VOL: 102, ISSUE: 47, PAGE NO: 42
David Williams, BSc, RGN, is specialist continence adviser
Sandra Moran, BA, RGN, is specialist continence adviser; both at Liverpool PCT
Engaging men in continence promotion is problematic due in part to a general failure to construct interventions that are sensitive to the gender-specific needs of men.
Although urinary incontinence affects more women than men, the prevalence of male urinary incontinence cannot be understated (Department of Health, 2000). One in 33 men living at home, aged 15-64, is incontinent of urine and this prevalence increases to between one in 14 and one in 10 men aged over 65. Furthermore, up to two-thirds of nursing home clients, of both sexes, may experience urinary incontinence (DH, 2000).
It is prudent to suggest that available statistical data on the prevalence of male urinary incontinence is significantly affected by under-reporting (Shepard et al, 2003) but engaging men so that they present with continence problems is a challenge that is reflected across a range of men’s health services (Shepard et al, 2003). Reluctance by men to disclose problems with urinary incontinence may be attributed to a male perception of masculinity and emotional inhibition (Holroyd, 1999).
The foundations of gender identity are constructed in the early formative years and men adopt covert coping strategies in an attempt to conceal urinary incontinence that often lead to increased morbidity and social isolation (NICE, 2002; Holroyd, 1999). The use of improvised containment devices including plastic bags, cut and modified plastic bottles and paper tissue have been described by men with continence problems.
Health professionals need to acknowledge these challenges when they undertake a continence assessment. A full continence assessment must precede any management strategy as promotion of continence and cure is the primary objective. Unfortunately, identification of a continence problem does not always guarantee that the most appropriate management plan will be selected. Professional inertia in some care settings does little to optimise the independence of the client with urinary bladder dysfunction and sadly a reliance on disposable absorbent pads diverts attention away from alternative containment options.
There is a growing body of knowledge available on the use of urinary sheaths. However, many nurses experience difficulty and have negative attitudes towards this management option. Much of this negativity is unfounded and is the result of poor initial assessment, inappropriate product choice and premature failure of the sheath system due to incorrect fitting (Booth and Lee, 2005). There are many types and sizes of urinary sheath on the UK Drug Tariff (Booth and Lee, 2005; Evans, 2005; Pomfret, 2003). The one-piece, self-adhesive urinary sheath is the most commonly used and is noted for its ease of application (Brodie, 2006).
A variety of width (20mm-40mm) and length (50mm-80mm) fittings are available, with some manufacturers identifying their sheath length as short, standard and long. It must be stressed that each manufacturer has a defined size range and provides its own measurement guides. It is recommended that these guides are used against the product for which they were designed as in many cases a 1mm discrepancy in sizing can lead to either the sheath falling off or penile trauma.
Successful outcomes are more likely with patients who are willing and able to work in partnership with the assessing health professional (case studies one and two). There is potential for penile trauma if a poor technique is used to remove a sheath and patients with cognitive impairment, who may pull or tamper with a sheath, should be assessed before the system is used. The assessment process may also identify a family carer who may be able to help a patient maintain a urinary sheath and drainage system independently (Pomfret, 2003).
Assessment must take account of penis retraction, which can be affected by factors such as changes in temperature, neurological deficits following cerebrovascular accidents and integrity of blood supply in patients with diabetes mellitus. If significant retraction is noted then the urinary sheath is unlikely to offer effective containment and will roll off the shaft of the penis. It may be more appropriate to explore other specialised containment options such as penile pouches or pubic pressure urinals (Booth and Lee, 2005; Evans, 2005) as these may offer men with severe penis retraction an alternative to body-worn absorbent pads.
Mild penis retraction does not necessarily mean that a urinary sheath system cannot be used and short-length sheaths have been successful with this group of patients (Pemberton et al, 2006).
The findings of a recent randomised control trial offer significant support for the use of urinary sheaths noting less bacteriuria, symptomatic urinary tract infection and death over the indwelling urinary catheters (Saint et al, 2006). Furthermore, this protection is especially apparent in men without dementia, suggesting that clinically adverse outcomes can be reduced if health professionals optimise alternative strategies to long-term indwelling catheters.
Sheaths following prostate surgery
Urinary sheaths can offer a non-invasive urine collection system for men who experience urinary incontinence following prostate surgery. Patterson (2004) noted that men do not receive information about post-operative urinary incontinence following prostate surgery and many are not appropriately referred to a continence nurse specialist. It is not uncommon for these symptoms to be inappropriately managed with a long-term indwelling urethral catheter, which may expose the patient to complications including infection (Bissett, 2005; Pemberton et al, 2006).
An active continence management strategy for these patients can include the use of a urinary sheath system during pelvic floor exercise programmes and bladder retraining regimens (see case study two).
