Ostomatology: Colostomy, ileostomy, urostomy

Over 700,000 people in the United States (US) are living with permanent ostomies with over 100,000 new colostomy or ileostomy surgeries per year (Sheetz et al., 2014). Health care providers are likely to care for an individual with an ostomy in many health care settings (such as home care, inpatient acute care, emergency room, long term care, and primary or ambulatory care).  Nurses, physicians, and therapists need to be knowledgeable of at least a few basics related to the assessment, care and pouching of the person with an ostomy (ostomate).

The word stoma comes from the Greek word for mouth.

A stoma, with regards to a fecal or urinary diversion (colostomy, ileostomy, urostomy), is the visible part of a temporary or permanent opening created in the abdominal wall during a surgical procedure to allow communication  from the inside of the body to the outside of the body to permit the elimination of feces or urine. An ostomy is typically created surgically, but infrequently, it may occur naturally (sometimes resulting in what is called a fistula). One example of a naturally occurring "ostomy" is when an intestine becomes obstructed and the individual does not receive medical attention to relieve the obstruction. In some of these cases, the body develops an enteric fistula (an abnormal tract to allow drainage from one part of the body to another or to the outside of the body) on its own to allow the fecal waste in the intestines (above the obstruction) to bypass the obstruction and find a way to exit the body. If the individual did not develop this fistula after a total obstruction (or receive a surgical intervention), it is very likely sepsis would occur - resulting in a fatal outcome. This was the unfortunate result for most persons with intestinal obstructions prior to the 1900s when anesthesia and abdominal ostomy surgical procedures were perfected.  

Early attempts at ostomy surgery have been reported since the 1750s, but without anesthesia, antibiotics or drainage collection devices, the outcomes were poor. Early attempts at fecal diversions (prior to antibiotics) were typically aimed at creating a stoma from the intestines to the lumbar region of the back. As one can imagine, these were incredibly difficult to manage. Dr. Rupert B. TurnballJr. (1913-1981) is credited with being one of the most influential surgeons in the advancement of ostomy care in the United States (US). He discovered karaya as a skin protectant and worked with one of his patients, Norma Gill (a grandmother with an ileostomy), to develop one of the first post-operative ostomy pouching appliances. Karaya was one of the first adhesives used in early pouching appliances and is sometimes still used today. Dr. Turnball and Mrs. Gill started the first enterostomal therapy training program in the US in the 1950s and helped to develop and guide manufacturing of many of the early ostomy management products commercially available. Other influential persons with regard to improving ostomy outcomes include surgeons, Dr. Bryan Brooke (who first standardized the technique of surgically “maturing” the stoma around 1952) and Dr. Henri Albert Hartmann (who as early as the 1920’s developed the surgical technique of delayed colon anastomosis where he removed the affected section of the sigmoid colon, created an end descending colostomy with the distal end of the healthy intestine and sutured closed the distal stump of what was left of the sigmoid colon, thus, creating the first "Hartmann's Pouch"- the pouch being left behind and included the rectum) (Wikipedia, 2016).

There are two major types of surgically created abdominal ostomies: fecal diversions and urinary diversions.

Ostomates should have their stoma examined at least annually as part of their overall general healthcare and head-to-toe physical examination. Health care practitioners should be familiar with typical normal and abnormal findings (in general) – similar to expected and unexpected findings during rectal exams. However, many primary care providers may be reluctant to actually visualize the stoma or ask the patient to remove the pouch for examination. Even if this patient has had a history of colon cancer, providers may not think about getting a fecal sample from the pouch or stoma for hemoccult screening. If the provider does ask for the pouch to be removed, do they have pouching supplies available or have they instructed the patient to bring an appliance change with them prior to the visit? Do they know how to remove and apply a pouching appliance? There are literally hundreds of types of ostomy appliances and care products. Do health care professionals know what is available and how to use them? It is not unreasonable for patients to expect that their health care provider will at least be familiar with basics of ostomy stoma care and management.

An ostomate is a person with an ostomy. A colostomate is a person with a colostomy.

