The Ostomy Files: An Ostomy Can Mean Continence

    The cardinal symptom of inflammatory bowel disease is diarrhea, which can be diurnal and/or nocturnal. Paraplegics and quadriplegics are plagued by urinary and/or fecal incontinence as a result of spinal injuries. The underlying concern with each of these patients is the ability to control and evacuate stool, urine, and gas at socially acceptable times and places.¹

“Will I find a bathroom in time?” “Will I embarrass myself?” “If I eat this, will I have diarrhea?” “Am I comfortable going out in public?” “Can I return to work?” “Do I have an odor?” Incontinent or paralyzed patients suffering with an infected sacral pressure ulcer are assessed for the role their incontinence may have in their wound infection. Accompanying incontinence of any etiology is the concomitant painful problem of peri-anal skin irritation and embarrassing odor.

    Fecal or urinary incontinence negatively affects quality of life — the ability to work, sleep, rest, self-care, and interact socially and sexually. When medical management or other forms of conservative management fails and quality of life is diminished, many of the patients described above decide they have simply had enough. When intractable incontinence or failure of other surgical interventions has forced the individual to curtail normal activities or risk a life-threatening infection, an ostomy is viewed as an opportunity to finally have control over bodily functions and get on with life. Contrary to the customary view that patients dread the idea of a permanent ostomy, people who have long-suffered with forms of chronic disease — or function-related incontinence frequently welcome the creation of an ostomy as a way of maintaining control over stool and urine and regaining control over their lives.

    The most common indications for surgical intervention in management of fecal incontinence include spinal cord injuries and inflammatory bowel disease.² Continent surgical alternatives also are now available, such as the creation of an ileal-anal reservoir or a Koch pouch. As with intestinal diversions, construction of an ileal conduit or another continent urinary procedure is major abdominal surgery. The ileal conduit requires the use of an external collection device. Urinary diversion also can be achieved with a continent urinary reservoir such as the Indiana pouch, the Koch urinary pouch, the Mitrofanoff pouch,³ or the Camay procedure for men, which permits normal voiding.

   Nurses caring for these patients must be cognizant of the fact that even under these circumstances, an ostomy requires psychosocial adaptation and readjustment of one’s body image. Some people are so relieved to be cured of incontinence or to be relieved of the severe perineal pain or social embarrassment that may have preceded the surgery, they experience a “honeymoon” period when they have not yet assimilated the ostomy into their self-concept or body image.⁴

    Ostomy care requires daily viewing of and interaction with the stoma and constant vigilance regarding the integrity of the surrounding skin. Sometimes the reality of what it means to live with an ostomy does not become apparent until some time after the surgery. Paraplegics or quadriplegics, who have already suffered enormous physical and emotional insults to their body image and sense of self, may have difficulty accepting another surgical procedure that further changes the body’s appearance, even though the patient wanted the procedure to regain continence. Patients experiencing a late integration of the stoma into their daily lives, when they had anticipated a different reality for themselves, need extra support, empathy, and understanding.

The Ostomy Files is made possible through the support of ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ

1. Rolstad BS, Hoyman K. Continent diversions and reservoirs. In: Hampton BG, Bryant RA, eds. Ostomies and Continent Diversions: Nursing Management. St. Louis, Mo.: Mosby Year Book; 1992:129–162.

2. Basch A, Jensen. Management of fecal incontinence. In: Doughty DB, ed. Urinary and Fecal Incontinence: Nursing Management. St. Louis, Mo.: Mosby Year Book;1991:235–268.

3. Gray M, Siegel SW, Troy R, Faller N, et al. Management of urinary incontinence. In: Doughty DB, ed. Urinary and Fecal Incontinence: Nursing Management. St. Louis, Mo.: Mosby Year Book;1991:95–150.

4. Neal LJ. Rehab’s role in incontinence treatment and ostomy care. Rehab Management. 2000. Available at: www.rehabpub.com. Accessed October 8, 2004.