Ostoma-Tology: Colostomy, Ileostomy, Urostomy

Approximately 725,000 to 1 million individuals in the United States have a continent diversion, and around 100,000 new ostomy surgeries are performed each year in this country (Burgess-stocks, 2022). Healthcare providers are likely to care for an individual with an ostomy in many settings (such as home care, inpatient acute care, emergency room, long-term care, primary or ambulatory care, or at a correctional facility). Nurses, primary care providers, and other healthcare specialists need to be knowledgeable of at least a few basics related to the assessment, care, and pouching of the person with an ostomy (often referred to as an 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.

Early attempts at ostomy surgery have been reported since the 1750s, but without anesthesia, antibiotics, or drainage collection devices, the outcomes were poor.

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

The role of the clinician working with an ostomy patient is that of an educator. The first encounter with a patient with an ostomy is critical, and when it takes place, it is equally important. For a patient who is preparing for surgery that will result in the creation of an ostomy, the clinician should preferably meet with the patient weeks or days prior to surgery. An optimum time would be during one or more visits to the provider's office; this is an opportunity to give a broad overview of what an ostomy is, allowing the patient to see and handle ostomy supplies, such as a pouch, clip, and wafer. During this time, providers should address questions from the patient, significant other, or family. Arranging for the patient to meet with an 'ostomy visitor' who has successfully gone through similar surgery can help lessen the patient's anxiety and provide reassurance. Permission from the patient must be obtained before arranging such a visit.

One thing the clinician must keep in mind is that the ostomy is probably not the patient's main concern. Their attention is focused on the disease or malfunction that necessitates surgery. The clinician can begin to gauge the patient's understanding of an ostomy by asking them what their surgeon has told them. The clinician should confirm this with the surgeon for a patient who is adamant that this will be a temporary ostomy and they don't need to spend time learning about it. If there is a possibility that the ostomy may end up being permanent, then it is important that the surgeon clarifies this with the patient.

Another scenario is a patient who ends up in the emergency department with severe abdominal pain or a traumatic injury, goes to surgery and wakes up with an ostomy. In these cases, there is no time for education or emotional preparation. These patients are often overwhelmed by the sudden change in their lives. They are grappling with what has happened and are not emotionally ready to learn about ostomy care.

The clinician must familiarize themselves with the case history and get input from the nursing staff caring for the patient and, if possible, the primary care provider and surgeon before interviewing the patient. Another important resource person is the social worker or case manager. They can advise the clinician about the patient's discharge plans and ask if there are concerns about the discharge. Does the patient need to go to a short-term rehabilitation center or skilled nursing unit before going home? The clinician will also need to ask about whether the patient's home environment is conducive to recuperation and ostomy care. This author encountered a patient in a clinic who had been discharged from another facility to a trailer home where the utilities and electricity had been cut off. In this care, the clinician and social worker must work together to review the patient's medical insurance coverage and sources for ostomy supplies. It is the patient's choice where to obtain ostomy supplies from. However, patients who have had no preparation for ostomy creation will need a great deal of help and guidance from the clinical and social worker with this step.

It is essential that patients going home with an ostomy have home healthcare. The patient may be resistant to having a 'stranger coming into my home.' It may appear as another step in losing control of their lives. The clinician needs to validate the patient's feelings and explain that home healthcare will help them regain their independence more quickly. Frequently, a patient will say, "My wife/husband/ partner will take care of it." This can be an assumption on the part of the patient without consulting their spouse or partner. The spouse or partner may or may not be willing to take on ostomy care. They may feel resentful, overwhelmed, or anxious about what is also a sudden change in their lives. A spouse or partner willing to become the caregiver will need ostomy education and training; the clinician can point out this to the patient, and the spouse or partner can reinforce this.

