Skill 12-5

Applying an External Urinary Sheath

When voluntary control of urination is difficult or not possible for patients with a penis, an alternative to an indwelling catheter is the condom-type urinary sheath , one type of external urine collection device for use on the penis (Newman, 2020b; Panchisin, 2016; Smart, 2014). This soft, pliable sheath made of silicone or latex material is applied externally to the penis and directs urine away from the body. Most devices are self-adhesive. The external urinary catheter is connected to drainage tubing and a collection bag and can be used with a leg bag.

Nursing care of a patient with a urinary sheath includes vigilant skin care to prevent excoriation. This includes removing the urinary sheath daily, washing the penis with skin cleanser and water and drying carefully, and inspecting the skin for irritation. In hot, humid weather, more frequent changing may be required. Always follow the manufacturer's instructions for applying the external urinary sheath because there are several variations. In all cases, take care to fasten the urinary sheath securely enough to prevent leakage, yet not so tightly as to constrict the blood vessels in the area. When using sheath-type devices, the tip of the tubing should be kept 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area.

Maintaining free urinary drainage is another nursing priority. Institute measures to prevent the tubing from becoming kinked and urine from backing up in the tubing. Urine can lead to excoriation of the glans, so position the tubing that collects the urine from the external urinary sheath so that it draws urine away from the penis.

Always use a measuring or sizing guide supplied by the manufacturer to ensure the correct size of sheath is applied. Apply skin barriers, such as Cavilon™ or Skin-Prep™, to the penis to protect penile skin from irritation and changes in integrity.

Delegation Considerations

The application of an external urinary sheath may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

External urinary sheath (condom catheter) in appropriate size
Skin protectant, such as Cavilon™ or Skin-Prep™
Velcro leg strap, catheter-securing device, or tape
Bath blanket
Reusable leg bag with tubing or urinary drainage setup
Premoistened disposable washcloths or
- Basin with warm water
- Skin cleanser, towel, washcloth
Disposable gloves
Additional PPE, as indicated
Washcloth and towel
Scissors

Assessment

Assess the patient's knowledge of the need for use of the urinary sheath. Ask the patient about any allergies, especially to latex or tape. Assess the size of the patient's penis to ensure that the appropriate-sized external urinary sheath is used; size is determined by penile diameter at the base of the penile shaft (Newman, 2020a). Inspect the penile skin and the skin in the groin and scrotal area, noting any areas of redness, irritation, or breakdown.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Toileting ADL deficit
Functional urinary incontinence
Altered skin integrity risk

Outcome Identification and Planning

The expected outcome to achieve when applying an external urinary sheath is that the patient's urine is diverted into the urine collection device, and the patient's skin remains clean, dry, intact, and without evidence of irritation or breakdown.

