I read with interest Dr Yeung's reporting of ostomate-specific public facilities in Japan that the Japanese ostomy groups successfully lobbied to provide the user with a place not only to empty their pouch but also to change their pouching system. The article demonstrates the cultural differences that we see in the management of the person with an ostomy. As I read the article, I was concerned about the need for the person with an ostomy to change their entire pouching system outside of a scheduled change that could or should be done at their home. In North America we work with our patients to help them define wear time as a predictable time period in which the pouching system is applied, worn, removed, and replaced with no leakage in between application and removal. While for some people with an ostomy, there are times when the seal is disturbed and leakage occurs necessitating an "emergency" change, this should not be the norm. Adaptation to living with an ostomy is a process of reintegration into society by participating in life as they did before the illness or medical condition that caused them to undergo ostomy surgery. Suggesting to a person with an ostomy that they require special washroom facilities separates them from society in a way that I believe is not proper or indicated.

Emptying an ostomy pouch for some can be difficult in some washroom facilities. The majority of the patients I work with describe the procedure for pouch emptying to be sitting on the toilet seat in a position that they can empty the pouch between their legs into the commode. Others do note that in some washrooms, sitting on the toilet seat is a challenge when the facilities are not clean; however, this is a problem that a person encounters with or without a stoma.

The percentage of people with an ostomy who encounter problems with the management of their stomas is reported to be as high as 75%1; patients who seek help in my outpatient clinic usually describe the problem as arising due to pouch seal failure. I can appreciate that some people with ostomies may hesitate to go out socially because of fear of leakage and the inability to manage the leakage when outside of their home. Providing people with pouch seal issues a resource such as access to a certified ostomy care nurse in an accessible stoma clinic should be our priority social item. Rather than campaigning the government for ostomy washrooms, I would suggest that we should be working with government agencies to provide reimbursement for ostomy care services in an accessible stoma clinic to make available the services that many people need to live successfully with a stoma.

Outside of the United States, management of a pouching system differs especially as related to wear time. Ostomy care nurses and product manufacturers in Europe and Asia report average wear time to be 24 hours (Nari Yoshikatsu, personal written communication, 6/17/2014). The seal of the pouching system outside of the United States is less aggressive and it may be understandable that a pouch seal could need changing when outside of one's own facilities and thus the need for an ostomy-specific washroom facility. I would suggest, however, that in North America such facilities should not be considered. Dr Yeung has introduced us to an intriguing issue, one that illustrates the difference in stoma management through the world.

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