Hospital stays are short, and the clinician in the facility will have a very short window of time to work with the patient with a new ostomy. To maximize this time, priorities need to be set. The issues discussed above about preparing for discharge all need to be taken care of. The clinician may have the urge to cram in as much ostomy education as possible, "please read this, watch this, tell me any questions you have." However, this approach rarely works unless the patient is highly motivated to learn. The clinician's first meeting with the patient should focus on getting to know the patient, putting them at ease, and asking if they have any questions. The first meeting may often seem to be unproductive; the patient may have little to say, be withdrawn, resentful, or angry. The clinician can leave educational materials with the patient and suggest that if the patient feels up to it, they should look through them before their next visit.

The next important step while the patient is in the facility is for the clinician to change the ostomy pouch; this allows the clinician to inspect the stoma, to ensure that it is functioning properly, to observe the condition of the peristomal skin area, and to determine if the ostomy pouch being used is the best choice, given the characteristics of the stoma. Determine if the patient has a partner or caregiver willing to be involved in ostomy care, even if only as an observer, and if possible, have them present when the clinician does the first pouch change.

Perhaps the most important advice to give a patient with a new ostomy is that ostomy care is not difficult. They may not believe you at first, but if you can relate ostomy care to something in the patient's life, this is a good place to start. What was, or is, the patient's occupation and hobbies? Someone whose occupation requires using their hands, such as precision and accuracy with measurements or numbers, has transferable skills that can assist with ostomy care. One key component of care is sizing the stoma size and adjusting the wafer opening as needed. A patient or caretaker who sews will also have skills that can be employed in ostomy care.

The clinician should allow plenty of time for the first pouch change and talk through the steps with the patient and caretaker, if present, in an unhurried manner. Gather the supplies to complete the procedure, which includes washcloths or disposable wipes for cleaning towels for drying around the stoma. A receptacle, usually a bedpan, is used to empty the pouch before removing it. Usually, for this first pouch change, the patient will be in bed, but when they are up and about at home, they can empty the pouch directly into the toilet. A good tip to share with the patient and caretaker is to put a layer of toilet paper in the toilet before emptying to prevent splashing.

The clinician should demonstrate removing the clip from the end of the pouch, unfolding it, and emptying it; this is the most essential step that the patient must be able to do before going home. Once the new pouch is applied, the clinician will demonstrate how to apply the clip and then have the patient or caretaker do a return demonstration. Once the clinician has taught the patient how to empty the pouch, the clinician needs to reinforce with the nursing staff on the unit that the patient is able to empty their pouch with standby assistance from staff. These opportunities for the patient to practice emptying the pouch before discharge are critical. The clinician should follow up with the nursing staff to ensure this is happening and get feedback from the staff on any problems or concerns the patient has. It is not uncommon for the patient to tell the nurses that they have been taught how to empty the pouch, and once they are home, they will do it – but in the hospital, they want the nursing staff to do it.

The first home health care visit should occur the day after the patient is discharged. The first 24 hours at home can be very stressful for the patient. There is no call bell or nursing staff around to respond if they have a problem. As part of their discharge the facility clinician must ensure that the patient and family have a contact telephone number for the home health agency and when to expect their first visit. Although patients with new ostomies may not be discharged home either in the short term or long term, this course will focus on the care of the patient in the home setting since this is the most challenging, and many facets of the content are applicable to patients in other discharge settings, such as long-term care or assisted living.

The clinician's first visit to the patient at home should focus on the following primary goals, although others can be added at the clinician's discretion and as time permits.

The primary goal is for the clinician to establish a good rapport with the patient and significant other or caretaker. One of the best ways to achieve this is to listen closely to what the patient and significant other have to say, as well as their fears, concerns, and sometimes anger and frustration about the situation they find themselves in. The clinician may not have answers to many of these issues, but they can direct the patient to resources that may be able to provide more help, such as the case manager or social worker who works with the home health agency.

The next important goal is to establish the role of the home health clinician, which is that of an educator. It is important that the patient and family understand that the clinician is not there 'to do' the ostomy care but to teach self-care to the patient with the assistance of family or caretaker as needed. There is a limit to the number of home health visits set by the payer source, and it is critical to ensure that each visit is used as a step toward patient independence in ostomy care. The patient, significant others, and the clinician will develop a plan of care for the patient. This will include:

• The frequency of visits.
• What the patient and significant other will achieve at each visit.
• Troubleshooting any problems that may arise.

