VOL: 98, ISSUE: 43, PAGE NO: 52
Wendy Colley, OBE, RGN, DN Cert, FETC, is clinical nurse specialist, continence care, West Cumbria PCT, Whitehaven
Evidence suggests that the prevalence of urinary incontinence among men living at home is over one in 33 men aged 15-64 and between one in 10 and one in 14 men aged 65 and over (Department of Health, 2000).
There are many products to promote continence or to manage incontinence in men. However, many health care professionals may not be aware of the choices available to meet individual circumstances.
Seeking help and assessment
It is essential for both men and women that bladder symptoms, which may include incontinence, are assessed by a professional who is able to identify the cause of the problem or arrange further investigations and, if necessary, refer to other professionals for further advice and treatment.
Selecting the appropriate appliance or product
When offering a male patient the choice of appropriate management options for incontinence, it is essential to consider his lifestyle and ability to manage the continence problem independently. The continence problem may be intermittent; therefore normal toileting must not be hampered at these times by a cumbersome system. There may only be difficulties overnight - for example, a man living alone may need to void urine several times but may be unable to get out of bed without assistance. Some men may not have a strong urinary flow and may dribble urine down clothes and on the floor around the toilet.
Considerations when selecting a product or appliance
The most important considerations are that any products or appliances used must not leak and must be discreet - no one else should be able to tell a product is being worn. The product must be easily managed. If the patient works he must be able to manage emptying or changing and disposal of any appliance or product without others in the workplace knowing. Other considerations include the following:
- The main difficulty or problem experienced by the patient;
- The volume and frequency of any urine leakage;
- Patient preference;
- Manual dexterity;
- Carer availability, if required.
The reason for adapting clothing is to make toileting easier, as the clothing can be adjusted more quickly. It is important for men to maintain their personal style of dress and image.
If the bladder problem does not necessitate product use then wearing loose fitting boxer shorts may be easier to manage than Y-fronts for men with arthritic hands. Younger men often wear jogging pants which older men may find acceptable for use in the house but may prefer trousers when going out. For these men it may be helpful to replace the button or zip fly opening with Velcro. Trousers or jogging pants should be comfortable, and when a continence management system is required the outline of any appliance or product must not be visible.
The standard male urinal for home use is generally made of hard plastic and may have a lid. It is possible to insert a non-spill adaptor into the neck of a urinal made from hard plastic, as this is useful for patients when there is a problem with spillage.
The Beambridge male draining jug is available on prescription or by mail order. This urinal is made from a softer, more flexible plastic. The manufacturers have added an outlet port to the urinal to which a drainage bag can be attached, allowing a greater capacity for urine storage without the risk of spillage. This is useful for men who void large volumes overnight and have difficulty emptying the standard urinal.
A pocket-sized reusable urinal, the Uribag, is available on prescription from several mail order companies and health care outlets. This comprises a latex bag and hard plastic neck with a leak-proof cap and holds over 1.1 litres after use. It is especially useful for wheelchair users when a toilet cannot be accessed.
A different option is a disposable, personal urinal, the Mini-Potti, containing biodegradable polymer, which will absorb up to 600ml of urine. The Mini-Potti is leakproof and odourless, turning the urine into gel, and may be used several times within its total capacity. It is lightweight and compact for storage. It is available from some pharmacy and mobility shop outlets.
For men who find their urine flow is weak, or whose penis is retracted, or who may dribble urine after the main flow is passed, resulting in wet patches on the trousers or toilet floor, may find a urine director useful. This is a reusable item made from a rubber compound or plastic. The penis is positioned entirely into the director, which is then pressed firmly against the lower abdomen. The director is aimed into the toilet bowl or gents’ urinal, ensuring direction of flow, preventing urine being voided on to clothing or the floor. The director should be washed in warm soapy water after use. It is possible to attach a urine drainage bag on to the outlet of the urine director so it can be used in a chair or by a patient who is unable to reach the toilet. Urine directors are available on prescription. Nurse prescribers will find such items under tubing and accessories and also in the section on urinal systems in the Drug Tariff.
