From Clinic to Recovery · First Edition
Chapter 14 — Colorectal Surgery and Living with a Stoma
Dr. Tamer Rushdy Elalfy · 20 min read
In this chapter
- 14.1 Common reasons for bowel surgery
- 14.2 Explaining a stoma
- 14.3 The psychological journey
- 14.4 Supporting adjustment
- 14.5 Faith and the stoma
- 14.6 Intimacy and relationships
- 14.7 Before the operation
- 14.8 After the operation
- 14.9 Reversal and bowel function afterward
- 14.10 Material risks
- 14.11 Consent checklist
- 14.12 Warning signs
- References
Bowel surgery is performed for cancer, diverticular disease, inflammatory bowel disease, and emergencies such as obstruction or perforation. For many patients the operation itself is not what they fear most. It is the possibility of a stoma: an opening of the bowel on the abdomen, with a pouch to collect waste. A stoma touches body image, intimacy, cleanliness, religious practice, work, and how a person believes others see them. Most people adapt well with good preparation and support, but depressive symptoms affect almost half of patients after stoma surgery [1]. This chapter covers the counseling for colorectal surgery, with particular emphasis on the psychological care of the person with a stoma.
Learning objectives After reading this chapter you should be able to:
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Table 14.1. Colorectal surgery and stomas at a glance.
| At a glance | |
|---|---|
| Common operations | Right or left colectomy; anterior resection of the rectum; abdominoperineal resection; emergency resection (Hartmann’s procedure) |
| When a stoma is made | To protect a low join (temporary ileostomy); when a join is unsafe (temporary colostomy); when the anus is removed (permanent colostomy) |
| Hospital stay | Usually 3 to 7 days with enhanced recovery |
| Risks every patient should hear | Leak from the join, infection, ileus, stoma problems, dehydration, change in bowel function after reversal, and low mood |
| The key counseling message | “A stoma changes how your body works, not who you are. Most people return to work, family life, prayer, and travel, and we will support you every step.” |
STEP 1 Explaining the operation and the stoma
14.1 Common reasons for bowel surgery
For bowel cancer, the operation is planned by the multidisciplinary team and may follow or precede chemotherapy or radiotherapy; breaking the news is covered in Section 1.7. For diverticulitis, the decision about elective resection is individualized according to the patient’s symptoms, complications, and quality of life, rather than the number of past episodes [2]. Inflammatory bowel disease and emergency operations raise the possibility of a stoma with little warning. All planned operations follow the enhanced recovery principles of Chapter 2, and preoperative education, including stoma education, shortens recovery [3].
14.2 Explaining a stoma
Explain what a stoma is, why it may be needed, which type is likely, and whether it is expected to be temporary or permanent (Figure 14.1). When a stoma is possible rather than certain, say so, and prepare the patient as though it will be made. Patients woken from an emergency operation with an unexpected stoma find adjustment much harder.
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 14.1. Ileostomy and colostomy compared, for use with patients.
Script: explaining a stoma What it is. “A stoma is where the end of the bowel is brought out through a small opening on your tummy. It looks pink and moist, like the inside of your mouth. It has no feeling. A soft pouch sticks to the skin around it and collects what would normally pass from your back passage.” Why. “In your case, we may need a stoma to let the join in your bowel heal safely. We expect it to be temporary, and to close it in a smaller operation, usually after a few months.” What it means for daily life. “Modern pouches are flat, discreet, and odor-proof. People with stomas work, pray, travel, swim, and have intimate relationships. Our stoma nurse will meet you before the operation, mark the best place for it, and teach you everything you need.” Feelings. “Many people feel shocked or upset at first. That is normal, and it usually gets easier. Please tell us how you are feeling, because we can help with that too.” |
14.3 The psychological journey
Adjustment to a stoma follows a recognizable path (Figure 14.2). Before surgery, patients fear disfigurement, smell, and rejection. The first sight of the stoma can cause shock, disgust, or grief, and some patients refuse to look at it or touch it for days. In the first weeks at home, leaks, noise, and fear of odor lead some people to withdraw from family, work, and the mosque. Most adapt over months, but a substantial minority remain anxious, low, or isolated. In a meta-analysis, depressive symptoms were present in almost half of patients after stoma surgery, more often than in comparable patients without a stoma [1].
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 14.2. The emotional journey with a stoma, and what helps at each stage.
Several factors make adjustment harder: an unexpected or emergency stoma, a permanent stoma, a poorly sited stoma that leaks, lack of confidence in self-care, an unsupportive partner, and cultural or religious concern about cleanliness. Several things make it easier: preoperative counseling and site marking, early hands-on teaching, a peer who has lived with a stoma, and a partner or family member who is involved and accepting.
14.4 Supporting adjustment
- Before surgery. Every patient who may need a stoma should see a stoma nurse for counseling and marking of the stoma site, which improves outcomes and quality of life [4]. Offer a meeting with a trained volunteer who has a stoma.
