What if a stoma is pale pink?

After your ostomy surgery, your healthcare team likely taught you how to care for your peristomal skin and what it should look like when it is healthy. Ideally, it should be intact without irritation, rash, or redness. The skin around your stoma should look just like the skin on the other side of your abdomen, or anywhere else on your body, free of redness, irritation, or damage. Healthy skin should be the rule, not the exception.

However, if your peristomal skin is irritated or damaged, there may be some signs of a peristomal skin complication (PSC), such as:

1. Discomfort, itching, soreness, or even pain around the stoma
2. Recurrent leakage under your pouching system or skin barrier
3. Excessive bleeding of your stoma – it’s normal for your stoma to slightly bleed after you wash it, but the bleeding should resolve quickly
4. A bulge in the skin around your stoma
5. Skin color changes from normal pink or red to pale, bluish purple, or black
6. A rash around the stoma that is red, or red with bumps – this may be due to a skin infection or sensitivity, or even leakage
7. Wart-like, pimple-like or blister-like bumps under the skin barrier – this type of irritation can happen any time, even if you’ve used the same product for months or years
8. Any type of wound or scratch on the peristomal skin

Peristomal Skin Complications — Potential causes and what to do

Irritated and damaged peristomal skin can occur for a variety of reasons. It can be caused by anything from a poor-fitting pouching system, to frequent skin barrier changes, to an allergic reaction to anything that contacts the skin, such as soaps or products used to prepare the peristomal skin. Some studies report up to 75 percent of people with an ostomy experience a PSC.* Although it is a common issue, it should not be ignored.

If you experience any signs of a PSC, contact your stoma care nurse. You should work with your healthcare team to determine the exact cause and the appropriate solution.

For more information on maintaining healthy skin and other topics, click here to visit the Hollister Ostomy Learning Center.

* Rapp CG, L Richbourg, JM Thorne. Difficulties Experienced by the Ostomate After Hospital Discharge. JWOCN. 2007;34(1):70-79.

The information provided herein is not medical advice and is not intended to substitute for the advice of your personal physician or other healthcare provider. This information should not be used to seek help in a medical emergency. If you experience a medical emergency, seek medical treatment in person immediately.

Editor’s note: This educational article is from one of our digital sponsors, Hollister Incorporated. Sponsor support along with donations from readers like you help to maintain our website and the free trusted resources of UOAA, a 501(c)(3) nonprofit organization.

Published on January 6, 2017 by Keisha Smith, MA, CWCMS

There are two main types of stomas, and they both have certain “ideal” characteristics in common. Do you know what they are?

You say potato, I say potahto. You say ostomy, I say … stoma. Huh? Those of us in wound care know that it’s not uncommon to hear the terms ostomy and stoma used interchangeably, even though they have different meanings.

What is a Stoma?

Let’s start with the basics:

• The stoma is the mouth-like, visible part of an ostomy.
• A fecal or urinary stoma is composed of mucous membrane or the lining of the intestine that’s exposed to the surface.
• Following ostomy surgery, effluent (output) – such as fecal matter, urine, or mucous – will pass through the opening of the stoma, called the lumen.
• The patient will not have voluntary control of the effluent expelled by the stoma.

Types of Stomas

There two major categories of stomas: the end and the loop.

End stoma

An end stoma is created when the surgeon brings one end of the GI tract through the abdominal wall, then folds it over. The the surgeon then removes the other end or sews it shut.

In some cases, the surgeon will create end stomas from both ends of the GI tract, called a double-barrel stoma. In this case, you’ll see two distinct stomas: the proximal stoma discharges stool and the distal stoma discharges mucous.  Sometimes an expanse of skin separates the two stomas, and sometimes they will share the same opening.  This construction is most common for infants or very small children.

Loop stoma

To create this type of colostomy, the surgeon lifts a loop of the transverse colon through the abdomen. The colon is given a small split on the side facing out, and a rod is placed underneath for support. The rod may be removed after a few days, when support is no longer needed. The proximal opening of the stoma drains stool from the intestine, while the distal opening of the stoma drains mucus.  Loop stomas are usually created for temporary ostomies.

Characteristics of an Ideal Healthy Stoma

Each stoma is unique, just as each patient’s physiology is unique. Different surgical techniques will result in stomas of different appearance. At the same time, the “ideal” stoma has some identifiable characteristics:

Moist

The inner surface of the stoma continually produces mucus to cleanse the stoma. Mucus production is a normal function of the intestines that serves as natural lubrication for food passing through the body. The mucus gives the healthy stoma a wet appearance.

