Ostomy 101: Colostomy, ileostom y,and urostomy

Wound Care Advisor • March/April 2013 • Volume 2, Number 2 www.WoundCareAdvisor.com 31

M ost patients are distressedto learn they need ostomysurgery to divert stool,urine, or both. Adapting to

ostomy surgery can be difficult at best,even with today’s advanced technologyand the wide assortment of ostomy sup-plies available. While recovering from thesurgery itself, patients must learn how tocontain or control feces or urine and howto minimize odor—without feeling like asocial outcast.

This article reviews three types of osto-my surgery—colostomy, ileostomy, andurostomy. Subsequent articles will discussostomy management and treatment ofstomal and peristomal skin complications.

ColostomyA colostomy may be done on any part of the colon. It may be permanent ortemporary.• A permanent colostomy is done when

the rectum must be removed or otherhealth problems prevent colostomy closure.

• A temporary colostomy is created to divert stool away from the diseasedportion of the colon or large intestine,giving the affected part of the boweltime to rest and heal. Depending onthe healing process, the patient mayneed the colostomy for a few weeks toa few months. Once the affected areais healed, the colostomy can be closedor reversed. Occasionally, a patientmay opt to keep the colostomy due to

fear of needing another surgery. (SeeColostomy indications.)

Types of colostomies include ascending,transverse, and descending and sigmoidcolostomy. Refer to the image below,which shows the normal intestines, as youread the descriptions.

Ascending colostomyIn this type of colostomy, the surgeon di-verts the bowel to an opening in the ab-dominal wall, rolls the bowel back onto itself, and stitches it to the abdominalwall. The stoma is on the right side of theabdomen, on the ascending portion ofthe colon. Because stool is diverted frommost of the colon, the output is liquidand full of digestive enzymes. The skinmust be protected from the effluent andthe patient must wear a drainable pouchat all times.

Ostomy 101: Colostomy, ileostomy, and urostomyUnderstanding the types of ostomy surgeries can help you provide better patient care. By Jackie Doubleman, BSN, RN, CWOCN

32 www.WoundCareAdvisor.com March/April 2013 • Volume 2, Number 2 •Wound Care Advisor

Transverse colostomyTwo types of transverse colostomies aredone—loop transverse colostomy and dou-ble-barrel transverse colostomy. Usually,they serve as temporary fecal diversions.• In transverse loop colostomy, the sur-

geon creates one stoma with a proximaland distal opening. The proximal open-ing expels stool while the distal openingeliminates mucus. This procedure allowsthe distal portion of the colon to restand heal; once it heals, the colostomymay be closed. Normally, a smallamount of stool and mucus is expelledfrom the anus.

• The double-barrel transverse colostomyrarely is done today. The surgeon com-pletely divides the bowel, leaving twostomas on the abdominal wall—a proxi-mal stoma that expels stool and a distalstoma that passes mucus. The distalstoma also may be called a mucous fis-tula, with the mucus expelled throughthe rectum. If the two stomas are sepa-rated on the abdominal wall, the patientwears a pouch over the proximal stomato collect feces and wears a piece ofplain gauze, a Vaseline gauze pad, or asmall pouch called a stoma cap over the

mucous fistula stoma. If the stomas arenear each other, a single pouch maycover both.

Descending colostomy and sigmoidcolostomyIn these procedures, the stoma is on theleft lower abdominal wall. The descendingcolostomy stoma is located just a few inch-es higher than the stoma for a sigmoidcolostomy. A sigmoid colostomy, the mostcommon colostomy type, may be perma-nent or temporary.

Abdominal perineal resection of the rec-tum is done in patients with distal rectalcancer. Today, with advanced technology

Indications for a colostomy include:

• diverticulitis

• inflammatory bowel disease

• colorectal cancer

• bowel obstruction (as from atumor)

• traumatic injury to the bowel

• certain birth defects.

Sometimes a colostomy isdone for temporary diversion,as in extensive pressure ulcersand for a patient awaiting sur-gery for hidradenitis suppurati-

va (a noncontagious skin dis-ease). Diseases mainly affect-ing children that require a fecaldiversion are:

• imperforate anus, an anorec-tal malformation in whichthe anus is absent or dis-placed from the normalanatomy

• Hirschsprung’s disease, inwhich an aganglionic por-tion of the large intestinecauses severe constipationor functional obstruction

• gastroschisis, in which theintestines protrude through

an opening in the abdominalwall

• omphalocele, a condition inwhich the intestines and oth-er organs protrude throughthe abdominal wall and arecovered with a membrane

• necrotizing enterocolitis, acondition primarily affectingpremature infants of lessthan 35 weeks’ gestation, inwhich inflammation, infec-tion, and perforation maycause a portion of the intes-tines to become necrotic and die.

Colostomy indications

Transverse loop colostomy

Transverse colon Supporting rod

Exteriorized loop ofbowel opened, withthe bowel mucosasutured to the skin


in surgical instrumentation, surgeons maybe able to accomplish a lower anastomosisin the rectum and thus prevent a perma-nent colostomy. If the rectum has been re-moved, the sigmoid colostomy is perma-nent. The patient may have the option toregain control over elimination throughcolostomy irrigation on a regular basis tostimulate peristalsis and evacuate the colonat a designated time. To be eligible forcolostomy irrigation, the patient must havehad only one or two bowel movementsdaily before becoming ill and requiringsurgery, and must be functionally able toperform irrigation. Because descendingand sigmoid colostomies are done in theleft lower quadrant, more of the colon isfunctional; therefore, fecal output usuallyhas a soft to firm consistency.

Ileostomy With an ileostomy, bowel diversion surgeryis restricted to the small intestine on thelower right abdominal wall and affects onlythe ileum. An ileostomy may be permanentor temporary, depending on whether therectum was removed. Indications for ileosto-my surgery include ulcerative colitis, Crohn’sdisease, familial polyposis, and cancer.

Because the colon is removed or by-passed, stool is liquid to semisoft and ap-pears green. The patient must learn toavoid dehydration and will need to wearan external ostomy bag 24 hours daily forfecal collection. Types of ileostomies in-clude the ileoanal reservoir and the Bar-nett continent intestinal reservoir (BCIR).

Ileoanal reservoirAlso known as the J-pouch or a continentdiversion, the ileoanal reservoir is an in-ternal pouch formed from the small intes-tine. It’s a widely accepted treatment option for patients with ulcerative colitisand familial polyposis because it elimi-nates the disease and doesn’t require apermanent ileostomy.

This complex procedure most often isdone in two stages. In the first procedure,the surgeon removes the colon but leavesthe anus intact and disease free; a tempo-rary ileostomy is created to divert stoolfrom the new J-pouch to promote healing.Usually within 4 to 8 weeks, the secondsurgery is done to take down the ileostomy.Afterward, the patient has six to ten bowelmovements per anus daily. After a fewmonths of adjustment, the patient may haveonly three to six bowel movements daily.

For critically ill patients who need emer-gency surgery, the surgeon may opt to doa three-stage procedure. The first surgeryis a total colectomy with rectal sparing anda temporary loop ileostomy. In the second,the surgeon constructs the J-pouch. Thethird is ileostomy takedown or reversal.

Descending colostomy

Descendingcolon

Stoma

Ilesotomy

Ileostomy Ileum


BCIRAn intra-abdominal ileostomy, the BCIR isused for patients who’ve had problemswith conventional ileostomy and difficultywearing an external ostomy bag, as wellas those who’ve failed with the Kockpouch, ileoanal anastomosis, or J-pouch.The BCIR was modified from the Kockpouch (a continent ileostomy) by Dr.William Barnett when he constructed the“living collar,” which is made from thesmall intestine and helps prevent leakagearound the stoma. The Kock pouch is aninternal pouch that stores liquid stool(600 to 1,000 ml) and is emptied with acatheter at the patient’s convenience twoto four times daily. The stoma empties directly into the toilet. Most patients coverthe stoma site with a small pad or band-age to absorb the mucus that accumulatesat the opening. As with any diversion,mucus formation at the stoma site is natu-ral because the intestine normally pro-duces mucus.

UrostomyAlso called a urinary diversion, a urostomy is indicated for cancer, bladder extrophy,neurogenic bladder, interstitial cystitis, and

ureter blockage caused by a kidney stoneor tumor. A urostomy can be one of sever-al types. This article describes the ilealconduit, neobladder, Indiana pouch, Miamipouch, and nephrostomy.

