Both disposable and reusable types of ECCSs are made from a variety of material including latex rubber, polyvinyl (PVC), silicone, or synthetic polymers. Latex is used in many urologic products, including all types of ECCSs, because it is a soft and flexible material. But the presence of latex material in many catheters, devices, and products creates a greater risk of an allergic reaction in urologic patients. In general, the use of latex in the healthcare setting is being phased out. Silicone sheaths have the advantage that they are latex-free and transparent, allowing visualization of the penile skin. Silicone MECs are also skin-friendly because of their biocompatibility, as they allow the skin to breathe by permitting the transfer of water vapor and oxygen and reducing the amount of moisture build-up under the sheath. PVC is a synthetic and resistant material that contains plasticizers. Placticizers can be a problem in long-term users [2]. MECs also often use polyurethane (PU), a thinner material which may be more comfortable for the wearer.

Self-adhesive or one-piece MECs are the most popular as they have an internal fixation of integral adhesive (adherent to the inside of the sheath) that sticks to the penile shaft [20]. They are rolled over the shaft of the penis (see Fig. 3.5) and pressed to ensure adherence. A section between the adhesive and distal end prevents kinking and the tip attaches to a drainage tube with a bag. Variations exist in the different types of adhesives, the placement of the adhesive on the MEC, and the size of adhesive area [2] (see Fig. 3.6). Self-adhesives MECs are preferred because they are easy to self-apply, are more secure, and are covered by most insurers. All-silicone MECs cause less irritation and fewer adverse reactions and thus are recommended for men with a latex allergy [17] (see Fig. 3.7). Some adhesive MECs have an applicator or a strip (see Fig. 3.8) that may assist the individual or caregiver in unrolling the sheath. These catheters may also be useful for patients with reduced manual dexterity. To ensure adequate drainage, most have an “anti-kinking” outlet and/or “anti-twisting” internal flap feature that reduces kinking and twisting at the distal end of the MEC, near the connection to the drainage tube [12] (see Fig. 3.9).

Two-piece sheaths have either an internal or external fixation method. External fixation methods are less effective than internal methods, as no adhesive is physically attaching the sheath to the penis, making the fixation less secure. Adhesive tapes are not recommended as they are inflexible and not designed for sheath fixation. They can result in constriction of the penis, interfere with voiding and cause trauma.

An internal fixation MEC has a double-sided hydrocolloid adhesive strip, separate from the sheath that has adhesive on both sides, and can be applied internally in a spiral fashion around the penile circumference (see Fig. 3.10). The thickness and size of adhesive strips can vary.
The strip is wrapped around the circumference of the penis and the catheter sheath is then rolled up and over the penis and strip. Pressure should be applied to ensure adherence. A strip can be too tight around the shaft so men who use this type of MEC should have penile sensation and understand correct application. These double-sided strips are more elastic, do not tend to absorb urine, and are better able to accommodate changes in penile size. Such strips may be more appropriate for men who have erectile function.

A second type of two-piece sheath has an external fixation that is foam or a Velcro™ reusable strap (see Fig. 3.11) which is secured around the shaft of the penis once the nonadhesive sheath is applied. External fixatives are sometimes placed on the end of the MEC for extra security (especially when using a one-piece system). But foam straps are not elastic, so they will not stretch and should be used with caution [21].

A third type is an inflatable retention ring that secures the catheter (see Fig. 3.12) with air inflation, and is deflated for removal. The inflatable MEC is nonsterile and can be reused.

Some men prefer external fixation, especially in cases where the catheter is removed and replaced frequently. Catheters with a circumferential band may be too restrictive for the shaft of the penis and should be used only by men who are cognitively intact and have penile sensation because they are associated with an increased risk of penile strangulation. In addition, external, two-piece MCEs can be difficult to apply and may not be as effective as one-piece MECs.

Non-penile sheath, glans-adherent external device , a more recent device in the MEC category, is gaining in popularity. This device is a small, soft adhesive faceplate or wafer in the shape of a daisy flower that adheres to a small area of the glans penis around the meatus. A hydrocolloid seal (hypoallergenic, latex-free) is placed over the faceplate (see Fig. 3.13). Hydrocolloid polymer is the material often used to produce wound dressings. It has a central urine outlet opening to make a complete parameatal seal and directs all urine into a leg (see Fig. 3.14) or bedside collection bag [22]. This device functions like an ostomy device for normal male anatomy, directing all urine immediately away from the meatus to establish an environment where the skin (including penile shaft and glans) is consistently protected from moisture or exposure to urine. By keeping the skin dry, the device prevents skin maceration, breakdown, and wounds. It is highly effective for all normal male anatomy. It allows the foreskin to return to a natural, forward position making it equally suitable for both circumcised and uncircumcised anatomy. If present, the foreskin must be pulled back to place this device and then returned to the natural forward position over the seal (see Fig. 3.15). The device is also a good urine containment product for men with a retracted penile shaft, who are obese with large girths, who experience frequent erections. Because this device is applied exclusively to the glans penis, it is recommended for patients with penile shaft ulceration, inflammation, irritation or for men who have developed an penile shaft allergic reaction to a more occlusive urisheath [23].

