Aside from a new physiological condition, a patient’s self-perception and acceptance after ostomy surgery could be a psychological challenge. For many ostomates, a lack of guidance in dealing with their new circumstances could induce other medical and mental-related problems, such as depression and social withdrawal.
“Patients have to face the challenge of acquiring skills to live with the altered body and experience a psychosocial transition. The use of collecting equipment is associated with negative feelings, such as fear, anguish, sadness, and helplessness, which can prompt self-deprecating experiences, linked to feelings of mutilation, loss of health and self-esteem, and reduced self-efficacy and a sense of chronic uselessness and incapacitation, among other emotions. Stoma patients experience changes in their lives especially related to their social network (work and leisure) and to sexuality, aggravating their feelings of insecurity and fear of rejection.
The possible negative psychological outcomes and emotional issues arising from the stoma make it essential for the provision of comprehensive patient care, with an interdisciplinary and specialized approach to the needs of patients and their families, with a view to full physical, emotional and social recovery towards rehabilitation. It is necessary to prepare patients, mainly during the perioperative period, when they experience anxiety and distress before the unknown – the ‘stoma’.”1
The effect of an ostomy transcends physical wellbeing and could impact all aspects of life, including the following:
- Social interactions.
- Psychological issues.
- Economic activities and professional growth.
- Family life.
Factors that can affect an ostomate’s self-acceptance
Having a different elimination means affects patients emotionally. However, individual circumstances determine how their self-esteem will react to the surgery.
Some of those circumstances include the following:
Cause of the ostomy
The primary health condition is important. An incurable problem such as cancer can be more devastating than a traumatic one.
“After surgery, many cancer patients with a stoma experience more stress and a variety of physical problems causing worry and shame. The stoma is usually red, swollen, and large immediately after surgery, which is unpleasant for the patient to look at for the first time. This emotional distress, along with physical problems and pain, isolation from others, and fear of death, will inevitably reduce the quality of life further in ostomy patients.
In recent years, efforts to enhance the quality of life in cancer patients as one of the important aims of treatment in oncology have encouraged health care providers to undertake more research to identify different dimensions of quality of life and effective ways to improve these. Nurses are important members of the health care team and have a significant role in caring for patients with cancer, in particular in identifying the needs of patients and their families, limiting complications of the disease, and improving quality of life”2
“Adjustment to life with an ostomy, whether temporary or permanent, is influenced by many factors, but a current lack of sufficient research with adequate methodological rigor limits the understanding of these variables. […] Postoperative psychological problems have been associated with a prior psychiatric history, dissatisfaction with preoperative preparation, stoma-related morbidity, loss of bodily control, and lack of self-efficacy in ostomy care. The lack of preoperative preparation, and in some life-threatening situations, the lack of informed consent, magnifies the trauma patient’s sense of loss of control. Orthopedic and neurologic injuries that prevent or delay the achievement of ostomy self-care can further erode the patient’s progress toward adjustment. Family and social support may be compromised or absent when the injury was caused by engaging in socially deviant behavior such as criminal activity, or risk-taking behavior.”3
Duration of the ostomy
“Colostomies can be temporary or permanent. Temporary colostomies will be reversed after sometime when the patient’s condition and the reason for the colostomy is done allow. Permanent colostomies are indicated when abdominoperineal resection is done, the cancer is unresectable or the sphincter is damaged beyond repairable. Although it is a life-saving procedure, both its construction and reversal have significant morbidity and mortality. Complications can be related to the colostomy itself or the indication for it. Common early complications include surgical site infection, wound dehiscence, colostomy necrosis and retraction. Awareness of the common indications plus the types and the complications may help in improving outcomes of patients.”4 Permanent ostomies are more likely to negatively impact a patient than temporary ones.
Ostomates have a constant expenditure related to stoma care. People with insufficient health care support or the financial means to meet these costs can lessen their quality of life. The financial standing is determining on whether patients meet their nutritional needs. This factor has a bearing on their overall health including mental wellbeing and self-acceptance.
Generally, age alters the perspective of life. A young ostomate may have additional concerns, regarding career goals, love, intimacy, and people’s acceptance or rejection. An elderly person might have similar concerns but the impact on their self-image and acceptance tends to decrease.
