Urinary sheaths for male incontinence
650
has disclosed or appear to be dismissive. The National Institute for Health and Care Excellence (NICE) (2010) advises offering a choice of containment products suitable for the man’s circumstances and in consultation with him. This suggests immediate action to achieve social continence until a diagnosis or management plan can be made. In practice, this may mean a ward-based nurse filling in a continence assessment form which would then be referred to a specialist continence nurse or a GP referring a patient in the surgery to a community continence advisor, for instance. Whatever the approach, a detailed medical, surgical, family and medication history will need to be taken followed by a physical examination by someone who is qualified to carry out a full assessment. Based on the assessment findings, a tentative diagnosis can be made as to the cause of the incontinence pending investigations and tests that are deemed relevant. In middle-aged or older men, the prostate becomes enlarged and is often the cause of lower urinary tract symptoms; however, cancer within the urinary tract also has to be ruled out in the presence of haematuria. Considering that incontinence can be cured in around 70% of cases (RCP, 1995), it is worth spending time finding out the cause through a thorough assessment. It is also worth considering the social context of the individual and physical restraints as the cause may be as simple as not being able to get to the toilet easily or difficulty in unfastening clothing.
The urinary sheath The male external catheter (MEC), condom catheter or urinary sheath is a soft, flexible sleeve that fits over the penis and culminates in a short tube that fits onto any standard urinary drainage system (Kyle, 2011).To the uninitiated, there is a large array of sheaths in different materials, lengths, and sizes from various manufacturers, so choice of the right product for a particular individual can be complex. It is not surprising therefore that incorrect use of the sheath leads to failure of the device and the belief by the health professional and/or the patient that the device doesn’t and will not work (Booth and Lee, 2005). The importance of correct measurement and sizing cannot be overemphasised as too large a size will fall off and too small will constrict blood flow to the penis. Most manufacturers supply a sizing guide
Table 1. Causes of urinary incontinence Age group
Disorder
Middle age
Detrusor overactivity Neuropathic bladder Bladder neck obstruction Underactive bladder disorders
Older men
Bladder outflow obstruction uncomplicated or associated with overactive bladder Neuropathic bladder Overactive bladder Underactive bladder states Extraurological causes, i.e. constipation, pharmacological agents, environmental factors
to achieve this by measuring the circumference of the penis at its widest point, which is usually 2 cm from the base. Even with correct sizing and choice of sheath, a patient may still experience problems and lose confidence in this method of containment. I read with interest the case studies in an article by Williams and Moran (2006) who are both specialist continence advisors as they described two patients with very different experiences of the urinary sheath. One patient abandoned the sheath in preference for bodyworn absorbent pads as he had excoriation of the skin and detachment of the sheath resulting in deterioration in his quality of life. The other stopped using pads in preference for the sheath because it improved his quality of life greatly and, with pelvic floor exercises, also improved his bladder function so that he only needed to use the sheath at night and on long journeys. This emphasises the importance of working with the individual seeking help over time to reach the best outcome for that person rather than looking for a quick-fix solution. Comparative research into types of urinary sheaths to aid the health professional choose the best product are limited to two studies. One compared six different self-adhesive sheaths and found that out of 58 volunteers, 74% found the Aquadry Clear Advantage sheath to be good overall (Fader et al, 2001). Pemberton et al (2006) compared the Aquadry Clear Advantage sheath with the newer Conveen Optima. Of the 36 participants who expressed a preference for a particular sheath, 67% preferred the Conveen Optima and 33% preferred the Clear Advantage sheath. The decisive factor was sheath security and confidence that it would not leak and cause social embarrassment.