Another goal for the first visit is to determine the suitability of the patient's home environment for ostomy care and any modifications that might be needed. Depending on the clinician's background (nursing, physical therapy, or occupational therapy), they may have unique skills in evaluating a home setting. The patient may point out concerns they have, such as finding the toilet too low to sit on and empty the ostomy pouch. The clinician may recommend a raised toilet seat and explore with the patient and family ways of obtaining one.

With each home visit, the patient and family should learn another step in ostomy care until they can independently demonstrate emptying and changing the ostomy pouch.

The clinician should also review the patient's current medication profile. Problems with the absorption of medications can arise related to the type of ostomy created. For example, depending on the length of the small intestine removed, extended-release medications may not be absorbed at all or incompletely absorbed. The clinician needs to advise the patient and caretaker to discuss this with their pharmacist.

The important questions that the patient and caregiver will need answers to include:

• How often should the pouch be emptied?
  • 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 to 1/2 full to prevent the weight of the pouch from pulling the wafer away from the skin. Because closed-end pouches are meant to be disposable, they are most often appropriate for colostomies, in which the pouch may only need to be changed once daily or every couple of days.
• Is stoma care going to be painful?
  • No, there are no sensory nerve endings in the stoma, which means that the patient does not experience any sensation.
• How often should the stoma be assessed?
  • The stoma and surrounding skin surfaces should be carefully assessed each time the pouching system is changed. Since the stoma has no sensory nerve endings, the patient may not be aware of whether the stoma becomes lacerated or injured. The patient and caretaker are advised that the best way to prevent injury to the stoma is by always using a gentle technique when doing ostomy care. The pouch is first emptied, and then the pouch and wafer are gently removed, starting at the top and slowly pulling it away from the skin. Measuring guides are used carefully. Don't force a measuring guide that is too small over the stoma. Ensure that the edges of the measuring guide are smooth. The stoma can be gently rubbed and cleaned with a moist washcloth. Cleaning of the peristomal area should also be done with a gentle touch (United Ostomy Association of America [UOAA], 2023).
• Should the patient or caretaker be concerned if the stoma is bleeding?
  • The stoma may have slight bleeding when it is being cleaned, which is not a concern. A stoma requires a good blood supply to stay healthy. However, suppose the patient or caretaker notices that blood is coming from inside the stoma, which could be a sign of intestinal bleeding, or they see blood in the stool or ostomy pouch. In that case, they need to contact their healthcare provider or ostomy clinician immediately.
• Does the pouch need to be rinsed out every time it's emptied?
  • No, the pouch does not need to be rinsed. However, this is a personal choice; some feel more comfortable rinsing the pouch. But this practice can weaken the adhesive seal.
• Is there going to be an odor from the pouch that people will be able to detect?
  • No, there should be no odor. Ostomy pouches are made to be odor-proof. This means that the odor stays in the pouch. When the pouch is emptied the person emptying the pouch will detect a fecal odor. But this is the only time that it should be noticeable. If this is stressful for the person emptying the pouch, there are in-pouch deodorants and odor eliminators that can be used. Keeping the bottom edge of the pouch clean is also important in preventing an odor.
• Is it possible to prevent the pouch from ballooning up with gas?
  • There are pouches made from charcoal that are available with gas filters. They allow gas to escape from the pouch while absorbing odor. However, these do not work as well when the stoma effluent is very liquid, which is standard with an ileostomy. Liquid stool can block the filter.
• What can be done to ensure that the pouching system is going to stick to the skin?
  • The skin barrier wafers that hold the pouching system in place are pressure-sensitive. A good seal depends on the wafer making maximum contact with the skin surface. One intervention the patient can do to aid this process is to apply gentle pressure to allow the wafer adhesive to come in full contact with the skin contours. After applying the new pouching system, the patient folds both hands over the wafer while resting comfortably. It is not necessary to lie down after changing the pouch, but if possible, the patient should avoid getting up and becoming active immediately afterward; this will also help the pouch to adhere more securely (Carmel et al., 2021).
• If the pouch starts leaking around the wafer a day or two before it needs to be changed, is it okay to seal it with tape?
  • No, once the pouch starts leaking, it needs to be changed. Adding tape may keep the pouching system in place, but the drainage leaking on the peristomal skin can cause severe excoriation.
• How does a healthy stoma look?
  • Stomas should be "nicely budded," sitting about 1 ½ to 2 inches above skin level on the abdomen. However, this is a description of the 'idea' stoma; in real life, many stomas don't look like this. Stomas can be different, and challenges present at the time of surgery can result in stomas that are flat at skin level or retracted, which means they are below skin level. Despite their appearance, these are all functioning stomas. However, they can pose a challenge for pouching, which we will discuss further in the next section dealing with pouching appliances.
  • Most stomas are a deep red color, apart from a ureterostomy, which is usually pale pink. The stoma should be moist and will be edematous in the immediate post-operative period. The edema will decrease gradually over the first 6-8 weeks after surgery (Carmel et al., 2021). As the edema resolves, the size of the stoma will change and become smaller. The os (opening of the stoma) should be nicely centered. However, in certain instances, this may not be the case. The clinician should ensure they can identify where the stoma opening is positioned and make the patient and caregiver aware of this. The stoma should be free of discoloration or growth.

