What happens when a pouch/bag is viewed by a person with an "incontinent" ostomy as too big? Conversely, what happens when the pouch/bag is viewed as too small? Both questions primarily address the volume capacities of pouches and not necessarily the shapes; however, shape and volume capacity are interrelated and affect pouch appearances as they fill.
The impetus for these comments derives from the manufacturing outcomes during the past two decades of the three major pouch manufacturers: Coloplast, ConvaTec, and Hollister. In particular, a size reduction and shape change in the normal or adult-sized drainable pouch I had been using for years took place without public explanation or forewarning. As a result of these changes, my normally uninterrupted sleep patterns were replaced by the necessity of awakening to empty a reduced capacity pouch, and I found it necessary to visit the bathroom more often to empty the pouch. Where I normally emptied 5 to 7 times while awake, I now found it necessary to empty 7 to 9 times. These changes were accompanied by a more pronounced bulging as the pouch filled, due in part from the reduced capacity, thinner pouch wall material, and an altered shape that no longer distributed the stool mass as discretely as before.
During the 1980s and 1990s I observed a uniformity of pouch shapes and sizes among the three major companies, resulting in no discernible differences between brands save for the identifying labels on the pouches or the boxes that contained them. I came to characterize this shared pouch identity as an example of "group-think" by the manufacturers as they designed and marketed these look-alike pouches.
I complained to the pouch manufacturers in the mid 1990s and was told that their marketing research, done primarily via focus groups, identified the need to make pouches smaller. In effect, a pouch that at one time was listed with a 770-mL volume capacity was now reduced to a 625-ml capacity. Furthermore, the manufacturers defended their actions with the following quoted statement: "Since we recommend the pouch be drained when the pouch is between 1/3 and 1/2 full, the resultant pouch volume change was determined to be acceptable for most users" (personal communication, representative of Hollister, Inc. Libertyville, Ill; 1997). Since a percentage of a lesser volume is still less than the same percentage of a larger volume, any reduction in the maximum pouch capacity will oblige a patient to empty more frequently.
Prima facie principles of incontinent ostomy management include: (1) creation of an ostomy precipitates an identity crisis of image and function, (2) pouch capacity is paramount to all other aesthetic needs, (3) the function of the pouch supersedes its appearance, (4) restricting pouch shape and volume choices constrains ostomy lifestyle functioning, and (5) variable ostomy outputs and diversion types require multiple pouch designs as do variations in body types and lifestyles. Ostomy pouches have three critical requirements: (1) containment (storage capacity), (2) control (of odor and sound), and (3) camouflage (discrete shaping). I refer to these as the three C requirements.
Without factoring in these essential principles for useful pouch designs, the manufacturers have altered and limited the practical options for a number of ostomates, ileostomies and urostomies in particular. In effect, fashion has supplanted practical function as it relates to pouch volumes, shapes, and materials employed in pouch construction. Some of the unintended consequences of the smaller and less effective shaping of these look-alike pouches are: (1) increased frequency of emptying while awake and during sleep, (2) increased pouch profile bulging or ptosis as it fills, (3) increased ostomate toileting anxiety, and (4) increased threats to the pouch/wafer seal.
As the lay and professional organizations devoted to ostomates strive to arrive at a useful consensus on ostomy management practices, they should not lose sight of the impact and utility of pouch design and capacity and their influence on both short- and long-term ostomy adjustment and management.
Some ostomates, concerned with the appearance of the pouch, try to hide it under snug or flattering clothing, resort to frequent emptying to keep its profile low, if not invisible, and fold it or use smaller pouches. Are these behaviors also a function of poor pouch profile secondary to flimsy wall construction? Other ostomates struggle to keep the flimsy and misshapen pouch from banging into private parts as it fills while also lamenting the reduced volume capacities. Just as a child generally accepts and masters whatever potty training, the person with a newly created ostomy must accept and master those ostomy potty and pouching strategies imposed or offered by the practitioner and the manufacturer/supplier.
In earlier days (1950s to 1980s), prior to and at the beginning of ET and WOCN/stoma care nurse intervention, many ostomates adapted as best as they could to the crop of pouches at hand. Ironically, there were many more pouch manufacturers then than there are now, and the size ranges offered allowed for larger volume capacities than are readily available now for the "average" ileostomate. On average, pouch emptying occurred about 5 to 7 times while awake; sleep intervals were usually uninterrupted. In fact, in 1976 and 1978, Hill and Kretschmer published their findings of the range of ileostomy outputs of stool and gas, finding a low of 611 mL and a high of 2,602 mL.1,2 These data appear not to have been noted or considered by pouch manufacturers when they reduced the volume capacities of the current crop of pouches. To what and whom were they responding during their numerous focus groups?
Recently, I undertook a series of Internet-based informal surveys and reviews of pouch size and shape issues, and my initial results and interpretations are as follows. I offered the following comments and asked the following questions.