Some colostomates (with proper education and supplies) may be able to irrigate their colostomies every 1 to 3 days and only need to wear a small "stoma cap" in between irrigations. However, this is a potential option ONLY for patients with colostomies situated in the descending colon. The irrigation procedure must become a regular routine for these individuals for the rest of their lives if they are to be successful with it. It typically requires a disciplined and regimented person. The irrigation procedure may be thought of as a bowel regime and enema rolled into one. It takes special equipment that is typically cleansed and re-used for up to one month per kit. The equipment consists of an irrigation bag resembling an enema bag, which has a capacity and is marked up to about 2000cc. This bag has a hook or clip to hang it from a hook in the bathroom and a long tube running down from the end of the bag, which has a clamp on it to adjust the flow of water through the tubing. A plastic cone that fits the end of the tubing, a long irrigation sleeve (to fit on their ostomy appliance during the irrigation), a clip for the end of the sleeve, and some lubricating jelly are also included in the kit. Colostomates that consider irrigation as a management option require much education and support (Howson, 2019).

Colostomates should be instructed to allow at least 45min to one hour for every irrigation and try to establish irrigation times at the same time each day and on a schedule as close to their previous normal bowel routine (as frequently as they used to have regular bowel movements) such as daily or every other day. For the first month or so, they should continue to wear full sized ostomy pouching appliances until their bowels are moving only in response to the irrigation and not in between times. If effluent continues to drain from their ostomy in between irrigations after 4 to 6 weeks of consistent irrigations, they may not be irrigating frequently enough. Consider moving to a daily schedule if they are currently attempting an every other day schedule. Maintaining this schedule is extremely important for their success, as the body should develop a regular pattern and within 4 to 6 weeks of routinely scheduled irrigations. They also may wish to consider how much fluid they are using during irrigation. Are they cleaning out the bowel fully enough at each irrigation? Once the body has successfully adopted an ostomy irrigation schedule, the patient may be able to wear only a small stoma cap appliance over the stoma in between irrigations. Ostomy irrigation procedures should be taught to the patient by an experienced enterostomal therapist or certified ostomy specialist/nurse. See below for a typical colostomy irrigation procedure. Remember, irrigation procedures as an ostomy management option should only be offered to those individuals with descending colon colostomies. The scientific literature does not support ostomy irrigation for any other type of ostomy. 

PICTURE HERE

Typical Descending Colostomy Irrigation Procedure:

1. Select the same time of day every time for irrigation

2. Allow 1 hour for entire procedure

3. Gather supplies

4. Close the clamp on the irrigation appliance tubing.

5. Fill irrigation bag with 1500-2000 ml of tepid (not cold, not really warm) water.

6. Hang the bag from a hook in the bathroom near the toilet.

7. Attach cone to end of irrigation tubing that is connected to irrigation bag.

8. Apply a water-soluble lubricant such as K-Y jelly to the cone.

9. Remove ostomy pouch or stoma cap from the wafer or flange, but leave the wafer or flange attached to the abdomen.

10. Gently insert lubricated cone tip into the stoma.

11. While holding the cone in place, slowly open irrigation tubing clamp to allow slow gradual filling of the colon with the tepid water. Close the clamp if any colon cramping is experienced and wait a few minutes before resuming irrigation at slower fill rate.

12. When irrigation slows and the colon will not accept any more water, close the irrigation clamp and remove the cone from the stoma.

13. Attach irrigation sleeve (very long pouch) to wafer/flange on the abdomen. This sleeve can be clamped at the end and worn in place while ostomate walks around the house, drinks a cup of coffee, read the paper, etc. For 20-40 minutes, until ostomy starts emptying the bulk of irrigation water and colon contents. At this time, ostomate may wish to return to the bathroom and unclamp irrigation sleeve/pouch, allowing contents to be emptied into the toilet. Ostomates may sit or stand for this procedure. It will likely take at least 20 minutes for the colon to empty. 

