Delayed wound healing occurs in various wound types and in patients with significant comorbidities. Hard-to-heal wounds have proven to be a challenging and worldwide crisis resulting in high financial burdens.
By Charles P. Buscemi, PhD, APRN, CWCN and Arturo Gonzalez, DNP, APRN, ANP-BC, CWCN-AP
Urinary catheters serve several purposes, including monitoring urine output, relieving urinary retention, and facilitating diagnosis of disease in the lower urinary tract. These catheters can be inserted easily and are universally available, which usually results in their continued and indiscriminate usage. Urinary catheters can be indwelling or external-condom types.1 The indwelling catheter can be either a suprapubic or a urethral catheter.2 The external catheter provides a safe alternative to an indwelling catheter for patients having urinary incontinence (UI). It comprises a sheath surrounding the penis with a tube situated at the tip linked to a collection bag. Conversely, the condom catheter seems an attractive option for patients with UI.2 About 40% of condom catheter users have urinary tract infections.3 Moreover, 15% of condom catheter users have necrosis, ulceration, inflammation, and constriction of the penile skin.3 There is also an additional risk of urine leakage and condom detachment. Furthermore, the use of the external catheter requires significant nursing time. Overall, the condom catheter cannot be satisfactorily used for managing UI; nevertheless, it is useful for the non-invasive measurement of bladder pressure.
The development of pressure injuries (PIs) is one of the key concerns associated with the use of condom catheters. Gulur and Drake1 reported that the use of a condom catheter in hospitalized patients increased the risk of developing a PI by 1.8 times when compared with patients without a condom catheter. This risk is most significant for stage II PIs. In addition, it has been reported older age, limited dexterity, disability, and immobility are important risk factors for developing PIs stemming from the use of condom catheters.1 Impaired mobility has been identified as an important risk factor in the development of PIs. Thus, immobile patients using condom catheters are at a higher risk of developing PIs.3 Because of such risks, the use of the external catheter for patients with UI is recommended only as a last resort.
Various investigators have examined the mechanism of PIs induced by the use of the condom catheter.1,3 First, it is possible that skin integrity may be compromised through discomfort, regular catheter changes, uneven or excessive adherence, and difficulty in applying or removing the condom catheter. Compromised skin integrity is prevalent in 15% of patients with UI who use condom catheters.2 The risk of compromised skin integrity is higher among patients with UI and spinal cord injury because of reduced sensation. In most cases, compromised skin integrity has been linked to improper use of the condom catheter.
PIs induced by condom catheters can also be caused by irritation. Irritation is characterized by discolored skin (pink or red) at the point where the adhesive or the condom catheter attaches to the skin.2 Irritation has been associated with using a condom catheter for an extended period or undergoing penile surgery before catheterization. Chronic irritation can also be attributed to urine leakage because of the improperly fitted catheter, which further results in ulceration.1 The extrinsic compression caused by the condom catheter can also cause PIs.
PIs associated with the use of condom catheters can also be caused by allergic reactions. Empirical evidence supports the allergic complications related to latex, plastic materials, adhesive substances, cement, and glues used for attaching the condom to the penis.1 Hypersensitivity often occurs when rubber condom catheters are used, and it often lasts for about 5 to 30 minutes following exposure to the latex catheter.2 Allergic reactions yield erythema, which is characterized by the inflammation or reddening of the skin. The skin may also appear smoothly stretched. The removal of the latex catheter often stops the allergic reaction that contributes to ulceration.2 The material used in the condom catheter is an important consideration. Evidence shows that condom-related dermatitis can be observed within 48 hours after applying the condom catheter,1 and it increases the risk of ulceration.
