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What Are Ostomies and Continent Diversions?

An ostomy is a surgically-created intestinal or urinary tract diversion that modifies the normal pathway for waste elimination. In a classical ostomy, digestive waste or urine exits the body through a piece of intestine which is brought through an opening in the abdominal wall. The piece of intestine which is thus brought outside the body is called a “stoma” and is usually dark pink in color:

Schematic drawing of a stoma (strictly speaking an “end” stoma, as there are also “loop” stomas that have two openings and a more irregular shape)

A pouching system is usually worn over the stoma to collect waste that flows out from the stoma. There are three kinds of classical ostomies with stomas of this sort.

The Three Classical Ostomies:

Ileostomy – An abdominal opening from the ileum (the lowest part of the small intestine) with a stoma that flows digestive waste. Most ileostomies created nowadays are temporary ones, which may be required when a surgical site lower in the digestive tract must be bypassed to give it time to heal. Surgeries that may require a temporary ileostomy include various colorectal cancer surgeries and J-Pouch surgery. A temporary ileostomy is usually constructed as a loop ileostomy. Permanent ileostomies were, in the past, often done for ulcerative colitis and familial polyposis, but aren't done as often for those conditions now, due to the rise of J-Pouch surgery. Permanent ileostomies may still be required for Crohn’s disease and various other conditions. An ileostomy stoma is usually located in the lower-right abdomen. Consistency of the output can vary from liquid to a semi-solid paste. A pouching system must always be worn over an ileostomy stoma.
Colostomy – An abdominal opening from the colon (large intestine) with a stoma that flows digestive waste. Colostomies may be either permanent or temporary. The number of permanent colostomies being created now has decreased, due to the rise of “sphincter sparing” colorectal cancer surgeries, which preserve continuity to the anus to allow reasonably normal defecation and require only a temporary ostomy, which is usually a temporary ileostomy. Permanent colostomies may still be required for very low rectal or anal cancers and various other conditions. Temporary colostomies are sometimes located in the transverse colon. Permanent colostomies are usually located in the sigmoid or descending colon. This type of (permanent) colostomy typically has a stoma in the lower-left abdomen and its output may have nearly the same consistency as normal stool. Colostomies of this sort can sometimes be managed with irrigation, which is basically an enema through the stoma. Colostomates who irrigate may report improved quality of life by controlling when output occurs and wearing only a “stoma cap” or other light dressing between irrigations. However, irrigation is strictly optional. Colostomates always have the option of wearing a pouching system all the time to catch output whenever it occurs.
Urostomy – An abdominal opening from the urinary tract which may be required when the bladder must be removed or bypassed. Normally, urine generated in the kidneys flows through the ureters to the bladder. It isn’t practical to pass ureters directly through the skin to make a stoma. Therefore, a short length of intestine is detached from the digestive tract and made to serve as a “conduit” for urine. This may be either a piece of the ileum (ileal conduit) or piece of the colon (colon conduit). One end of the conduit is connected to the ureters, while the other end is passed through the abdominal wall and made into a stoma. Since the stoma is made of intestine, it looks the same as an ileostomy or colostomy stoma, but it flows urine instead of digestive waste. A pouching system must always be worn over a urostomy stoma. A “night drainage system” can also be useful to prevent over-filling of the pouch overnight.

Continent Diversions:

As alternatives to classical ostomies, some patients can opt for “continent diversions” which avoid having to wear a pouching system. There are four main kinds of continent diversions:

J-Pouch – Also known as Ileoanal Reservoir, Pelvic Pouch, Restorative Proctocolectomy, and Ileal Pouch Anal Anastomosis (IPAA). There are also geometric variants of the internal pouch represented by letters J, S and W, but the term “J-Pouch” tends to be used generically for any of them. This is now generally considered the preferred surgery for ulcerative colitis or familial polyposis. The colon and rectum are removed and the end of the ileum is made into an internal pouch or reservoir for stool storage, to serve as a substitute rectum. This internal pouch is pulled down into the pelvis, to the position of the original rectum, and connected to the anus to enable (more-or-less) normal defecation. The patient’s original anal sphincters are used to provide continence; thus, candidates for this procedure must have intact anal sphincters in good condition. The procedure is often performed with two or three separate surgeries, where patients are given temporary ileostomies between the surgeries. When successful, the patient may have around 4 to 6 soft bowel movements per day. A common complication, perhaps in around 50% of cases, is “pouchitis” (inflammation of the internal pouch). Pouchitis can usually be treated effectively with medication, but occasionally becomes severe enough to warrant removal of the internal pouch. Another situation that may require removing a J-Pouch is when a patient who was originally diagnosed with ulcerative colitis turns out to have Crohn’s disease which ends up attacking the internal pouch.
Continent Ileostomy – Also known as “Kock Pouch” in honor of its inventor, Dr. Nils Kock of Sweden. This is another possible surgery for ulcerative colitis or familial polyposis. The colon and rectum are removed and the end of the ileum is made into an internal pouch or reservoir for stool storage. In this case, the internal pouch is kept in the abdominal cavity and connected to an opening in the abdominal wall with a special stoma through which the patient can insert a catheter to empty the internal reservoir. The special stoma is designed to function as a one-way valve to minimize leakage that might occur between catheterizations. When successful, the patient may catheterize 2 to 5 times a day and wear only a light dressing over the stoma at other times. Considering that the J-Pouch is now generally considered the preferred surgery for ulcerative colitis and familial polyposis, the Kock Pouch has become more of a niche procedure, performed by only a small number of surgeons. A variant of the Kock Pouch called the Barnett Continent Intestinal Reservoir (BCIR) has been advertised heavily but is performed at only a few hospitals (only one in the U.S.). The main situations in which continent ileostomies are sometimes still done are for patients who want to avoid a conventional ileostomy and aren’t candidates for a J-Pouch (for example, lack of adequate anal sphincters), or patients who’ve had a J-Pouch that failed and want to try another continent procedure. It should be understood, however, that, like the J-Pouch, Kock pouches are also susceptible to pouchitis and would also likely be attacked if the patient has Crohn’s disease.
Continent Urostomy – In the description of the classical urostomy above, a short length of intestine is detached from the digestive tract and made into a conduit for urine. To make a continent urostomy, a larger section of intestine is detached from the digestive tract and made into an internal pouch or reservoir for storing urine, to serve as a substitute bladder. This internal pouch is connected to an opening in the abdominal wall with a special stoma through which the patient can insert a catheter to empty the internal reservoir. The special stoma is designed to function as a one-way valve to minimize leakage that might occur between catheterizations. When successful, the patient may catheterize 4 to 6 times a day and wear only a light dressing over the stoma at other times. There are several surgical variations in construction of the internal urinary reservoir. The version performed most often is called the “Indiana Pouch” although there are other variations, including one called a “Kock Pouch,” named for the same Dr. Kock who invented the continent ileostomy.
Neobladder – This can be considered the urinary analog of the J-Pouch. As in a continent urostomy, a section of intestine is detached from the digestive tract and made into an internal pouch or reservoir for storing urine. In this case, the internal pouch is pulled down into the pelvis, to the position of the original bladder, and connected to the patient’s original urethra to enable (more-or-less) normal urination. This is the most difficult kind of urinary diversion surgery. As one requirement, the patient must have an adequate intact length of their original urethra. (However, if the bladder has been removed because of cancer, part or all of the urethra may also have been removed.) The procedure tends to be performed more often in men than in women because women have shorter urethras.

Terminology Confusion:

Here are several areas where people sometimes get confused about ostomy terminology:

Overuse of the name “colostomy” – As used by the general public, the name “colostomy” is often applied generically to all ostomies or, at least, all fecal ostomies. Thus, ileostomies are often incorrectly called “colostomies.” And, in fact, this error is sometimes made, not only by the general public, but even by personnel who work in hospitals. As a result, patients who get ileostomies (especially temporary ones) sometimes come home from the hospital thinking they have a colostomy. It should be understood, however, that if the stoma is in the lower-right abdomen, with output that may vary from liquid to semi-solid paste and may require emptying the pouching system half a dozen times a day, it’s probably an ileostomy, not a colostomy.
When urostomies are called “ileostomies” – The most common classical urostomy is the ileal conduit, where the stoma is made from a piece of ileum which has been detached from the digestive tract. Some urologists believe that if the stoma is made from ileum it should always be called an “ileostomy.” Those of us in ostomy support groups prefer that the name “ileostomy” be used only when the stoma is made from ileum which is still part of the active digestive system and flows digestive waste. However, given the terminology used by some urologists, we must be aware that when patients report having an “ileostomy,” sometimes they actually have an ileal conduit urostomy.
“Kock Pouch” can be fecal or urinary – The name “Kock Pouch” is synonymous with the continent ileostomy but is also a type of continent urostomy, as both were developed by the same Dr. Kock of Sweden. It’s true that the type of continent urostomy done most often these days is the “Indiana Pouch.” But still, when a patient reports having a “Kock Pouch,” it may be ambiguous whether they have a fecal or urinary diversion.
Spelling of “Kock” Pouch – The correct spelling is “Kock,” named for Dr. Nils Kock, the Swedish surgeon (1924–2011) who developed continent ileostomies and continent urostomies. The name is sometimes misspelled “Koch,” perhaps due to confusion with a famous German physician, Dr. Robert Koch, who is considered the founder of modern bacteriology but lived a century earlier (1843–1910) and had nothing to do with intestinal or urinary diversion surgeries.
Another kind of J-Pouch – The kind of J-Pouch described above in the “Continent Diversions” section is the ileo-anal J-Pouch, which is a technique for preserving continuity to the anus when the entire colon and rectum are removed, as may be required for some conditions such as ulcerative colitis. There is also a colo-anal J-Pouch, which is a technique that may be used in some sphincter sparing colorectal cancer surgeries for reconnecting tissues above and below the resected cancer.

This page last revised 2019-12-02

OKLAHOMA OSTOMY GROUPS

MORE OSTOMY INFORMATION

What Are Ostomies and Continent Diversions?

The Three Classical Ostomies:

Continent Diversions:

Terminology Confusion: