One Size Does Not Fit All in Ostomy Care
Stomas come in all shapes and sizes, just as people do. A pouch system must fit a person properly to obtain a predictable wear time and prevent peristomal skin complications. Patients require reassessment in the first few weeks after surgery as their stoma changes size and their abdomen becomes less distended.1 Throughout their lifespan, people with an ostomy require evaluation of the pouch system as the abdomen changes with weight loss or gain, abdominal surgery, and aging.2
Leakage occurs when the pouch system does not fit a person correctly. Individuals who experience leakage have a decreased quality of life.3 Patients withdraw from social, leisure, and sexual activities after a series of pouch seal leakages or an embarrassing social situation caused by their stoma.1 People become afraid to leave their house.1 Poorly adhering pouch systems can also lead to peristomal skin complications.1,4 Leakage of pouch systems can also lead to emergency department visits and hospital readmissions.5
People with an ostomy require a thorough assessment to determine their proper pouching system. The type of stoma and amount of output influence pouch and skin barrier selection.6 The location and abdominal contours must be assessed as the skin barrier should conform to the abdomen.6 A skin barrier should be sized to fit the size and shape of the stoma.6 The person’s lifestyle, personal preferences, visual acuity, and manual dexterity should also be considered.6 The environment or weather to which a person is exposed can also influence skin barrier selection. There are many different options to match a person’s stoma and abdomen. It is essential to understand the differences in the options to determine the most appropriate pouch system.
TYPES OF POUCHES
Pouch selection is based on stoma output. A urostomy requires a drainable pouch with a tap closure.2 The tap closure allows for urine drainage. The pouch has an antireflex valve that prevents urine from collecting by the stoma and washing away the skin barrier. An adaptor allows the pouch to be connected to a drainage bag for use at night.
Fecal pouches are either drainable or closed-end. Drainable pouches allow for drainage of output frequently throughout the day. Types of closures are either velcro or clip closure. High-output pouches are also available. These pouches are larger and have a larger tap output, which allows the drainage of fecal particulate. These pouches can be connected to a drainable bag for high-output stomas. Closed-end pouches are discarded instead of emptied, and a new pouch is applied as needed. Generally, closed-end pouches should be considered for people who empty the pouch once or twice daily.
TYPES OF SKIN BARRIERS
An ostomy pouch system’s skin barrier has direct contact with the skin. The goal of the skin barrier is to provide adherence, protect the skin, and offer gentle removal. Most barriers are made with a combination of hydrocolloids, carboxymethyl cellulose, adhesives, pectin, gelatin, and polymers.2 The formulation of skin barriers varies with manufacturer and type of product. Standard-wear barriers tend to absorb liquid but erode from liquid effluent. Therefore, this formulation is best with formed output, such as in persons with colostomies. This product is also suitable for those with excessive perspiration. Extended-wear barriers are designed to absorb less and adhere more, which allows for a longer wear time. These products are best for liquid output, such as in persons with a urostomy, ileostomy, or jejunostomy.
The ceramide-infused barrier protects peristomal skin from transepidermal water loss by forming a protective layer in the skin.7 This skin barrier can be used to prevent peristomal skin complications and relieve peristomal itching.7
Silicone barriers that do not absorb liquid are also available. A breathable matrix prevents moisture from being trapped under the wafer.8 The silicone barrier also displays effective adhesion and allows for atraumatic removal.8
ONE-PIECE VERSUS TWO-PIECE POUCH SYSTEMS
With a one-piece pouch system, the pouch is attached to the skin barrier. In a two-piece pouch system, the pouch and the skin barrier are separate pieces. All types of pouches and skin barriers are available in both the one-piece and two-piece systems. For information on application, see the United Ostomy Association of America’s website, https://www.ostomy.org/types-pouching-systems/.
A one-piece pouch system can be the simplest for patients because there is no need to attach the pouch to the skin barrier. This system can be an effective option for those with limited dexterity. Wearing just the one-piece pouch provides a lower profile. A one-piece pouch may be cheaper than a two-piece system. However, the pouch cannot be repositioned after it is applied to the skin. A flat one-piece pouch is flexible and may be most effective for a stoma in a deep crease or skinfold.2
Two-piece pouch systems have various mechanisms to connect the pouch to the wafer. There are stationary couplings, floating flange couplings, and adhesive couplings.2 Stationary couplings have a plastic flange adhered to the skin barrier. With the floating flange coupling, there is room under the flange to allow for fingers to assist with applying the pouch. Adhesive couplings have a lower profile as there is no flange, just a landing zone for the adhesive seal. Two-piece pouches allow people to visualize their stoma with application. Additionally, the pouch can be repositioned (to allow for connection to a night drainable bag) or changed periodically (as with closed-end pouches).
SHAPES OF SKIN BARRIERS
Pouch systems come in all shapes to accommodate different abdomens. Wafers are flat, convex, and concave. These shapes are available in one-piece and two-piece pouching options, along with all types of pouches. A flat wafer has a level adhesive surface.2 This wafer works well for protruding stomas on a firm abdomen with a flat pouching surface.
