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Irrigating Your Colostomy

Disclaimer
This article was written at my request by Michiel, a friend who is a colostomate who has irrigated for approximately two years. His experiences with irrigation may not be the same as yours - everyone is different. If you are considering using irrigation as a way of managing your colostomy, please speak to your Enterostomal Therapist first as he/she will be best trained in showing you the best way to irrigate.
This article is only meant as a guide only and should not be used as a substitute for professional medical advice.

IRRIGATION: A WAY OF ACHIEVING FAECAL CONTINENCE FOR COLOSTOMISTS

Important Note: Irrigation is only suitable for those people with a colostomy.
It is not suitable for those with an ileostomy or a urostomy.

Many people with a colostomy of the sigmoid or descending colon can irrigate. Itís a good way of achieving faecal continence for 24 to 48 hours. Some people even manage to stay stool free for 72 hours, though they are the exceptions. But check this procedure with your specialists first, since they have seen your guts. And discuss the procedure with your ET nurse, he or she will patiently describe the steps to take, will discuss what new appliances you need and tell you how to get started.

I will try to do the same in this article, based on what my ET nurse taught me, what the manuals that come with an irrigation-set tell and what I have read in several newsgroups. Please note: reading about the procedure might make you think "Oh, this is not for me, itís too much trouble, it takes too much time". Once you start, you will quickly adjust to this new routine. The first couple of times you might feel a bit nervous and you will follow all the guidelines to the point. As soon as routine sets in, you will go on Ďautomatic pilotí and you will surprise yourself how quickly itís all over and done with. You will even long for these quiet 15 to 30 minutes on the loo, the best time to "get to read your favourite author", as one guy who irrigates calls it. And next to the fact that you will regain new continence, thereís heaps of other benefits, such as: less gas, less bad odour, less diarrhoea, less constipation, less skin irritation and heaps of more freedom and comfort, since you no longer need a conventional pouch.

What You Need

  • The irrigation set. All major brands carry this item. Itís basically a plastic water container with a long tube and a separate shorter tube with a regulator and a cone. Some brands carry closed containers, with just an opening to put the tap water in. Some have containers which are open at the top. I like these better, since you can dry them after each use and find they are easier to clean (with a mixture of tap water and plain vinegar or household bleach). You should clean the container and the separate tube with the cone this way at least once a month. I personally like the container by Coloplast best, since it is open at the top and has a built in thermometer, showing the temperature both in *C and in *F. The containers always have marks per 500cc and pint.
  • Secondly you need an irrigation sleeve: basically a long opaque or clear plastic bag, open at the top and at the bottom. They come as one-piece and two-piece, depending on a person's choice of ostomy management.
  • Thirdly you need some pegs, which come with the set, as well as some lubricant, for instance KY-gel. I always take an extra water bottle into the loo. More about that under Procedure.
  • Oh yes, I almost forgot, you need a new hook in the toilet room. Since you donít want to sit there for 30 minutes holding a lot of water high in the air. With the hook in place, the bottom of the water container should be on shoulder height, while standing. Some manuals mention shoulder height in a sitting position. I did this at first, but later put the hook up higher to get better pressure. Thereís always the regulator on the tube, in case the water flows in too fast.
  • Once you are done, you need some wipes or tissue paper to clean up and a small plastic garbage bag to get rid of the sleeve. The first week you need time as well, and you need to be left alone. More about that in the next chapter.


When And Where To Irrigate
Your ET nurse will have discussed the procedure with you. In some countries they guide you through the first sessions, for instance while you are still in the hospital. In Holland, where I live, specialists are not too keen to start so quickly. My surgeon explained this as follows: ĎYou need to learn the Ďconventionalí methods of taking care of your ostomy. You might end up in the hospital again, unable to irrigate, and at some point you will undoubtedly get a bad spell of diarrhoea. You will be thankful being able to handle conventional pouches et alí. I sure was pissed at him, but he sure was right. So I started some four months after my op. I gently declined the offer made by my ET nurse to do a first session in her rooms. I know, they have seen me butt naked time and again, but poop is poop and is a very private matter. I am sure she was quite relieved ;-) However, she advised me to have someone close by, since the first time, all this being so new, four hands and two minds can come in handy. Hence my friend was present at her first lecture.

