Today, ostomates have a wide variety of products to choose from. There are literally thousands of wafers, pouches, powders, pastes, belts, skin barriers, adhesive removers, and paraphernalia such as ostomy covers and intimate apparel on the market. Most home health agencies, medical equipment or pharmacy suppliers can provide ostomy supplies - and there is always the internet! Many ostomy supplies may be ordered directly from the manufacturers, and most manufacturers also provide free 1-800 numbers to call, which are staffed by certified ostomy nurses to answer common questions. Some of the most well known ostomy suppliers (in no order of preference, and this list is not meant to be all-inclusive) include: ConvaTec, Hollister Inc., Coloplast Corp., Cymed Ostomy Co., Torbot Group, Inc., The Perma-Type Company, Nu-Hope Laboratories, Inc., Marlen Manufacturing and Development Co., Genairex, Inc., Schena Ostomy Technologies, Inc., MicroSkin, and Blanchard Ostomy Products (United Ostomy Association of America website).
The pouches and wafers which attach to a person with an ostomy to allow the drainage and collection and disposal of fecal or urinary waste are typically called appliances. In general, there are two main types of ostomy appliances. The first type is a one-piece appliance where the "wafer" or flange (the part that sticks to the skin around the stoma) is permanently attached to the pouch (the bag that holds the waste or effluent). A person with a colostomy may be able to expect up to 5 to 7 days wear time out of a one-piece, drainable appliance. A drainable appliance is one that has a re-closable opening at the distal end of the pouch to allow for periodic drainage and re-closure during the day. A person with an ileostomy or urostomy may get slightly less wear time of these appliances due to the thinner consistency of drainage/effluent. The pouches for urostomies are slightly different than pouches for fecal diversions. Urostomy pouches typically have an antireflux design built into the pouch itself to discourage the backflow of urine when the individual is reclining (may be as simple as multiple layers of plastic within the pouch design). Urostomy pouches also have a different drainage valve at the end of the pouch to allow liquid waste to drain but would clog up quickly with fecal matter if these pouches were used incorrectly with ileostomies.
In one-piece drainable appliances, the pouch and wafer are permanently joined to each other and they have an opening at the end of the pouch, which provides a way to drain the effluent from the end of the pouch whenever it gets 1/3 to 1/2 full. All ostomy pouches (colostomy, ileostomy, and urostomy) should be emptied when 1/3rd to 1/2 full to prevent the weight of the pouch from pulling the wafer away from the skin. Two-piece drainable appliances also have a wafer that attaches to the skin and may be able to stay in place for 3 to 7 days, but it also has a separate drainable pouch, which attaches to the flange (ordinarily with a plastic or metal locking ring). The pouch in a two-piece system may typically be changed twice as often as the wafer. Drainable pouches are usually rinsed out daily. Non-drainable or closed-end pouches may be either part of a one-piece system or (more commonly) part of a two-piece system. They have a sealed end (unable to open it) and are meant to be disposable. Because closed-end pouches are meant to be disposable, they are most often appropriate for colostomies which may only need to change the pouch once daily.
Typically, the amounts of ostomy supplies covered by insurance companies are set by the usual amounts covered by Medicare. These amounts of supplies are determined based on manufacturer guidelines which state how long the wafer and/or pouch are meant to be worn. In most cases, a two-piece appliance with drainable pouches will be covered at 5-10 wafers per month and 10-20 drainable pouches per month. A closed-end pouch for colostomates may be covered at 30-60 per month because it is anticipated that they will need to change them at least daily. One-piece appliances may only be covered at 10 per month, depending on the type of appliance. These limits may not agree with patient’s hygiene habits or personal preferences, so it is important for the health care provider following a patient with an ostomy to provide good educational instruction to the patient and caregiver about what types of appliances are available, excellent skin care and proper use of all appliances ordered for patients (Howson, 2019).
This is a list of basic supplies most new ostomy patients should have ordered at discharge and be taught how to use: the appliance (wafers/pouches, clips for the end of the pouches, if applicable), skin barrier wipes, adhesive remover wipes, stomahesive or skin sealant paste, stomahesive or karaya powder, and an ostomy belt (attaches to the ostomy pouch and goes around the waist for greater security). If the patient has an ileal conduit (urostomy), a night-time drainage bag or bottle that holds at least 1500 cc and adapters for the night-time drainage container tubing to attach to the pouch should be ordered, also, leg bags should be considered for all urostomy patients (Pearson, et. al., 2020).
At discharge all patients should be taught at a minimum:
- Care for the stoma, especially cleansing and protecting – stomas do not have pain sensation and may bleed easily if rubbed too hard. Use plain water, or mild soap and water for ileostomies and colostomies and the same or a mild vinegar solution and water for urostomy stomas (the vinegar cuts through the uric acid of the urine). A mild vinegar solution would be quarter strength household vinegar or 1 part white household vinegar mixed with 3 parts water (1 cup white vinegar mixed with 3 cups water).
- Stomas should be examined at each health care provider follow-up visit. Stomas should be “nicely budded” sitting about 1 ½ to 2 inches above skin level on the abdomen. They should be pink and moist. The os (opening of the stoma) should be nicely centered. The stoma should be free of discoloration or growths (Grove, et. al., 2019).
- Proper measurement of stoma – stoma should be measured to assure proper size of wafer opening so that no skin is visible around the stoma when the appliance is in place. The stoma will likely shrink slightly in the first 2 weeks, so stoma should be re-measured after 2-4 weeks post-op, to assure continued proper sizing of the appliance. Using paste or moldable waxy rings/seals around the stoma before applying the appliance will help reduce the chance of leaking if the stoma size changes slightly during these first few weeks.
