Assessing Stoma and Peristomal Skin Problems

In an ideal world, all stomas would be perfectly shaped, located on a flat abdomen with no creases or folds and be easily pouched with a good seal to avoid leakage. The reality, however, is that stomas – like people living with an ostomy – are all different. Through widening your understanding of stoma problems, you can give your ostomy patients the best possible support and offer an empathetic ear.

In the following article, we’ve listed several different stoma problems, each with a definition and reference image. This information is taken from the Practical Guide to Stomas and Peristomal Skin Complications. A booklet designed to support clinician care for their patients’ stoma, skin, and soul. This document was developed through valuable contributions from expert stoma care nurses around the world.

We hope you find the following information useful for supporting your continuing education requirements while there is limited face-to-face education available.

Flush stoma
As the name suggests, a flush stoma does not protrude and is at the same level as the peristomal skin. A flush stoma may be a result of the surgeon’s technique or may occur over time with any abdominal changes, such as weight gain.

Management and intervention:
While most flush stomas do not cause problems, it may require the use of a soft or shallow convex barrier to keep the stoma output from getting under the skin barrier and causing peristomal skin irritation.

Pancaking can sometimes occur with a flush stoma. This is when feaces collects around the stoma and sticks to the top of the pouch. It may be useful to try a lubricating deodorant to help the stool pass into the pouch.

Retracted stoma
A retracted stoma is when there is a disappearance of the normal stoma protrusion below skin level. It may also be referred to as a recessed stoma. This may allow the stoma output to get under the skin barrier and may result in discomfort or soreness to the peristomal skin.

Management and intervention:
The goal is to heighten the level of the stoma above the skin. Ostomy seals or ostomy paste may help obtain a good seal around the stoma. Use of a convex barrier with or without the aid of an ostomy belt may help protrude the stoma to or above the skin level.

Prolapsed stoma
A prolapsed stoma is the telescoping of the intestine through the stoma and appears as the patient’s stoma sticks out longer than usual. A stoma can prolapse for one of several reasons, such as the straining of abdominal muscles, long-term coughing, or pregnancy. It’s quite common for a stoma to prolapse at some point in an ostomate’s life; however, it may lead to difficulties with attaching a pouch.

Management and intervention:
A prolapsed stoma isn’t necessarily a medical emergency unless there are definite side effects, such as a change in stoma colour or severe pain at the site. It’s recommended for a stoma care specialist or medical practitioner to assess any patient with a prolapsed stoma.

It is best to consider applying the pouch when the prolapse is reduced by having the patient lie flat and apply gentle pressure over the stoma.

To accomodate the oedematous stoma, consider cutting the skin barrier larger than the stoma size. Exposed surrounding skin may be protected with the use of a skin protective wipe or barrier seal.

Hernia
A parastomal hernia occurs when an abnormal protrusion of bowel passes through a weakened area in the abdominal wall. The area around the stoma appears as a swelling or protuberance. Around 5-10% of people with colostomies experience a parastomal hernia and about 3-10% in ileostomy patients.

The size of the swelling differs depending on the size of the weakened abdominal wall and how much bowel protrudes through it. Other factors include age, weight, smoking, strenuous activity, and surgery.

Management and intervention:
Conservative management and no surgical intervention is the treatment of choice for the asymptomatic patient. A flexible pouching system is recommended to accommodate for the change in stoma size and body contour.

The use of support garmets may help the herniated area. The patient may also benefit from a regular diet and fluids that help soften stool and prevent constipation.

Stenosis
The word ‘stenosis’ derives from the Greek language, meaning ‘narrow.’ As such, patients who have stenosis can expect their stoma to become small, tight, and constricted. Like other types of stomas, stenosis can be caused by factors that include surgical technique, inflammation, adhesions, and more. Patients may notice a reduction in stoma output and symptoms that include abdominal cramps, ribbon-like stool, constipation, or increased flatus.

Management and intervention:
Stenosis is not necessarily a medical emergency unless the stoma is non-functioning, the patient is experiencing pain, or vomiting occurs. Management of mild stenosis may include a low residue diet, stool softeners and, liquids. In some instances, the stoma may require dilation or surgical correction. You or another medical practitioner should assess the patient if there are concerns.

Granulomas
Granulomas are red lumps/lesions that can appear on the surface of a stoma or where the bowel joins the skin. These lesions can cause significant discomfort to the patient and sometimes result in bleeding or poor pouch adhesion. In some cases, granulomas occur where there is friction from an appliance, belts, or clothing.

Management and intervention:
The granulomas may be painful, bleed easily, and cause the pouch to leak. In some instances, a soft and flexible pouching system may be appropriate. Be sure to reduce any areas where there may be additional friction from the pouching system. A healthcare professional should assess a patient who is experiencing pain or discomfort from granulomas.

Want to learn more about how to manage different stoma issues? Head to our Practical Guide for Stoma Problems, where you will find intervention techniques for other conditions that include:

• Stoma separation
• Folliculitis
• Necrosis
• Laceration
• Oedema
• Fungal infection

You can also find lots of useful ostomy-related resources in the Professional Care section of our website. Together, we can help your patients feel confident, reassured, and ready for the future.