As far as follow-up, typically, new ostomates should be seen 2 weeks postoperatively by an ostomy specialist, and then in routine follow-up visits every 4-6 weeks x 6-12 months and then annually and as needed. Ostomy supplies after the first month or so, when the best appliance has been determined for the patient’s needs, should be ordered for 3 to 12 months refills, as the patient’s insurance coverage allows.

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 1/3^rd 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:

1. 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).
2. 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.   
3. 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. 
4. Typically first thing in the morning before eating or drinking anything is the best time to change appliances.
5. 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.  
6. 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).
7. 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.
8. 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).  

The most common problems new ostomates have tend to be related to leaking and peristomal skin irritation, although dehydration (especially with ileostomies), surgical site infection, stomal stricture or retraction, stomal granulomas (benign growths), and mucocutaneous separation (the surgical suture line around the stoma pulls apart) may also occur (J. C. R. M. C. Colwell, Goldberg, & Carmel, 2004; Ratliff, Scarano, Donovan, & Colwell, 2005; Richbourg, Thorpe, & Rapp, 2007; J. C. Colwell & Beitz, 2007; Kann, 2008; Goldberg et al., 2010; Gray et al., 2013; Sheetz et al., 2014).

Taking appropriate steps to prevent or minimize appliance leaking and keep the skin around the stoma intact should be one of the highest priorities of the healthcare provider helping to manage ostomy stoma care.  

Skin irritation due to moisture includes the potential for fungal skin infections. Addressing leaking appliances as soon as possible can avoid this complication. However, if fungal infection is a problem, a light dusting of miconazole 2% topical powder alternating and blotting with skin barrier wipe to seal it in (alternate this up to 3 times) before applying a wafer and changing the wafer every 2-3 days may be helpful (Grove, et. al., 2019). Other not so common complications seen in ostomies include pyoderma gangrenosum (peristomal skin complication), varices, polyps, and cancerous growths.        

While any growth on a stoma should be checked by a health care provider familiar with ostomies, the most common growths are granulomas. They are small round raised growths on the stoma (usually smaller than a pencil eraser in diameter) – and usually the same pink color as the stoma. These may occur from mechanical irritation, or for unknown reasons. They are typically benign and may bleed easily. These may be controlled by chemical cauterization of the lesion itself with a silver nitrate stick and may require re-treatment in 2 to 4 weeks. *Please note, any discolored lesion or unusual growth on a stoma warrants inspection by an experienced health care provider and sometimes, biopsy.

Another fairly common peristomal complication is a peristomal hernia (a bulging around the base of the stoma from a hernia formation at any time post-operatively). This is typically managed non-surgically by the application of a hernia binder: a strong elastic binder which goes around the abdomen but has a circle cut out corresponding to the stoma site, which allows the pouching appliance to be pulled through after the binder is applied. These binders are available in various widths from 3 inches to 12 inches wide (www.nu-hope.com). The elastic binder is measured for the patient’s abdominal girth and applied, fastened with Velcro. If hernia binders do not adequately manage the hernia symptoms, surgical intervention may be considered. However, there is a high rate of hernia recurrence. Close follow-up by healthcare providers is the key to minimizing complications (Pearson, et. al., 2020).

Grove, G. Houser, T., Sibbald, G. and Salvadalena G. (2019). Measouring epidermal effects of ostomy skin barriers. Journal of International Society for Bioengineering and the Skin. 25:2. Pp 179-186.

Howson, R. (2019) Stoma education for the older person is about keeping it as simple a:s 1, 2, 3. Journal of Stomal Therapy Australia. 39:3 pp 20-22.

Pearson, R. Knight, S. Ng, J., Robertson, I. McKenzie, C. Angus, M. (2020). Stoma-related complication following ostomy surgery in 3 acute care hospitals: A cohort study. Journal of Wound, Ostomy and Continence nursing. 47:1. Pp 32-38

Sheetz, K. H., Waits, S. A., Krell, R. W., Morris, A. M., Englesbe, M. J., Campbell, D. A., Hendren, S., ... Hendren, S. (January 01, 2014). Complication rates of ostomy surgery are high and vary significantly between hospitals. Diseases of the Colon and Rectum, 57, 5, 632-637.