Types of Colostomies and Pouching Systems

A colostomy can be short-term (temporary) or life-long (permanent) and can be made in any part of the colon. The different types of colostomies are based on where they are located on the colon.

Temporary colostomies

Certain lower bowel problems are treated by giving part of the bowel a rest. It’s kept empty by keeping stool from getting to that part of the bowel. To do this, a short-term (temporary) colostomy is created so that the bowel can heal. This healing process usually takes a few weeks or months, but may take years. In time, the colostomy will be reversed (removed) and the bowel will work like it did before – the stool will exit from the anus again.

Permanent colostomies

When part of the colon or the rectum becomes diseased, a long-term (permanent) colostomy must be made. The diseased part of the bowel is removed or permanently rested. In this case, the colostomy is considered permanent and is not expected to be closed in the future.

Transverse colostomies

A transverse colostomy is one of the most common types. There are 2 types of transverse colostomies: the loop transverse colostomy and the double-barrel transverse colostomy. The transverse colostomy is in the upper abdomen, either in the middle or toward the right side of the body. This type of colostomy allows the stool to leave the body before it reaches the descending colon. Some of the colon problems that can lead to a transverse colostomy include:

• Diverticulitis. This is inflammation of diverticula (little sacs along the colon). It can cause abscesses, scarring with stricture (abnormal narrowing), or rupture of the colon and infection in severe cases.
• Inflammatory bowel disease
• Cancer
• Obstruction (blockage)
• Injury
• Birth defects

If there are problems in the lower bowel, the affected part of the bowel might need time to rest and heal. A transverse colostomy may be used to keep stool out of the area of the colon that’s inflamed, infected, diseased, or newly operated on – this allows healing to take place. This type of colostomy is usually temporary. Depending on the healing process, the colostomy may be needed for a few weeks or months, but possibly for years. If the colon heals over time, the colostomy is likely to be surgically reversed (closed). You will have normal bowel function after it's reversed.

A permanent transverse colostomy is made when the lower portion of the colon must be removed or permanently rested, or if other health problems make the patient unable to have more surgery. The colostomy is then the permanent exit for stool and will not be closed in the future.

Loop transverse colostomy (Figures 2 and 3): The loop colostomy may look like one very large stoma, but it has 2 openings. One opening puts out stool, the other only puts out mucus. The colon normally makes small amounts of mucus to protect itself from the bowel contents. This mucus passes with the bowel movements and is usually not noticed. Despite the colostomy, the resting part of the colon keeps making mucus that will come out either through the stoma or through the rectum and anus. This is normal and expected.

Double-barrel transverse colostomy (Figures 4 and 5): When creating a double-barrel colostomy, the surgeon divides the bowel completely. Each opening is brought to the surface as a separate stoma. The 2 stomas may or may not be separated by skin. Here, too, one opening puts out stool and the other puts out only mucus (this smaller stoma is called a mucus fistula). Sometimes the end of the inactive part of the bowel is sewn closed and left inside the belly. Then there’s only one stoma. The mucus from the resting portion of the bowel comes out through the anus

Changes in the newly formed transverse colostomy

Right after surgery, your colostomy may be covered with bandages or it may have a clear pouch over it. The type of pouch used right after surgery is usually different from those you’ll use at home. Before you look at your colostomy for the first time, keep in mind that it may be quite swollen after surgery; there may also be bruises and stitches. While a stoma normally is moist and pink or red in color, it may be darker at first. Your stoma will change a lot as it heals. It will get smaller and any discoloration will go away, leaving a moist red or pink stoma. This may take several weeks.

You’ll soon notice that, although you can usually tell when your colostomy is going to pass stool or gas, you can’t control it. Your colostomy does not have a valve-like sphincter muscle like your anus does. Because of this, you’ll need to wear a pouch over your colostomy to collect the output. Your ostomy nurse or doctor will help you find a pouching system that’s right for you.  This is also discussed in more detail below in "Choosing a colostomy pouching system."