© 2014 MA Healthcare Ltd
M
ale urinary incontinence is more prevalent in the older man, who typically does not find this problem easy to talk about or address without profound embarrassment. In an older but often quoted study by Thomas et al (1980), which defined incontinence as ‘the involuntary loss of urine on two or more occasions per month’, 6.9% of male respondents over the age of 65 years had urinary incontinence. More recently in the document Good Practice in Continence Services, the Department of Health (2000) states that between 1 in 14 and 1 in 10 men over the age of 65 have urinary incontinence. Certainly, with an ageing population, this problem is only going to increase and it is incumbent on health professionals, often nurses, to find effective and cost-effective ways of managing it. Although we are in the current cost-saving-focused climate in the NHS, the personal cost of urinary incontinence to an individual man’s quality of life cannot be underestimated and should be addressed sensitively and knowledgeably using the best and most suitable products available. Good quality continence care has been well documented as supporting patient dignity and improving quality of life (Royal College of Nursing (RCN), 2008). It should be remembered that urinary incontinence in middle-aged and elderly men is a symptom of an underlying problem, the causes of which are summarised in Table 1 (Royal College of Physicians (RCP), 1995). A continence assessment carried out by a competent practitioner or as part of a holistic health assessment of the individual is vital to identify the cause of the incontinence, which will then guide management of the problem. The context in which this initial assessment takes place can vary greatly but nurses who have already developed an understanding relationship with the individual would be in an ideal position to probe a little deeper in their questioning if they recognise a continence issue. If a key question such as ‘Are you having problems with your bladder or controlling your urine?’ elicits a positive response, then the choice rests with the health professional to decide whether to deal with the situation immediately or refer the individual to a continence specialist, who would be able to offer more specialist knowledge and resources, or to a doctor, who would investigate the cause of the incontinence further. The important thing is not to ignore what the individual
British Journal of Nursing, 2014, Vol 23, No 12
British Journal of Nursing. Downloaded from magonlinelibrary.com by 128.119.168.112 on October 7, 2015. For personal use only. No other uses without permission. . All rights reserved.
Since these studies were done, more advances have been made in the design and manufacture of sheaths and there are other good products available. For instance, for the very short penis, the Clinimed® Bioderm is an external device that attaches to the head of the penis with hydrocolloid flanges that look like petals of a flower. It can remain in place for up to 3 days and attaches to any urinary drainage system (Kyle, 2011). Of course there will be patients for whom the sheath is not suitable and Table 2 summarises user suitability.
Conclusion
Men for whom sheath is suitable
Men for whom sheath is not suitable
■■ For
■■ Men
stress, urge or continuous incontinence ■■ Temporary need for containment such as travelling, night time, shopping ■■ To control urine flow if spraying occurs when voiding ■■ Men who require versatility when using containment products
who have a retracted penis with broken or excoriated skin ■■ Men with confusion or dementia as they may try to pull the sheath off ■■ Men who have urinary retention ■■ Men who have a history of recurrent UTI ■■ Men with reduced dexterity who do not have a carer to help apply the sheath ■■ Men who have a large glans and a narrow shaft of the penis ■■ Men
professional. More comparative studies would be helpful to update our knowledge on this subject and better inform our choices on the BJN best product available. Booth F, Lee L (2005) A guide to selecting and using urinary sheaths. Nurs Times 101(47): 43-6 Department of Health (2000) Good practice in continence services. DH, London. http://tinyurl.com/n9bdl4y (accessed 11 June 2014) Fader M, Pettersson L, Dean G, Brooks R, Cottenden AM, Malone-Lee J (2001) Sheaths for urinary incontinence: a randomized crossover trial. BJU Int 88(4): 367-72 Kyle G (2011) The use of urinary sheaths in male incontinence. Br J Nurs 20(6): 338 National Institute for Health and Care Excellence (2010) Lower urinary tract symptoms: The management of lower
urinary tract symptoms in men. NICE, London. http:// tinyurl.com/lydtxaq (accessed 11 June 2014) Pemberton P, Brooks A, Eriksen CM et al (2006) A comparative study of two types of urinary sheath. Nurs Times 102(7): 36-41 Royal College of Nursing (2008) Catheter care. RCN guidance for nurses. RCN, London. http://tinyurl.com/ c23aww (accessed 11 June 2014) Royal College of Physicians (1995) Incontinence: causes, management and provision of services. RCP, London Thomas TM, Plymat KR, Blannin J, Meade TW (1980) Prevalence of urinary incontinence. BMJ 281(6250): 1243-5 Williams D, Moran S (2006) Use of urinary sheaths in male incontinence. Nurs Times 102(47): 42-5
Clare Smart
Urology Nurse Specialist Urology Department Homerton Hospital, London
© 2014 MA Healthcare Ltd
Urinary incontinence is common among middle-aged and older men who may find it difficult to discuss this embarrassing problem with health professionals. However, a tactful approach can lead to an appropriate assessment of the problem which in many cases can be improved or resolved without the need for containment products. For those whose lives can be considerably improved by the use of a urinary sheath, correct fitting and use determines its success as well as the support of a knowledgeable and resourceful health
Table 2. Suitability of urinary sheath for men with urinary incontinence
652
British Journal of Nursing, 2014, Vol 23, No 12
British Journal of Nursing. Downloaded from magonlinelibrary.com by 128.119.168.112 on October 7, 2015. For personal use only. No other uses without permission. . All rights reserved.
