Domiciliary colostomy irrigation guideline (G118)

Patients with colostomies often suffer from lack of control over stool discharge and gas emissions, as well as the associated aesthetic and psychological factors. Domiciliary colostomy irrigation can reduce these issues for patients.

The method of flushing the intestine, also called irrigation is recommended for selected patients with colostomies in order to facilitate control over stool discharge. This makes it possible for such patients to reduce their usual care needs to a minimum and also benefit from considerably better comfort, discretion and quality of life.

The aim of the irrigation is to stimulate the intestine to increase the movement of its contents (called peristalsis) by rinsing it regularly. This happens due to a tissue stretch stimulus triggered by the flow of water.

The enhanced movement of intestinal contents results in a complete evacuation of the colon at the desired time, and thus the patient can then enjoy up to 48 hours with no evacuation. The length of this period depends, amongst other factors, on the length of intestine which remains, as well as on the patient’s dietary habits.

In addition, this flushing of the intestine can reduce the amount of gas producing bacteria in the intestine, resulting in a significant reduction in flatulence.

Such irrigation does not replace the functions of the intestine, but rather enhances the natural ability of the colon to empty itself. There is no decrease in effect over time as generally occurs, for example, with the regular and long-term use of laxatives.

Sticking to a regular schedule is a critical factor in the success of the irrigation method.

This guideline has been produced to ensure that teaching patients how to perform domiciliary colostomy irrigation is performed safely, consistently and to a high standard within NHS Ayrshire & Arran.

This guideline will have an impact on Stoma Clinical Nurse Specialist and Stoma Link Nurses employed by NHS Ayrshire & Arran who are deemed competent in domiciliary stoma irrigation.

• End colostomy - A colostomy is a surgical procedure to divert one end of the large intestine (colon) through an opening in the abdominal wall (tummy). The end of the bowel is called a stoma. A pouch is placed over the stoma to collect waste products that usually pass through the colon and out of the body through the rectum and anus (back passage).
• Peristalsis - the involuntary constriction and relaxation of the muscles of the intestine or another canal, creating wave-like movements that push the contents of the canal forward.
• Domicilary - concerned with or occurring in someone's home.

Patients suitable for domiciliary colostomy irrigation will be identified by their stoma care nurse specialist (SCN). If the patient chooses to commence domiciliary colostomy irrigation as an alternative to wearing / changing colostomy pouches, the SCN will seek permission from the patient's colorectal surgeon and then make arrangements for education on domiciliary colostomy irrigation.

• permanent end colostomy
• at least 6 month post-op
• patient fully recovered from surgery
• formed stool
• motivated / mentally alert patient
• no existing co-morbidities
• good dexterity.

• active disease (malignancy, inflammatory bowel disease (IBD), diverticular disease)
• serious cardiac disease – heart failure
• serious kidney disease
• large parastomal hernia
• stenosed stoma
• prolapsed stoma
• diarrhoea
• poor dexterity
• reduced mobility
• visual impairment
• receiving cancer treatment.

All patients must meet the inclusion criteria set out in section 5.2 and exhibit none of the criteria stipulated in the exclusion criteria in section 5.3. The patient must be given a full explanation of the domiciliary colostomy irrigation procedure in written and verbal format. Following this patient consent must be obtained using the form in appendix 1. This will be filed in the patient's stoma clinical nurse specialist's clinical notes.

The procedure will be carried out daily for 5 days (same time each day) and then every 48hrs. However some patients may choose to irrigate more frequently.

Patient must educated on when not to irrigate (i.e. if suffering from diarrhoea).The patient must also be informed of the potential adverse effects of colostomy irrigation and educated on how to minimise the risk of these occurring or managing these should they occur. These include:

• vasovagal episode
• abdominal pain / cramping
• difficulty inserting the cone
• breakthrough faeces.

• starter set (water container, tubing, cone)
• base plate
• belt
• sleeve
• pouch
• disposal bag
• dry wipes
• tap water.

Patients must be educated on how to replace equipment.

The following procedure will be carried out by the stoma clinical nurse specialist/stoma link nurse in the patient’s own home/domiciliary setting, in accordance with NHS Ayrshire & Arran’s Lone Worker Policy.

• prepare starter kit / equipment and explain the components to the patient
• demonstrate to the patient how to set up equipment in the bathroom
• explain the need to digitate colostomy to establish direction of bowel lumen to position cone and carry out the procedure
• demonstrate how to insert cone into colostomy
• explain how to regulate the flow of water
• educate patient on the volume and temperature of water to be used and insert water into colostomy
• demonstrate how remove cone from colostomy
• after approx 10-20mins, explain how to manage the sleeve as the water expels from the colostomy
• assess and explain how to establish when adequate time has passed and demonstrate how to remove the sleeve
• inform patient to apply their usual stoma pouch
• demonstrate how to dispose of / clean equipment.

Patient consent form - appendix 1 (prior to procedure)

• document intervention / education in patients stoma care notes
• document clear instructions for the patient on frequency of irrigation
• provide stoma clinical nurse specialist contact details
• email letter (appendix 2) to the patient's general practitioner advising of the patients decision to carry out domiciliary colostomy irrigation and request a prescription for the equipment.

The stoma clinical nurse specialist or stoma link nurse will:

• contact the patient by phone within 3-5 days to establish progress with the patient
• maintain contact with the patient via telephone until the patient in confident to continue domiciliary colostomy irrigation long term.

All guidelines and policies require review using the NHS Ayrshire and Arran Impact Assessment Toolkit by staff trained in this process.

Staff are reminded that they may have patients who require communication in a form other than English e.g. other languages or signing. Additionally, some patients may have difficulties with written material. At all times, communication and material should be in the patients preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on this guideline e.g. choice of gender of healthcare professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability that makes it difficult for them to be treated/examined as set out in the guideline requiring adaptations to be made.

Patient’s sexuality may or may not be relevant to the implementation of this guideline however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexuality may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality and Diversity Impact Assessment Tool Kit. No additional equality & diversity issues were identified.

Consent form for domiciliary colostomy irrigation

GP information letter / prescription request