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Family. Ask the patient whom they want involved. A spouse who learns stoma care alongside the patient, and who is not shocked by it, is one of the strongest supports. Respect a patient who prefers to keep it private.
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The first look. Plan the first look with the nurse, at a time the patient chooses. Staff should keep calm, neutral expressions while handling the stoma; patients watch faces closely.
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Self-care. Aim for independence in emptying and changing the pouch before discharge. Confidence in self-care is closely linked to adjustment.
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Practical fixes for fears. Odor filters and deodorants, emptying before outings, pouch covers, high-waisted underwear, and a small kit for travel address the commonest worries.
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Screening. Ask about mood at every visit, using simple questions or a validated tool, and refer for psychological support when needed.
Words that help and words that hurt Avoid: “bag” said with distaste; “dirty”; “disabled”; a visible reaction to smell or appearance; “you will get used to it.” Prefer: “pouch” or “appliance”; “your stoma looks healthy”; “many people feel like this at first”; “what worries you most about it?” Ask, do not assume: “How are you feeling about your stoma?” “Has it changed how you go out or see people?” “Is there anything you have stopped doing because of it?” |
Caution: screening for low mood and self-harm Ask at every follow-up: “Over the last two weeks, have you often felt down, depressed, or hopeless? Have you lost interest or pleasure in doing things?” If the answer is yes, ask more, and refer for psychological assessment. If a patient expresses thoughts of self-harm or that life is not worth living, do not leave it for the next appointment: arrange same-day assessment according to your hospital’s policy. |
14.5 Faith and the stoma
For Muslim patients, the stoma raises immediate questions about ritual purity, prayer, fasting, and pilgrimage, and these concerns are a major reason for lower quality of life after stoma surgery [5]. Many patients are reluctant to ask, and many clinicians do not raise the subject. Reviews of Islamic scholarly opinion conclude that a person with a stoma can perform ablution and pray, attend the mosque, and perform Hajj and Umrah, and may fast when it is medically safe; the stoma is generally treated like other continuous conditions, so ablution is performed for each prayer time [5]. Religion-specific counseling before and after surgery improves quality of life [5].
Practical guidance for prayer and fasting
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14.6 Intimacy and relationships
Fear of rejection by a spouse is one of the deepest worries, and one that patients rarely raise. Ask gently, with the patient alone, and offer practical advice: emptying the pouch beforehand, using a small or opaque pouch or a cover, and choosing positions that avoid pressure on the stoma. Rectal surgery can affect the pelvic nerves, causing erectile or ejaculatory problems in men and pain or dryness in women; discuss this before surgery and offer referral if it occurs. Pregnancy is possible with a stoma, with specialist support.
STEP 2 Preparation, medicines, and recovery
14.7 Before the operation
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Stoma counseling and site marking by the stoma nurse, with the patient sitting, standing, and bending, and with their usual clothes and belt line in mind [4].
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Bowel preparation and antibiotics according to the unit protocol.
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Enhanced recovery as in Chapter 2: carbohydrate and fluid advice, early mobilization, and early feeding.
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Medicines. Blood thinners, diabetes medicines, and weight-loss injections need individual plans (Chapters 18, 22, and 23).
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Supplies. Make sure the patient knows how to obtain stoma supplies after discharge, including in other cities or when traveling.
14.8 After the operation
The stoma is swollen at first and shrinks over about six weeks, so the pouch size needs adjusting. An ileostomy produces liquid output, and high output can cause dehydration and kidney injury; teach patients to measure output, drink oral rehydration solution rather than only plain water, add salt, and seek help if output is high or they feel dizzy. Before discharge, the patient or a family member should be able to empty and change the pouch, and should know how to contact the stoma nurse.
14.9 Reversal and bowel function afterward
A temporary stoma is usually closed after the join has healed, often after a few months or after chemotherapy. Not every temporary stoma is reversed, because of complications, further treatment, or the patient’s health, and patients should know this [unit data]. After reversal of a stoma that protected a low rectal join, bowel function often changes, with urgency, frequency, clustering, or incontinence, known as low anterior resection syndrome. Major symptoms affect about 41 in 100 patients [6]. They often improve over the first one to two years, and treatments are available. Some patients with severe symptoms prefer to keep or return to a stoma.
Table 14.2. Typical recovery after bowel surgery with a stoma.
| Activity | Usually from | Notes |
|---|---|---|
| Walking | The first day | Walk several times a day |
| Showering | Day 2 | You can shower with or without the pouch on |
| Driving | About 3 to 4 weeks | When you can brake firmly without pain |
| Office work | About 4 to 6 weeks | Longer if chemotherapy follows |
| Lifting | Light from the start; heavy after about 3 months | A support belt may help reduce the risk of a hernia around the stoma |
| Swimming | After about 6 weeks | Modern pouches are waterproof |
| Prayer | From the first day | Empty the pouch and clean the area before ablution |
| Ramadan fasting | After recovery | Usually possible with a colostomy; take care with an ileostomy because of dehydration |
| Intimacy | When you feel ready | Empty the pouch first; a cover or smaller pouch may help |
STEP 3 Questions patients ask
“Will people be able to smell it?”
