enough to allow natural movement of the penis. It is important that the penis can expand and contract freely. If the sheath is too small, it may cause constriction of the penis and tissue breakdown. If it is too large, it can leak or slip off.
  • The penile skin should be checked on a daily basis to ensure that it does not become red or show signs of irritation. Sheaths are disposable and should only be used once and for no longer than 24 hours as per the manufacturer's guidelines

The following general principles and precautions should apply when using a sheath system:

  • The genital area should be washed with soap and water to remove anything likely to impair adhesion of the sheath to the penis, eg, cream or talc.
  • The foreskin should be in its normal position and not be retracted prior to application of the sheath.
  • Check skin condition as the sheath should not be applied to damaged or broken skin.
  • Do not locate adhesive area of the sheath within 2 cm of the tip of the penis.
  • Pubic hairs should be clipped back at the base of the penis, otherwise they can impair adhesion of the sheath; they can also make it very painful when the sheath is removed. A pubic hair guard may be used to prevent hair becoming caught in the sheath.
  • The sheath should be rolled back according to the manufacturer's instructions prior to application to create a space between the end of the penis and the sheath outlet.
  • If the reinforced ring of the sheath causes pressure at the base of the penis it should be removed as per the manufacturer's recommendations.
  • It is important that the urine is able to drain freely (nonrestrictive clothing will ensure the outlet tubing does not become kinked).
  • To reduce the risk of trauma to the skin the sheath can be removed with soap and water.
  • The sheath may normally be disposed of in normal household waste, although this may be subject to local regulations.

New developments
A new generation of sheaths are now available. Innovative designs and ease of application have made them much more patient friendly. Examples of these sheaths include the Bard Encompass™, the Conveen Optima (Coloplast) and the Bioderm sheath (Clinimed).
The design of the latex-free Encompass sheath features longer tubing from the tip of the penis to the catheter bag.  The extended length of the tube prevents the urine pooling around the tip of the penis thus reducing the risk of infection.  Due to its unique design, this sheath was suggested for use in our department for a gentleman with a light dribble incontinence using a catheter valve rather than a catheter bag (see Case study). The use of a catheter valve represented a more discreet option, while still maintaining the effectiveness of the sheath.
The Conveen Optima sheath has discreet packaging and is easy to apply due to its double strip grip. In a comparative study by Pemberton, the Optima was reported to be well tolerated in terms of handling, application and provided a sense of security when on, fairing well against the popular Clear Advantage sheath.(6)
An innovation for men with a retracted or a very short penis is the Bioderm sheath. While there is no research available in the UK, an American study reported good results in 40 men who had a retracted penis. The sheath itself is made of hydrocolloid which is applied directly over the glans penis and connected to a drainage bag. It does not require measurement, however it is available with two apertures for men with either a circular or oval meatus and can remain in place for up to three days.

Conclusion
The audit confirmed that sheaths are underutilised in the management of male incontinence within our area, despite new penile sheath developments. The results highlighted that training is required to give healthcare professionals the competence and confidence in applying and educating patients and carers. Further research could look at a larger population of male patients with urinary incontinence who use a sheath system, and how this impacts on their quality of life.
There are many sheaths on the market with local continence services being able to advise on the latest products and innovations. With new developments in sheaths and therefore more patient choice, they can provide a more viable option as opposed to using disposable products or catheters to manage male urinary incontinence.
However, it is recognised that penile sheaths are not suitable for every male patient who is assessed with a continence problem. Nevertheless, if a healthcare professional has the underpinning knowledge to assess individual patient continence needs, then selection and fitting of an appropriate sheath system will ensure not only patient confidence but also optimum continence care and management.

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References

  1. Department of Health. Good practice in continence services. London: Department of Health; 2000.
  2. Royal College of Physicians of London. Incontinence: causes, management and provision of services. London: Royal College of Physicians; 1995.
  3. Norton C. Nursing for continence. 2nd ed. UK: Beaconsfield Publishers Ltd; 1996.
  4. PPD data on file from Bard Ltd.
  5. Brodie A. A guide to the management of one-piece urinary sheaths. Nurs Times 2006;102:49,51.
  6. Pemberton P, Brooks A, Eriksen C, et al. A comparative study of two types of urinary sheath. Nurs Times 2006;102:36-41.
  7. Pellowe CM, Pratt RJ, Harper P, et al. Evidence-based guidelines for preventing healthcare-associated infections in primary and community care in England. J Hosp Infect 2003;55:S2-S127.
  8. Pomfret I. Back to basics: urinary sheaths. JCN Online 2003;17. Available from: http://www.jcn.co.uk/journal.asp?MonthNum=10&YearNum=2003&Type=backissue...
  9. Pomfret I. Urinary continence management- penile sheaths. JCN Online 2000;14. Available from http://www.jcn.co.uk/journal.asp?MonthNum=04&YearNum=2000&Type=backissue...