I am offering a quick survey about drainable pouches and their respective sizes for all of you who have the traditional "incontinent" types of ostomy that necessitate the wearing of a drainable pouch. Please note that I am not asking any opinions about clothing or fashion conflicts that may arise because of the pouch at this time.
I am asking for simple and clear answers or sentences in reply to the following questions or statements.
1. Identify exactly what type of incontinent ostomy you have and how long overall you have had your ostomy. State whether or not you have high volume outputs from your stoma and why. For example, if you have a fecal or stool ostomy state what type and for how long. If you have an incontinent urinary stoma, state what type and for how long.
2. State whether or not your current drainable pouch size is adequate in volume capacity. If so, say so. If not, say whether or not the pouch is too small or too big for you.
3. State whether or not you have to interrupt your sleep cycle in order to empty the pouch.
4. State whether or not you wish a larger capacity pouch were available to permit uninterrupted sleep cycles and or prolonged emptying cycles during waking hours.
5. State whether or not you feel the pouch size currently used by you hampers your daily activities. Put another way, do you wish that you did not have to worry about emptying your pouch so often?
6. State whether or not the make up of the pouch is too flimsy or too rigid.
7. Does the pouch distort when it is filling up such that it is annoying to you? If you wear an additional pouch cover does it fall off the pouch because of any pouch distortion when the pouch is filling up?
8. Does the pouch get in the way of your private parts, ie, the genital zone as it fills up? How do you handle this situation?
9. Is the pouch too long or too short?
10. How many times during the day do you empty the pouch? How full do you allow the pouch before emptying?
11. How many times are you awakened to empty the pouch?
12. Has the pouch leaked during sleep because it overflowed or overfilled? If so, how often in a month?
I received 89 replies to this informal survey; 36 replies came from the United Ostomy Association general discussion board, 19 were from Shaz's Web site (http://www.ostomates.org) and 34 were received in response to a journal editorial from 2003. Based on these responses, I have reached several conclusions. There appears to be a perceptual divide between more experienced and newer ostomates when it comes to the suitability of the current selection of pouch sizes and shapes. More experienced ostomates who have enjoyed the benefit of larger pouch sizes prior to the mid-1990s, now lament the loss of those larger sized pouches. Less experienced ostomates, having no other point of reference, are less likely to note significant deficits with current designs. Based on these observations, newer ostomates do not seem to mind frequent bathroom trips because of altered expectations and inexperience with larger pouches. Nevertheless, I question whether or not any ostomate should be "tethered" to the toilet? Instead, I submit that a diverse range of ostomy behaviors and patient types exist and a broader range of pouch sizes and shapes should exist to meet our needs.
Unfortunately, this has not been the case since the 1990s. In effect, ostomy pouch manufacturers, through manipulation of pouch capacities and shapes, have effectively shaped or altered ostomy management behaviors in both patients and practitioners. Sadly, this is not a good outcome. Manufacturers should not be dictating ostomy management behaviors; rather they should be adapting their roles and products to meeting legitimate and practical needs of the ostomy community they serve.
Given their lack of experience with larger pouches, it is not surprising that newer ostomates do not favor a larger pouch and do not mind frequenting the toilet sometimes up to 10 or 15 times during waking hours.
It is a bit of a paradox to expect a "smaller" pouch to appear less bulky as it fills. The less the volume capacity the quicker it fills, and given the ineffective shaping and flimsy materials used, the sooner its misshapen bulk appears. Think of a spill or puddle of fluid spread over a given area. Now take the volume of this spill and confine it to a smaller area. You will either have to mop up the overflow immediately or dig a deeper hole to contain it within the smaller area. With the smaller ostomy pouch one will have to either empty more frequently or accept the bulging profile sooner. In either case, as fluid (ie, stool or urine) accumulates in the pouch, the fluid level rises higher and with increasing pressure to threaten the pouch seal. Moreover, we haven't even begun to address the additional burden of flatus further displacing the limited volume for fecal diversions. Add to this scenario the clothing impingement or bending stresses placed upon this bulging little pouch and the potential for early seal rupture or peristomal skin irritation increases manifestly.
Varying body sizes, shapes, and activities of people with ostomies, as well as varying stomal output behaviors, do require different pouch size and shape choices. Ironically, in light of the recent American trends in body morphology, the shift toward higher body mass indices suggests further that smaller pouches are less suitable for the enlarging (bariatric) patient. Proper pouch shaping and wall material choices can offer a flattering and comfortable appearance as the pouch fills. Anyone familiar with clothing style and shape flattering strategies knows this well. Flimsy or soft fabrics will not "hide" sins as easily as stiffer ones will. Flimsy plastic pouch walls will not preserve a flattering or lower pouch profile as it begins to fill. Nor will poor shapes and constrained pouch volumes permit a flattering profile with a reasonable margin of safety between emptying episodes.
If history and longstanding experience teach us anything it is that not all changes or "improvements" are necessarily for the better, and in the case of ostomy pouch manufacturing trends, the "group think" approach taken by the major companies of late has not resulted in appropriate choices or competitive options for a variety of ostomy patients.
Mike D'Orazio, ET
November 2005
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