managing incontinence with external catheter collection systems

by Diane K. Newman, RNC, MSN, CRNP, FAAN

For some people with moderate to severe urinary incontinence (urine leakage), an external condom catheter system may the best solution. Men, especially, find external catheters to be convenient and simple to use. There are a few female external catheters available but, so far, they are much less easy to apply and use.

One method of managing urinary incontinence (unwanted urine leakage) in men is by using an external condom catheter system or ECCS for collecting the urine that leaks. ECCS systems work well for men with moderate to severe urine leakage or for times when the man cannot make it to the toilet without having an incontinence accident.

The ECCS consists of a flexible sheath (also called a condom catheter, Texas catheter, penile sheath, or external male catheter) that is pulled over the penis. The end of the catheter is connected to a long drainage tube and attached to a urinary drainage bag. The sheath is usually made of latex rubber, vinyl, or silicone and easily slips onto the penis. It is held in place either by a double-sided adhesive strap or a strap made of latex or foam that is wrapped around the penis.

When the correct-sized sheath is put on and fastened properly, urine will not come in contact with the skin. Both disposable and reusable versions are available but care should be taken to follow some basic wearing time recommendations. Reusable sheaths should be left on for 24 hours only and reapplied after they have been washed and the penis has been washed and dried. The disposable type should be used for only 24 hours also.

Studies of Appropriate Use for Incontinence

There are few published studies that compare the effects of different condom catheters on the skin of the penis, and those studies that do exist were done with disposable types only (Fader, Petterssson, et al., 2001). Also, the studies give conflicting outcomes that leave the safety and use of condom catheters in nursing home and hospital patients in question (Saint et al., 2006). One study in men in a VA Medical Center showed the ECCS to be comfortable and convenient, occasionally leaked urine but nurses at the facility preferred to use condom catheters rather than indwelling catheters (Saint et al., 1999). Further studies need to be done that compare all existing products in terms of improvements in comfort, convenience, and ease and longevity of adherence (Newman and Wein, 2009).

In a more recent study of male patients in a hospital, Saint et al. (2006) found a protective effect with the use of condom catheters in men without dementia. In contrast with an indwelling urinary or Foley catheter, the condom catheter users experienced fewer bacteria in the urine, fewer UTIs and a lower death rate. Men also preferred the ECCS for its comfort.

Another study by Pemberton et al. (2006) found that external catheters were easy to use and should be applied with gloves for best infection control. These studies do not clarify the role of ECCS use with institutionalized men although their use appears to show a lower risk of bacteriuria than with indwelling catheters. One flaw with these studies is that the majority of data were collected on male patients living in extended care facilities (Ouslander, Greengold & Chen, 1987).

In a recent systematic review from Cochrane of men with neurogenic bladder, no conclusions could be drawn about appropriate use of catheter types from existing randomized or quasi-randomized controlled trials (Jamison, Maquire, & McCann, 2004).

When to Use an ECCS for Incontinence

The first step in deciding whether an ECCS is appropriate for a particular patient is to perform the following assessment:

Manual Dexterity
The patient or a caregiver must have the hand dexterity to apply the condom catheter correctly. Before recommending the use of an ECCS, the patient or caregiver should demonstrate the ability to apply and remove the catheter correctly. If the patient lives in a nursing home, staff members can be taught proper application techniques.
Penis Size
The width, circumference and length of the penis must allow for proper application of the catheter. Aging men and those who have had genital cancer treatments may experience penis "shrinkage" or retraction to the point where a catheter cannot be kept in place. A retracted penis pouch, which is similar to an ostomy pouch, might be more appropriate for these patients.
Skin Condition
Condom catheters should be used only in men with intact skin on the penile shaft and scrotum. It is important to look at the skin on the penis and scrotum every day to see if there is any redness, open sores, and/or rashes from bacterial or yeast infections. Skin products called "barrier films" are good to use on men who are likely to develop skin problems and can be applied on the penile shaft before putting on the catheter. Clear catheters made of silicone allow the skin to be monitored while they are in place.