Have everything you need ready in the bathroom. Think of what you need in the loo (our house has a separate lavatory, so I carry what I need there). Basically what you need is the loo to yourself, demand one hour for your first session. In case you have children, do it after they have left for school. If your partner still has to use the toilet, ask him or her to do so. Make sure that the toilet has an agreeable temperature. Have the newspaper or the book you are reading and/or your pack of cigarettes ready. A toilet with a small basin with running water (cold is ok) is very practical. More on that under Procedure. Do your first session in a relaxed atmosphere, for instance in the weekend or on any day that you are not going to have to leave for work. Drink lots of fluids after you wake up. Coffee, tea, juice, plain water, all is okay. Have some breakfast. This is important, since your bowel will react to the food, making the first irrigation a little easier. You might also feel a bit nauseous and some food helps. Also your bowel will react with a peristaltic movement because of the food. And anyways, breakfast is the most important meal, isnít it?

The Procedure

  • Use tap water on body temperature or even a little cooler. It does help to scare the colon a bit. Never ever use water which is too warm. Believe me, I have made this mistake once and had problems for days after.
  • Fill the container and hang it on the hook. Fill the extra water bottle.
  • Remove your pouch. If soiled, clean the skin around the stoma and stick the sleeve in place. Some people use a silicone ring together with a belt - that is really a personal preference.
  • Have the pegs and the gel ready. Sit on the toilet seat. Some manuals mention sitting in front of it, some people irrigate in the bathtub. Why, I wouldnít know. If you sit just like in the old days, the lower part of the sleeve hangs neatly in the water and waste drops in the water where it should go.
  • Apply some lubricant on the cone.
  • Open the regulator and let some water flow out. Not in the stoma, but in the sleeve or in the basin. This way the air gets out of the tube.
  • Now gently insert the cone into your stoma, with the regulator shut.
  • Cover the cone with the cuff of the irrigation sleeve. Press the cone firmly into your stoma. Open the regulator.
  • At first nothing much may happen. Remember, this is your first time and even your stoma knows this. Relax, take some deep, short breaths, exhale well. Often this is enough to start the inflow of the water.
  • Gently aim the cone in a different direction, in case the water doesnít get in. Not one stoma is alike. On some people it goes straight into the abdomen, for others it follows a slightly different direction. (You can digitally examine yourself while under the shower, but some people find this frightening.)
  • Let the water flow in freely, keeping the cone in place. During your first sessions this may feel uncomfortable. Just close the regulator, take some deep breaths and open the regulator once again.
  • The process of water flowing in will take around five minutes. On some days it goes real quick, on other days it may be a little slow. Just be patient.
  • Now for the amount of water: there seems to be an American and a European way. As if the rest of the world doesnít irrigate ;-) Americans use around 1500cc and I have even talked to people who use more. In Europe we learn to use anything between 500cc to 1000cc. Studies have shown that 500cc could be enough to irrigate. My gastro-enterologist even claims that anything in excess simply flows into the ileum, although there is a valve between the colon and ileum. Apparently this valve is not watertight. Lately there has been some concern of distending the colon by using too much water on a regular basis. Anyway, I do as my ET nurse taught me. She said to start using 800cc, but then I am a tall guy at 6í4íí or 194 cm.
  • After that lot is in, I keep the cone pressed against the stoma for some time until I feel the pressure building up. Be prepared.
  • Remove the cone but make sure the cuff of the sleeve is up. Water and output may start evacuating right away with force.
  • Close the top of the sleeve with one or two pegs. Just relax and sit back. Some people do some yoga or breath exercises to relax better, some read the paper or a book, I smoke a cigarette. I know, bad habit, but then I never overdo on alcohol, I eat healthy and always practise safe sex ;-)
  • Now for the stool that comes out: the first part will be quite solid, almost like in the old days. Then it is on to the more watery output. The last bit will be half digested food, always very smelly and probably very gassy.
  • I usually end my session with a big burp. Thank you! For me, that is a sure sign that I am done.
But for the newcomers itís not over yet. My ET nurse taught me to use a second input of water. Remember, there is a whole lot of water in the container, which shouldnít go to waste.
  • First use some to clean the inside of the sleeve and maybe to rinse the stoma a bit. Then let another 300cc flow in and sort of repeat the procedure. So again keep the cone pressed to your stoma until you feel the pressure. Then remove the cone and wait for any output. She taught me to do this, until the second lot of water is almost liquid, meaning that all the stool has evacuated with the first irrigation. Once the second lot of water started to come out more or less clear on a regular basis, I started using just one input of water. Irrigation is a lot about training your colon to behave like you want it to. Using two inputs of water sure trained my colon.
All in all you will have been on the loo for about 30Ė45 minutes, but in time it will go quicker.
  • Use whatever water is left to clean the inside of the sleeve. I do this standing up, which sometimes gives a little extra output. I then need the extra water bottle to clean the sleeve once more. Also check the outside. An extra toilet flush will clean the outside of the sleeve as well.
  • Fold the sleeve up and use the pegs to close the two layers on the top by folding them once more.
  • You now deserve a time out. Some people use this to brush their teeth, some to make coffee or tea, some people exercise a bit. I also use it to dry the reservoir and to clean the cone with some mild soap and water. Moving around will force any stool out that hasnít evacuated yet. At first, really take this extra half hour. By the time you are a pro, you will feel whether you are empty and ready to hit the shower.


