How should I manage a 74‑year‑old man with a longstanding ostomy that is not draining, continuously leaking, and causing peristomal pain, who requests evaluation by an ostomy specialist?

Management of Ostomy Dysfunction with Leakage and Peristomal Pain

This patient requires immediate referral to an enterostomal therapist (wound ostomy and continence nurse) or surgeon for comprehensive evaluation, as the combination of poor drainage, continuous leakage, and pain suggests structural complications that cannot be adequately managed with appliance adjustments alone. 1

Immediate Assessment Priorities

Before or concurrent with specialist referral, evaluate for life-threatening complications:

• Examine for incarcerated parastomal hernia, which presents as a painful, non-reducible bulge and constitutes a surgical emergency requiring immediate intervention to prevent bowel ischemia 1
• Assess for stomal obstruction or stricture, particularly if drainage is poor—this may manifest as decreased output, abdominal distension, or cramping 1
• Inspect the stoma itself for ischemia/necrosis (dark discoloration), retraction (stoma flush with or below skin level), or prolapse (excessive protrusion) 2, 3
• Evaluate peristomal skin for severe excoriation, fungal infection (itchy maculopapular rash with satellite borders), or signs of pyoderma gangrenosum 1, 4, 5

Why Specialist Referral is Essential

The patient's request is clinically appropriate because:

• Continuous leakage with pain indicates the problem extends beyond simple appliance fit issues and likely involves structural abnormalities requiring expert assessment 1
• Parastomal hernias occur in up to 50% of ostomates within 5 years and frequently cause pouching difficulties and pain requiring specialized management 1
• Stomal retraction or stenosis may be preventing adequate drainage and causing the leakage pattern described 2, 3
• Enterostomal therapists have specialized training in complex pouching techniques and can identify subtle structural problems that general practitioners may miss 5

Interim Management While Awaiting Specialist Evaluation

For Leakage Control:

• Optimize pouching technique by using convex appliances, ostomy belts, paste, or barrier rings to elevate the stoma off the peristomal skin 1
• Heat the appliance with a hair dryer before application and have the patient lie flat for several minutes after application to improve seal 1
• Ensure peristomal skin is completely dry before appliance placement, using a fine dusting of stomal powder followed by skin sealant if skin breakdown is present 1
• Cut the appliance opening one-eighth inch larger than the stoma to prevent mucosal irritation while limiting effluent contact with skin 1

For Effluent Management:

• Thicken stool output with antidiarrheal medications (loperamide or diphenoxylate) to facilitate more solid effluent and reduce leakage 1
• Assess for high ostomy output (>1000-2000 mL/day), which may indicate infection, obstruction, or other treatable causes requiring workup 1, 2

For Peristomal Skin Protection:

• Apply antifungal powder if fungal infection is suspected (itchy rash with satellite borders), seal with skin sealant, and reassess in 2 weeks 1, 4
• Use skin sealant or zinc oxide to create a protective barrier against further effluent damage 4, 5

Common Pitfalls to Avoid

• Do not delay specialist referral assuming this is simply an appliance fit problem—the combination of symptoms suggests structural pathology 1
• Do not miss an incarcerated hernia, which requires emergency surgical intervention and can progress to bowel ischemia 1
• Do not attribute all pain to skin irritation—pain may indicate hernia, obstruction, or stomal ischemia requiring urgent evaluation 1, 3
• Do not attempt to manage persistent leakage beyond 2 weeks without specialist input, as this leads to progressive skin damage, increased costs, and significant quality of life impairment 1

Expected Specialist Interventions

The enterostomal therapist or surgeon will:

• Perform detailed stomal and peristomal assessment to identify structural abnormalities (hernia, retraction, stenosis, prolapse) 1, 3
• Provide advanced pouching solutions including custom convex systems, specialized barrier products, and fitting techniques 1
• Determine if surgical revision is indicated for significant hernias causing obstruction, refractory retraction, or stenosis 1, 3
• Coordinate with medical equipment suppliers to ensure access to appropriate specialized products 1

The patient's self-advocacy in requesting specialist evaluation demonstrates appropriate recognition that his ostomy complications exceed routine management and warrant expert intervention to prevent further morbidity.