Compressive complication is another potential cause of PIs induced by condom catheters, especially among patients with impaired pain and pressure sensation, such as those with spinal cord injury. Compression by the condom catheter may result in non-penetrating or penetrating lesions.4 Failure to assess the patient properly and use of the wrong catheter size result in penile strangulation. Evidence suggests that patients using condom catheters may develop discoloration and gangrenous changes as a result of catheter compression. The compressive effects associated with the condom catheter emanate from either the various types of tapes used for securing the catheter in place or the hard roller ring.4 These compressive aspects of the condom catheter can yield either penetrating or non-penetrating lesions that subsequently cause ulceration. With respect to penetrating lesions, the hard roller ring of the catheter produces a gradual pressure defect that may not be realized by patients who have impaired pain or pressure sensation. Failing to detect the condition in time can lead the ring to cut into the skin as well as the subcutaneous tissues.2 Moreover, the use of tapes, alone or together with condom rings, has been reported to cause pressure defects. Regarding non-penetrating lesions, penile compression by the tapes or roller ring may result in prepuce edema devoid of visible lesions, and this further contributes to pressure ulceration. The urethra becomes partly constricted; hence, the flow of urine is slowed, and the intraurethral pressure is increased. PIs at the penile shaft also occur as a result of using catheters that are too small or roller pressure that is too high.1 Additionally, pressure from the tape or adhesive strip may cause ulceration in the penile shaft. A PI at the foreskin is the result of pressure from the catheter that is too high, such as from an erection.
Evidence-based methods exist to help prevent the occurrence of PIs when condom catheters are used. If extended use of condom catheters is needed, irritation can be minimized by intermittent insertion.3 In addition, proper catheter use is recommended, which entails considering the size and length of the catheter, as well as the materials used in manufacturing the catheter to prevent allergic reactions. Earlier removal of catheters has also been reported to minimize the occurrence of PIs stemming from the use of condom catheters.4 Recent advances in technology have facilitated the use of super absorbent polymers in the manufacture of condom catheters, which promotes the prolonged use of these catheters. The effect of frequency of catheter changes is also an important consideration when trying to minimize PIs induced by condom catheters. Stickler2 reported that changing catheters less frequently resulted in wetter skin relative to the group with more frequent changing of pads. Patients in the group whose pads were replaced often had a higher risk of developing stage II PIs because their skin was more susceptible to abrasion and friction.
Medical Devices and Pressure Injury
PIs are seen in soft tissues that have been subjected to external pressure. Tissues underneath medical devices used for either treatment or monitoring are susceptible to these injuries. PIs induced by medical devices tend to be more complicated when compared with other PIs because the device may be a primary treatment or diagnostic requirement.5 Medical device–associated PIs denote localized injury of the skin or the tissue beneath because of pressure exerted by a medical device.6 The injury to the soft tissue often takes the shape of the medical device. These PIs can develop to become full-thickness PIs because of the unavailability of adipose tissue in the ulceration area.
The incidence and prevalence of medical device-induce PIs have been thoroughly explored in the literature. Black and Kalowes7 indicated that, for cervical neck collars, the incidence of PIs is 33% after five days of use and 44% when these collars are used for more than five days. In the pediatric population, the development of medical device–associated PIs can occur rapidly because of physiological immaturity and high skin intolerance. In a prospective study of children aged up to 8 years, the incidence of medical device–associated ulceration was 8%.6 The most common devices that contributed to this ulceration were endotracheal tubes, airway pressure masks, and oxygen saturation probes, which accounted for 74% of all the ulcerations documented. In adult patients, the prevalence of medical device–associated PIs was found to be 9.1%, and these PIs were most common in the buttocks, heels, and sacral region.7 Black and Kalowes7 further reported that medical devices accounted for 34.5% of all the reported PIs acquired in the hospital setting; these PIs were reported to occur commonly in the ears and lower legs. These investigators also reported that patients using medical devices had a 2.4-fold higher risk of developing PIs.
