A colostomy is a surgical procedure to divert one end of the large intestine (colon) through an opening in the abdominal wall (tummy).
The end of the bowel is called a stoma. A pouch is placed over the stoma to collect waste products that usually pass through the colon and out of the body through the rectum and anus (back passage).
A colostomy can be permanent or temporary.
It's estimated that around 6,400 permanent colostomies are carried out each year in the UK.
Why a colostomy may be needed
A colostomy may be used when there's a problem with an area of the colon. The colostomy diverts digestive waste away from the affected area, to give it a chance to heal.
In other cases, a colostomy is formed after a section of the colon has been removed and the bowel can't be joined back together. This may only be temporary, with a further operation to remove the colostomy at a later date, or it may be permanent.
A colostomy may be used to treat the following conditions:
- Bowel cancer
- Crohn's disease
- Anal cancer – In rare cases, a permanent colostomy may be needed to treat anal cancer. This is usually only necessary if other treatments, such as chemotherapy or radiotherapy, have been unsuccessful.
- Vaginal cancer or cervical cancer – In some cases, a major operation known as a pelvic exenteration is required to treat cancer that has spread into the pelvis. A permanent colostomy is required as part of the operation.
- Bowel incontinence – A colostomy can be formed as a last resort, if all other medical and surgical treatments prove unsuccessful.
- Injury – If a part of the colon needs to be removed following an injury, such as a knife or gunshot wound, a colostomy may need to be formed. The colostomy is usually temporary, but in some cases can become permanent.
- Hirschsprung's disease – In this rare disease, the bowel doesn't work because it lacks the necessary nerve cells. Surgery is sometimes required to prevent the colon from becoming blocked. During the operation, the section of the colon lacking the nerve cells is removed and a colostomy is formed, so stools can leave the body. Depending on how much of the colon is removed, the colostomy may be temporary or permanent.
Types of colostomy
There are 2 main ways a colostomy can be formed:
- A loop colostomy – where a loop of colon is pulled out through a hole in your abdomen, before being opened up and stitched to the skin.
- An end colostomy – where one end of the colon is pulled out through a hole in your abdomen and stitched to the skin.
Loop colostomies tend to be temporary and require a further operation at a later date to reverse the procedure. It's also possible to reverse an end colostomy, but this is less common. You'll usually have to stay in hospital for 3-10 days after a colostomy or colostomy reversal.
A similar procedure, known as an ileostomy, is sometimes used as an alternative to a colostomy. This involves creating a stoma by diverting the small intestine instead of the large intestine.
Living with a colostomy
It's natural to be concerned that your day-to-day activities will be restricted and that others will notice you're wearing a colostomy bag.
However, modern colostomy equipment is discreet and secure, and there's no reason why you shouldn't be able to do the activities you enjoyed before, without experiencing the symptoms that made the colostomy necessary in the first place.
Adjusting to life with a colostomy can be challenging, but most people become accustomed to it over time.
You'll usually see a specialist stoma nurse before and after having a colostomy, although you may not be able to see them before the procedure if it's carried out in an emergency. Specialist stoma nurses can offer support and advice to help you adapt to life with a colostomy.
How it's performed
There are several different ways a colostomy can be performed. The specific technique used will depend on your circumstances.
The 2 main surgical techniques are:
- open surgery (laparotomy) – where the surgeon makes a long incision in the abdomen to access the colon
- laparoscopic (or keyhole) surgery – where the surgeon makes several smaller incisions and uses a miniature video camera and special surgical instruments to access the colon
Where possible, keyhole surgery is the preferred choice. This is because research has shown that patients recover quicker and have a reduced risk of complications.
However, in emergency situations, such as a bowel obstruction, the staff and equipment needed for a keyhole operation may not be available, so an open operation needs to be performed.
All colostomy procedures are carried out under general anaesthetic, which means you're asleep during surgery.
Types of colostomy
There are 2 main ways a colostomy can be formed:
- a loop colostomy
- an end colostomy
To form a loop colostomy, a loop of colon is pulled out through an incision in your abdomen. This section of colon is opened up and stitched to the skin to form an opening called a stoma. The stoma will have 2 openings, but they will be close together and you may not be able to see both.
One of the openings is connected to the functioning part of your bowel. This is where waste products leave your body after the operation. The other opening is connected to the "inactive" part of your bowel, leading to your rectum. This opening only produces small amounts of mucus.
The position of the stoma depends on which section of the colon is diverted, although it's usually on the left-hand side of your abdomen, below your belt line. If the operation is planned in advance, you'll meet a specialist stoma nurse before the operation to discuss possible locations for the stoma. This may not be possible if the operation is performed as an emergency.
