Stoma Issues.

We ostomates are a funny bunch. We look at photos of other people’s stomas and say things like “Ooh, that’s a pretty one” and “I have stoma envy!” Much like in a beauty pageant, a winning stoma would be the perfect size, shape, and height (length), and not make loud, embarrassing farts. But let’s face it - most of us are going to be runners-up, for a variety of reasons.  

Size & shape – By size, I mean the dimension of your stoma opening, and the size (or girth) of the stoma poking through it. By shape, I mean whether your opening is a perfect circle, or some other shape, like an oval. There’s no such thing as a standard size or shape. What’s important to know is what’s normal for you, not what’s normal to anyone else. Any change in your normal should be noted. The most common changes you might see are: 

Changes during surgery recovery – Immediately after surgery, your stoma will most likely be swollen. Because you’ve never seen a stoma before, it may not look swollen, but expect that it will decrease in size over the next 6-8 weeks. Then it should pretty much stabilize. During this recovery period, measure the dimension of your stoma frequently when you change your appliance, in case you need to adjust the hole in your baseplate.  

Stoma opening grows – Sometimes the opening for your stoma can get bigger. This is often caused by a hernia, pregnancy, or weight gain - anything that increases the size of your abdomen and stretches the skin. We’re not talking about dramatic changes in size here, but even a tiny change can affect how exactly the baseplate fits around the stoma. If the opening in your abdomen becomes bigger than the hole in your baseplate, then output can seep underneath, causing skin irritations, leaks, and/or problems with the baseplate sticking on your skin. If you start having any of these problems, check if your opening has enlarged. If so, re-measure and adjust the hole in your baseplate.  

Stoma swelling – Many stomas swell at times and then go back to normal. This usually means there’s a buildup of pressure from the inside, like a bowel movement about to push through. But it could also be a warning sign of a blockage.  

Length - Typically, a stoma sticks out a little. But it could be flush with the surface of your skin, or even sink in below the surface. That’s called a retracted stoma. If it sticks out more than an inch (2.5 cm), it’s a prolapsed stoma. Whether it’s an innie or an outie, both can be managed conservatively if it isn’t too extreme. Otherwise, it can be fixed with surgery.  

Flush or retracted stoma – The purpose of a stoma is to protrude out from your abdomen enough that the output can drop down neatly into your pouch. If it’s level with your skin or sinks in below that, you can have problems with leaking, seepage, or pancaking.  

A flush or retracted stoma can often be managed with a convex baseplate. This kind of baseplate has a rigid, circular indentation in the center that fits around the hole in your abdomen, pushing down around the hole so your stoma will stick out a little. You can get a light, regular, or deep convex baseplate – meaning how shallow or deep the indentation is, depending on your need. 

The deeper the convexity, the more pressure you’ll need to keep it pressed into your stomach. Wearing an ostomy belt that hooks into tabs on the side of your baseplate or pouch can help to keep it snug. Flange extenders can also help keep the baseplate stuck on well.  

Use the minimum convexity you can get away with. The more pressure against the skin around your stoma, particularly from a rigid appliance, the greater the risk of developing pressure ulcers.  

Prolapsed stoma – This can be caused by pressure from inside your body, like chronic coughing or sneezing, heavy lifting, weight gain, pregnancy, or a tumor. It can also happen as a result of an over-sized hole made in your abdomen during the surgery. It’s more common with temporary loop stomas (either colostomy or ileostomy) than permanent end stomas.  

Some prolapsed stomas change, sticking out more when you’re standing and going back to normal when you’re lying down. This is ok, but you should check that the stoma doesn’t rub against the hole in the baseplate as it moves in and out. You won’t feel this, because the stoma has no nerve endings, so you have to watch for symptoms - like bleeding or a white or yellow line on the stoma where it’s been rubbing. If this is happening, you could switch to a moldable baseplate, which has no hard edges around the hole.  

Whether your prolapsed stoma stays out all the time or is more mobile, the first thing to do is have a stoma nurse look at it, and decide on treatment together. Conservative management techniques include: 

Lying down to relax the stomach muscles and reduce the abdominal pressure, then very gently pressing on the stoma to encourage it to go back inside. Make sure you have a stoma nurse teach you how to do this first!   

If the prolapsed stoma is swollen, an ice pack (wrapped in a towel) can help reduce the swelling so it will retract. Keep the pouch on, and don’t do it for more than 5 minutes at a time. Remember that if it’s frequently swollen, you might need to increase the size of the hole in your baseplate.  

This next tip sounds crazy, but I’ve read many medical articles and reports from people who do it, all insisting that it works. Put sugar on it. I swear!! Regular, granulated sugar. Sprinkle several spoonfuls on your prolapsed or swollen stoma, leave it on for 20-30 minutes, and it will draw out excess fluid, often shrinking the stoma enough that it can retract. It’s much like sprinkling sugar on sliced strawberries. It acts as a dessicant, drawing out the water. Keep a lot of gauze around the area. This can be messy. Like with strawberries, there’s going to be a sugary syrup left behind.  

There are specialized pouches, belts, and stoma guards designed to protect prolapsed stomas from external trauma. Again, consult with your stoma nurse to learn what products might work best for your particular situation.  

In most cases, there’s no danger in having a prolapsed stoma. It’s really more of an inconvenience. But occasionally, problems can arise that require medical treatment. 

Watch for changes in the color of your prolapsed stoma. If it becomes dark red or purple, or changes to a very pale pink, it could mean a problem with the blood supply to the stoma. 

A poor blood supply can also cause small white or pale yellow patches (ischemic ulcers). 

A third sign of trouble is a change in your stoma’s temperature (i.e., instead of being body temperature, it feels cool).  

Also watch out for any change in how your stoma is producing output, particularly if it’s reduced, which may be a sign of a blockage. 

If you notice any of these symptoms, have it checked out by your stoma nurse or surgeon. If surgery is required, they might “re-size” your stoma or “re-site” it (move it to another location on your abdomen).  

Color - Your stoma should be the usual rosy red, moist, and shiny - like the inside of your mouth. This means it’s getting a good, healthy blood supply. As mentioned above, any unusual change in its color should be checked out with a doctor.  

Remember we’re not talking about the color of your output here. That can often be an unusual color – most often because of something you’ve eaten. But that won’t affect the color of your stoma.  

If your stoma becomes pale, it means it’s not getting enough blood supply. This can happen if the baseplate hole is too small. If so, change baseplates and cut a larger hole.  

If you’re sure the hole isn’t too small, or color isn’t restored after you enlarge the hole, go to your doctor or the ER. It could mean a blockage, an internal “pinching” of the intestine, an iron deficiency, or some other condition that needs treatment.  

If your stoma turns dusky blue, dark brown, purple, or black, you should seek medical advice right away. This can be a sign of necrosis (which literally means the death of tissue). In the case of a stoma, it can happen if the blood flow to or from the stoma is restricted or cut off. The necrosis can be mild and limited to a small part of the stoma, or severe and more extensive. Treatment depends on the severity.  

The most important thing is to seek medical help immediately if you think this may be happening. 

Courtesy Joan Scott, author of The Ostomy Raft