Arnold-Long and colleagues8 studied the prevalence of medical device–associated PIs over an 11-month period in long-term acute care settings. The results showed that 44% of hospital-acquired PIs in the study cohort stemmed from the use of medical devices. Of these PIs, 14% were stage 1, 50% were stage 2, and 36% were stage 3.8
The prevalence of medical device–associated PIs in the state of Minnesota has also been explored.9 These investigators found that 70.3% of PIs stemming from medical devices occurred in the neck, face, or head as a result of using nasogastric tubes, oxygen tubing, or cervical collars, whereas 20.3% of the PIs occurred in the foot, ankle, or heel as a result of using boots, support stockings, and immobilizers.9 These researchers also reported that about one-third of the severe PIs were attributable to the use of medical devices.9 The frequency of PIs differs based on the type of medical devices. The highest rate of PIs results from the use of oxygen delivery devices such as endotracheal tubes.7 Other devices that are frequently associated with PIs include elastic stockings (12%), urinary catheters (14.7%), fecal containment devices (14.7%), pressure masks (6%), pulse oximetry devices (9% in children), tracheostomy ties and flanges (8.1%), nasal cannulas (12.9%-47%), and nasogastric tubes (8%).7 Thus, it can be concluded that the incidence and prevalence of medical device–associated PIs depend on the type of medical device used.
It is imperative to differentiate medical device–associated PIs from immobility-related hospital-acquired PIs. This distinction is achieved by assessing the location of hospital-acquired PIs. Hospital-acquired ulcerations are often located over surfaces with a bone beneath or tissue that is exposed to a supportive device.6 Conversely, medical device–related PIs often mimic the location and shape of a medical device. The common risk factors for immobility-related hospital-acquired PIs and medical device–associated PIs include inadequate oxygenation, nutritional deficiencies, shear, friction, moisture, sensory deficits, inactivity, and impaired mobility.7 A distinctive feature of medical device–related PIs is that the external pressure comes from a rigid plastic material utilized for manufacturing medical devices. For instance, medical devices used for treatment, prevention, and monitoring usually have a component made using a hard plastic material, which presses the skin and causes ulceration.7 Oxygen tubing is a well-known culprit in medical device–associated PIs. In addition, some medical devices must be securely held in one place to avoid being dislodged. This means that these devices rarely move, so shear forces are an unlikely etiology.7 Nevertheless, securement dressings or straps can put pressure on the skin. For instance, Goodell10 reported that the pulse oximetry device exerted a pressure of 20.7 mm Hg to the earlobe, which is equal to a force of 0.24 pounds exerted to a surface of 0.3 square inches. Although the study by Goodell10 did not show casualty, it highlighted the magnitude of pressure emanating from some medical devices. Medical devices that are tightly fitted can result in edema emanating from inflammation or fluid resuscitation, especially among patients having inflammatory conditions. Moreover, improper selection or size of medical devices aggravates the risk of ulceration.
Evidence-based approaches have been described in the literature to help prevent the development of medical device–induced PIs. Preventing medical device–associated PIs commences with using the appropriate size of medical devices.9 This requires clinicians to familiarize themselves with the medical devices used in their clinical setting.7 Another important prevention consideration for medical device–associated PIs is securing the devices using straps or tape without any tension.10 The skin should be examined before repositioning or changing the medical device.
Dialkyl Carbamoyl Chloride (DACC)
Infection and bacterial colonization have been found to cause delayed healing of wounds. Using antimicrobial dressings is the recommended intervention for controlling bacterial load and reducing the spread of infection.11 Diverse forms of non-medicated dressings with distinctive bacterial binding action based on the hydrophobicity principle to eliminate fungi and bacteria from a wound are currently available.12 These products are used for removing bacterial loads and offer an alternative intervention to other antimicrobial agents. They can also be utilized on all wound types, ranging from infected to colonized wounds and from highly exuding to lightly exuding wounds.13 Unlike conventional microbial dressings, these products do not have any pharmacologically or chemically active substances.11 Instead, they depend on a physical action mode utilizing a coating derived from dialkyl carbamoyl chloride (DACC) for reducing bacterial load in an infected wound.13 These dressings have a DACC coating with hydrophobic attributes. Most wound microorganisms are hydrophobic; therefore, in the presence of moisture, they are irreversibly bound to the DACC because of hydrophobic interaction. This interaction renders the microorganisms inert and thus prevents them from releasing harmful substances or reproducing.14 With each change of the dressing, the hydrophobic microorganisms are eliminated, thereby lowering the bacterial load in an infected wound and stimulating healing by non-hydrophobic microorganisms.
