Introduction
Sheaths are effective urine containment system that fit over the penis and are attached to a drainage bag. They are indicated for male patient with moderate to severe incontinence, and for men who have functional impairment (paraplasia) or have limp disability; in case they can pass urine freely, and high volume post void residual urine excluded.
Case report
A thirty year old male patient, who had myelitis at age 18, at that time he suffered from quadraplasia associated with stool and urinary incontinence, the patient retained full power of his limps after multiple sessions of physiotherapy within one year, he also retained stool control after 3 years, unfortunately he can't get back urine control yet. The advice was to manage his continuous urine incontinence by wearing penile sheath. With time the patient fall in severe depression, that in addition to financial causes pushes the patient to neglect care of the sheath.
The patient presented after getting married complaining of very ugly penis with long urethral defect (about 6cm). The defect has hard texture and can be divided to three zones (proximal, intermediate, and distal). The proximal zone which is about 3cm in length has almost complete loss of corpus spongiosum. The intermediate zone about 1 cm length contains a stony hard fibrous tissue encircling the urethra. About (50%) of corpus spongiosum at distal zone was lost it is about 2cm in length (Fig. 1).
Fig. 1.
Left lateral view of fully erected penis, taken after 50 mg sildenafil ingestion. The penis bends ventrally due to tethered fibrous tissue of the defect.
Surgical repair started after insertion of 16F silicon Foley catheter (Fig. 2). Dissection between the hard texture skin of the defect and underlying tissue has been done. All fibrous tissue at intermediate and distal zones removed leaving a thin membranous layer covering the Foley catheter, the tissue sent to pathology to be identified and to rule out malignant changes.
Fig. 2.
Right Ventrolateral view at time of operation. Almost Complete loss of urethra and corpus spongiosum at proximal zone of the defect. Fistula at the center of distal zone noticed.
The tissue surrounding the proximal urethral defect was dissected and inverted to cover the Foley catheter making the urethra continues again, all other ugly tissue are dissected and removed and sent to pathology.
Tow parallel incision done at the ventral proximal healthy penile skin and extended to the scrotum for 11cm length. Dissection done between dartos and buck fascia in the penile zone, and between the dartos and external spermatic fascia in the scrotal zone, creating a flap that freely reach the distal normal ventral penile skin to cover the penile defect ventrally, the flap fixed by Interrupted 2-0 polydioxanone suture.
Dressing removed 3 days after (Fig. 3); Foley catheter removed 14 days after.
Fig. 3.
Post-operative appearance.
Discussion
Special consideration is needed when the patient or carer is unable to manage penile sheath. In this case indwelling suprapubic catheter inserted to control incontinence and prevent farther damage to penile tissue. Twenty sessions of electromagnetic pulse chair failed to recover urine control. Artificial urethral sphincter implantation is other management option for this patient continuous incontinence.
Penile sheath moistening the penile skin as it collect urine, moisture contributes to maceration; so mild friction or shearing forces applied by adhesive material may damage skin and make it more vulnerable to infections that also exacerbate penile skin damage.
Some patients applies external pressure to control urine leak, pressure obstruct capillary blood and deprives tissue oxygen and nutrients, this lead to necrosis and ulcer formation.
Conclusion
Sheaths need regular care and changing. It may destruct the penile tissue if neglected. Regular sheaths change every 24 hours is mandatory to wash the penis, allow it to dry, and care of excoriation that may happen.
Patients managed with penile sheath should have strict follow up, any abrasion should managed seriously, other urine collection option should be used to give enough time for skin healing.
Patients have incontinence and carer should have special psychological support, insurance and financial support; they also need a thorough counseling, training, and illustration of all other options for urine containment devices.
Patients should be counseled never to apply any external pressure around the sheath it may exacerbate ulceration and lead to skin loss and even organ loss. The manufacturing quality of the sheath must be addressed and the size to be used should be measured correctly.