650
has disclosed or appear to be dismissive. The National Institute for Health and Care Excellence (NICE) (2010) advises offering a choice of containment products suitable for the man’s circumstances and in consultation with him. This suggests immediate action to achieve social continence until a diagnosis or management plan can be made. In practice, this may mean a ward-based nurse filling in a continence assessment form which would then be referred to a specialist continence nurse or a GP referring a patient in the surgery to a community continence advisor, for instance. Whatever the approach, a detailed medical, surgical, family and medication history will need to be taken followed by a physical examination by someone who is qualified to carry out a full assessment. Based on the assessment findings, a tentative diagnosis can be made as to the cause of the incontinence pending investigations and tests that are deemed relevant. In middle-aged or older men, the prostate becomes enlarged and is often the cause of lower urinary tract symptoms; however, cancer within the urinary tract also has to be ruled out in the presence of haematuria. Considering that incontinence can be cured in around 70% of cases (RCP, 1995), it is worth spending time finding out the cause through a thorough assessment. It is also worth considering the social context of the individual and physical restraints as the cause may be as simple as not being able to get to the toilet easily or difficulty in unfastening clothing.
The urinary sheath The male external catheter (MEC), condom catheter or urinary sheath is a soft, flexible sleeve that fits over the penis and culminates in a short tube that fits onto any standard urinary drainage system (Kyle, 2011).To the uninitiated, there is a large array of sheaths in different materials, lengths, and sizes from various manufacturers, so choice of the right product for a particular individual can be complex. It is not surprising therefore that incorrect use of the sheath leads to failure of the device and the belief by the health professional and/or the patient that the device doesn’t and will not work (Booth and Lee, 2005). The importance of correct measurement and sizing cannot be overemphasised as too large a size will fall off and too small will constrict blood flow to the penis. Most manufacturers supply a sizing guide
Table 1. Causes of urinary incontinence Age group
Disorder
Middle age
Detrusor overactivity Neuropathic bladder Bladder neck obstruction Underactive bladder disorders
Older men
Bladder outflow obstruction uncomplicated or associated with overactive bladder Neuropathic bladder Overactive bladder Underactive bladder states Extraurological causes, i.e. constipation, pharmacological agents, environmental factors
to achieve this by measuring the circumference of the penis at its widest point, which is usually 2 cm from the base. Even with correct sizing and choice of sheath, a patient may still experience problems and lose confidence in this method of containment. I read with interest the case studies in an article by Williams and Moran (2006) who are both specialist continence advisors as they described two patients with very different experiences of the urinary sheath. One patient abandoned the sheath in preference for bodyworn absorbent pads as he had excoriation of the skin and detachment of the sheath resulting in deterioration in his quality of life. The other stopped using pads in preference for the sheath because it improved his quality of life greatly and, with pelvic floor exercises, also improved his bladder function so that he only needed to use the sheath at night and on long journeys. This emphasises the importance of working with the individual seeking help over time to reach the best outcome for that person rather than looking for a quick-fix solution. Comparative research into types of urinary sheaths to aid the health professional choose the best product are limited to two studies. One compared six different self-adhesive sheaths and found that out of 58 volunteers, 74% found the Aquadry Clear Advantage sheath to be good overall (Fader et al, 2001). Pemberton et al (2006) compared the Aquadry Clear Advantage sheath with the newer Conveen Optima. Of the 36 participants who expressed a preference for a particular sheath, 67% preferred the Conveen Optima and 33% preferred the Clear Advantage sheath. The decisive factor was sheath security and confidence that it would not leak and cause social embarrassment.