A Schedule
Of course you want to know whether you can make it into the Guinness Book of World Records. You want to know how often you have to irrigate. Maybe you can do it on alternate days too. Well, the average is 48 hours, a Belgium study shows this. But my ET nurse told me to irrigate every morning for at least a fortnight. She said it takes two weeks minimum to train the colon.

I have a confession to make: I cheated right away. Listen, I am a regular guy and I so much wanted to belong to the Ďaverage groupí. I didnít even make the big jump with some 36 hour sessions in between. I took the deep plunge within a week after my first irrigation. Is that the sensible thing to do? No way! Mind you, I didnít have any accidents and wore a regular pouch during the night, but still.....

I donít want you to blame me for waking up in a soiled bed - or any embarrassing accidents during the day, so hereís my advice. Start with regular morning sessions. Wear a pouch for the first days. If you remain stool free, you can opt for a stoma cap or a patch during the day. Keep wearing a pouch at night. Just see what happens. If there is no stool during the day or night, it means you are getting there real fast. Shift to a 36 hour schedule, but still wear a pouch during night time. And so on and on. Add another 12 hours if you remain mostly stool free (meaning a little output right before your next irrigation is due), it shouldn't worry you that much. Remember, you are still in training. And always keep in mind that your colon will not evacuate a whole lot of stool, since you are irrigating. Thatís how I found out that a 48 hour schedule is the right one for me. But once you are on a schedule, try to stick to it.

Your colon is trained, so it will behave. Not always, mind you. So far, and I started irrigating about two years ago, I have had two bouts where my colon had a mind of itís own. When I mentioned this to my surgeon, he answered: ĎSo has mineí. My reply was: ĎDo you have an ostomy too?í No he hadnít, but he explained that he also had bouts where he had to go to the toilet several times during the day. Itís not much different when you have an ostomy.

What Sort Of Appliance To Wear
Some people opt to wear a regular pouch. As stated in the previous chapter, this makes sense during the learning process. But once you notice you remain stool free between sessions, itís on to less obvious products. Almost all brands carry stoma caps. They are round and measure 10cm/4inch in diameter. All come with a built in charcoal filter, most are available as one and two piece. Americans often mention just a patch, a band aid kind of plaster. So far I havenít seen these in Europe, so I have no experience with these. Braun Biotrol has some more choice. The fanciest item is the Iryfix: rectangular at 8cm/3inch by 6cm/2.5inch. But what is different is it has a charcoal filter which you place in your stoma and a band aid top which you stick on your abdomen. Nobody can tell you have an ostomy, unless they know this item. One precaution though, you have to remain stool free, since it wonít hold output. Braun Biotrol also carries the Petite: a little smaller even than the Iryfix, but made of two layers as the more conventional products. So it sticks a little more out from your body. Coloplast also carries the Conseal plug. The new thing here is the foam plug, which is inserted into the stoma. The face plate, which is round, sticks to your abdomen. The best thing about this plug is that it absolutely reduces all noise to a non level. And it can, in case of an accident, hold back quite a bit of stool. I would say call around for samples and stick to what suits you best.

