I’ve had a colostomy for several years and have not had any problems. Quite recently, my stoma became very long and I was told that I have a prolapse. What is a prolapse and is there anything I can do?
A prolapse is a stoma that essentially telescopes out through itself, causing abnormal lengthening. The appearance of a prolapsed stoma can be distressing, and you should consider some changes to your stoma care.
Prolapse is a complication associated more with colostomies than with ileostomies, and is more frequent in those with loop colostomies, particularly loop stomas located in the transverse colon, than with end stomas. (End stomas result from a complete cut through the intestine with the end pulled through the abdominal wall, while loop stomas result when an intestinal loop is pulled through the abdominal wall and an incision made into part of the loop.)
While we don’t fully understand why a prolapse occurs, several factors could contribute to the development of a prolapsed stoma:
- poor abdominal muscle tone,
- weight gain/obesity,
- surgical technique (such as a large opening in the abdominal wall, where the bowel was brought through to create the stoma at the time of surgery),
- increased pressure within the abdomen, such as that associated with coughing and increased fluid in the abdomen (ascites), and
- a colostomy that was brought out through the abdominal incision.
Some characteristics of a prolapse may influence your care of the stoma. A prolapse may be positional in that it could be present or absent depending on whether you are sitting, lying down, or standing. You may notice when you are standing that the prolapse is evident, but when you lie down for a while, your stoma may return to its usual size. This is called a spontaneous reduction. Sometimes the stoma will remain prolapsed and will become swollen. It can enlarge in diameter as well as in length.
The blood supply to a prolapsed stoma can become compromised, causing a change in the colour and/or warmth of the stoma. Poor blood supply can cause a variety of changes to your stoma, from small ulcerations on the surface (called ischemic ulcers) that look like yellowy-white patches, to more significant changes in colour or temperature. The stoma can become dark red or purple, or sometimes a very pale pink, and may be cool to touch. You may also notice that your stoma does not function as well with a prolapse, potentially causing signs of an obstruction. If you notice changes to the colour and/or temperature of your stoma, or are worried that it may not be functioning normally, you should seek medical attention.
A prolapsed stoma does require some changes to your routine care. Aside from monitoring colour, temperature, and function, you may need to consider changes to the type of pouching system you are using. If the prolapse is large, you may need to consider a larger/longer pouch that will accommodate both the stoma and the usual volume of stool. You may find that you need to empty or change your pouch more often. You may also need to have an alternate flange, one that will not cause trauma to your stoma.
If your prolapse is very mobile (i.e. it slides in and out with position changes), then there is a risk of lacerating the stoma with the edge of the flange. Lacerations do not cause pain, but you may notice some bleeding on the stoma or a white line where the flange has been rubbing against it. You may need to adjust the opening of your flange (measure when the stoma is at its largest), or may need to switch to an alternate product such as a moldable flange (available from ConvaTec) that will not hurt your stoma. Your ET can help you reassess your pouching needs.
If your stoma remains prolapsed, then you will need to protect it from external trauma. The type of work you do, the activities you like to participate in, and even regular daily habits such as leaning against a counter for meal preparation, may all cause stoma bruising. Stoma guards or protectors are available and may work for you, depending on your stoma size. Prolapse belts (belts that help to keep the prolapse reduced) are commercially available but generally the pressure from the prolapse is stronger than the belt, allowing the stoma to wiggle past the belt itself. Some two-piece coupling mechanisms may also cause trauma to the stoma, either by direct pressure or by rubbing against the mechanism, or by inadvertently trapping some of the stomal surface in between the pouch and the flange as they attach. A one-piece system or coupling mechanisms with lower profiles may also work for you. Again, your ET will help you to determine if your care would improve with a stoma protector, prolapse belt, or alternate pouching system.
You might find it challenging to find clothing that is comfortable, does not cause trauma to your stoma, and still helps conceal your stoma and pouch. Belts or waistbands should not rest directly across your stoma. To improve comfort, you could try simple adjustments such as changing the rise of pants to be above or below your stoma. Other clothing details such as pleats in pants or skirts, patterned clothes, or layered styles may help to conceal any bulges.
Lastly, depending on the severity of your prolapse or the symptoms you experience, you may require a referral to a surgeon for revision (surgical repair) of your stoma. Your surgeon will discuss the potential risks and benefits of a stoma revision, and whether this is an option for you.