Implementation

Action	Rationale
1. Gather equipment.	Assembling equipment provides for an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Close the curtains around the bed and close the door to the room, if possible. Discuss the procedure with the patient. Ask the patient if they have any allergies, especially to latex.	This ensures the patient's privacy. Discussion promotes reassurance and provides knowledge about the procedure. Dialogue encourages patient participation and allows for individualized nursing care. Some external urinary sheaths are made of latex.
5. Assemble equipment on the overbed table or other surface within reach.	Arranging items nearby is convenient, saves time, and prevents unnecessary stretching and twisting of muscles on the part of the nurse.
6. Adjust the bed to a comfortable working height (VHACEOSH, 2016). Stand on the patient's right side if you are right-handed, or on patient's left side if you are left-handed.	Having the bed at the proper height prevents back and muscle strain. Positioning on one side allows for ease of use of your dominant hand for device application.
7. Prepare the urinary drainage setup or reusable leg bag for attachment to the external urinary sheath.	This provides for an organized approach to the task.
8. Position the patient on their back with the thighs slightly apart. Drape the patient so that only the area around the penis is exposed. Slide the waterproof pad under the patient.	Positioning allows access to the site. Draping prevents unnecessary exposure and promotes warmth. The waterproof pad will protect bed linens from moisture.
9. Put on gloves. Trim the pubic hair at the base of the penis.	Gloves prevent contact with blood and body fluids. Trimming the pubic hair prevents pulling of hair by adhesive; do not shave hair to avoid irritation associated with shaving (Newman, 2020a).
10. Clean the genital area with a washcloth, skin cleanser, and warm water. If the patient is uncircumcised, retract the foreskin and clean the glans of the penis. Replace the foreskin. Clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. Wash the shaft of the penis using downward strokes toward the pubic area. Rinse and dry. Remove gloves. Perform hand hygiene.	Washing removes urine, secretions, and microorganisms. The penis must be clean and dry to minimize skin irritation. If the foreskin is left retracted, it may cause venous congestion in the glans of the penis, leading to edema. Hand hygiene prevents the spread of microorganisms.
11. Put on gloves. Apply skin protectant to the penis and allow it to dry.	Gloves prevent contact with blood and body fluids. Skin protectant minimizes the risk of skin irritation from adhesive and moisture and increases the adhesive's ability to adhere to skin.
12. Roll the external urinary sheath outward onto itself. Grasp the penis firmly with your nondominant hand. Apply the external urinary sheath by rolling it onto the penis with your dominant hand (Figure 1). Leave 1 to 2 inches (2.5 to 5 cm) of space between the tip of the penis and the end of the external urinary sheath.	Rolling the external urinary sheath outward allows for easier application. The space prevents irritation to the tip of the penis and allows free drainage of urine.
13. Apply pressure to the sheath at the base of the penis for 10 to 15 seconds.	Application of pressure ensures good adherence of the adhesive to the skin.
14. Connect the external urinary sheath to the drainage setup (Figure 2). Avoid kinking or twisting drainage tubing.	The collection device keeps the patient dry. Kinked tubing encourages backflow of urine.
15. Remove gloves. Perform hand hygiene. Secure the drainage tubing to the patient's inner thigh with the Velcro leg strap, catheter securement device, or tape. Leave some slack in the tubing for leg movement.	Proper attachment prevents tension on the sheath and potential inadvertent removal. Hand hygiene prevents the spread of microorganisms.
16. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.	Positioning and covering provide warmth and promote comfort. The bed in the lowest position promotes patient safety.
17. Secure the drainage bag below the level of the bladder. Check that the drainage tubing is not kinked and that movement of the side rails does not interfere with the drainage bag.	This facilitates drainage of urine and prevents the backflow of urine.
18. Remove equipment. Remove additional PPE, if used. Perform hand hygiene.	Proper disposal of equipment prevents transmission of microorganisms. Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcome has been met when the patient's urine has been diverted into the urine collection device, and the patient's skin has remained clean, dry, intact, and without evidence of irritation or breakdown.

Documentation

Guidelines

Document the assessment data supporting the decision to use an external urinary sheath, the application of the external urinary sheath, and the condition of the patient's skin. Record urine output on the intake and output record.

Sample Documentation

7/12/25

1910 Patient incontinent of urine; states: “It just comes too fast. I can't get to the bathroom in time.” Perineal skin slightly reddened. Discussed rationale for use of external urinary sheath. Patient and wife agreeable to trying external urinary sheath. Medium-sized external urinary sheath applied; urine draining into collection bag without leakage. Leg bag in place for daytime use. Patient verbalized understanding of need to call for assistance to empty drainage bag.

—B. Clapp, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

External urinary sheath leaks with every voiding: Check the size of the external urinary sheath. If it is too big or too small, it may leak. Check the space between the tip of the penis and the end of the external urinary sheath. If this space is too small, the urine has no place to go and will leak out.
External urinary sheath will not stay on patient: Ensure that the external urinary sheath is correct size, and that the penis is thoroughly dried before applying the external urinary sheath. Remind the patient that the external urinary sheath is in place, so that they do not tug at the tubing. If the patient has a retracted penis, an external urinary sheath may not be the best choice; there are pouches made for patients with a retracted penis.
When assessing the patient's penis, you find a break in skin integrity: Do not reapply the external urinary sheath. Allow the skin to be open to the air as much as possible. If your facility has a wound, ostomy, and continence nurse, arrange for a consult.

EVIDENCE FOR PRACTICE

Prevention of Catheter-Associated Infections

Centers for Disease Control and Prevention (CDC). (2015, October). Healthcare-associated infections (HAIs). Catheter-associated urinary tract infections (CAUTI). https://www.cdc.gov/hai/ca_uti/uti.html

This site provides resources for health care providers and patients, including the CDC guidelines for prevention of catheter-associated infections. These guidelines recommend considering the use of alternatives to indwelling urethral catheterization in selected patients, when appropriate, such as the use of external urinary sheaths in cooperative patients with male genitalia without urinary retention or bladder outlet obstruction.

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Skill 12-5

EVIDENCE FOR PRACTICE