Types and Application of ECCS Systems for Incontinence

Many men will try and use several types of condom catheters. They need to find the correct size for each type and learn to put then on and use them correctly. Condom catheter diameters range from 20 to 40 mm in 5 to 10 mm steps. (Newman, 2004) Choosing the best size is very important if you want to use them successfully. ECCS manufacturers provide measurement guides to help find the right size. Once the penis is pulled gently forward, the guide can be place halfway down its shaft to find the best size. If the man is still getting erections, care should be taken to make sure the catheter is large enough to allow for nighttime erections.

All men, but especially those who do not have good sensations in their penis and scrotum, should be taught never to use rubber bands or tape to keep on the condom catheter. The catheter itself should fit snugly but not too tight so it does not constrict the penis. If wrinkles in the sheath appear, the catheter size is probably too big. Once the catheter is being used, if a small amount of urine is leaking, squeezing the sheath usually creates a better seal. Adhesives commonly used with ostomy bags can be used with sheaths. A small amount of adhesive is applied to the skin on the penis and allowed to dry before putting on the catheter. It is important that the catheter is put on correctly and by the best methods.

There are several ways to attach the catheter to the penis and for collecting urine and they include:

One piece, self-adhesive catheters are a popular choice because they are easy to put on. You roll these over the penile shaft and press the catheter to help the adhesive stick to the skin. Some of the newer versions that are made entirely of silicone are less likely to cause skin irritation or other negative reactions and should be use in men with latex allergy or sensitivity (Edlich et al., 2000).
Two-piece systems consist of a sheath and separate hydrocolloid strips, which have adhesive on both the inside and outside. The strips are wrapped around the penis first and then the catheter is rolled up the penis, over the strips and then pressed to stick. It is possible to put on the strips in a way that is too tight for the penis and they should not be used unless the man is able to remember they are on and sensation on his penis. This type is more difficult to put on than the one-piece systems.
Nonadhesive systems are held in place with either an inflatable ring or a Velcro strap that can be wrapped around the sheath. They are resusable.
Catheters with applicators help a man or his caregiver apply the sheath properly and may be best for men with slightly impaired use of their hands.
An external device called the Liberty Pouch is a small flower shaped wafer that is applied and sealed to the penis tip. The device is made of a hydrocolloid material and is covered by a second layer of material that wraps around the glans to increase protection. The outside of the wafer is designed to direct urine into a tube for collection in a compatible bag that is stored in underwear or pants. This product is especially useful for men with a short or retracted penis and for uncircumsized men. The foreskin is retracted to allow application of the device and is brought forward to cover it.
A variety of external pouches is available. Most are similar to ostomy pouches and require adhesives to secure them to the body (Newman et al., 2004). Different kinds are available and include a retracted or short penis. Some are designed for women who are unable to use a bathroom or toilet. Because the pouches adhere directly to the skin, removing the pubic hair surrounding the base of the penis or the female perineum is necessary. Skin irritation is often the result of shaving so trimming the hair before putting thee on is good thing to do.

When putting a pouch on a man, the adhesive area of the pouch should be trimmed in size so the opening matches the bottom or base of the penis. The pouch is put on over the penis and pressed onto the trimmed area to activate the adhesive. The pouch can be connected to a collection bag via tubing or it can simply be emptied as needed.

Putting a pouch on a woman can be a challenge as it more difficult. Besides trimming the pubic hair, the woman or caregiver has to put on an adhesive paste to make sure the pouch sticks to the skin and stays in place. The pouch itself, which is made of a form-fitting plastic, is applied over the labia. Leakage is often a problem with this one because it is hard to create a good seal. Unfortunately, any innovations since it was first introduced have not solved this problem (Newman et al., 2004). The ideal female pouch would be designed for the bedridden or wheel-chair bound woman and would create a better seal more easily.
A variety of male reusable ECCSs are available that are worn on the body in the manner of an external catheter. Typically, these are used for incontinence that occurs after prostate cancer surgery or for an older man. Some of these devices require no adhesive. The sheath is held on with a reusable foam band and Velcro, which is less likely to cause skin irritation or breakdown.

A variant is the AlphaDry, which consists of a one-piece condom catheter with a one-way valve and a small reservoir to be emptied every two or three hours and that can be stored in a man's underwear.