Reducing bacterial load (bioburden) is important in wound healing. Infection hampers healing and leads to hospitalization and morbidity.12 Without careful management, infection can spread rapidly. Removing the devitalized tissue is a good wound management practice needed to lower the bacterial burden.15 Bacterial effects on the wound range from colonization to infection followed by tissue invasion, actions that underscore the importance of reducing the bacterial load to facilitate wound healing.
DACC has been found to be effective in lessening the bacterial load. The findings of studies and in vitro testing employing moist wound samples have indicated that using DACC dressings can reduce bacterial load in the wound.16 One DACC-coated dressing showed binding action to various common pathogens in wounds, such as Candida albicans, Pseudomonas aeruginosa, and Staphylococcus aureus.14 This dressing was reported to be most effective for highly exuding wound samples.
The benefits associated with using DACC-coated dressings have been documented in the literature. The first benefit is that these products do not have any active antimicrobial agent; hence, there is no risk of developing resistant bacterial strains.11 Additionally, these products do not produce chemically active substances in the wound bed as a result of the dressing, thereby eliminating the risk of systemic absorption, skin staining, and sensitization.14 Furthermore, DACC has been found to cause no allergic reactions.13 The indications for use of DACC-coated dressings is diverse, such as fungal infections, chronic wounds, traumatic wounds, and postoperative wounds, among others.
Statement of the Problem: In older and immobile patients, the use of condom catheters to control UI significantly increases the risk of medical device–related PIs. Although antimicrobial dressings are commonly used to promote resolution of these types of wound, treatment failure can occur, resulting in the development of a recalcitrant wound.
Purpose: This case study reviews the use of hydrophobic, DACC dressings to resolve a recalcitrant medical device–related pressure injury to the penis that was caused by a condom catheter used to control nocturnal UI.
Method: Three patients with similar wounds (stage III device-related PIs to the posterior proximal region of the penis that were caused by condom catheters) were treated using antimicrobial dressings. Two of the patients experienced wound resolution within 12 weeks. The third patient developed a recalcitrant wound that was subsequently treated with saline irrigation and the use of DACC dressings over an eight-week period.
Case History: The patient with the recalcitrant wound was a 63-year-old paraplegic, white man receiving advanced wound care services in his home. At the initiation of services, the patient was being treated by the primary care provider with mupirocin, with no improvement. The patient was referred for home-based wound care treatment. The treating clinician immediately discontinued the condom catheter and instructed the patient’s wife on performing straight catheterizations. Initially, the PI was treated with silver foam. It was thought that foam would provide some cushion because the ulcer was at the base of the penis and some antimicrobial protection given the location of the wound and the patient’s bowel incontinence. However, the wound experienced delay in healing. It was decided to use a gel-impregnated DACC dressing. Gel-impregnated dressings allow for maximum conformation, given the difficult location of the wound.
Results: Wound resolution in this patient treated with DACC dressings occurred during the eight-week treatment period. This finding suggests that DACC may provide a viable alternative for the treatment of recalcitrant device-related PIs.
The use of DACC dressings represents a novel approach to the treatment of non-healing device-related PIs. These dressings do not have any pharmacological or chemically active substances to promote wound healing. Rather, these dressings have a hydrophobic attribute that binds and removes the microorganisms commonly found in most wounds. Further investigation of DACC dressings for the first-line treatment of device-related PIs is warranted to evaluate their efficacy in wound care. This is especially true in light of antimicrobial resistance, which can arise through the continued use of antimicrobial dressings.