One benefit of using a urinary sheath is that urine is stored in a drainage bag and this is an option for men who have significant functional impairment. Many of these patients are supported in their own homes with social care packages and may spend protracted periods of time alone between support visits. Despite the technology used to produce modern absorbent pads, removal of the urine away from the body may help prevent or manage skin contamination and breakdown.
The appropriate management of urinary incontinence is a significant determinant of survival following stroke and it is estimated that up to 52% of patients following a stroke experience a combination of urge and functional incontinence (Brittain, 2002). This problem is also a characteristic of other neurological conditions such as multiple sclerosis, Parkinson’s disease and spina bifida. The most common bladder dysfunction experienced by clients with these conditions is neurogenic detrusor overactivity (Haslam, 2005).
The associated loss of function that often accompanies these conditions results in episodes of urinary incontinence that can have a profound impact on quality of life. Many clients with these conditions are managed with long-term urethral catheters but this may not represent the most appropriate option. Other options include intermittent catheterisation and body-worn absorbent pads. In the case of male clients, urinary sheaths offer a containment system that may be used to support existing management plans, such as intermittent catheterisation regimens, where intermittent urethral leakage of urine persists.
The progressive nature of many neurological conditions dictates that regular bladder scans and monitoring of urine output must be undertaken to detect potential increases in residual urine and ensure renal function is not compromised.
Penile sheaths are successful in the management of moderate to severe urinary incontinence and can provide a suitable alternative to disposable products. However, incorrect size and fitting can also cause anxiety and discomfort. Patients need to be confident in the knowledge that the sheath system is reliable, can be removed and changed easily, is discreet and will cause them no harm.
Case study one
Mr Taylor (patient’s name has been changed) was referred to the community continence promotion team with symptoms of urgency, frequency, penile pain and incontinence when he stood up. He had type 2 diabetes and had a past urological history of bilateral renal stones, ureterscopy and pyeloplasty and renal impairment.
He had refused further investigations, including urodynamic studies and flexible cystoscopy examination, and previous treatments to manage his bladder symptoms, including anticholinergic therapy, had not been effective. An ultrasound bladder scan excluded overflow incontinence.
Containment represented the most appropriate strategy for the management of his urinary incontinence and the choice was limited to disposable products and urinary sheath systems.
A trial period with a sheath was commenced but the patient experienced excoriation of the penile shaft due to poor technique on removal and sheath detachment when he passed urine. These problems were having a negative effect on the patient’s quality of life leading to social isolation, low self-esteem, anxiety and disturbed sleep.
The patient was feeling negative about continuing with the sheath system and reported some disruption in his relationship with his wife and family members.
Changes were made to the management regimen which included the use of a skin protection barrier film to the penile shaft. However, Mr Taylor continued to report problems and requested a change to body-worn absorbent pads.
This case study shows that, despite thorough assessment, patient education and support, a urinary sheath system may not be suitable for all men. Each client must be assessed objectively and individually, with treatment and management planned accordingly.
Case study two
Mr Jefferies (patient’s name has been changed) is aged 69 and was recently discharged from hospital following a transurethral resection of prostate. He attended the continence clinic one month after his surgery with urinary urgency and nocturnal enuresis. He had no other health problems and before his prostate problem enjoyed regular holidays with his wife.
He reported that he was distressed and embarrassed by his urinary incontinence which had caused him to move in to a separate bedroom at night. Although he was using continence pads purchased by his wife he was not happy wearing them. Mr Jefferies was also worried his children and grandchildren might be able to smell urine when they visited.
A bladder ultrasound scan confirmed that no significant residual urine was present in the bladder and routine urinalysis showed no sign of urinary tract infection. Mr Jefferies reported a regular bowel pattern with no strain and a daily fluid intake of approximately 1200ml, consisting of tea, juices and two mugs of coffee each day.
Mr Jefferies requested a management plan that would enable him to resume his activities outside his home and help him with urinary leakage during the night.
He was measured for a short-length silicone urinary sheath (Convene Optima) as he felt it was the easiest to apply. This was attached to a 500ml anti-kink leg bag and supported with a catheter retention strap and leg bag retention sleeve. Correct measurement of the leg bag outlet tube length is vital to achieve optimum positioning for emptying the bag. It was also emphasised that the leg bag must remain securely in place on the leg when a night drainage bag is attached for use in bed. Failure to follow this advice may result in the sheath becoming detached during the night.
Following a period of initial adjustment and after starting a pelvic floor exercise programme, Mr Jefferies was able to adopt the urinary sheath system and stop using continence pads. At his review he reported he had returned to sharing a bed with his wife and he was considering booking a holiday. After six months he reported a significant improvement in his bladder function and was only using the urinary sheath at night and during long journeys. The use of a urinary sheath system significantly improved Mr Jefferies quality of life and enabled him to manage his urinary incontinence with greater confidence.
This article has been double-blind peer-reviewed.