No. Modern pouches are sealed and have odor filters. You will notice a smell only when emptying or changing it, as with going to the toilet.
“Will my husband or wife still find me attractive?”
Most couples adjust well, especially when the partner is involved from the start. Many people find their partner is more accepting than they feared. If you would like, we can talk with both of you together.
“Can I still pray?”
Yes. Scholars agree that you can perform ablution and pray, and go to the mosque. Empty the pouch and clean around it before ablution, and perform ablution for each prayer time [5].
“Can I fast in Ramadan or go for Umrah or Hajj?”
Many people do. With a colostomy, fasting is usually possible once you have recovered. With an ileostomy, there is a risk of dehydration, so plan with us first. For pilgrimage, take plenty of supplies and plan for the heat [5].
“Can I wear normal clothes, swim, and exercise?”
Yes. Most people wear their usual clothes. Pouches are waterproof, and you can swim and exercise once recovered.
“Will I be able to work?”
Most people return to their usual work. If your work involves heavy lifting, we will discuss a support belt and a gradual return.
“I cannot look at it. Is something wrong with me?”
No. Many people feel this way at first. We will go at your pace, and most people find it gets easier within days or weeks.
“Should I tell people about it?”
That is your choice. Some people tell only close family; others are open. There is no right answer.
“Will my stoma definitely be reversed?”
We plan to reverse a temporary stoma, but not every one is closed, sometimes because of other treatment or health problems. We will review this with you.
“What will my bowels be like after reversal?”
After surgery low in the rectum, many people have frequent or urgent bowel movements at first. About 4 in 10 have major symptoms [6], which often improve over a year or two, and there are treatments.
“Can I have children?”
Yes. Pregnancy is possible with a stoma. Tell your team early so that we can support you.
STEP 4 Risks, warning signs, and consent
14.10 Material risks
Table 14.3. Material risks of colorectal surgery and stomas. Square brackets mark figures to replace with unit data.
| Band | Risk | Typical frequency | Example wording |
|---|---|---|---|
| Common | Depressive symptoms after stoma surgery | Almost half of patients [1] | “Many people feel low after a stoma. Please tell us, because help is available.” |
| Common | Sore skin around the stoma; pouch leaks | [unit data] | “Sore skin is the most common stoma problem. The nurse can usually fix it quickly.” |
| Common | Change in bowel function after reversal of a low join | Major symptoms in about 41 in 100 [6] | “About 4 in 10 have major bowel symptoms after reversal, often improving with time.” |
| Less common | Leak from the bowel join | [unit data] | “Rarely, the join leaks and needs a drain or another operation.” |
| Less common | High output and dehydration with an ileostomy | [unit data] | “If the output is very high, you can become dry and need fluids.” |
| Less common | Hernia around the stoma, prolapse, or narrowing | [unit data] | “A bulge can develop around the stoma over time.” |
| Less common | Temporary stoma not reversed | [unit data] | “Not every temporary stoma is closed.” |
| Rare but serious | Poor blood supply to the stoma; bleeding; blood clots; death | [unit data] | “Rarely, the stoma loses its blood supply and needs urgent surgery.” |
14.11 Consent checklist
Before the patient signs ☐ Operation explained, including whether a stoma is planned, possible, temporary, or permanent. ☐ Stoma nurse counseling and site marking done; peer visitor offered. ☐ Psychological effects discussed openly, with permission to talk about feelings. ☐ Faith concerns asked about and addressed: prayer, ablution, fasting, and pilgrimage. ☐ Intimacy and possible nerve effects discussed privately. ☐ Risks from Table 14.3 explained, including leak, dehydration, reversal, and bowel function afterward. ☐ Family involvement agreed according to the patient’s wishes. ☐ Who will perform the operation, including trainee involvement under supervision. ☐ Teach-back done; patient guide and stoma supplies plan given. |
14.12 Warning signs
Table 14.4. Green, amber, and red warning signs after bowel surgery and with a stoma.
| Level | Signs after bowel surgery or with a stoma | What to do |
|---|---|---|
| Green | A swollen stoma in the first weeks, shrinking gradually Small spots of blood when cleaning the stoma Feeling emotional or tearful in the first weeks | Expected. Follow the guide and talk to your stoma nurse. |
| Amber | Sore, red, or broken skin around the stoma, or frequent leaks Ileostomy output above about 1.5 liters a day, or very watery A bulge around the stoma Feeling low most days, or avoiding people | Call the stoma nurse or clinic the same day. |
| Red | A stoma that turns dark red, purple, or black No output for 24 hours with pain, bloating, or vomiting Dizziness, little urine, or confusion with high output Fever with increasing tummy pain Thoughts of harming yourself | Go to the emergency department now, or call for urgent help. |
Key points
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STEP 5 Patient education guide
The following pages may be photocopied and given to patients. Tick the type of stoma, and add your unit’s name, the stoma nurse’s phone number, and the review date before use.