The stoma will appear large at first, as the effects of surgery cause it to swell. It usually shrinks during the weeks after surgery, reaching its final size after about 8 weeks. The stoma will be red and moist. It has no nerve endings, so it isn't painful to touch. It may bleed when touched, but this is entirely normal and no cause for concern.
In some cases, a support device (called a rod or bridge) may be used to hold the loop of colon in place while it heals. This will usually be removed after a few days.
A loop colostomy is usually formed temporarily to treat conditions such as diverticulitis, Crohn’s disease and bowel cancer.
To form an end colostomy, one end of the colon is pulled out through an incision in your abdomen and stitched to the skin to create a stoma.
Like when a loop colostomy is formed, the position of the stoma depends on which section of the colon is diverted. However, it's usually on the left-hand side of your abdomen, below your belt line.
If the operation is planned in advance, you'll meet a specialist stoma nurse before the operation to discuss possible locations for the stoma. This may not be possible if the operation is performed as an emergency.
The stoma will have one opening, through which waste products pass. The other end of the colon, which goes down to your rectum, is sealed and left inside your abdomen.
End colostomies are often permanent, although temporary end colostomies are sometimes formed as an emergency to treat bowel obstructions, colon injuries or bowel cancer.
Alternative to colostomy
In some cases, it may be possible to have an alternative procedure called an ileostomy.
This is formed in a similar way to a colostomy, but it involves diverting the small intestine instead of the large intestine.
An ileostomy may sometimes be preferable to a colostomy, because an internal pouch for waste products can be created that's connected to your anus. This can allow you to control your bowel actions in a more normal way.
After a colostomy, you'll need to stay in hospital for a few days while you recover.
When you wake up after the operation, you may be attached to several different devices, including:
- a drip into your vein that provides fluids (an intravenous drip)
- a tube inserted into your bladder to remove urine (a catheter)
- an oxygen mask or nasal tubes (cannula) to help you breathe
These will be removed as you recover from surgery.
A clear colostomy bag will be placed over the opening (stoma) in your abdomen, so it can be easily monitored and drained. The first bag is often larger than normal colostomy bags and is usually replaced with a smaller bag before you go home.
While you're recovering in hospital, a stoma nurse will teach you how to care for your stoma, including how to empty and change the pouch.
They'll teach you how to keep your stoma and surrounding skin clean and free from irritation, and also give you advice and treatment if you develop an infection.
The nurse will explain the different types of equipment available and how to get new supplies.
After you leave hospital, you'll be seen at home by a local stoma nurse. This may be the same stoma nurse you saw in hospital.
Most people are well enough to leave hospital 3-10 days after the operation.
It's important to avoid any strenuous activities at home that could place a strain on your abdomen, such as lifting heavy objects. Your stoma nurse will give you advice on resuming normal activities.
In the first few weeks after your operation, you may experience excessive flatulence (gas) and unpredictable discharge from your stoma. This should start to improve as your bowel recovers from the effects of the operation.
It's important to be aware of the possible problems you may experience after a colostomy.
People who have a colostomy, but have an intact rectum and anus, often experience a discharge of mucus from their rectum. Mucus is produced by the lining of the bowel to help the passage of stools.
The lining of the bowel continues to produce mucus, even though it no longer serves any purpose. The longer the length of the remaining section of your bowel, the more likely you are to experience rectal discharge.
The mucus can vary, from a clear "egg white" to a sticky, glue-like consistency. If there's blood or pus in the discharge, contact your GP, because it may be a sign of infection or tissue damage.
Managing the discharge
The mucus can either leak out of your rectum and anus or build up into a ball, which can become uncomfortable.
The pattern of rectal discharge varies in each individual. Some people experience episodes every few weeks, while others experience several episodes a day.
Many people find that the most effective method of managing rectal discharge is to sit on the toilet each day and push down as if passing a stool. This should remove any mucus located in the rectum and prevent it building into a ball.
However, some people find this hard to do, because surgery has reduced the sensation in their rectum. If this is the case, contact your GP, because you may need further treatment.
Glycerine suppositories (which you insert into your bottom) can often help. When the capsules dissolve, they make the mucus more watery, so it's easier to get rid of.
In some cases, the mucus can irritate the skin around the anus. Using a barrier skin cream should help. You may need to try a few before you find one that works for you. Your pharmacist can advise on the different creams available.
Some people have reported that eating certain foods increases the production of mucus. While there's no scientific evidence to support this, you may want to consider keeping a food diary for a few weeks to see if certain foods could be linked to an increase in mucus production.