Complications with ECCSs

Using external condom catheters can cause a variety of problems for the user including ischemia, skin irritation, maceration of the penis tip, and penile edema or urethral obstruction. All of these complications occur more frequently when the catheter is not put on correctly or is used for longer than recommended. Complications can also occur under the following conditions:

Skin that is constantly wet can soften and be worn away by a condom catheter. Skin barrier products can be used prior to the application of the sheath to protect the skin from constant wetness.
Adhesive straps, especially the kind with adhesives on both sides, can cause strangulation of the penis or constrict it excessively and should be used with caution. A better option, especially for men with erectile function, is a barrier strap that can stretch to accommodate the penis enlargement.
External devices can cause infections but this happens less with these devices when compared to intermittent or indwelling catheters.
When a tight sheath is routinely rolled over an uncircumsized penis, phimosis may occur where the foreskin can no longer be retracted.
Penile sheaths for incontinence are designed to prevent leakage of urine but they also prevent air from reaching the skin and allowing it to breathe. As a result, skin can break down with minor erosion and dermatitis. Clear silicone sheaths offer an advantage over other materials in that they allow the person to see the skin condition while they are worn and also allow some oxygen and water vapor to reach the skin. If skin problems do develop, it is important to determine the cause, if possible, and to remove the condom catheter until the condition heals. Some possible causes of skin breakdown include latex allergy, a urinary tract infection, improper removal of the sheath by pulling, which can tear the skin, or using a sheath that is too small.

Condom catheters are more likely to cause problems when they are used improperly or for too long a time period. A man with decreased penile and scrotal sensation may not be aware that problems are starting or may not be aware enough to mention them to caregivers. Nurses who are trained on ECCS use can prevent many of these problems by insuring that correct sizes and application techniques are used and that frequent monitoring is done to catch problems early.

Many methods are available for managing urinary incontinence.

References

Edlich, R.F., Bailey T., Pine, S.A., Williams, R., Rodeheaver, G.T., & Steers, W.D. (2000). Biomechanical performance of silicone and latex external condom catheters. Journal of Long-Term Effects of Medical Implants, 10, 291-299.

Fader, M., Pettersson, L., Dean, G., Brooks, R., Cottenden, A.M., & Malone-Lee, J. (2001). Sheaths for urinary incontinence: A randomized crossover trial. BJU International, 88, 367-372.

Jamison, J., Maguire, S., & McCann, J. (2004). Catheter policies for management of long term voiding problems in adults with neurogenic bladder disorders. Cochrane Database of Systematic Reviews, (2), CD004375.

Linsenmeyer, T.A., Bodner, D.R., Creasey, G.H., Green, B.G., Groah, S.L., & Joseph, A. for the Consortium for Spinal Cord Medicine. (2006). Bladder management for adults with spinal cord injury: A clinical practice guideline for health-care providers. Journal of Spinal Cord Medicine, 29, 527-573.

Newman, D.K. and Wein, A.J. (2009). Managing and Treating Urinary Incontinence, 2nd Edition, Health Professions Press, Baltimore, Maryland:365-483.

Newman, D.K., (2008) Internal and external urinary catheters: a primer for clinical practice. Ostomy Wound Manage. Dec;54(12):18-35.

Newman, D.K. (2004a). Incontinence products and devices for the elderly. Urologic Nursing, 24, 316-334.

Newman, D.K., Fader, M., & Bliss, D.Z. (2004b). Managing incontinence using technology, devices and products. Nursing Research, 53(6 Suppl.), S42-S48.

Ouslander, J.G., Greengold, B., & Chen, S. (1987). External catheter use and urinary tract infections among incontinent male nursing home patients. Journal of the American Geriatrics Society, 35, 1063-1070.

Pemberton P, Brooks A, Eriksen CM, Frost S, Graham S, Greenman L, et al. (2006). A comparative study of two types of urinary sheath. Nursing Times, 102(7), 36-41.

Saint, S., Kaufman, S.R., Rogers, M.A., Baker, P.D., Ossenkop, K., & Lipsky, B.A. (2006). Condom versus indwelling urinary catheters: A randomized trial. Journal of the American Geriatrics Society, 54,1055-1061.

Posted March 2009

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