PATIENT GUIDE Living with Your Stoma For you and your family. Your stoma nurse will go through it with you. |
Your stoma
☐ Ileostomy (small bowel)
☐ Colostomy (large bowel)
☐ Temporary: we plan to close it in about ______ months
☐ Permanent
Your feelings are normal
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Many people feel shocked, sad, angry, or embarrassed at first. This usually gets easier with time.
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Take your time to look at and touch your stoma. Your nurse will help you.
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Talk to someone you trust: your spouse, a family member, your nurse, or someone who has a stoma.
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If you feel low most days, lose interest in things, or avoid people, tell us. Help is available.
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If you have thoughts of harming yourself, get help the same day.
1. Looking after your stoma
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Empty the pouch when it is one-third to half full.
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Change it as your nurse showed you. Measure the stoma for the first weeks, because it shrinks.
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Clean the skin with warm water and dry it well. Do not use soap or cream unless your nurse advises.
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Order supplies before you run out. Supplier: ______________________
2. Food and drink
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Eat small, regular meals and chew well.
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Ileostomy: drink at least 1.5 to 2 liters a day, including oral rehydration drinks, and add a little salt to food. Measure your output if asked.
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Some foods cause gas or odor, such as onions, eggs, and fizzy drinks. Try foods one at a time.
3. Prayer, fasting, and pilgrimage
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You can perform ablution and pray, and go to the mosque.
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Empty the pouch and clean around it before ablution. Keep clean prayer clothes ready.
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Ask us before fasting, especially with an ileostomy.
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For Umrah or Hajj, take extra supplies in your hand luggage and drink plenty.
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You can talk to an imam or religious adviser if you wish.
4. Clothes, intimacy, and daily life
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Most people wear their usual clothes.
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Before intimacy, empty the pouch. A cover or smaller pouch may help you feel more confident.
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You can shower, swim, exercise, and travel once recovered.
5. Getting back to normal
| Activity | Usually from |
|---|---|
| Walking | The first day. Walk more each day. |
| Driving | About 3 to 4 weeks |
| Office work | About 4 to 6 weeks |
| Heavy lifting | After about 3 months. Ask about a support belt. |
| Swimming | After about 6 weeks |
| Prayer | From the first day |
6. Follow-up
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Your stoma nurse appointment: ______________________
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Your surgeon appointment: ______________________
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Support group or stoma visitor: ______________________
7. Warning signs: when to get help
| Level | What you notice | What to do |
|---|---|---|
| GREEN | Swollen stoma in the first weeks; small spots of blood when cleaning; feeling emotional | This is normal. Talk to your stoma nurse. |
| AMBER | Sore or broken skin; frequent leaks; very watery or high output; a bulge around the stoma; feeling low most days | Call your stoma nurse today. |
| RED | Stoma turns dark, purple, or black; no output for 24 hours with pain or vomiting; dizzy with little urine; fever with tummy pain; thoughts of harming yourself | Go to the emergency department now, or call for urgent help. |
My contacts Stoma nurse: ______________________ Hours: ______________ Out of hours: ______________________ My questions: ____________________________________________________________ [Unit name] [Guide version and review date] |
References
1. Kovoor JG, Jacobsen JHW, Stretton B, et al. Depression after stoma surgery: a systematic review and meta-analysis. BMC Psychiatry. 2023;23:352.
2. Hall J, Hardiman K, Lee S, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis. Dis Colon Rectum. 2020;63(6):728-747.
3. Gustafsson UO, Rockall TA, Wexner S, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations 2025. Surgery. 2025;184:109397. doi:10.1016/j.surg.2025.109397
4. Hendren S, Hammond K, Glasgow SC, et al. Clinical practice guidelines for ostomy surgery. Dis Colon Rectum. 2015;58(4):375-387.
5. Iqbal F, Kujan O, Bowley DM, Keighley MRB, Vaizey CJ. Quality of life after ostomy surgery in Muslim patients: a systematic review of the literature and suggestions for clinical practice. J Wound Ostomy Continence Nurs. 2016;43(4):385-391.
6. Croese AD, Lonie JM, Trollope AF, Vangaveti VN, Ho YH. A meta-analysis of the prevalence of low anterior resection syndrome and systematic review of risk factors. Int J Surg. 2018;56:234-241.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.