1. Gulur DM, Drake MJ. Urinary catheters and other devices. In: Wein AJ, Andersson KE, Drake MJ, Dmochowski RR, eds. Bladder Dysfunction in the Adult. New York, NY: Humana (Springer); 2014:113-119. doi:10.1007/978-1-4939-0853-0_12
2. Stickler DJ. Clinical complications of urinary catheters caused by crystalline biofilms: something needs to be done. J Intern Med. 2014;276(2):120-129. doi:10.1111/joim.12220
3. Feneley RC, Hopley IB, Wells PN. Urinary catheters: history, current status, adverse events and research agenda. J Med Eng Technol. 2015;39(8):459-470. doi:10.3109/03091902.2015.1085600
4. Paul S, Dalela D, Prakash J, Sankhwar S. Penile elephantiasis: a rare consequence of inappropriate use of condom as external urinary collection receptacle. BMJ Case Rep. 2013;2013:bcr2012008446. http://casereports.bmj.com/content/2013/bcr-2012-008446.full
5. Coyer FM, Stotts NA, Blackman VS. A prospective window into medical device-related pressure ulcers in intensive care. Int Wound J. 2014;11(6):656-664. doi:10.1111/iwj.12026
6. Murray J, Noonan C, Quigley S, Curley M. Medical device-related hospital-acquired pressure ulcers in children: an integrative review. J Pediatr Nurs. 2013;28(6):585-595.
7. Black J, Kalowes P. Medical device-related pressure ulcers. Chronic Wound Care Manage Res. 2016;3:91-99. doi:10.2147/cwcmr.s82370
8. Arnold-Long M, Ayer M, Borchert K. Medical device–related pressure injuries in long-term acute care hospital setting. J Wound, Ostomy Continence Nurs. 2017;44(4):325-330. doi:10.1097/won.0000000000000347
9. Apold J, Rydrych D. Preventing device-related pressure ulcers. J Nurs Care Qual. 2012;27(1):28-34. doi:10.1097/ncq.0b013e31822b1fd9
10. Goodell TT. An in vitro quantification of pressures exerted by earlobe pulse oximeter probes following reports of device-related pressure ulcers in ICU patients. Ostomy Wound Manage. 2012;58(11):30-34. https://www.ncbi.nlm.nih.gov/pubmed/23134900
11. Braunwarth H, Brill FHH. Antimicrobial efficacy of modern wound dressings: oligodynamic bactericidal versus hydrophobic adsorption effect. Wound Med. 2014;5:16-20. doi:10.1016/j.wndm.2014.04.003
12. Cooper R, Jenkins L. Binding of two bacterial biofilms to dialkyl carbamoyl chloride (DACC)-coated dressings in vitro. J Wound Care. 2016;25(2):76-82. doi:10.12968/jowc.2016.25.2.76
13. Hewish J. Understanding the role of antimicrobial dressings. Wound Essentials. 2012;7(1):84-90.
14. Choi J-S, Lee J-H, Kim S-M, Kim Y-J, Choi J-Y, Jun Y-J. Hydrogel-impregnated dressings for graft fixation: a case series. J Wound Care. 2015;24(7):326-328. doi:10.12968/jowc.2015.24.7.326
15. Cutting K, McGuire J. Safe, long-term management of bioburden that helps promote healing: evidence review of DACC technology. J Wound Care. 2015;24(5 suppl):S3-S5. doi:10.12968/jowc.2015.24.sup5a.s3
16. Lucas L, Iseler J, Gale L. Evaluation of a new, novel male external urinary management device. Poster presented at Cleveland Clinic’s Spring 2013 WOC Nursing Symposium, Cleveland, OH, April 12, 2013. http://www.eloquesthealthcare.com/wp-content/uploads/2014/03/Spectrum-He...
About the Authors
Drs. Charles Buscemi (left) and Arturo Gonzalez (right) are on the faculty of Florida International University, Nicole Wertheim College of Nursing and Health Sciences, Miami, Florida. They are also Nurse Practitioners in clinical practice specializing in wound care. Dr. Buscemi is certified as a CWCN and Dr Gonzalez as a CWCN-AP from the Wound, Ostomy and Continence Nursing Certification Board.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.