Today, patients with ostomies have a wide variety of products to choose from. 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 (UOAA, 2023).

The pouches and wafers that attach to a person with an ostomy to allow the drainage, 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). The second is the two-piece pouching system.

• One-piece pouching system: An advantage of using a one-piece system is that it may provide more flexibility than a two-piece system and provide a better seal for stomas that are located in skin folds.
• Two-piece pouching system: This system has the advantage of allowing the patient to see the stoma while applying the wafer, which can help with good placement of the wafer. Another advantage of the two-piece system is that it permits the patient to change the ostomy pouch without having to change the skin barrier. For example, the patient may prefer to wear a smaller pouch during the day when they can empty it frequently and change to a longer one for nighttime use.

In the early days after stoma creation most patients feel more comfortable sticking with the pouching system that they start out with in the facility. However, the clinician should advise them that there are more options to choose from that may suit their lifestyle.

The wafer can come in two distinct shapes, either flat or convex. The flat wafer usually works well when the stoma is well-budded, and the peristomal skin surfaces are flat. However, if the stoma is either at or below the peristomal skin level, a convex wafer is a good choice. These wafers come with varying degrees of convexity, and their goal is to assist the stoma to protrude above skin level so that an adequate seal can be obtained. Another feature of convex wafers is that they can be soft, bendable, or firm. This means that for practical use, the soft convexity will bend with the body contours. Firm convexity does not bend and remains firm, helping to keep skin creases and folds flat. Deciding on the most appropriate type of wafer to use is key to preventing stoma leakage. The clinician can begin by assessing the stoma with the patient in different positions. For most people, lying supine will create a flat abdominal surface; however, in the sitting or standing positions, abdominal folds and creases can be apparent, and at times, the stoma will 'disappear' in abdominal folds.

Deciding on the steps to take next can be challenging and can depend on the clinician's level of experience with ostomy care. Some clinicians may need assistance, and most home health agencies should either have a certified ostomy clinician on staff or consult with one. A good recommendation is that both clinicians do a home visit together so that the homecare clinician can get firsthand experience of the interventions proposed by the certified ostomy clinician. If this option is not available, the clinician can call and speak with the ostomy clinician at the company where the patient is getting their ostomy supplies from. Some companies now offer the option of telehealth consultations. The homecare clinician needs to discuss with the patient if this is something they would be comfortable doing and check with the ostomy company if there are charges for this consultation. Before changing completely to a different wafer, it is wise to ask the ostomy company for samples of different types of convex wafers. The clinician and the patient can try these out and determine which one works best for the patient.