© 2014 MA Healthcare Ltd
M
ale urinary incontinence is more prevalent in the older man, who typically does not find this problem easy to talk about or address without profound embarrassment. In an older but often quoted study by Thomas et al (1980), which defined incontinence as ‘the involuntary loss of urine on two or more occasions per month’, 6.9% of male respondents over the age of 65 years had urinary incontinence. More recently in the document Good Practice in Continence Services, the Department of Health (2000) states that between 1 in 14 and 1 in 10 men over the age of 65 have urinary incontinence. Certainly, with an ageing population, this problem is only going to increase and it is incumbent on health professionals, often nurses, to find effective and cost-effective ways of managing it. Although we are in the current cost-saving-focused climate in the NHS, the personal cost of urinary incontinence to an individual man’s quality of life cannot be underestimated and should be addressed sensitively and knowledgeably using the best and most suitable products available. Good quality continence care has been well documented as supporting patient dignity and improving quality of life (Royal College of Nursing (RCN), 2008). It should be remembered that urinary incontinence in middle-aged and elderly men is a symptom of an underlying problem, the causes of which are summarised in Table 1 (Royal College of Physicians (RCP), 1995). A continence assessment carried out by a competent practitioner or as part of a holistic health assessment of the individual is vital to identify the cause of the incontinence, which will then guide management of the problem. The context in which this initial assessment takes place can vary greatly but nurses who have already developed an understanding relationship with the individual would be in an ideal position to probe a little deeper in their questioning if they recognise a continence issue. If a key question such as ‘Are you having problems with your bladder or controlling your urine?’ elicits a positive response, then the choice rests with the health professional to decide whether to deal with the situation immediately or refer the individual to a continence specialist, who would be able to offer more specialist knowledge and resources, or to a doctor, who would investigate the cause of the incontinence further. The important thing is not to ignore what the individual
British Journal of Nursing, 2014, Vol 23, No 12
British Journal of Nursing. Downloaded from magonlinelibrary.com by 128.119.168.112 on October 7, 2015. For personal use only. No other uses without permission. . All rights reserved.
Since these studies were done, more advances have been made in the design and manufacture of sheaths and there are other good products available. For instance, for the very short penis, the Clinimed® Bioderm is an external device that attaches to the head of the penis with hydrocolloid flanges that look like petals of a flower. It can remain in place for up to 3 days and attaches to any urinary drainage system (Kyle, 2011). Of course there will be patients for whom the sheath is not suitable and Table 2 summarises user suitability.
Conclusion
Men for whom sheath is suitable
Men for whom sheath is not suitable
■■ For
■■ Men
stress, urge or continuous incontinence ■■ Temporary need for containment such as travelling, night time, shopping ■■ To control urine flow if spraying occurs when voiding ■■ Men who require versatility when using containment products
who have a retracted penis with broken or excoriated skin ■■ Men with confusion or dementia as they may try to pull the sheath off ■■ Men who have urinary retention ■■ Men who have a history of recurrent UTI ■■ Men with reduced dexterity who do not have a carer to help apply the sheath ■■ Men who have a large glans and a narrow shaft of the penis ■■ Men
professional. More comparative studies would be helpful to update our knowledge on this subject and better inform our choices on the BJN best product available. Booth F, Lee L (2005) A guide to selecting and using urinary sheaths. Nurs Times 101(47): 43-6 Department of Health (2000) Good practice in continence services. DH, London. http://tinyurl.com/n9bdl4y (accessed 11 June 2014) Fader M, Pettersson L, Dean G, Brooks R, Cottenden AM, Malone-Lee J (2001) Sheaths for urinary incontinence: a randomized crossover trial. BJU Int 88(4): 367-72 Kyle G (2011) The use of urinary sheaths in male incontinence. Br J Nurs 20(6): 338 National Institute for Health and Care Excellence (2010) Lower urinary tract symptoms: The management of lower
urinary tract symptoms in men. NICE, London. http:// tinyurl.com/lydtxaq (accessed 11 June 2014) Pemberton P, Brooks A, Eriksen CM et al (2006) A comparative study of two types of urinary sheath. Nurs Times 102(7): 36-41 Royal College of Nursing (2008) Catheter care. RCN guidance for nurses. RCN, London. http://tinyurl.com/ c23aww (accessed 11 June 2014) Royal College of Physicians (1995) Incontinence: causes, management and provision of services. RCP, London Thomas TM, Plymat KR, Blannin J, Meade TW (1980) Prevalence of urinary incontinence. BMJ 281(6250): 1243-5 Williams D, Moran S (2006) Use of urinary sheaths in male incontinence. Nurs Times 102(47): 42-5
Clare Smart
Urology Nurse Specialist Urology Department Homerton Hospital, London
© 2014 MA Healthcare Ltd
Urinary incontinence is common among middle-aged and older men who may find it difficult to discuss this embarrassing problem with health professionals. However, a tactful approach can lead to an appropriate assessment of the problem which in many cases can be improved or resolved without the need for containment products. For those whose lives can be considerably improved by the use of a urinary sheath, correct fitting and use determines its success as well as the support of a knowledgeable and resourceful health
Table 2. Suitability of urinary sheath for men with urinary incontinence
652
British Journal of Nursing, 2014, Vol 23, No 12
British Journal of Nursing. Downloaded from magonlinelibrary.com by 128.119.168.112 on October 7, 2015. For personal use only. No other uses without permission. . All rights reserved.
