To Irrigate or Not?

“To irrigate or not?” is a question for those who live with a sigmoid or descending colostomy. Colostomy irrigation is a procedure in which fluid is instilled into a colostomy to stimulate evacuation of stool from the colon.¹ The goal of irrigation is to have no output between irrigations.¹ Relative contraindications of colostomy irrigation include irritable bowel syndrome, peristomal hernia, postradiation damage to the bowel, diverticulitis, and Crohn’s disease.¹

BENEFITS OF COLOSTOMY IRRIGATION

Colostomy irrigation is a well-established procedure with many benefits for people who choose to irrigate via their stoma. People have been able to gain control over evacuation of stool, and this results in a feeling of increased confidence.² For some people, colostomy irrigation eliminates the passage of stool between irrigations, whereas it decreases the output frequency for others.¹ This decreased frequency leads to reduced use of ostomy supplies.¹ Some people do not have to wear a pouch at all.³ Colostomy irrigation also decreases gas and odor.¹ This can be especially beneficial for those with challenging contours that contribute to leakage of the pouch system and subsequent peristomal skin irritation.²

Colostomy irrigation is associated with an increased quality of life compared to those who do not irrigate.¹ People gain control of bowel function and no longer need to worry about leakage of the pouching system, passage of stool at inopportune times, carrying ostomy supplies, and disposal of the pouches.² This increases confidence in social situations and can positively affect occupational interactions and intimate relationships.⁴ Additionally, people experience fewer skin problems and sleep issues.¹ The positive aspects of colostomy irrigation are exemplified by statements from people who irrigate. Jim Murray, President of United Ostomy Associations of America (UOAA), reports the following:

I have been irrigating regularly since 2006. I am an active senior, traveling quite a bit, visiting friends and relatives, presenting on behalf of UOAA and performing on stage occasionally, riding on Mardi Gras floats during parades … my wife and I enjoy at least two cruises a year. Irrigation provides me the freedom to do all of this without having to cope with stool in the pouch. I simply plan when to empty and merrily go about my business.

Co-Chair of the Advocacy Committee of UOAA, Susan Mueller, reports,

I have been using irrigation as an ostomy management practice since my first year living with an ostomy, 18 years ago! For me, this option was pivotal in my acceptance of and adjustment to life [with a colostomy]. All [persons with a colostomy] who fit the criteria for irrigation should be informed of this choice. I think the time and energy utilized is an easy tradeoff for the predictability and freedom this gives me.

In addition to an improved lifestyle, colostomy irrigation provides cost savings. The cost of ostomy products is decreased because fewer pouches are used or because pouches are eliminated.¹ For people who do not have output between irrigations, a small bandage can be used over their stoma.³ Furthermore, costs associated with health services for treatment of peristomal complications and leakage concerns are decreased with resolution of peristomal issues.⁵

PRESCRIPTION OF COLOSTOMY IRRIGATION

I work in an outpatient ostomy clinic that educates patients about colostomy irrigation. In my experience, many patients wait to leave the house until their colostomy evacuates in the morning. This may take several hours when they do not irrigate. In addition, these patients may experience spontaneous episodes of stool and gas through the ostomy throughout the day and are disturbed by bulging of the pouch by the output.

Most patients I have instructed on the procedure of colostomy irrigation choose to continue doing so and are happy with the additional control it provides them. One patient I worked with was told not to irrigate after having hernia surgery. Due to fear of leakage, noise of passing gas, and concern of odor, he had not left his house in years. He was so grateful when I told him he was able to return to colostomy irrigation. As a result, he returned to having an active life, leaving the house to eat at restaurants and spending time with his family.

Unfortunately, colostomy irrigation is not routinely recommended. Of persons with a permanent colostomy, 50% never had irrigation offered to them.^3,6 A survey sent to certified wound ostomy and continence nurses found that only half of the nurses teach colostomy irrigation and often only if requested by the patient or physician.⁷ The reasons nurses listed for not teaching colostomy irrigation include lack of education about the procedure, too time-consuming for the patient, patient choice, improved ostomy pouching systems, and lack of time for teaching.⁸ Performing colostomy irrigation takes about an hour.² When comparing irrigation time to time providing care to the ostomy throughout the day for those who do not irrigate, there is no significant difference.¹

The option of colostomy irrigation should be discussed with patients before discharge from the hospital, and teaching tips should be provided in patients’ discharge instructions.^4,8 Teaching can be completed in a patient’s home or an outpatient clinic.⁴ Resources for teaching can be found in the UOAA’s colostomy guide, in YouTube videos, or in an older article from the UOAA’s Discussion Board.

The question, “To irrigate or not?” can only be answered by those who live with a sigmoid or descending colostomy. These people need to be educated to make an informed decision about this option, which may improve their quality of life.

REFERENCES

1. Kent DJ, Long MA, Bauer C. Does colostomy irrigation affect functional outcomes and quality of life in persons with a colostomy? J Wound Ostomy Continence Nurs. 2015;42(2):155-161. doi:10.1097/WON.0000000000000121

2. Whiteley I, Lyons AM, Riccardi R. A qualitative interpretation of the relevance of colostomy irrigation today. J Stomal Therapy Australia. 2012;32(3):6-20.

3. Grant M, McMullen CK, Altschuler A, et al. Irrigation practices in long-term survivors of colorectal cancer with colostomies. Clin J Oncol Nurs. 2012;16(5):514-519. doi:10.1188/12.CJON.514-519

4. Bauer C, Arnold-Long M, Kent DJ. Colostomy irrigation to maintain continence: an old method revived. Nursing. 2016;46(8):59-62. doi:10.1097/01.NURSE:0000484963.00982.b5

5. Varma S. Issues in irrigation for people with a permanent colostomy: a review. Br J Nurs. 2009;18(4):S15-18. doi:10.12968/bjon.2009.18.Sup1.39633

6. Feddern M-L, Emmertsen KJ, Laurberg S. Life with a stoma after curative resection for rectal cancer: a population-based cross-sectional study. Colorectal Dis. 2015;17(11):1011-1017. doi:10.1111/codi.13041

7. Cobb MD, Grant M, Tallman NJ, et al. Colostomy irrigation: current knowledge and practice of WOC nurses. J Wound Ostomy Continence Nurs. 2015;42(1):65-70. doi:10.1097/WON.0000000000000075

8. Tallman, NJ, Cobb MD, Grant M, et al.  Colostomy irrigation: issues most important to wound, ostomy and continence nurses. J Wound Ostomy Continence Nurse. 2015;42(5):487-493. doi:10.1097/WON.0000000000000170

Ms Erbe is an ostomy nurse practitioner at the Medical College of Wisconsin and has more than 30 years of experience in inpatient and clinic care settings. She is committed to improving outcomes and quality of care for patients with wounds and ostomies and serves on UOAA Education Committee.
This column was not subject to the Wound Management & Prevention peer-review process.