Ileal conduitBecause of its low complication rate andhigh patient satisfaction, an ileal conduit isthe most common urinary diversion tech-nique after a radical cystectomy for inva-sive bladder cancer. The conduit is createdfrom the terminal ileum of the small intes-tine. The surgeon resects the ureters fromthe bladder and performs ureteroentericanastomosis. After closing one end of theconduit, the surgeon brings the other endthrough a premarked site in the right low-er quadrant of the abdominal wall, creat-ing a stoma.

The goal of an ileal conduit is to expelurine directly from the conduit via thestoma into an external pouch. Patientswear a urinary pouch 24 hours daily andmust empty it several times a day. Be-cause they don’t feel the urge to urinate,they must learn to empty the pouchwhen they feel it getting heavy withurine. They empty it directly into the toi-let through the spout on the end. Usual-ly, the pouch is changed two or threetimes per week. Patients with good weartime and no peri stomal skin irritationmay need to change it only once a weekbut must drink at least eight glasses ofliquid daily to prevent ascending urinarytract infection.

Ileal pouch. This shows a W-pouch; a J-pouch formation

is more often used.

Ileum (small intestine)

Anus andrectum intact

Colon removed

End ileostomy

Fistula

Anus

Ileo-analanastomosis

Ileal reservoir (pouch)formed from loops of

small intestine

Ileal conduit urostomy

Left kidney

Right kidney

Colon

Right ureter

Left ureter

Uretero-ilealanastomosis

Isolatesegment of ileum withblood supply


NeobladderThis continent urinary diversion is done inpatients whose bladder has been removeddue to cancer. It closely mimics the urinarybladder’s storage function. The surgeonmakes part of the small intestine into aninternal reservoir and sews it to the ure-thra. The ureters are attached to drain intothe reservoir, providing a downward urineflow to prevent urine back-up and thushelp prevent kidney infection. Urine pass-es from the kidney down the ureters tothe reservoir and through the urethra, as innormal urine passage.

Candidates for neobladder surgery musthave a low risk of urethral cancer recur-rence and be highly motivated to follow a strict care regimen for the first fewmonths. After surgery, they lack the nor-mal urge to urinate, so for the first fewmonths they must void “by the clock.”Initially, they experience nocturnal incon-tinence, but urinary leakage during theday is unlikely. The neobladder continuesto enlarge and function better over thefirst few years.

The main advantage of this surgery isthat with time and patience, the patientcan use the bathroom to urinate the sameway as before surgery. Neobladders usual-ly are done on men because the female in-ternal anatomy makes neobladder creationmuch more difficult.

Indiana pouchThe Indiana pouch is used for urinary diversion after bladder cancer, pelvic ex-enteration, bladder extrophy, or neuro-genic bladder. Patients with this continentreservoir must catheterize it to emptystored urine.

The Indiana pouch is created from approximately 2' of the ascending colon. The surgeon brings a small portion of the ileum and the end segment throughthe abdominal wall to create a stoma.The ileocecal valve is included in thereservoir and functions as a one-way

valve to help prevent urinary leakagefrom the stoma.

The patient leaves the hospital using legbags connected to one tube through thestoma and into the reservoir, and connect-ed to another tube through a temporaryopening into the abdominal wall andreservoir. After sufficient healing, the stom-al tube is removed and the patient istaught to catheterize the stoma or pouchevery 2 hours. After 1 month, if X-raysdon’t show urine leakage from the pouch,the last drainage tube is removed. Thenthe patient catheterizes the pouch every 3hours around the clock. As the pouch con-tinues to expand, emptying time may in-crease to 4 or 6 hours, with pouch capaci-ty up to 1,200 ml.

Patients need to irrigate the pouch dailywith 60 ml sterile water to remove mucus,salts, and bacteria. After about 6 months,they usually can sleep through the nightwithout emptying the pouch if they limitliquid intake in the evening.

Miami pouchAnother type of continent urostomy, theMiami pouch is created by a gynecologiconcologist at the time of an anterior ortotal pelvic exenteration. It’s constructedusing the distal ileum and ascendingcolon. Continence is developed with tapering of the ileum, intussusception ofthe ileal cecal valve, and detubularizingof the colonic segment. With this pouch,pressure is lower than urethral pressureentering it and lower than that of the efferent bowel leaving it, reducing risk of urinary reflux.