Managing a transverse colostomy

When a colostomy is made in the right half of the colon (near the ascending colon), only a short portion of colon leading to it is active. The stool that comes out of a transverse colostomy varies from person to person and even from time to time. A few transverse colostomies put out firm or paste-like stool at infrequent intervals, but most of them move often and put out soft or loose, oatmeal-like stool.

It’s important to know that the stool contains digestive enzymes (chemicals made by the body to break down food). These enzymes are very irritating, so the nearby skin must be protected with a skin barrier. (See "Protecting the skin around the stoma" under Caring for a Colostomy for more on this.)

Trying to control a transverse colostomy with special diets, medicines, enemas, or irrigations usually doesn’t work and is not usually advised. In most cases, a pouching system is worn over a transverse colostomy at all times. A lightweight, drainable pouch holds the output and protects the skin from contact with the stool. The pouch doesn’t usually bulge, and it’s not easy to see under your clothes.

Bowel movements with a transverse colostomy

A transverse colostomy will put out stool no matter what you do. Keep in mind these points:

• The right pouching system (also called an appliance) for you is one that will keep you from soiling your clothing.
• The firmness of your stool is affected by what you eat and drink.
• Gas and odor are part of the digestive process and cannot be prevented. But they can be controlled. Your pouch will help to control odors.
• Empty the pouch when it’s about 1/3 to 1/2 full to keep it from leaking or bulging under your clothes. It's best to arrange a space in your bathroom at home, and to find a bathroom when you're out, where you can empty your pouch.
• Change the pouch system before there’s a leak. It’s best to change it no more than once a day and not less than once every 3 or 4 days.
• The ostomy output can irritate your skin. You can help prevent skin problems by having a correctly fitted pouch system and by using special materials for ostomy care.

Ascending colostomy

The ascending colostomy is placed on the right side of the belly. Only a short portion of colon remains active. This means that the output is liquid and contains many digestive enzymes. A drainable pouch must be worn at all times, and the skin must be protected from the output. This type of colostomy is rare because an ileostomy is often a better choice if the discharge is liquid. (For more on this, see Ileostomy: A Guide.)

Caring for an ascending colostomy is much like caring for a transverse colostomy (as discussed above).

Descending and sigmoid colostomies

Located in the descending colon, the descending colostomy (Figure 6) is placed on the lower left side of the belly. Most often, the output is firm and can be controlled.

A sigmoid colostomy (Figure 7) is the most common type of colostomy. It’s made in the sigmoid colon, and located just a few inches lower than a descending colostomy. Because there’s more working colon, it may put out solid stool on a more regular schedule. 

Both the descending and the sigmoid colostomies can have a double-barrel or single-barrel opening. The single-barrel, or end colostomy, is more common. The stoma of the end colostomy is either sewn flush with the skin or it’s turned back on itself (like the turned-down top of a sock).

You will notice with a descending or sigmoid colostomy:

• The stool is firmer or more like paste. It doesn’t have as much of the irritating digestive enzymes in it.
• Stool output may happen as a reflex at regular, expected times. The bowel movement will take place after a certain amount of stool has collected in the bowel above the colostomy. Two or 3 days may go between movements
• Spilling may happen between movements because there’s no muscle to hold the stool back. Many people use a lightweight, disposable pouch to prevent accidents
• Feeling the need to empty the bowel (reflex) will happen quite naturally in some people. Others may need mild stimulation, such as juice, coffee, a meal, a mild laxative, or irrigation. 

Bowel movements with a descending or sigmoid colostomy

A bowel movement through a colostomy happens naturally like a normal movement through the anus. But, unlike the anal opening, the colostomy does not have nerves or a sphincter muscle that can help to stop the passage of stool.

• You must wear a pouch to collect anything that might come through, whether it’s expected or not. Many lightweight pouches are hard to see under clothes. They stick to the skin around the colostomy and may be worn all the time, or only as needed.
• For some people, eating certain foods at certain times can make the bowel move at a time that works best for them. Some people use only this method to keep bowel movements on a regular schedule, while others use it with irrigation.

Constipation or loose stool

Many people think that you must have a bowel movement every day. In truth, this varies from person to person. Some people have 2 or 3 movements a day, while others have a bowel movement every 2 or 3 days or even less often. It may take some time after surgery to figure out what’s normal for you.