A hernia occurs when an internal part of the body, such as an organ, pushes through a weakness in the muscle or surrounding tissue wall.
In cases of parastomal hernia, the intestines push through the muscles around the stoma, resulting in a noticeable bulge under the skin. People with colostomies have an increased risk of developing parastomal hernias, because the muscles in their abdomen have been weakened during surgery.
Ways of preventing a parastomal hernia include:
- wearing a support belt or underwear
- avoiding heavy lifting and straining
- maintaining a healthy weight, because being overweight can place additional strain on your abdominal muscles
A parastomal hernia isn't usually painful, but it may be more difficult to hold the colostomy appliance in place and change it.
Most hernias can be managed without the need for surgery, with advice and support from your stoma care nurse. In some cases, surgery may be required to repair the hernia. However, even after surgery, the hernia can reoccur.
Some people develop a blockage in their stoma because of a build-up of food. Signs of a blockage can include:
- not passing many stools, or passing watery stools
- bloating and swelling in your abdomen (tummy)
- tummy cramps
- a swollen stoma
- nausea and/or vomiting
If you think your stoma is obstructed, it's recommended that you:
- avoid eating solid food for the time being
- drink plenty of fluids
- massage your tummy and the area around your stoma
- lie on your back, pull your knees up to your chest and roll from side to side for a few minutes
- take a hot bath for 15-20 minutes (to help relax the muscles in your tummy)
However, if there's no improvement within two hours and you've tried these steps, you should immediately contact your GP or stoma nurse for advice, or visit your local Accident and Emergency (A&E) department, because there's a risk your colon could burst (rupture).
Find your local A&E department.
You can reduce your chances of developing a stoma blockage by chewing your food slowly and thoroughly, keeping hydrated, and not eating large amounts of food at one time.
You should also try to avoid foods known to cause blockage problems, such as corn, celery, popcorn, nuts, coleslaw, coconut macaroons, grapefruit, Chinese vegetables such as bamboo shoots and water chestnuts, raisins, dried fruit, potato skins, apple skins and orange rinds.
A number of other complications can occur after a colostomy, such as:
- skin problems – where the skin around the stoma becomes irritated and sore; your stoma care team will explain how to manage this
- stomal fistula – where a small channel develops in the skin alongside the stoma; depending on the position of the fistula, appropriate bags and good skin management may be all that's needed to treat this problem
- stoma retraction – where the stoma sinks below the level of the skin after the initial swelling goes down, which can lead to leakages, because it can be difficult for colostomy bags to form a good seal; different types of pouches and appliances can help ease this problem, although further surgery may sometimes be needed to correct it
- stoma prolapse – where the stoma comes out too far above the level of the skin; using a different type of colostomy bag can sometimes ease this problem if the prolapse is small, although further surgery may be required
- stomal stricture (stenosis) – where the stoma becomes scarred and narrowed; further surgery may be needed to correct it if there's a risk of blockage
- leakage – where digestive waste leaks from the colon onto the surrounding skin or within the abdomen; trying different bags and appliances may help an external leak, but further surgery may be needed if the leak is internal
- stomal ischaemia – where the blood supply to the stoma is reduced after surgery; this may require further surgery to correct
Living with a colostomy
It can be difficult to adjust to a colostomy at first, but it doesn't mean you can't have a full and active life.
You may find the following information useful if you have a colostomy, or are due to have one in the near future.
After a colostomy is formed, the opening in your abdomen (known as the stoma) produces digestive waste in the form of faeces. The consistency of your faeces depends on which part of your colon is diverted, as well as your diet and fluid intake.
A colostomy pouch will usually be required to collect your faeces. These pouches often need to be removed and replaced when full (usually 1 to 3 times a day), although drainable pouches that only need to be replaced every 1 or 2 days may be used if you have particularly loose faeces.
There's a wide range of colostomy appliances available, including:
- a one-piece pouch – the bag and flange (part that sticks to your skin) are joined together; the appliance is removed when full and disposed of
- a two-piece pouch – the bag and flange are separate, but can be connected; the flange can be left on your skin for several days and the bag removed and disposed of several times a day
If you produce faeces in a regular and predictable pattern, you may not always need to wear a colostomy bag. However, as occasional leakages can occur, it's recommended that you wear a small stoma cap.
A specialist stoma nurse, who usually sees you before and after the colostomy is formed, will help you choose the most suitable appliance.
To help reduce skin irritation, colostomy appliances are made from hypoallergenic (non-allergic) material and contain special filters that ensure the appliance doesn't release any unpleasant odours.