A convex wafer has a curved adhesive surface that presses down on the abdomen. All convexities are not created equal. There are many different degrees and types of convexity. Convexity ranges from soft to firm, and light to deep. A soft convex wafer is compressible, whereas some convex wafers are hard and nonbendable. The degree of convexity varies from shallow to deep.
Convexity works well for all types of stomas.9 Indications for convexity include flush stomas, stomas with the opening at skin level, and liquid output.9 Convexity can be used to flatten creases and folds seen around a stoma when a person is in a sitting position.2 The depth of convexity should be used to fit the depth of creases and folds.10 The least amount of convexity should be used to obtain an adequate seal to minimize the risk of a peristomal pressure-related injury.10
There are different indications for the compressibility of the wafer. When convexity is required, a soft convex wafer or an easily compressible convex barrier should be considered in the postoperative period or with a firm abdomen.10 Firm convex wafers are used to flatten the abdomen or assist with stoma protrusion.10 Soft abdomens often require a firm convex wafer.10 Flexibility should also be considered with the use of convexity. To fit in abdominal skin folds, a more flexible wafer should be considered when convexity is required.10
Concave wafers (convex flip) appear convex but flip with application. After being applied, they are concave and form a cup shape. These skin barriers work with peristomal hernias or around bulges on the abdomen.
CONCLUSION
It may take multiple attempts to determine the correct pouch system. It is important to explain this to people who are experiencing leakage. Additionally, accessory products may be essential for a good pouching seal. These accessories will be covered in a future article.
Resources available for assistance for people with ostomies include wound ostomy continence nurses and ostomy manufacturers (Table). Manufacturers offer product sampling programs that allow people to try products before ordering. The manufacturers also are familiar with their product lines and can provide product assistance.
Considering a person’s preferences and the appropriate fit can lead to an improved quality of life for those living with an ostomy. Obtaining the best fit is essential for people to return to normal function after surgery and remain active throughout their lives. Therefore, this information is important for anyone caring for a patient with an ostomy.
REFERENCES
1. Colwell JC, Bain KA, Hansen AS, Droste W, Vendelbo G, James-Reid S. International consensus results: Development of practice guidelines for assessment of peristomal body and stoma profiles, patient engagement, and patient follow-up. J Wound Ostomy Continence Nurs. 2019;46(6):497-504. doi:10.1097/WON.0000000000000599
2. Colwell J, Hudson K. Selection of pouching system. Wound, Ostomy, and Continence Nurses Society Core Curriculum: Ostomy Management. 2nd ed. Wolters Kluwer; 2022.
3. Goldstine J, van Hees R, van de Vorst D, Skountrianos G, Nichols T. Factors influencing health-related quality of life of those in the Netherlands living with an ostomy. Br J Nurs. 2019;28(22):S10-S17. doi:10.12968/bjon.2019.28.22.S10
4. Burch J. Maintaining peristomal skin integrity. Br J Community Nurs. 2018;23(1):30-33. doi:10.12968/bjcn.2018.23.1.30
5. Houston N. Mad, crazy or to be expected?: Diana’s journey from child abuse, surgical violation and a hernia repair: how stomal therapy intervened to make a difference. J Stomal Ther Australia. 2019;39(4):23-24.
6. Wound, Ostomy and Continence Nurses Society; Guideline Development Task Force. WOCN Society clinical guideline: management of the adult patient with a fecal or urinary ostomy-an executive summary. J Wound Ostomy Continence Nurs. 2018;45(1):50-58. doi:10.1097/WON.0000000000000396
7. Colwell JC, Pittman J, Raizman R, Salvadalena G. Randomized controlled trial determining variances in ostomy skin conditions and the economic impact (ADVOCATE trial). J Wound Ostomy Continence Nurs. 2018;45(1):37-42. doi:10.1097/WON.0000000000000389
8. Lager P, Loxdale L. Use of breathable silicone technology in an ostomy appliance flange. Br J Nurs. 2021;30(supll 8):25-35. doi:10.12968/bjon.2021.30.Sup8.25
9. Hoeflok J, Salvadalena G, Pridham S, Droste W, McNichol L, Gray M. Use of convexity in ostomy care: results of an international consensus meeting. J Wound Ostomy Continence Nurs. 2017;44(1):55-62. doi:10.1097/WON.0000000000000291
10. McNichol L, Cobb T, Depaifve Y, Quigley M, Smitka K, Gray M. Characteristics of convex skin barriers and clinical application: results of an international consensus panel. J Wound Ostomy Continence Nurs. 2021;48(6):524-532. doi:10.1097/WON.0000000000000831
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 United Ostomy Associations of America, Inc. (UOAA) Education Committee. Please send inquiries to advocacy@ostomy.org. Information in this article was provided by UOAA. UOAA does not endorse particular products, manufacturers, providers, or other sellers of ostomy products.
This column was not subject to the Wound Management & Prevention peer-review process.