While many descending and sigmoid colostomies can be trained to move regularly, some cannot. Training, with or without stimulation, is likely to happen only in those people who had regular bowel movements before they became ill. If bowel movements were irregular in earlier years, it may be hard, or impossible, to have regular, predictable colostomy function. Spastic colon, irritable bowel, and some types of indigestion are some conditions that cause people with colostomies to continue to have bouts of constipation or loose stool. 

Closing or reversing a colostomy

If you’re going to have your colostomy closed, the surgeon might mention plans to “take it down” or “reverse it” in a few weeks or months, but sometimes the doctor doesn’t say anything about it. It’s best to talk to your surgeon about these things before you leave the hospital so you know what the plans are and when to see the surgeon again. If you’re at home now and didn’t get instructions, call the doctor’s office or clinic and find out what the doctor wants you to do. It’s your job to stay in touch with the doctor.

Many things must be taken into account when thinking about closing a colostomy, such as:

• The reason you needed the colostomy
• Whether you can handle more surgery
• Your health since the operation
• Other problems that may have come up during or after surgery

Choosing a pouching system

Deciding what pouching system or appliance is best for you is a very personal matter. When you’re trying out your first pouching system, it’s best to talk with an ostomy nurse or someone who has experience in this area. There should be someone in the hospital who can get you started with equipment and instructions after surgery.

As you’re getting ready to leave the hospital, be sure you are referred to a Wound Ostomy Continence nurse (WOCN or WOC nurse, also called an ostomy nurse), a clinic, an ostomy manufacturer, or a chapter of the United Ostomy Associations of America. Even if you must go out of town to get such help, it’s worthwhile, as you want to get a good start and avoid mistakes. Even with help, you may have to try different types or brands of pouching systems to find the one that best suits you.

There are many things to think about when trying to find the pouching system that will work best for you. The length of the stoma, abdominal firmness and shape, the location of the stoma, scars and folds near the stoma, and your height and weight all must be considered. Special changes may have to be made for stomas near the hipbone, waistline, groin, or scars. Some companies have custom-made products to fit unusual situations.

A good pouching system should:

• Stay secure, with a good leak-proof seal that lasts for up to 3 days
• Be odor-resistant
• Protect the skin around the stoma
• Be nearly invisible under clothing
• Be easy to put on and take off
• Allow you to shower or bathe with the pouch on, if you wish to do so

Types of pouching systems

Pouches come in many styles and sizes, and an ostomy nurse can help you choose the best one for your situation and lifestyle. They all have a collection pouch to collect stool drainage that comes out of the stoma and an adhesive barrier (called a flange, skin barrier, or wafer) that protects the surrounding skin. There are 2 main types of systems available:

• One-piece pouches have both a pouch and skin barrier attached together in the same unit. When the pouch is removed, the barrier also comes off.
• Two-piece systems are made up of a skin barrier separate from a pouch. When the pouch is taken off, the barrier stays in place.

Some pouching systems can be opened at the bottom for easy emptying. Others are closed and are taken off when they are full. Still others allow the adhesive skin barrier to stay on the body while the pouch may be taken off, washed out, and reused. Pouches are made from odor-resistant materials and vary in cost. They can be either clear or opaque and come in different lengths.

Figures 8 through 15 show some of the different kinds of pouches, plus other supplies that may be needed, such as flanges, clips, and belts (to help hold the pouch in place).

The opening of the skin barrier or wafer of the pouch needs to fit your stoma. The opening should be no more than 1/8 inch larger than the stoma. Depending on the pouch design, you may need to cut a hole out for your stoma, or the wafer may be sized and pre-cut. The size of the hole is important because the wafer is designed to protect the nearby skin from the stoma output and be as gentle to the skin as possible.

Keep in mind a stoma's size can change if it becomes swollen or for other reasons. For example, after surgery, your stoma may be swollen for about 6 to 8 weeks. During this time the stoma should be measured about once a week. A measuring card may be included in boxes of pouches, or you can make your own template to match your stoma shape and get the best fit.

Stoma cap