There are additional products that can make living with a colostomy more convenient, including:
- support belts and girdles
- deodorisers that can be inserted into your appliance
- protective skin wipes
- adhesive remover sprays
- protective stoma rings
- specially designed underwear and swimwear
Your stoma care nurse can advise you on the most appropriate equipment to manage your colostomy successfully.
You'll be given an initial supply of colostomy appliances before you leave hospital, as well as your prescription information. You should let your GP know your prescription information, so they can make a note of it in your medical records and issue prescriptions in the future.
Your prescription can either be taken to the chemist or sent to a specialist supplier, who will deliver the appliances. There's no need to stockpile supplies, but it's recommended that you order more appliances while you still have plenty left, so you don't run out.
There's currently no charge for either permanent or temporary colostomy equipment supplied on an NHS Scotland prescription.
Irrigation is an alternative to wearing a colostomy appliance. It involves washing out your colon with water either every day or every other day.
This involves gently inserting a small device into your stoma and attaching it to a bag full of water and an irrigation sleeve, which acts in a similar way to a colostomy pouch.
You slowly move water into your colon, so it washes it out and moves the stools into the irrigation sleeve. The equipment can be disposed of once the process is complete. A cap is used to cover your stoma in between irrigations.
Advantages of irrigation include:
- you choose when you want to perform irrigation
- you don't have to wear a colostomy appliance (but may have to wear a small cap)
- you should be able to enjoy a more varied diet
- you should experience less flatulence (gas)
Disadvantages of irrigation include:
- it's a time-consuming process that takes 45 to 60 minutes to complete, usually on a daily basis
- to achieve the best results, irrigation should be carried out at the same time every day, which could cause you problems when you're away from home on holiday or with work
Some people also find irrigation unpleasant. It's possible to go back to using a colostomy pouch if you find irrigation isn't suitable for you.
Irrigation may not be possible in some circumstances. For example, people with Crohn’s disease or diverticulitis are unable to irrigate their colon, as it's too damaged. Irrigation is also not suitable for people having a course of chemotherapy or radiotherapy.
Irrigation probably isn't advisable for young children, as it's quite time-consuming.
In the first few weeks after having a colostomy, it's likely that you'll be put on a low-fibre diet. This is because having a high-fibre diet can increase the size of your stools, which can cause the bowel to become temporarily blocked. After around 8 weeks, you'll usually be able to resume a normal diet.
As you recover, you can start to eat a healthy, balanced diet that includes plenty of fresh fruit and vegetables.
Find out about how to eat a healthy balanced diet.
You should be able to return to the diet you previously enjoyed. If you previously had a restricted diet, you should be able to reintroduce the restricted foods.
Smell and wind
Many people worry that their colostomy will give off a smell that others will notice.
All modern appliances have air filters with charcoal in them, which neutralises the smell. Most people will be aware of the smell of their colostomy, because it's their own body. However, someone standing next to you won't be able to smell the stoma.
Immediately after your surgery, your colostomy will make excess wind and noise. This will slowly reduce as your bowel recovers.
Your stoma nurse can advise on products you can use to help reduce any smell, and dietary advice to reduce wind.
Many medicines are designed to dissolve slowly in your digestive system. Having a colostomy shouldn't alter the effectiveness of your usual medication. If you do notice any tablets in your appliance, notify your pharmacist or GP who will recommend an alternative medication for you to take.
In the weeks following surgery, it's usually recommended you do some gentle exercise to help recovery.
How well you recover will determine how much exercise you can do. If you feel any pain, stop immediately.
All colostomy bags are waterproof, so you can go swimming.
Once your bowel has healed, there's no reason why you can't return to work. If your job is particularly strenuous and involves a lot of heavy lifting, you may need to wear a support belt or a girdle. Your stoma nurse can advise about this.
It's likely to take several months before you're ready to return to work. However, it all depends on how well you recover and the type of work you do. When you do return, you're likely to find it very tiring. It's a good idea to discuss potential options with your employer before having a colostomy operation.
Some employers may be happy to provide a degree of flexibility, such as allowing you to work part-time or at home, until your strength improves. Your employer may also be able to provide additional support, such as giving you access to changing facilities or adjusting your work responsibilities so you don't have to do lots of heavy lifting.
You don't have to tell your work colleagues about your colostomy (unless you want to). Some people find it's a good idea to tell one person in the workplace, in case they need any support or advice.
There's no reason why you can't travel freely when you've had a colostomy, although you'll probably need extra time when planning your journey.
Most stoma companies have a small information leaflet you can carry with you at all times, available in several different languages.
Your stoma nurse can give you advice about travelling with a stoma. It's recommended that you have travel insurance.
One essential item for people with a colostomy is a RADAR key. This provides you with access to public disabled toilets, so you can change your colostomy appliance when you need to.