Beefy red

Blood flow is essential to the health of the stoma. Normal stoma tissue is highly vascular and will appear deep pink to red. Pale pink is also normal in a urinary stoma. Stoma tissue may even bleed slightly when rubbed or irritated, which is normal. When a stoma turns pale, or dark, it means there’s a problem with the blood supply, so be sure to investigate.

A round stoma is easiest to measure with circular rulers. It also works best with pre-cut skin barriers (the part of the ostomy appliance that affixes to the skin and attaches to pouch). An oval or irregularly shaped stoma may require cut-to-fit skin barriers.

The shape is affected by the type of ostomy and the individual’s body composition. The shape can also vary with the wave-like muscular contractions of the intestines, the peristaltic movement.

Budded/Protruding

When a stoma has a rosebud shape (rather than flat or retracted), it protrudes into the pouching system. This allows the effluent to fall out into the pouch away from the body. The ideal protrusion is 2-3 cm with a lumen in the very center.

Strategically Located

To easily accommodate the skin barrier, it’s ideal to have 2-3 inches of flat skin around the stoma. Avoid beltlines, bony prominences, skin folds, suture lines, or the umbilicus (belly button). Also, the patient will have more success managing a stoma located in an area that he or she can see and reach.

Stoma Assessment

The stoma itself has no sensory nerve endings, which means there is no sensation for the patient. In other words, the patient may not feel pain or discomfort if the stoma becomes lacerated or injured. Therefore, your thorough clinical assessment of the stoma and the surrounding skin is essential to catching problems early.

Stoma Education

Joy Hooper, RN, BSN, CWOCN, OMS, WCC, Clinical Instructor

WCEI instructor Joy Hooper RN, BSN, CWOCN, OMS, WCC offers a one-hour webinar to help you conduct a stomal and peristomal skin assessment. View the webinar for free by using the code BLOG. Educational credit is available.

For advanced training and board certification in ostomy care, take the week-long WCEI Ostomy Management Specialist® (OMS) course and NAWCO certification exam, held at locations throughout the US. It will get you current with standards of care to help this underserved patient population.

By Rosalyn S. Jordan, RN, BSN, MSc, CWOCN, WCC, OMS; and Judith LaDonna Burns, LPN, WCC, DFC

About 1 million people in the United States have either temporary or permanent stomas. A stoma is created surgically to divert fecal material or urine in patients with GI or urinary tract diseases or disorders.

A stoma has no sensory nerve endings and is insensitive to pain. Yet several complications can affect it, making accurate assessment crucial. These complications may occur during the immediate postoperative period, within 30 days after surgery, or later. Lifelong assessment by a healthcare provider with knowledge of ostomy surgeries and complications is important.

Immediately after surgery, a healthy GI stoma appears red, moist, and shiny. Edema of the stoma is expected for the first 6 to 8 weeks. A healthy urinary stoma is pale or pink, edematous, moist, and shiny. Usually, it shrinks to about one-third the initial size after the first 6 to 8 weeks as edema subsides. The stoma warrants close observation as pouching types and sizes may need to be changed during this time. Teach the patient and family caregivers to report changes or signs and symptoms of stoma complications to a healthcare provider. If complications are recognized early, the problem may be resolved without surgical intervention.

Stoma complications range from a simple, unsightly protrusion to conditions that require emergency treatment and possible surgery. Clinicians must be able to recognize complications and provide necessary treatment and therapy early. Complications include parastomal hernias, stoma trauma, mucocutaneous separation, necrosis, prolapse, retraction, and stenosis. Although one complication can lead to and even promote others, all require attention and treatment.

Parastomal hernia

A parastomal hernia involves an ostomy in the area where the stoma exits the abdominal cavity. The intestine or bowel extends beyond the abdominal cavity or abdominal muscles; the area around the stoma appears as a swelling or protuberance. Parastomal hernias are incisional hernias in the area of the abdominal musculature that was incised to bring the intestine through the abdominal wall to form the stoma. They may completely surround the stoma (called circumferential hernias) or may invade only part of the stoma.

Parastomal hernias can occur any time after the surgical procedure but usually happen within the first 2 years. Recurrences are common if the hernia needs to be repaired surgically. Risk factors may be patient related or technical. Patient-related risk factors include obesity, poor nutritional status at the time of surgery, presurgical steroid therapy, wound sepsis, and chronic cough. Risk factors related to technical issues include size of the surgical opening and whether surgery was done on an emergency or elective basis.