“Sexuality is a complex phenomenon affecting body image, feelings, and interpersonal relationships. A person’s sexuality is closely associated to their body image. Many people with stomas have concerns that their sexual attractiveness has been diminished. People with stomas experience some uncertainty about their sexual attractiveness and manage this difficulty in different ways. Some want to expose themselves and see how their partner responds. If their partner does not see the stoma as a problem, they could more easily accept the stoma as a part of themselves. Some hide their stoma bag when undressing; keeping it out of their partner’s sight believing that their body is ‘destroyed’. Some are afraid of discussing sex with their partner, worried about their reactions. They fear that ultimately the relationship will fail. A person’s body image and sexuality are major factors in determining the effect of a stoma on a person’s quality of life.”5
Ostomy related complications
Complications tend to cause patients to develop poor self-acceptance due to the added mental and physical stress, impacting on other aspects of their life. “Several studies have shown that the overall complication rate after ostomy surgery is about 21–70%, including late complications such as peristomal dermatitis, parastomal hernia, prolapse and stenosis. Strikingly, some com-plications remain untreated for years, and a large group of ostomates is ‘out of sight’ of healthcare professionals. When complications arise, ostomates wait too long to contact healthcare professionals or do not contact them at all. It is unknown whether or how those ostomates deal with ostomy-related problems and how these problems might affect their quality of life (QOL)”6
How to help ostomy patients increase self-acceptance
Self-acceptance is the first step in living successfully with an ostomy. Chances increase depending on how the patient prepares before the surgery and postoperative support.
“Persons living with ostomies require specialized care and management to sustain physical health and quality of life (QOL). The provision of specialized ostomy care begins preoperatively and continues throughout the postoperative and rehabilitative period and throughout the patient’s lifetime with an ostomy. Ongoing stoma and ostomy appliance sizing, the treatment of peristomal skin complications, ostomy appliance modiﬁcations, access to ostomy products and financial assistance, dietary consultation, and emotional support are just a few of the health management issues that require ongoing management following creation of an ostomy.”7
The health care team should help the patient understand:
- Why the ostomy is necessary
- What the surgical procedure entails
- The expected appearance changes on their abdomen
- The expected duration of the ostomy
The healthcare team should assess their patient’s general view on the surgery and prospects of having an ostomy for possibly the rest of their life, and also help them deal with those emotions.
A great number of patients can go into postoperative depression and denial.
“The life changes that individuals with an ostomy undergo may have psychological and social consequences. For these people, living with a new device in their body may lead to fear, embarrassment, and self-doubt. In this context, the family is of fundamental importance, given its role as a form of support structure to the ostomate. However, vulnerability among family members has also been observed. Thus, a multi-professional health team could play an important role in informing and improving the quality of life of the ostomates, as well as that of the family unit.
However, each person is unique, with his/her own way of dealing with the situation and adapting to this new life condition that possibly involves suffering, pain, uncertainties, myths, and fears. Monitoring the ostomates is essential, as they need support to overcome the changes brought about by an ostomy and the partial loss of a bodily system aimed at maintaining their control over defecation and gas leakage.”8
An ostomy nurse or other qualified medical professionals can help improve ostomy patient’s self-acceptance:
- Visiting the patient often and treating them with dignity
- Including emotional support as they offer stoma care training
- Helping them accept that the stoma is now part of them and it is there to improve their life. Motivating the patient to look and touch the stoma may help
- Encouraging the patient to speak about their positive and negative feelings.
- Identifying the patient’s rate of acceptance and referring them to other qualified professionals for an integrated support approach.
- Informing the patient about ostomy accessories that can help them to confidently lead a more active and productive life.
- Helping the patient understand about nutritional measures to address odor issues, flatulence and stomal discharge consistency.
Learning to Live with a Stoma
“Once the ostomate is discharged home, the actual learning-to-live-with-the-stoma process begins. All advice is general and may need to be specifically tailored for the individual ostomate. If in doubt, the stoma specialist nurse can be contacted for further advice by the community nurse or the ostomate. Some ostomates have problems adjusting to life with a stoma and the community nurse will possibly be the person contacted or who notices the problem. It is ideal when visiting and assessing an ostomate in the community to try and ensure that holistic care is provided. However, this is not always easily achieved when there are limited resources and a lack of familiarity with stoma care can result in caution on behalf of the nurse.”9
Daily Activities with Ostomies
“In returning to a routine of normal daily activities, the patient should wait at least six to eight weeks before resuming his or her previous activities. Very heavy lifting should be avoided, and resuming sports activities will depend on the person’s physical condition at that time.
Once the ostomate has fully recovered his or her strength, he or she can enjoy a full range of physical activities just like before having the ostomy placed. The most important thing for the ostomate to remember is that he or she must manage the ostomy properly.