You can get a RADAR key by contacting the Colostomy Association, which is a leading UK charity and support group for people with a colostomy.
When travelling abroad, it's a good idea to take plenty of colostomy supplies with you, because you may have difficulty getting hold of them in another country.
There are several practical issues that could have an impact on your sex life and your relationships.
Women who have had their rectum removed may find that having sex in the traditional "missionary position" is painful because the rectum no longer supports the vagina during sex. Trying different positions may help.
After surgery, many women also find their vagina is much drier, which can make sex uncomfortable. Applying a lubricating jelly before having sex may help.
Having weight placed on your stoma during sex can be painful, so you may want to avoid positions that could cause pain. Alternatively, you could protect the stoma with a cushion or pillow.
Your stoma nurse can give you more advice.
Following a colostomy, some men find the blood supply and nerve endings to their penis have become damaged. This can make it difficult getting or maintaining an erection (erectile dysfunction).
There are several ways to treat erectile dysfunction, including taking a medication called sildenafil, which helps increase blood supply to the penis.
Other sex-related issues
Aside from practical issues, you may be concerned about body image, self-confidence and how your partner may react to your colostomy, which can also have an impact on your sex life.
It's important to stress that many people who have a colostomy enjoy a good sex life, although it can take several months to build up the confidence and trust to make this possible.
If you have a long-term partner, you may want to ask them if they want to see your stoma and colostomy equipment. Some people’s partners want to take an interest, but others may find it too upsetting, at least in the short term. There is no right or wrong way to react, so try not to take a refusal as a personal rejection.
If the appearance of your stoma and colostomy equipment is off-putting during sex, you can always cover them with a nightgown or boxer shorts.
Other tips that may improve your sex life include:
- changing your appliance before having sex
- changing your appliance to a small stoma cap before having sex
- covering the appliance with a satin or cotton cover (if the feel of the appliance against your skin is a distraction during sex)
- keeping your sense of humour: embarrassing mishaps often occur during sex, whether or not you have a colostomy
You should avoid having anal sex (if the rectum hasn't been removed) after a colostomy because this can lead to painful tearing and bleeding. You should also avoid using the stoma itself for penetrative sex because this can seriously damage it.
If your colostomy is intended to be temporary, further surgery will be needed to reverse it at a later date.
The reversal operation will only be carried out when you're in good health and fully recovered from the effects of the colostomy formation operation. This will usually be at least 12 weeks or more after the initial surgery.
However, the reversal may need to be delayed for longer if you require further treatment such as chemotherapy, or haven't recovered from the original operation when the colostomy was formed. There's no time limit for having the stoma reversed and some people may live with their colostomy for several years before it's reversed.
In some cases, reversing a colostomy may not be recommended. For example, if the muscles that control your anus (sphincter muscles) were damaged after surgery, reversing the colostomy may cause bowel incontinence.
Reversing a loop colostomy is a relatively straightforward process. An incision is made around the stoma to allow the surgeon to gain access to the inside of your abdomen. The upper section of your colon is reattached to the remaining section of your colon.
It's also possible to reverse an end colostomy. However, the surgeon needs to make a larger incision to locate and reattach the 2 sections of the colon. Therefore, it takes longer to recover from this type of surgery and there's a greater risk of complications.
Recovering from colostomy reversal surgery
Most people are well enough to leave hospital 3-10 days after colostomy reversal surgery, depending on which colostomy procedure you had reversed.
It's likely to take some time before you resume normal bowel function and routine. Some people experience constipation or diarrhoea, although this normally resolves with time.
Some people may experience a sore anus after the reversal. This should improve as the anus becomes used to having stools pass through it again. It may help to thoroughly wash the skin around your anus with warm water after every bowel movement, then pat it dry with a soft cloth and apply a common barrier cream. Avoid baby wipes, talcum powder or scented toilet tissues, as these can cause further irritation.
Other possible problems include an increased frequency or urgency to go to the toilet, excessive flatulence and some bowel incontinence or leakage.
As your digestive system is often sensitive after a colostomy reversal, you may be recommended to avoid eating late at night. Avoiding large meals and eating little and often instead may also help. Certain foods are also more likely to irritate the gut, and it may be helpful to limit or avoid:
- citrus fruits – such as grapefruits and oranges
- spicy food – such as curries
- large fatty meals
- vegetables that increase flatulence – such as cabbage and onions
- large amounts of alcohol or fizzy drinks
The reversal operation is usually a smaller procedure than the initial colostomy procedure. However, it still takes several weeks to recover and return to normal activities.
03 March 2023
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