Parastomal hernias occur in four types. (See Types of parastomal hernias by clicking the PDF icon above.) Initially, a parastomal hernia begins as an unsightly distention in the area surrounding the stoma; the hernia enlarges, causing pain, discomfort, and pouching problems resulting in peristomal skin complications that require frequent assessment. Conservative therapy is the usual initial treatment. Adjustments to the pouching system typically are required so changes in the shape of the pouching surface can be accommodated. Also, a hernia support binder or pouch support belt may be helpful. Avoid convex pouching systems; if this isn’t possible, use these systems with extreme caution. If the patient irrigates the colostomy, an ostomy management specialist should advise the patient to discontinue irrigation until the parastomal hernia resolves.

Stoma trauma

Stoma trauma occurs when the stoma is injured, typically from a laceration. Lacerations usually result from the pouch appliance or clothing. Belt-line stomas are easily traumatized and injury may occur from both clothing belts and pouch support belts. Stoma lacerations commonly result from a small opening in the flange or a misaligned pouch opening. Other causes include parastomal or stomal prolapse with possible stoma enlargement or edema.

Signs and symptoms of stoma trauma include bright red bleeding, a visible cut, and a yellowish-white linear discoloration. Lacerations may heal spontaneously. If the culprit is the pouching system, make sure nothing within the system comes in contact with the stoma. Usually direct pressure controls bleeding, but if bleeding continues, refer the patient to a physician for treatment.

Mucocutaneous separation

Mucocutaneous separation occurs when the stoma separates from the skin at the junction between the skin and the intestine used to form the stoma. Causes are related to poor wound-healing capacity, such as malnutrition, steroid therapy, diabetes, infection, or radiation of the abdominal area. Tension or tautness of the suture line also can cause mucocutaneous separation.

This complication usually arises early and can lead to other serious conditions, such as infection, peritonitis, and stomal stenosis. The area of the separation may completely surround the stoma (known as a circumferential separation), or the separation may affect only certain areas of the stoma/skin junction. The separation may be superficial or deep.

The first sign of mucocutaneous separation may be induration. Treat the separation as a wound, and apply wound-healing principles: Absorb drainage, reduce dead space, use the proper dressing, and promote wound healing. The proper dressing depends on wound depth and amount of wound drainage. Be sure to assess the wound, using the “clock method” to describe location; measure the wound area in centimeters; and describe the type of tissue in the wound bed. Be aware that slough may be present.

Treatment of the wound dictates how often the pouch is changed. A two-piece pouching system commonly is used to reduce the number of pouch changes. Cover the wound dressing with the pouching system unless the wound is infected. If infection is present, let the wound drain into the pouch and heal by secondary intention. Don’t use a convex pouching system, because this may cause additional injury to the mucocutaneous junction.

Stoma necrosis

Blood flow and tissue perfusion are essential to stoma health. Deficient blood flow causes stoma necrosis. A stoma may be affected by both arterial and venous blood compromise. The cause of necrosis usually relates to the surgical procedure, such as tension or too much trimming of the mesentery, or the vascular system that provides blood flow to the intestine. Other causes of vascular compromise include hypovolemia, embolus, and excessive edema.

Stoma necrosis usually occurs within the first 5 postoperative days. The stoma appears discolored rather than red, moist, and shiny. Discoloration may be cyanotic, black, dark red, dusky bluish purple, or brown. The stoma mucosa may be hard and dry or flaccid. Also, the stoma has a foul odor. Associated complications may include stoma retraction, mucocutaneous separation, stoma stenosis, and peritonitis.

Report signs and symptoms to the primary care provider immediately. Superficial necrosis may resolve with necrotic tissue simply sloughing away. But if tissue below the fascial level is involved, surgery is necessary. A transparent two-piece pouching system is recommended for frequent stoma assessment. The pouch may need to be resized often.

Stoma prolapse

A stoma prolapse occurs when the stoma moves or becomes displaced from its proper position. The proximal segment of the bowel intussuscepts and slides through the orifice of the stoma, appearing to telescope. This occurs more often in loop transverse colostomies. A prolapsed stoma increases in both length and size. Prolapse may be associated with stoma retraction and parastomal hernias.

Causes of stoma prolapse include large abdominal-wall openings, inadequate bowel fixation to the abdominal wall during surgery, increased abdominal pressure, lack of fascial support, obesity, pregnancy, and poor muscle tone.