History
I have wondered for some time why irrigating your colon isnít advertised a lot more. I donít mean in the commercial sense of the word, but for instance by word of mouth. When my surgeon told me the day before my operation that I had to have a permanent colostomy, I said right away: I am going to irrigate. He was very unresponsive. One reason is explained under When and Where. The other was real simple: he didnít know whether I would come out alive, since the surgery included a proctectomy as well and he didnít want to burden me with too much info on the pre-operation day.

But I knew people could irrigate. My father had a colostomy shortly before he died, but he did not irrigate. Although I was very young at the time, somebody must have mentioned the possibility, and this knowledge just stuck with me.

Now I know a little more. The cone we use is still a recent invention. It dates back to 1972. You know, tupperware time and other products made of soft plastic. This cone is a true find, since it allows the water to flow in without any water spilling back the wrong way. Because the cone serves as a seal as well. Before í72 people had to use long catheters of rubber or other non flexible materials, which led to a lot of colon perforations, with sometimes death as a result.

For decades professionals have argued pro and contra irrigating. As a result, this method was found to be unsafe for a long time. Irrigations were only done in hospitals, usually when there was a medical necessity. In í74 Hollister marketed the first irrigation set as we know it today. But many healthcare professionals were educated with all the old, horrible stories of colon perforations, and as a consequence didnít trust the new product too much. I have also heard a person tell of an ET nurse who simply refused to teach her how to irrigate, since the ET found the procedure too gross for words. This woman lost her colon and ended up with an ileostomy. And still I hear of many people with a colostomy who simply donít know that irrigation is a real option. I truly hope that this article helps in making this procedure better known. And I hope that many people will learn to get control over their bowel, instead of the colon controlling them and their every day life and activities.

Troubleshooting

The water doesnít flow in:

  • Often people are too tense. Close the regulator and take a short, deep breath. Exhale well and long. I donít want you to hyperventilate ;-) Proceed after a little while.
  • Gently move the cone a little bit and aim it in at a different angle. While moving the cone, some gas and water might evacuate. Thatís okay, donít worry.
  • The pressure is too low. In other words, the position of the reservoir is too low. Have someone hold it higher. If it helps, put the hook higher up.
The water is in, but it doesnít come out:
  • It can happen that your colon is dehydrated. Drink a couple of glasses of water. That most often helps.
  • You might have some spasms. Relax and gently massage your abdomen. Shuffling you upper body a bit might also help.
The water rushes out right after removing the cone:
  • That often means that you remove it too quickly. Keep the cone pressed to your stoma for at least 30 seconds. Sometimes you will feel the pressure getting less. That means that the water is reaching further up in your colon.
When not to irrigate:
  • You should not irrigate when you have active UC, CD or Diverticulitis.
  • People who experience diarrhoea are also advised not to irrigate.
  • A stomal prolapse or peristomal hernia can make irrigation a very difficult procedure. However, it should be mentioned that both are not absolute contra indications.
  • Those undergoing chemo- or radiation therapy should consider waiting for about six weeks on finishing their treatment before commencing to irrigate. Normally there is digestive system upheaval during this time.
I am sad to say that Mich passed away on New Year's Eve of 2003. He was well loved and that prompted me to transfer his messages of condolences onto his own page on this site.

If you have any questions regarding irrigation, please post your questions on the Ostomy Message Board so that others may benefit from your questions and answers - Colostomates who irrigate, check thiss board regularly.

Michiel
Amsterdam,
August 2000.


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If you would like to use any of the images in these pages, please email me to get permission. Thanks.

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