- Care of the surrounding skin – peristomal skin irritation (skin irritation to the skin immediately around the stoma) is the most common post-op complication for all ostomies (Ratliff et al, 2005). Here are some tips to pass on to the patient:
- Keep the skin clean and dry before applying the appliance.
- If you have a lot of hair in this area – use an electric razor, not a blade razor, to avoid irritating skin and potentially causing skin infection of the hair follicles.
- Do not use any bath soap to this skin that contains moisturizers (this will leave a residue on the skin and prevent the appliance from adhering well).
- Always use a skin barrier (skin protecting) wipe or liquid to the skin and let it dry completely before applying the wafer.
- Consider a “crusting technique” when slight skin irritation is noted: When applying the skin barrier wipe, alternate applying a light dusting of stomahesive powder and blot with another skin barrier wipe. Repeat up to 3 times to lay down a thick protecting coating on the skin that will help the appliance stick better at the same time, protecting the skin from all moisture.
- Consider using ostomy paste, seals, waxy rings to help fill in any skin folds, or irregular topography of the skin and make the skin as flat and smooth as possible for the wafer to adhere to.
- If the appliance is leaking, change it. Don’t ever tape it down to get one more day use from it!
- If there is a lot of leftover adhesive from the previous appliance, remove it gently with an adhesive remover wipe, but then use a mild soap and warm water to remove the adhesive remover oily residue completely – and dry completely (or the new wafer may not stick!).
- Urostomy patients may wish to rinse the stoma and surrounding skin with ¼ strength vinegar solution to reduce mucous, odor and skin irritation from urine contact.
- Typically first thing in the morning before eating or drinking anything is the best time to change appliances.
- If the person has a colostomy and uses drainable pouches, a small amount of vegetable oil may be placed inside the pouch and the pouch rubbed on each side to coat the inside of the pouch lightly (before the pouch is applied to the wafer or abdomen). This will allow formed fecal matter to slide right out of the end when emptying the pouch.
- If the patient has an ileostomy that has a very active stoma (lost of effluent), so that changing the appliance is difficult, and if they are not a diabetic, they may eat 1 or 2 large marshmallows 20 minutes before changing their ileostomy appliance to slow down the effluent temporarily (lasts up to 1 hour).
- Urostomy patients could use a ¼ vinegar solution (described above in #1) to rinse their urostomy pouches and night-time drainage containers with and let them air dry. This will help reduce urine odors.
- At the first sign of any peristomal skin irritation, a person with an ostomy should contact their health care provider and be seen as soon as possible to prevent further skin breakdown, which may make pouching very difficult.
When ostomates have sufficiently recovered from their surgeries and adjusted to the initial changes of their new life with an ostomy, they should be encouraged to resume activities they normally enjoy (skydiving, motorcycling, swimming, fishing, etc.) with minimal adjustments for ostomy management. There are many ways to assure adequate appliance function while allowing for even the most active lifestyles. Occasionally, special equipment may be needed. For instance, swimming, snorkeling, and scuba diving with an ostomy appliance may require a well-fitting wetsuit or special product which one could find on the internet made especially for waterproofing the ostomy appliance during such activities (example: www.drypro.com).
Traveling on long trips, airplane rides, etc. may require more frequent appliance changes and pouch emptying as well as larger capacity pouches and/or leg bag extensions (carrying Ziploc bags with them may come in handy for pouch disposal in public bathrooms). The United Ostomy Associations of America (www.ostomy.org) has a lot of very useful information on their website for ostomates, caregivers and healthcare providers including suggestions for travel and getting through security with an ostomy as well as advocacy for issues such as equal access to public swimming pools, etc. Intimacy concerns may be minimized for the ostomate by utilizing a variety of different ostomy appliance covers and special underwear, swimwear and lingerie made specifically for ostomates (example of one website: www.ostomysecrets.com). It is important for healthcare providers to have a list of resources for their patients with ostomies, or refer them to an experienced enterostomal therapist (ET) or certified ostomy nurse/specialist for an in-depth consultation.
The best time to refer a patient to an ostomy specialist is ideally pre-operatively, before the ostomy surgery occurs. The Wound, Ostomy and Continence Society (WOCN) and the American Society of Colon & Rectal Surgeons (ASCRS) recommend all patients who are scheduled for a surgery (which may potentially result in an ostomy) have a preoperative evaluation and ostomy site marking done by an “experienced, educated and competent clinician.” Ostomy site marking may be done with a surgical marking pen days before surgery as long as the surgical marking remains visible on the skin until the time of surgery. Please note, the surgeon typically does the “surgical site” marking the day of surgery – marking where she/he intends to make incisions. Ostomy site marking is where the trained ostomy clinician (with the patient’s input) deems the optimal stoma site to be. The optimal ostomy site is within the rectus muscle, for stability and support. In ostomy site marking, care is taken to avoid belt lines, skin folds, too close to the midline, outside of the rectus muscle, and outside of patient’s visual fields. In addition to pre-operative ostomy consultations, post-operative evaluation, teaching and follow-up should also be conducted as soon as possible after surgery by an experienced ostomy clinician. If any ostomy complications arise, it is imperative a referral be made to an experienced ostomy clinician as soon as possible after the complications are noted, to avoid further deterioration (Pearson, et. al., 2020).