A person with a colostomy may be able to expect up to 5 to 7 days of wear time out of a one-piece, drainable appliance. A drainable appliance 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. A good rule of thumb to share with the patient and caregiver is that if the pouch system begins to leak on day six or whatever, make day five (or the day before leakage) the regular changing day. The goal is to prevent effluent from coming in contact with the peristomal skin.

The pouches for urostomies are slightly different than pouches for fecal diversions. Urostomy pouches typically have an anti-reflux design built into the pouch itself to discourage the backflow of urine when the individual is reclining (maybe 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. Still, they would clog up quickly with fecal matter if these pouches were used incorrectly with ileostomies. The urostomy drainage system can be connected to an overnight collection bag using a special adaptor; this prevents the need for pouch emptying during the night and allows the patient an undisturbed night's sleep.

Typically, the amounts of ostomy supplies covered by insurance companies are set by the usual amounts covered by Medicare.

Stoma measurement guidelines:

The stoma should be measured to ensure the proper size of the wafer/barrier opening so that no skin is visible around the stoma when the appliance is in place. A newly created stoma should be measured every two weeks. 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. The paste is of two types, one with alcohol and one that is alcohol-free. The latter is the best option for patients with denuded skin around the stoma since it will prevent burning and discomfort. Paste is not recommended to be used with those who have a urostomy since urine rapidly erodes the paste, and no advantage is obtained from its use.

A round stoma is the simplest to measure with the circular guides provided with the ostomy supplies. However, for an irregular or oval-shaped stoma, the clinician may have to create their own measuring guide; this can be done by placing a piece of clear plastic over the stoma and using a pen or sharpie to trace the outline of the stoma. Transfer the outline to a piece of soft cardboard or strong paper. Gently place the finished template over the stoma and adjust the size as necessary. Remember to start small; you can always make it bigger, but you will have to start again if the template is cut too large (UOAA, 2023).

Once the stoma has reached its permanent size, another option for the patient is wafers with a precut opening. However, this option only works with a round stoma, but it can be helpful for a patient who prefers not to have to cut out the opening or for someone who finds it difficult or impossible to do.

The three main types of stoma wafers are:

• Cut-to-fit
• Precut round
• Moldable, stretch to fit

The cut-to-fit usually has a small opening that is used as a starting point to cut the barrier to fit the size and shape of the stoma. The moldable, stretch barrier should not be cut. The patient or caretaker is taught to use their fingers to roll back and shape the opening to fit the stoma.

Ostomy pouch accessories:

There is a wide range of ostomy accessories, some more beneficial than others. Patients and caretakers will often find these in vendor catalogs and may ask the clinician about them. Some useful accessories, as well as the paste and seals mentioned above, include stoma belts, pouch liners, and pouch covers.

• Stoma belts can only be used with pouching systems with belt tabs on each side. They come in several different sizes and are usually adjustable. The belt is applied securely around the patient's body and helps to improve the pouch seal. It is important for the clinician to educate the patient and caretaker not to apply the belt too tightly, as the added pressure can cause skin damage. For many ostomates, stoma belts give them an extra sense of security, especially when they are going out in the community.
• Pouch liners: These can be used with the two-piece pouching system. The liner is put inside the pouch to gather the effluent from the stoma. When it is time to empty the pouch, it is disconnected from the wafer, and the liner is removed and can be discarded into the toilet. A new liner is then placed in the pouch and reconnected to the wafer.

Care of the surrounding skin:

Peristomal skin irritation (irritation to the skin immediately around the stoma) is the most common post-op complication for all ostomies. Some important patient and caretaker education to prevent peristomal skin irritation include:

• When changing the ostomy system, gently but thoroughly clean and dry the peristomal area.
• If the patient has 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. Shaving the hair will allow for a better seal and atraumatic removal of the pouching system when it is changed.
• Do not use any bath soap that contains moisturizers on this skin (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 on 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 protective coating on the skin that will help the appliance stick better while protecting the skin from all moisture.
• Consider using ostomy paste, seals, and 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's use from it!
• If there is a lot of leftover adhesive on the peristomal area from the previous appliance, remove it gently with an adhesive remover wipe, 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.

Changing ostomy appliances:

• Typically, the 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.
• Urostomy patients could use a ¼ vinegar solution (described above in #1) to rinse their urostomy pouches and nighttime drainage containers and let them air dry; this will help reduce urine odors.
• A gentle push-pull technique is used to remove the ostomy appliances. Starting at the top of the wafer, the patient or caretaker uses one hand to push the skin back from the appliances, and the other hand is used to pull it away from the skin carefully. Patients and caretakers must be advised not to get into the habit of quickly yanking off the appliance, as this can cause stripping of the epidermis's upper layer and leave the peristomal area susceptible to excoriation.
• At the first sign of any peristomal skin irritation, a person with an ostomy should contact their healthcare provider and be seen as soon as possible to prevent further skin breakdown, which may make pouching very difficult. Signs of peristomal skin problems include a burning sensation, itching, or pain under the wafer.
• The clinician should teach the patient that when applying a new ostomy system, place the opening, or spout, of the pouch at the six o'clock position, as this will make emptying easier.

Patients with ostomies should have their stoma examined at least annually as part of their overall general healthcare and head-to-toe physical examination. Healthcare practitioners should be familiar with typical normal and abnormal findings (in general), which are 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 asks 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 healthcare professionals know what is available and how to use them? It is not unreasonable for patients to expect their healthcare provider to be familiar with ostomy stoma care and management. Patients and caretakers should be advised to bring a small bag of ostomy supplies with them whenever they leave home, including a new pouching appliance. The post-operative plan for a patient with a new ostomy may recommend at least one follow-up appointment at an ostomy outpatient clinic, where they can be seen by a skilled ostomy clinician.

Some patients with colostomies (with proper education and supplies) may be able to irrigate their colostomies every 1-3 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. Other considerations for successful ostomy irrigation include a patient with good eyesight and manual dexterity. It is also important to assess the current functioning of the patient's ostomy. If the patient has 1-2 semi-formed or formed stools daily, they are considered good candidates for irrigation. 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 2000 cc. 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 to adjust the water flow 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. Patients who consider irrigation as a management option require much education and support.

Patients should be instructed to allow at least 45 minutes 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 wearing full-sized ostomy pouching appliances until their colostomy moves 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 every other day schedule. Maintaining this schedule is extremely important for their success, as the body should develop a regular pattern within 4 to 6 weeks of routinely scheduled irrigations. They may also wish to consider how much fluid they use 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.

Typical descending colostomy irrigation procedure:

1. Select the same time of day every time for irrigation.
2. Allow one hour for the entire procedure.
3. Gather supplies.
4. Close the clamp on the irrigation appliance tubing.
5. Fill the irrigation bag with 1500-2000 milliliters (mL) of tepid (not cold, not really warm) water.
6. Hang the bag from a hook in the bathroom near the toilet.
7. Attach the cone to the end of the irrigation tubing connected to the irrigation bag.
8. Apply a water-soluble lubricant such as K-Y jelly to the cone.
9. Remove the ostomy pouch or stoma cap from the wafer or flange, but leave the wafer or flange attached to the abdomen.
10. Gently insert the lubricated cone tip into the stoma.
11. While holding the cone in place, slowly open the irrigation tubing clamp to allow slow, gradual filling of the colon with tepid water. Close the clamp if any colon cramping is experienced and wait a few minutes before resuming irrigation at a 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 the irrigation sleeve (very long pouch) to the wafer/flange on the abdomen. This sleeve can be clamped at the end and worn in place while the patient walks around the house, drinks coffee, reads the paper, etc., for 20-40 minutes until the ostomy starts emptying the bulk of irrigation water and colon contents. At this time, the patient may wish to return to the bathroom and unclamp the irrigation sleeve/pouch, allowing contents to be emptied into the toilet. Patients may sit or stand for this procedure. It will likely take at least 20 minutes for the colon to empty.