The Miami pouch has proven to be re-liable in terms of continence and protect-ing the upper urinary tract. The mostcommon complications are urethral stric-ture, difficulty with catheterization, andpyelonephritis. Quality of life improvesafter a Miami pouch or Indiana pouchcontinent urostomy because these proce-dures avoid an external pouch, even


though they require intermittent self-catheterization.

NephrostomyA nephrostomy is an artificial opening cre-ated between the skin and kidney by asurgeon or interventional radiologist. Usingultrasound guidance or computed-tomog-raphy fluoroscopy, the practitioner placesa catheter in the renal pelvis.

This procedure is done to prevent kid-ney damage related to urinary blockage.The nephrostomy tube allows the kidneyto function properly and protects it fromfurther damage and possible infection;once the condition necessitating thenephrostomy has been treated or correct-ed, the tube can be removed. If it mustremain in place for an extended time, itmust be exchanged periodically.

The patient wears an external urosto-my pouch over the tube. Depending onindividual circumstances, patients mayhave bilateral nephrostomy tubes or a leftor right nephrostomy tube. If only onekidney is blocked, one neophrostomytube will be placed; the patient voidsnormally and has to keep the neophros-tomy pouch emptied. The nephrostomytube may need to be irrigated regularlyin a sterile procedure, as ordered by thesurgeon.

Help patients resume active livesWhen confronted with the need for a fecalor urinary diversion, all patients and theirfamilies have concerns and questions, andmany feel frightened and isolated. Referthem to a local ostomy support group orthe United Ostomy Associations of Ameri-ca to help them get through this transitionperiod.

Every patient has the right to be clean,dry, and odor free. To achieve this goaland resume a normal lifestyle, patientsmust learn about ostomy management.Quality of life after a fecal or urinary di-version can improve if patients understand

about the specific surgery required andlearn how to perform self-care. Patientswith any type of continent fecal or uri-nary diversion should wear a medicalalert medallion in case they are uncon-scious in an emergency situation. Oncepatients know how to care for themselves,they can resume full, active lives. Time,patience, and a good sense of humor canhelp them live life and enjoy it despite theostomy. n

Selected referencesBeitz JM. Continent diversions: the new gold stan-dard of ileoanal reservoir and neobladder. OstomyWound Manage. 2004;50(9):26-35.

Beitz JM, Gerlach M, Ginsburg P, Ho M, McCann E,et al. Ostomy Wound Manage. 2010;56(10):22-38.

Colwell JC, Goldberg MT, Carmel JE. Fecal and Uri-nary Diversions: Management Principles. Philadel-phia, PA: Elsevier; 2004.

Costa JA, Kreder K. Urinary diversions and neoblad-ders. Medscape Reference: Drugs, Diseases and Pro-cedures. Updated May 16, 2012. http://emedicine.medscape.com/article/451882-overview. AccessedFebruary 28, 2013.

Geng V, Eelen P, Fillingham S, Holroyd S, KiesbyeB, et al. Good Practice in Health Care: ContinentUrinary Diversion. Arnhem, The Netherlands: Euro-pean Association of Urology Nurses; 2009.

Gordon PH. Intestinal stomas. In: Gordon PH,Nvatvongs S, eds. Principles and Practice of Surgery forthe Colon, Rectum and Anus. 3rd ed. CRC Press; 2007.

Gutman N. Colostomy Guide. United Ostomy Associ-ations of America; 2011.

Herlufsen P, Olsen AG, Carlsen B, Nybaek H, Karls-mark T, et al. Study of peristomal skin disorders inpatients with permanent stomas. Br J Nurs. 2006;15(16):854-62.

Nie A, Douglas E. Pediatric Ostomy Care: Best Prac-tice for Clinicians. WOCN Society Annual Confer-ence: New Orleans, Louisiana; 2011.

D’Orazio M, Ozorio C. On the lack of universal os-tomy follow-up. J Wound Ostomy Continence Nurs.2008;35(3):313-15.

United Ostomy Associations of America. What is anostomy? www.ostomy.org/ostomy_info/whatis.shtml.Accessed February 28, 2013.

Jackie Doubleman is a certified wound and ostomy care nurse at St. Vincent’s Hospital inBirmingham, Alabama.

Documents

Ostomy 101: Colostomy, ileostom y,and urostomy