Irrigation for Colostomies
Question:
I have a colostomy and someone suggested I could try irrigation to manage it. What is irrigation?
Answer:
Irrigations for colostomies involve the regular installation of moderate to large volumes of water to clear the colon of stool. Essentially, it is an enema into the stoma resulting in the clearing of stool from the colon. Some individuals who have colostomies choose to use irrigations as a means to regulate the function of their stoma. This allows for predictable bowel movements and the use of smaller pouches, such as stoma caps, in between irrigations. Not everyone with a stoma can use irrigations to manage their stomas; several factors must be considered before embarking on this process
As mentioned above, irrigations may be used by individuals who have a colostomy; more specifically, individuals who have a descending or sigmoid colostomy. People who have a transverse colostomy, an ileostomy, or a urinary stoma (ileal conduit, urostomy) cannot use irrigations to manage their stoma. If you are unsure what kind of stoma you have, contact your general surgeon or Enterostomal Therapy Nurse (ET) to discuss and review your type of stoma. Equally, individuals who have a continent diversion, such as a Koch pouch, would not use the same irrigation process described in this article to manage the function of their diversion; alternate methods are used in these circumstances.
Other factors must also be considered when determining if irrigations are an appropriate choice for you. If you have undergone, or will be undergoing, chemotherapy and/or radiation therapy (to the lower abdomen/pelvis), then irrigation may not be an option for you. Chemotherapy and radiation therapy can either temporarily or permanently alter the frequency and consistency of your stomal function, making the process of irrigation problematic. If you have a parastomal hernia, and even if you are able to reduce your hernia, irrigations are generally not recommended to regulate your bowel function. Irrigations with a hernia may result in bowel obstructions or other complications. If your stoma prolapses (becomes unusually long), then irrigations are also not an option for you. Irregular bowel function or consistency (for example, diarrhea) also make successful irrigations problematic and are generally not recommended. While not an absolute contraindication to irrigations, elderly people with a new colostomy may find the actual process difficult to learn and master, and therefore may not opt to try this technique. Lastly, if your stoma is temporary, then irrigations are also not appropriate as a management technique.
Given all of these restrictions, irrigations are most successful for individuals who have a descending or sigmoid colostomy with semi-formed or formed stool that is passed at regular intervals. Maintaining a regime of regular exercise and regular dietary habits (i.e., eating generally at the same times each day) will also help to regulate the bowel. Irrigations work by “habituating” the bowel to a regular, predictable routine: with daily or once every second day regular installations of moderate to large amounts of fluid, the bowel develops the “habit” of knowing that it will be thoroughly cleansed of stool on a regular basis. As a result, it will “learn” not to function in between the irrigations (except for flatus), allowing you to have some degree of predictability around bowel function, and to wear smaller pouches or stoma caps. The key to success is regularity: if you travel a lot, find your routines and schedules are often unpredictable, then this may not be the best way to manage your colostomy.
Perhaps the most significant determinant of whether colostomy irrigations are suitable for you is based on your motivation and patience. The entire daily process of instilling fluid and allowing the colon to empty takes about 45-60 minutes. The process of habituating your bowel to the irrigations takes weeks. As mentioned before, the bowel is used to habit, and it will take some time for it to learn the new habit of regular enemas. During this period of adaptation, it is recommended that you continue to wear your regular pouching system, as you may find that you still may pass small amounts of stool during the day/night despite the irrigation. In time, your bowel function will be more predictable and you will be able to wear smaller stomal caps.
Irrigations do require the use of some special equipment. Irrigations sets are often available through the common ostomy product manufacturers. These sets usually include a large volume irrigation bag that holds the fluid to be instilled; a length of tubing with a clamp (to regulate the flow of fluid), and a cone attached to the end of the tubing. The cones are gently inserted into the stoma, and are used to prevent the backflow of fluid during the irrigation. Irrigation sleeves are applied over the stoma (either directly onto the skin, or attached to your regular flange), and are generally longer than normal pouches to allow for easy, “splash-free” drainage into a toilet. Some sort of hook well above the toilet, where the irrigation bag can hang, is useful to allow for the gravity flow of fluid into the stoma. Most individuals will use between 500 to 1000 milliliters of warm tap water daily to irrigate their stoma. Required volumes will vary between individuals.
While irrigations can provide predictability in stoma function and can improve the esthetics of pouching appliances for some individuals, concerns about the long-term use of irrigations have been poorly studied. People who use irrigations over a prolonged period of time (many years) may find that the volume of fluid required to complete a successful irrigation can increase. Some individuals report needing to use between 2000 and 3000 ml of fluid (and hence more time to instill the fluid) as they get older. It is generally accepted that as the bowel becomes increasingly dependent upon the irrigations as a means of cleansing, it can become problematic to stop the irrigations and return to regular pouching. Trying to stimulate the bowel to function “normally” again, without the aid of a regular enema, can be difficult. It may require the use of laxatives to help stimulate regular function. This is a consideration for the older adult, as irrigations may become functionally difficult to manage (poor hand dexterity, poor eyesight).
Some final considerations include your access to safe tap water. If you use well water, or are unsure about the potability of your water source, then you may want to use bottled water for your irrigations. Equally, if you are traveling and want to continue with your irrigations and are not sure about the safety of the local water source, bottled water may again be your best option. On occasion, you may still have episodes of diarrhea due to flu or unsafe food sources. As a result, you may want to keep a small supply of your regular pouching system, to allow for easier management.
If you think irrigations may be an option for you, contact your Enterostomal Therapy Nurse for discussion and teaching regarding this management method.