Post-operative complications can broadly be divided into two categories: peristomal skin problems and stoma complications.

The most common problems with new ostomies 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.

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 a 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.

While maceration of the peristomal skin surface can happen with all ostomy types, it is most commonly found in patients with urostomies. It is important that the stoma opening on the wafer is correctly sized to prevent urine from pooling on the peristomal skin surface.

Pseudoverrucous lesions are thickened irregular areas that develop on the peristomal surface. They are caused by chronic exposure to stoma drainage, which results in repeated skin irritation. They may appear as white, grayish, or dark red papules. Patients may complain that the lesions are itchy, bleed easily, or interfere with obtaining a secure wafer seal. The primary management intervention is to prevent stoma drainage from coming in contact with the peristomal area, which should resolve the problem. Further treatment may require the patient to be seen by a wound care specialist or their primary care provider. If there is any doubt about the etiology of the lesions, or they are not resolved with standard interventions, a skin biopsy may be needed.

Other not-so-common complications seen in ostomies include pyoderma gangrenosum (peristomal skin complication), varices, polyps, and cancerous growths. Stoma complications can be divided into two categories: early complications that usually happen within 30 days post-surgery and late complications that occur at least 30 days post-surgery.

One of the most common early stomal complications is stomal necrosis, which is the death of the stomal tissue resulting from diminished blood flow. The mechanism that causes this is the strain on or insufficiency of the mesenteric vasculature. Stomal necrosis can develop more frequently in the presence of obesity. The evident sign of necrosis occurring is a change in the color of the stoma, which can progress from pink to black. Any change in stomal color needs to be promptly evaluated by an ostomy specialist or the surgeon who created the ostomy. One of the important factors is determining the extent of the necrosis, which determines the treatment approach. If it is established that the ischemia and necrosis are superficial and occurring above the level of the fascia, no interventions other than close observation may be warranted. The top layer of the stoma will usually shed, exposing a red, viable stoma in its place. Surgical intervention may be needed if the necrosis occurs at a deeper level.

Another complication that may be observed is stomal retraction; this description is typically used for a stoma that disappears below the level of the skin or is situated at the skin level. There is some suggestion that this condition may be more common in overweight and obese patients. A retracted stoma can cause significant problems with pouching and obtaining an adequate seal around the stoma. The use of a convex pouching system and an ostomy belt may be helpful. In some severe cases, a new stoma may need to be created.

A peristomal hernia (a bulging around the base of the stoma from a hernia formation at any time post-operatively) is considered to be a later stomal complication, and many occur during the first year after surgery. A peristomal hernia is typically managed non-surgically by the application of a hernia binder: a strong elastic binder that 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. The elastic binder is measured for the patient's abdominal girth, applied, and fastened with Velcro. Surgical intervention may be considered if hernia binders do not adequately manage the hernia symptoms. 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).

Stomal stenosis is another late complication; this occurs due to the narrowing or shrinkage of the stoma at the skin level or deeper fascia level. The patient may complain of pain with stomal evacuation and note that stools are small and thin. However, the patient can also experience constipation followed by loud passage of a large amount of stool with a lot of gas. Patients with urostomies and stomal stenosis may present with recurring urinary tract infections, flank pain, and projectile urine flow. Conservative management of mild stenosis is recommended, including stool softeners, a low-residue diet, and increased fluid intake. Stomal dilation can be done by a qualified clinician who is experienced in this procedure. A dilator is carefully introduced into the stoma to increase its size gradually. However, it should only be used as a short-term practice. More serious cases of stomal stenosis may require surgical intervention.

When patients with ostomies 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 ensure 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 that one could find on the internet made especially for waterproofing the ostomy appliance during such activities (example: here).

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 has a lot of very useful information on their website for patients, 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. Robert A. Winfree, PhD, provides useful 'tips and tricks' for those traveling with an ostomy, such as never checking in medical supplies when flying and standing up often to prevent tubing from getting kinked when wearing a drainage bag (Winfree, 2024). Intimacy concerns may be minimized by utilizing a variety of different ostomy appliance covers and special underwear, swimwear, and lingerie made specifically for patients with ostomies (example of one website here). 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 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 surgery (which may potentially result in an ostomy) have a pre-operative 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 that the surgeon typically does the "surgical site" marking the day of surgery, where they intend 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 and skin folds, which are too close to the midline, outside the rectus muscle, and outside the 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 to make a referral to an experienced ostomy clinician as soon as possible after the complications are noted to avoid further deterioration (Carmel et al., 2021; Pearson et al., 2020).

Some emotional challenges that a patient with an ostomy may face, especially in the early post-operative period, include problems with self-image and self-esteem. After the patient has completed the initial phase of recovery, physical appearance, body image, and concerns surrounding sexuality become more predominant. Support from significant others, consultation with an ostomy specialist, and discussing concerns with the surgeon who performed the ostomy are important.

Ostomy patients will frequently observe others' reactions to the stoma and mirror what they see. If, for example, a significant other is squeamish about being in contact with the stoma and finds it distasteful, this will have a negative impact on the patient's self-image and self-worth. The clinician needs to be aware that some aspects of ostomy education need to focus more on the significant other than the patient. One of the best resources available to ostomates, significant others, and family members is ostomy support groups. Clinicians working with ostomy patients need to know what ostomy support groups are in the vicinity and who the contact persons are. These groups provide support, encouragement, experience, and an accepting environment. These groups are often led by an ostomy specialist who can answer questions and provide valuable information.

Areas of sexual concern and how the surgery would affect sexual functioning should be part of the discussion with the surgeon both in the pre-operative and post-operative phases. If the patient still has questions about sexuality after ostomy creation, the clinician should encourage them to discuss these issues with their surgeon. One of the primary questions that needs to be addressed is when the patient can resume sexual activity after surgery. The surgeon's recommendation about this should be followed. Some basic information that the clinician can give the patient regarding sexual activity includes fostering open and honest communication between the patient and their partner preparing for sexual activity by having a clean and securely attached pouch in place. Also, the importance of never using the stoma for sexual activity since this could cause significant damage to it.

Scenario

Susan is a 54-year-old female who is in the hospital after surgery, where a fecal diversion was created. Susan is depressed that she had to have this procedure and now has a negative self-image. In order to be discharged from the hospital, Susan must learn to perform ostomy care.

Interventions/Strategies

The nurse practitioner caring for Susan knows that the hospital stay after this procedure is short, and they must set priorities and educate the patient while helping the patient have a positive self-image. The nurse practitioner informs the staff to teach the patient how to perform the necessary care while maintaining a positive self-image and working alongside the patient.

Discussion of Outcomes

After discharge, the patient was visited by an ostomy clinician. The patient seemed more positive and was motivated to show the ostomy clinician what she had learned and how she was progressing in her own care.

If the nurse practitioner had hastily approached Susan's care without sympathy, the patient might not have been as willing to learn, potentially creating obstacles in home care and further increasing her negative self-image.

• Burgess-Stocks, J., Gleba, J., Lawrence, K., & Mueller, S. (2022). Ostomy and Continent Diversion Patient Bill of Rights: Research validation of standards of care. Journal of Wound, Ostomy, and Continence Nursing, 49(3), 251–260. Visit Source.
• Carmel, J. E., Colwell, J. C., & Goldberg, M.T. (2021). Wound, ostomy, and continence nurses society core curriculum: Ostomy management. (2nd ed.) Wolters Kluwer. Visit Source.
• Pearson, R., Knight, S. R., Ng, J. C. K., Robertson, I., McKenzie, C., & Macdonald, A. M. (2020). Stoma-related complications following ostomy surgery in 3 acute care hospitals: A Cohort Study. Journal of Wound, Ostomy, and Continence Nursing, 47(1), 32–38. Visit Source.
• United Ostomy Association of America (UOAA). (2023). Understanding stoma and ostomy basics. United Ostomy Association of America. Visit Source.
• Winfree, R, A. (2024). The Phoenix Magazine, 19(23), 46-49.