Preliminary data indicates that the occlusive nature of the parameatal seal and application site cleansing may reduce the incidence of infection to less than 4%, more than a 10-fold improvement over any other modality [24]. Parameatal glans hygiene is required prior to application, thereby reducing ambient bacteria. The parameatal hydrocolloid seal establishes an occlusive dressing that can prevent bacteria from accessing the urinary meatus. The hydrocolloid seal will adhere to clean, dry skin for an average of 24–72 h. Although initial applications may have a shorter wear time, the device may be worn up to 3 days. The seal turns a milky-white color when the device is ready to be changed. Soaking the seal with warm water will allow the device to slide off easily.

Proper application is essential for successful utilization of the device (see Fig. 3.16) and it requires more dexterity than in applying a one-piece sheath. If application is not performed correctly, the device may be more likely to come off early or leak. Patients who experience a sudden, large diuresis have reported a feeling of suction on the tip of the penis, which tends to be more noticeable than in patients who experience this sensation when wearing a more traditional form of MEC.

This device has two sizes: standard size is indicated in patients who have normal anatomy of the external urethral meatus. Men who have a hypospadiac or enlarged urinary meatus (e.g., spinal cord injury patients as a result of long-term use of IUCs), may need to use the XLS model which has a larger outlet channel. Patients should use the tube holder recommended by the manufacturer or a conventional thigh strap to secure the urinary drainage tubing to the leg to avoid undue traction. An extension tube may be necessary.

There are currently only two available EPs and they are made from flexible vinyl.

External pouches are modeled on ostomy appliances. One type is a bodyworn pubic pressure type flange, which fits over the penis and sits against the abdomen using straps (see Fig. 3.17). A second type is a pouch with a pectin-based adhesive skin barrier that secures the device to the pubis [25]. The pouch holds about 90 mL but is more effective if connected to a drainage bag (see Chap. 4) using an extension tube. The pouch can be left in place for up to 3 days.

In men, the opening of an EP may be widened to allow for application over the penis and the integral adhesive barrier is attached to the pubis (see Fig. 3.18). In women, the opening can also be widened, and the adhesive is placed over the mons pubis (see Fig. 3.19).

Pouches are available for men with a retracted penis or with a shorter length penis or who cannot use a regular MEC [26]. They are also available for nonambulatory incontinent women [27].

Prior to application, the skin should be cleansed and pubic hair removed at the base of the penis in men and the perineum in women. The hair should be trimmed, not shaved, because shaving causes more irritation. Pouches can be attached to dependent drainage.

In men, the base of the penile shaft is assessed. The opening in the adhesive surface of the hydrocolloid wafer barrier should be cut to the circumference of the widest point of the penis. The wafer opening should be large enough that the penis is able to pass through the pouch and be able to move freely within the pouch [10]. The pouch is then applied over the penis and the adhesive is adhered to the pubis (base of the penis).

The female urinary pouch is a one-piece system that encompasses the labia and features an integral adhesive barrier. Training in device application is necessary and actual application can be time intensive, requiring removal of the mons pubis hair and the use of adhesive paste to increase adherence to the perineum. The vulvar opening is measured; the barrier is cut to fit the woman and then adhered to the labia. Problems with leakage persist with these pouches as poor adherence is common, especially in women.

Designs have not been significantly changed since this device was first introduced [28, 29, 30]. Pieper and Cleland [31] provided a review of external female devices noting that early designs involved a vaginal insert or locator to anchor the device and prevent urine from flowing into the vagina. A urine collection receptacle, which may have resembled a cup-shaped device, was either placed between the labia or suctioned against the meatus. They [31] designed and tested a “female urine collection device ” that consisted of a latex periurethral adapter that fit laterally between the labia minora and vertically between the clitoris and vaginal orifice. The drainage part of the adapter surrounded the urethra, adhering with the use of adhesive. However, none of the early designs proved to be effective in collecting urine in women. The ideal device for women would be one that is easy to place and works well for women who are bedridden, who transfer from beds to chairs, or who use wheelchairs. Also, if correctly fitted, urine should not contaminate the skin.

Unfortunately, no device has proven to be very useful for women.

Technological advances are making these products more available and more user-friendly. The main driver for these technological advances has been the military and, in particular, Air Force pilots. Agarwal and Subramaniam [33] developed a set of 56 questions addressing nine areas of pilot concern associated with long duration flying of which in-flight urine disposal was one of the areas. A total of 30 male pilots with a mean age of 30 years were questioned about their preferred method of in-flight urine disposal. Most pilots (80%) agreed that the adult diaper was not an appropriate method for urine disposal and 95% reported never using a diaper for in-flight urination . In aircraft used for long missions, pilots use the negative-G strap, a thick flat strap that presses on the crotch. Urination requires a loosening of the strap, which in the absence of an autopilot, is difficult if not impossible for these pilots. Sixty-six percent reported preferring condom drainage and 100% of these pilots felt that better research is needed for urine disposal.

Von Thesling et al. [37] reported on a male in-flight urine collection device, a reusable latex sheath-style catheter worn throughout flight and affixed during donning of a pressure suit. This device has evolved into sensor-driven technology that actively pulls urine away from the body (see Fig. 3.23).