Systems for urine collection or urine absorption
Urine drainage sheaths (incontinence sheaths, penile sheaths and external catheters)
Currently there is an extensive choice of urinary drainage sheaths available on prescription, which can be categorised generally into three types:
- Drainage sheaths with an adhesive already applied to the inner surface of the sheath, making the sheath self-adhesive. Some self-adhesive sheaths are packaged with their own applicator or positioner. For men with slight to moderate retraction of the penis, some manufacturers make shorter-length sheaths;
- Drainage sheaths with no adhesive, but contained in the packaging may be a separate, single or double-sided adhesive strip. This is applied to the penis; the sheath is then fitted over the strip, which holds it in position. These are usually known as a ‘two-piece’ system;
- Drainage sheaths with no adhesive, but a separate skin adhesive solution in a tube or bottle for application to the penis before fitting the sheath, may be used. There are a variety of incontinence fixing strips, including some for use externally around the outside of the sheath, and adhesives available on prescription, supplied separately from sheaths.
Drainage sheaths are also available in latex or a latex-free material, and each sheath may be left in place for one to three days between changes (Drug Tariff, 2002). However, nurses should always refer to the manufacturers’ recommendations, as some recommend changing the sheath every 24 hours, and it is important to consider the condition of the patient’s skin.
Principles in sheath selection
- Always measure the girth of the penis at the base, using the measuring guide supplied by the manufacturer, to ensure a sheath of the correct size is selected. Incorrect size of sheath will result in failure of the system and may cause pressure or skin damage to the penis;
- If the penis is slight to moderately retracted, consider one of the shorter-length drainage sheaths. If the penis is severely retracted, consider a specialist appliance - for example, those described under urinal systems (see below);
- Consider the material to be used. Non-latex material is available for those with latex allergy. The transparency of clear silicone sheaths allows the skin condition to be checked without removing the sheath;
- Discuss the types of sheath fixation with the patient, considering who will apply the sheath and their manual dexterity;
- Select an appropriate urine drainage bag for attachment of the sheath after fitting.
Principles in applying the drainage sheath
- Wash the penile area with warm water and unperfumed soap, rinse and dry thoroughly or use a foam skin cleanser. Do not use talcum powder or any creams. You may apply a skin-protecting film, which also increases the adhesive strength of the sheath;
- If necessary, trim pubic hair but do not shave this area, as shaving may make the skin sore;
- To aid application, cover the pubic hair by cutting a hole in a tissue and place over the penis;
- Apply the sheath, including any separate fixative if this type of sheath is selected, as instructed by the manufacturer. Always remove plastic applicators/sheath positioners as instructed. Remove the tissue;
- Do not allow the sheath adhesive to come into contact with the glans, and do not retract the foreskin if the patient is uncircumcised;
- Attach the previously selected urine drainage bag and secure.
Removing the drainage sheath
Gently and evenly roll the sheath off the penis without traction. This may be more comfortable if removed in the bath or shower.
Specialist appliances, such as pubic pressure urinals, are available on prescription for men with a retracted penis who are unable to be reliably dry using a drainage sheath. This device must be fitted correctly and, if the patient is unable to do this himself, he must have an able and willing carer to do this for him.
A specialist working or trained in this field must make the assessment and measure the patient for a body-worn appliance, which may have several components. Continence advisers are able to advise on this type of appliance and refer to such specialists when necessary. Those untrained in the use of this type of appliance should not attempt to prescribe, as an ill-fitting appliance will not keep the patient dry and is a waste of resources, as the cost can exceed £100. Patients should have two appliances - one to wear and one to wash - and each appliance should last six months (Drug Tariff, 2002).
Disposable and reusable absorbent products
Most disposable absorbent products are suitable for men, and in addition there is a small, shaped pouch available that is suitable for slight incontinence or intermittent dribbling urinary incontinence. Which product is chosen depends on the findings of a full assessment, also taking into consideration the following:
- The volume of urine voided;
- The pattern of voiding;
- Ability of the patient to be self-caring;
- Patient preference and lifestyle.
Reusable absorbent products
Washable products can offer a more convenient, cost-effective solution for some men with continence problems. These include men’s briefs and Y-front fly briefs which have an integral absorbent pad with waterproof backing and a stay-dry surface. Washable pouch-style pads, booster pads, mini-slips and maxi-briefs are also available.
The main criteria for selecting a washable product is that it must fit in with the lifestyle of the user. If the product needs to be changed, then private facilities must be available and the user must be able to store the used product discreetly before returning home.
Washable pants are useful for an intermittent, slight dribbling incontinence, or to give confidence during bladder retraining. If higher-absorbency products are used for more severe leakage, washing facilities must be adequate and the level of product availability sufficient to maintain requirements.
Those assessing continence problems should be aware of the many choices and ensure that male patients receive comprehensive advice when selecting and fitting products to ensure that expensive, quality products achieve optimal performance.
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