Unless the patient complains of pain, has a circulatory problem, or has signs or symptoms of bowel obstruction, conservative treatment is used for uncomplicated stoma prolapse. The prolapse usually can be reduced with the patient in a supine position. After reduction, applying a hernia support binder often helps. Also, a stoma shield can be used to protect the stoma. A prolapsed stoma may require a larger pouch to accommodate the larger stoma. Some clinicians use cold compresses and sprinkle table sugar on the stoma; the sugar provides osmotic therapy or causes a fluid shift across the stoma mucosa and reduces edema.

Stoma retraction

The best-formed stoma protrudes about 2.5 cm, with the lumen located at the top center or apex of the stoma to guide the effluent flow directly into the pouch. In stoma retraction, the stoma has receded about 0.5 cm below the skin surface. Retraction may be circumferential or may occur in only one section of the stoma.

The usual causes of stoma retraction are tension of the intestine or obesity. Stoma retraction during the immediate postoperative period relates to poor blood flow, obesity, poor nutritional status, stenosis, early removal of a supporting device with loop stomas, stoma placement in a deep skinfold, or thick abdominal walls. Late complications usually result from weight gain or adhesions. Stoma retraction is most common in patients with ileostomies.

A retracted stoma has a concave, bowl-shaped appearance. Retraction causes a poor pouching surface, leading to frequent peristomal skin complications. Typical therapy is use of a convex pouching system and a stoma belt. If obtaining a pouch seal is a problem and the patient has recurrent peristomal skin problems from leakage, stoma revision should be considered.

Stoma stenosis

Stoma stenosis is narrowing or constriction of the stoma or its lumen. This condition may occur at the skin or fascial level of the stoma. Causes include hyperplasia, adhesions, sepsis, radiation of the intestine before stoma surgery, local inflammation, hyperkeratosis, and surgical technique.

Stoma stenosis frequently is associated with Crohn’s disease. You may notice a reduction or other change in effluent output with both urinary and GI ostomies. With GI stoma stenosis, bowel obstruction frequently occurs; signs and symptoms are abdominal cramps, diarrhea, increased flatus, explosive stool, and narrow-caliber stool. The initial sign is increased flatus. With urinary stoma stenosis, signs and symptoms include
decreased urinary output, flank pain, high residual urine in conduit, forceful urine output, and recurrent urinary tract infections.

Partial or complete bowel obstruction and stoma stenosis at the fascial level
require surgical intervention. Conservative therapy includes a low-residue diet, increased fluid intake, and correct use of stool softeners or laxatives for colosto­mies.

Most stoma complications are preventable and result from poor stoma placement. Up to 20% of patients with stoma complications require surgical revision of the stoma. All patients with ostomies require ongoing, accurate assessment and, if needed, early intervention by trained clinicians.

Selected references
Al-Niaimi F, Lyon CC. Primary adenocarcinoma in peristomal skin: a case study. Ostomy Wound Manage. 2010;56(1):45-7.

Appleby SL. Role of the wound ostomy continence nurse in the home care setting: a patient case study. Home Healthc Nurse. 2011:29(3);169-77.

Black P. Managing physical postoperative stoma complications. Br J Nurs. 2009:18(17):S4-10.

Burch J. Management of stoma complications. Nurs Times. 2011;107(45):17-8, 20.

Butler DL. Early postoperative complications following ostomy surgery: a review. J Wound Ostomy Continence Nurs. 2009:36(5):513-9.

Husain SG, Cataldo TE. Late stomal complications. Clin Colon Rectal Surg. 2008:21(1):31-40.

Jones T, Springfield T, Brudwick M, Ladd A. Fecal ostomies: practical management for the home health clinician. Home Healthc Nurse. 2011;29(5):306-17.

Kann BR. Early stomal complications. Clin Colon Rectal Surg. 2008:21(1):23-30.

Nybaek H, Jemec GB. Skin problems in stoma patients. J Eur Acad Dermatol Venereol. 2010;24(3):249-57.

Shabbir J, Britton DC. Stomal complications: a literature overview. Colorectal Dis. 2010;12(10):958-64.

Szymanski KM, St-Cyr D, Alam T, Kassouf W. External stoma and peristomal complications following radical cyctectomy and ileal conduit diversion: a systematic review. Ostomy Wound Manage. 2010;56(1):28-35.

Wound, Ostomy, Continence Clinical Practice Ostomy Subcommittee. Stoma Complications: Best Practice for Clinicians. Mt. Laurel, NJ; 2007.

Rosalyn S. Jordan is the senior director of Clinical Services at RecoverCare, LLC, in Louisville, Kentucky. Judith LaDonna Burns is currently pursuing a BSN and plans to gain certification as an Ostomy Management Specialist.