What is a colostomy?
A colostomy (referred to as stoma) is a piece of colon that is brought through the skin to provide the body with an alternative way to eliminate the waste of digestion. Patients with medical conditions such as inflammatory bowel disease, colorectal cancer, or emergency bowel surgery can require colostomy as part of their treatment. Its main purpose is to divert the fecal stream. For some patients a colostomy is used as a permanent treatment but for some it is a temporary measure which is reversed at a later phase. There are 2 types of colostomy: end colostomy [Figure 1] and loop colostomy [Figure 2].
When a colostomy is in place, the stool comes out through it instead of the anus. In most patients, the output from a colostomy is formed and similar in consistency to stool. If a colostomy is created using the ascending or transverse colon, the output can be softer and more liquid in the early recovery period [Figure 3]. Ensuring a proper fit of the appliance to collect the waste is an important part of your care. Failure to properly care for your stoma on a daily basis can lead to skin irritation. While a colostomy is a life changing event, the majority of patients learn how effectively manage their stoma and after a period of psychological and physical adaptation they can lead successful and productive lives.
You will be able to resume physical activity gradually after surgery [see section on Post Abdominal Surgery Care for general information]. However, in the long-term avoid very heavy lifting and contact sports, such as football, wrestling, and martial arts. It is important to secure your pouch well to the skin and wear a pouch belt. For sports like running or jumping, consider wearing a close-fitting underpants or sport brief that can keep your pouch snug against your skin. If you are concerned about excessive sweating or getting the pouch wet, you can use a waterproof tape along the edges of the pouch.
Wearing a pouch
Dr. Maher Abbas and his team will discuss with you the general care of the colostomy. You will get daily teaching by the nursing staff while you are hospitalized. After discharge you will return to the clinic and seek the assistance of an enterostomal nurse (specializing in colostomy care). The first step is choosing the best area to place the colostomy. This allows you to properly care for it and be able to wear your clothes comfortably. For most patients, a colostomy is placed in the left lower aspect of the abdomen but in some cases other areas are chosen. The pouch you wear on the skin can be 1 piece or 2 pieces [Figure 4 and Figure 5]. The pouch needs to stick to your skin well and the opening needs to match the size of the stoma. Cutting too wide of an opening can lead to skin irritation and if made too small it can rub against the stoma and make it bleed and inflamed along the edges. The size of the stoma will change the first few weeks as the swelling from surgery resolves. You will need to adjust the opening in the pouch. Ideally each appliance pouch should remain on the skin for 3 to 5 days. It is important to keep the skin dry. The use of an adhesive skin barrier can be helpful. Clean the skin carefully every time you change the pouch. If you are hairy, keep the area as hair free as possible using an electric razor or a round ended scissors. Opaque pouches and fabric pouch covers keep the waste from being visible. The use of a fabric pouch cover makes wearing the pouch more comfortable by reducing heat build-up between the plastic pouch and your skin. Using a stoma belt (a belt that attaches to both sides of the bag and wraps around the abdomen) can provide you with support. There are numerous types that you can find on the internet.
Showering and bathing
You are encouraged to bathe or shower with your pouch on or you can take it off and run water on the stoma. While your pouch is off, the stoma may continue to function. To avoid the situation, take a shower after stool has come out into the pouch. For some patients with regular bowel habits, the timing of output can be predictable. In others, it may be more random and dependent on what you eat. When you wash around the stoma, be gentle. Use a clean, soft cloth and a small amount of non-oily soap. Don’t be afraid to gently run water on the colostomy as it does not harm it. Water will not get inside your abdomen. Do not be concerned if you see a little blood. Some bleeding is normal because the stoma has such a rich blood supply. Rinse and dry the skin well. You can use a hair dryer set on COOL to dry it.
What to Eat
During the first month after your surgery, adjustment to your diet is necessary as you adapt to the new stoma. Beyond a month, you can gradually advance to a regular diet without much restriction. The key is to avoid severe constipation and impaction of the stoma. Chew very well everything you eat and as you re-introduce items into your diet, do it gradually in small amounts. In the early postoperative period, eat 4 to 6 smaller meals per day and drink plenty of fluids throughout the day. Eating large meals or drinking large amounts of liquids may cause you to bloat and possibly develop cramping as the stool goes through the stoma. Chew food very well. Avoid large amounts of popcorn, nuts, very fibrous fruits, dried fruits, mushrooms, bean sprouts, and large pieces of poorly chewed fish, meat, and/or bread. In general, a soft diet low in residue is preferred for most patients during that early recovery period when the stoma is swollen. Foods that can help to loosen stools are raw vegetables, spices, prunes, chocolate, fresh fruits, and coffee. Foods that can thicken output include ripe bananas, boiled rice, marshmallows, porridge, peanut butter, mashed potato, white bread, and pasta. Numerous internet websites can be informative. A list of some of these websites is provided at the end of this handout.
Emptying the Pouch
Once a stoma matures and is well regulated, it requires emptying once or twice a day in most patients. Empty the bag when it is one-third full. Empty the contents in a toilet bowl. If you are concerned about liquid splashing inside the bowl, you can float a few sheets of toilet paper before you empty the pouch or flush the toilet while you empty the pouch. In the early recovery period, you may experience a liquid output especially if you have a colostomy from the right or transverse colon. As time goes by, a more formed consistency is to be expected. You can rinse the inside of the pouch as often as you need to. The inside of the pouch can be flushed with warm water. Wipe clean the spout and edges of the pouch before closing.
Adjusting the Colostomy Output
The output from a mature left sided colostomy (descending or sigmoid colon) is about 200 to 500 ml of stool per day. A right sided colostomy can have more depending on what you eat and whether it is in the ascending colon or transverse. As the swelling goes down and you resume regular diet, your pattern of stool may mirror what your baseline bowel habits were before the surgery (i.e. the consistency and frequency of your stool). However, that is not always the case as surgical removal of any portion of the intestine can impact your function. By the second month, you will have some idea about your new baseline. Ideally you want to avoid constipation or loose stools. If the output is too liquid you can slow it down with the dietary modifications listed above. If you cannot control loose stools with your diet, you can add Imodium (anti-diarrheal medication). Start with a 2 mg capsule once a day about 30 minutes before a meal. If most of your stools are in the morning take it before breakfast but if later in the day then take before lunch or dinner. You can take up to 3 times before meals but do it gradually to avoid tipping yourself into constipation. If the output is too hard, you can add fiber powder such as 1 tablespoon of psyllium with 1-2 cups of water or juice once or twice a day. For more severe constipation, you can take a laxative. Check the information in the sections on Fiber Supplements and Laxatives. When you take a fiber supplement always drink plenty of fluids.
Irrigation of the colostomy can be helpful in some patients for 2 reasons: to evacuate hard constipated stools or to clean the colon for regularity. If your bowel habits were regular with formed stool prior to your operation, it may be possible to train your colostomy so that it empties at the same time every day by flushing the stool out. One advantage is that for the rest of the day, there would be minimal activity from the stoma. You need a colostomy irrigation kit (a variety of these kits are available on the internet). Instructions are included in these kits and you can find educational videos and instructions. See the provided resources at the end of this document for some educational videos.
Managing Gas and Odor
During your early recovery, you may notice excessive gas from the stoma. This is normal and it will improve as the stoma self regulates. Offensive odor does not have to be a worry. Most current pouches are made of materials that confine odor to the inside of the pouch and some have charcoal filters. The only time you should notice any odor is when you change or empty the pouch. Attention to what you eat can be helpful [see section on Gas Reduction]. Avoiding large amount of eggs, cabbage, onions, fish, baked or dried beans, asparagus, melons, fatty food, carbonated drinks, milk, cheese, and alcohol can minimize the amount of gas and odor. Deodorants placed inside the pouch and some commercially available tablets can help with odor (charcoal tablets, chlorophyll tablets, bismuth subgallate, and bismuth subcarbonate). Vanilla or mouthwash in the pouch works well. Food that minimize odor include parsley, spearmint, yogurt, and buttermilk. To minimize excessive gas, stir some of the carbonation out of the problem beverages, avoid chewing gum, and don’t gulp down food too fast.
Sexual Activity and Adjusting to Your Colostomy
Living with a colostomy takes some psychological and physical adjustment. Brief transient depression can be a normal part of the process. Give yourself time. It takes about 3 months to recover physically from major surgery. Joining a support group either in person or online can be very helpful. A list of online resources is listed at the end of this handout. Talk to your enterostomal nurse, your spouse, close relative, or a trusted friend. It is important to reach out to people and not walk this journey alone.
When you are physically recovered from the surgery, you can gradually resume sexual activity in a non-pressured fashion. Empty the pouch beforehand. You and your partner may need to make some minor adjustments in positioning to avoid too much friction on your pouch. Contact during lovemaking cannot hurt your stoma. Wear a smaller pouch and cover with pleasing fabric or a sexy undergarment. Remember that the stoma only covers a small area of your body. If you are in a new relationship, build the relationship before you discuss your colostomy and sexual activity. Gradually establishing trust and emotional connection is key. A colostomy should not prevent you from being intimate. It is important to note that some patients can experience sexual dysfunction after pelvic surgery especially if they have received radiation therapy. If you are experiencing any problems with erectile dysfunction, lack of libido, or vaginal pain/dryness, discuss with Dr. Maher Abbas. A referral to a urologist or gynecologist may prove very helpful.
If you take enteric-coated pills and time-released medications, tell Dr. Maher Abbas for guidance. Such medications have coatings that may not dissolve properly if you have a colostomy from the right side of the colon (ascending or transverse colon) and may pass unabsorbed into the pouch especially in the early part of your recovery. This is usually not an issue with a colostomy from the left colon (descending or sigmoid colon). Liquid medications or soft pills can be preferable if available. If you take diuretics medications (water pills commonly used to control blood pressure or swelling), inform Dr. Maher Abbas.
Signs to watch for
Watch for the following signs during your early recovery and contact Dr. Maher Abbas’ office or go to the Emergency room if symptoms are very severe:
- Abdominal cramps and distention
- Continuous bleeding from the stoma
- Dark or concentrated urine
- Dry mouth, increased thirst
- Fever (Temperature >38 ° Celsius, >100.4 ° Fahrenheit)
- No output from the stoma for 1 to 2 days
- Separation and retraction of the stoma from surrounding skin
- Stoma turns purple or black
- Vomiting, inability to tolerate food or liquids
You will be scheduled for weekly follow-up visits for the first month. In some cases, you will be seen more frequently. It is imperative that you show up to all your scheduled appointments to ensure proper stoma care. If you have any concerns or new findings, you can return to the office at any time.
Further Useful Resources
For Stoma Organizations
For Stoma Irrigation
Any questions? Contact Dr. Maher A. Abbas’ office nurse here!