Sports and play activities can be enjoyed just as before. Skiing, horseback riding, golfing, and many more activities can be pursued, and even swimming is not out of the question. The activities that should be avoided are things like weight lifting and contact sports, as these could result in damage to the stoma itself. The patient who has to lift heavy weights for his or her work should get clearance from their physician before doing so.
The same style of clothing can be worn as before the ostomy placement; belts can be worn, pantyhose can be used, and even girdles without the stays can be worn. Clothing shouldn’t be too tight, however, or the clothes might rub over the stoma and cause it to bleed.
Bathing for the ostomate is not as bad as one might think. When taking a bath or shower, the person can leave the pouch on or off. Bathing in and of itself will not make the pouch come off. Water will not harm the stoma, and usually all that is needed is a Band-aid to cover the site if the person chooses not to bathe with the pouch on. If the ostomate does choose to bathe without a pouch, he or she should pick a time when the ostomy will not be so active.
The ostomy patient should be able to return to work as soon as the recovery period is over, generally in about six to eight weeks. The only concern, as stated before, is that the person should not do any heavy lifting. If the person has any concerns about returning to work, he or she should consult their physician or enteral stomal therapist.”10
Increasing self-acceptance and all the previous measures are should help the patient lead a regular life. Specialists encourage patients to actively participate in routine stoma management, such as placing and emptying the pouch, to see the process as a natural part of their life. Seek for adequate professional help if you or an ostomy patient you know has self-acceptance or self-esteem problems.
(1) Silva, N. M., Santos, M. A. D., Rosado, S. R., Galvão, C. M., & Sonobe, H. M. (2017). Psychological aspects of patients with intestinal stoma: integrative review. Available online at http://www.scielo.br/pdf/rlae/v25/0104-1169-rlae-25-e2950.pdf
(2) Dabirian, A., Yaghmaei, F., Rassouli, M., & Tafreshi, M. Z. (2011). Quality of life in ostomy patients: a qualitative study. Patient preference and adherence, 5, 1. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3034300/
(3) Steele, S. E. (2006). When trauma means a stoma. Journal of Wound Ostomy & Continence Nursing, 33(5), 491-500. Available online at https://nursing.ceconnection.com/ovidfiles/00152192-200609000-00006.pdf
(4) Engida, A., Ayelign, T., Mahteme, B., Aida, T., & Abreham, B. (2016). Types and indications of colostomy and determinants of outcomes of patients after surgery. Ethiopian journal of health sciences, 26(2), 117-122. Available online at https://www.researchgate.net/publication/301277428_Types_and_Indications_of_Colostomy_and_Determinants_of_Outcomes_of_Patients_After_Surgery
(5) Shaffy, S., Kaur, S., Das, K., & Gupta, R. (2012). Physical, nutritional and sexual problems experienced by the patients with colostomy/ileostomy: a qualitative study. Nursing and Midwifery Research Journal, 8(3), 210-22. Available online at http://medind.nic.in/nad/t12/i3/nadt12i3p210.pdf
(6) Vonk-Klaassen, S. M., de Vocht, H. M., den Ouden, M. E., Eddes, E. H., & Schuurmans, M. J. (2016). Ostomy-related problems and their impact on quality of life of colorectal cancer ostomates: a systematic review. Quality of Life Research, 25(1), 125-133. Available online at https://link.springer.com/article/10.1007/s11136-015-1050-3
(7) Recalla, S., English, K., Nazarali, R., Mayo, S., Miller, D., & Gray, M. (2013). Ostomy care and management: a systematic review. Journal of Wound Ostomy & Continence Nursing, 40(5), 489-500. Available online at https://www.researchgate.net/publication/251568692_Ostomy_Care_and_Management_A_Systematic_Review
(8) Cetolin, S. F., Beltrame, V., Cetolin, S. K., & Presta, A. A. (2013). Social and family dynamic with patients with definitive intestinal ostomy. Available online at http://www.scielo.br/scielo.php?pid=S0102-67202013000300003&script=sci_arttext&tlng=en
(9) Burch, J. (2011). Resuming a normal life: holistic care of the person with an ostomy. British journal of community nursing, 16(8), 366-373. Available online at https://pdfs.semanticscholar.org/20fe/fe3fae8a1edf50a6defe7b668b09e4aa556b.pdf
(10) Wittenauer, J. (2007). Caring for the ostomy Patient. National Center of Continuing Education, 20, 70-77. Available online at https://www.nursece.com/pdfs/218_ostomy.pdf