Ask your doctor if colostomy irrigation is right for you
By Mary Lou Boyer, BSEd, RN, CWOCN Lifetime Achievement Award Winner, Cleveland Clinic
You may have seen or heard the term “irrigation” used in conjunction with ostomy care. There are several different ways this word is used and it can have very different meanings.
Some people with ostomies say that they “irrigate” their pouch or appliance each time they empty. In these cases, it is a matter of adding water to help loosen thick or formed stool to assist in emptying the thick stool from the pouch. Or it can mean rinsing out the pouch with water until the pouch appears clean. In other cases the term “irrigation” is used when referring to a procedure that some people with descending or sigmoid colostomies may use to cleanse or regulate the bowel by instilling water into the large intestine through the stoma. This is called “colostomy irrigation”.
Over the many years that colostomy irrigation has been an option in colostomy care, there has been some debate about whether or not an individual should irrigate. In making that decision the following are questions that should be considered: what is colostomy irrigation? Who is an appropriate candidate? Why is it done? When is it done? And how is it done? This article is an attempt to answer these questions.
Colostomy irrigation is a method of assisting the bowels to move at a certain time. The procedure itself is similar to an enema, however it is done with specialized equipment to instill warm water through the colostomy stoma. A large water bag with tubing that has a cone-shaped tip is inserted into the opening of the stoma. The cone-shaped catheter tip allows the water to flow into the colon while preventing the water from leaking back out. As the colon fills with water, it distends. This distention stimulates colon peristalsis and mass contractions that lead to stool evacuation.
Colostomy irrigation is an option only for people who have a descending or sigmoid colostomy. In the normal bowel, the function of the colon is to absorb water from the waste material and to store it for a normal bowel movement. In most cases this can be as often as once or twice a day, or less frequent, such as every other day. There must be enough of the large intestine to absorb and store. The anal sphincter muscle is used to control the bowel movement until a convenient time. When most of the colon is still in place, the bowel can generally return to the usual pattern the person had prior to surgery. With a colostomy there is no longer a sphincter muscle to hold the stool in until a convenient time to go to the bathroom. Stool will flow into the pouch with no control over the timing. This loss of control that comes along with having a stoma can result in stool flow into the pouch at inconvenient or embarrassing times. Gas can also be an issue.
Colostomy Irrigation is used to empty the colon for any of the following reasons.
• To regulate the bowel
• Clean out the bowel for testing procedures, including colonoscopy
• To stimulate bowel function for constipation or if the colon is very slow to wake up after the colostomy surgery
When colostomy irrigation is used to help stimulate bowel function after intestinal surgery, only a small amount of warm water is instilled. This is done after the normal waiting time for stool flow has passed. Anesthesia, pain medications and inactivity after surgery all contribute to slowing the bowel down and delaying return of normal peristalsis needed to have bowel function. Colostomy irrigation can be used as a possible method for cleansing the bowel in preparation for colonoscopy, laboratory testing, x-rays, barium enema and CT scans, as well as any other testing that requires the bowel to be empty for clear visualization by the physician. Cleaning out the bowel for testing has shifted more toward oral preparations with the advancements of laxative-type bowel cleansing medications. However, irrigation is still an option, especially for those patients with certain health issues or who cannot tolerate oral preparations.
When colostomy irrigation is used to regulate the bowel, the procedure is done daily. If the normal pre-surgery bowel pattern was less frequent than daily, the procedure can be done every other day. It may take a couple of weeks to “train” the bowel to completely empty at the time of irrigation. The desired result is to move all of the stool out with irrigation and have no spillage of stool into the pouch between irrigations. The best results are obtained by doing the procedure at the same time every day in order to ”train” the bowel for evacuating on a regular basis at a convenient time. For some people it is most convenient to perform irrigation in the morning and for others the best time is in the evening when they are not rushing off to work or other daily activities. It is up to the patient’s personal preference.
If the procedure works well, the person with a descending or sigmoid colostomy can count on regular evacuations and the need for a pouch is minimized. The patient who irrigates successfully may wear only a small stoma cap or gauze square over the stoma between irrigations. Some wear a small pouch just for security.
Colostomy irrigation is not always appropriate or even desirable for every person who has a sigmoid or descending colostomy. The person’s age, physical and mental ability to learn and perform the procedure, the disease process, and whether or not the ostomy is temporary or permanent are all factors that need to be considered.
Irrigation is NOT recommended for people with any of the following conditions:
• Stomal prolapse – Irrigating can increase the risk for further prolapse
• Parastomal hernia – Hernias change the contour and angle of the intestine so there is increased risk for bowel perforation and poor evacuation results
• Children or young adults – In younger people, routine irrigation may create bowel dependency. In other words the bowel may not be able to function normally without irrigation if the routine is started at an early age.
• Pelvic or abdominal radiation – Radiation can cause damage to the tissue of the intestine. Anyone with abdominal radiation has an extreme risk of bowel perforation, so it is important not to add any extra pressure to the fragile tissue.
• Diverticulitis – Because the bowel tissue is already compromised from this disease process, there is a much higher risk of bowel perforation.
• Patients with limited manual dexterity • Patients with poor learning ability
• Persons who had poor bowel regularity before surgery will likely have poor results from irrigation
• Extremely ill or terminally ill patients – Routine irrigation is usually not recommended for these patients because of the time and energy required for the procedure
When colostomy irrigation is being considered, it is important to first determine if the individual is a good candidate. In other words, are there are any of the above risk factors? If not, then consider the advantages and disadvantages of the procedure, keeping in mind that the procedure, from start to finish, can take up to 45 minutes or even an hour.
The chief advantage is regaining control over fecal elimination. If irrigation is successful, it can reduce the number of pouches used. It may even be possible to choose not to wear a pouch and only use a small protective covering. Successful management of the colostomy with irrigation may assist in the psychosocial adjustment to the colostomy. Disadvantages include the time required for the procedure and not all patients can achieve complete control with irrigation. If elimination patterns change or become unpredictable, the patient may not be free of bowel movements between irrigations.
Research shows that colostomy irrigation was first used in the 1920s and through the years it was taught routinely to patients with a descending colon or sigmoid colostomy. Among the chief reasons for teaching this routinely was the lack of quality pouches to contain thick or formed stool as they were bulky and did not adhere well to the skin. As pouching systems improved with more advanced technology, Colostomy irrigation as a widely used “routine” procedure lessened and began to be used more for personal preference, or on a need to know basis.
Regulation of the colostomy using irrigation is a personal matter. Life style and occupation often lead in making the choice. The final decision of whether to use this method or not should be made by the patient with proper guidance from health care professionals. Only those patients who meet the established criteria for irrigation should proceed with using this method of bowel management.
1. Gather equipment
2. Fill irrigation container with 1 liter warm water. Run some water through the tubing to remove air
3. Hang container at shoulder height with patient sitting on toilet or chair near toilet.
4. Remove old pouch or covering from stoma
5. Attach irrigation sleeve over stoma
6. Lubricate cone irrigator and gently insert into stoma. Hold cone gently but firmly against stoma to prevent backflow of water.
7. Open clamp and allow water to flow. If cramping occurs, shut off water flow, keeping cone in place until cramp subsides, then continue.
8. After water has been instilled, gently withdraw cone and close top of irrigation sleeve.
9. Allow 15-20 minutes for most of return, dry and clamp bottom of sleeve. Patient may proceed with other activities.
10. Leave sleeve in place for approximately 20 minutes
11. When evacuation is complete, remove sleeve, clean peristomal skin and apply pouch or protective covering.
12. Wash equipment.