Wafer fit around stoma - snug or loose?

Hi there. I seem to be having a terrible time getting the right fit around my stoma. Twice now when I have cut the wafer thinking it was perfect, my home health nurse has said it was too snug and cut it larger. The problem I have with this is that I then see stool pooling around my stoma and it seems to be too large of a gap. I am currently fighting a problem with skin breakdown around my stoma. Here's my question - how snug of a fit should the wafer be? Home health nurse said to me if it's too snug, I could harm the stoma. Is this true? It seems like I'm doing more harm by having it too loose. She did apply some paste this time around, so I'm hoping it helps some, but again I see the stool just sitting around the gap between the wafer and my stoma. Any advice is appreciated!!

Is your stoma of an irregular size or oval? I only used cut-to-fit wafers for a few months while recovering from surgery. Once the swelling had gone down and my stoma was its finished size, I then used pre-cut. I found that the cut-to-fit barriers didn't last me half as long. The reason why nurses will tell you to not cut it too tight of a fit is one, to allow your stoma to expand when passing food, and two, cut-to-fit barriers can leave sharp edges that can cut your stoma and cause bleeding - which is very hard to get to stop. I have to pay for my supplies 100% out of pocket, so I need to get as much wear-time out of them as I can. So I'm thankful I average 7 days on a barrier. So I order mine a really snug fit to get that great wear time and not have any skin around the stoma, which as you know gets very red and irritated from the high acidic nature of our output. One possible alternative is to cut them a little larger as your WOC nurse says, and use a moldable ring or barrier on your skin that fits snug around your stoma (Eakin seals are a popular one) and place the ostomy flange on over the top.

I'm told my stoma is a "lovely oval". It is definitely still shrinking. I started out at 1-1/2" and now am at 1-1/8" even though when I use the template I measure 1" exactly. But this is where the nurse says I need to go a little bigger. I have heard a lot of people talk about the Eakin seals so perhaps I should look into that. My skin is definitely having a hard time right now and looks bad around the stoma (raw, raw, raw). She did apply a paste so I hope it helps some. I did receive a free sample of the moldable ring so I guess I could also ask to try that. She suggested I start changing my appliance every other day right now while my skin is so bad. Dreading this. I look forward to the day when I can order the pre-cut wafers. Thanks so much for the input. I am so lost in this whole process and struggling to come to terms with it.

It is a lot of practice.
You should have a size guide with your stoma products. Get a rough measurement, maybe a few millimeters bigger, and use the paste around the wafer. That seemed to work for me.
Keep the template and you should be ok.

I was told the same thing and I suddenly decided this is crazy - if the skin is breaking down because the digestive acids, whatever, are eating the skin, then it is time to rethink the size -- so I did one not a smidgeon bigger than the stoma - the skin was immediately better but it took a couple times to be 100%. I absolutely do not let the bag stay over 3 days and if anything feels itchy, it means the skin is being compromised so get it off as soon as you can - obviously if you are at work or wherever you can wait awhile, but I learned that was an immediate clue. I am wishing you the best of luck. Also, the stoma will change over time - I am nearly 7 months out with FAP and have had 3 size changes already - smaller as it "heals". The stoma does not "hurt" as there are no pain cells there, but all the tissue sure is sensitive to pain.

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Thanks, guys, for the feedback. My appliance was changed yesterday, and already my skin is itching under the wafer. I have my first post-op appointment tomorrow and will see my ostomy nurse from the hospital at this appointment. I am anxious for her to see how my wafer cutout looks and get her input. I almost wanted to change the bag today but really wanted to know if the hole for my stoma has been cut too big so I can say something to my home health nurse who keeps insisting on cutting it bigger than the measurement. Hopefully, I return home tomorrow better informed and better instructed on cutting the wafer so I can get my poor skin to heal. It's upsetting that I'm only 3 weeks into this, and my skin looks as bad as it does around the stoma. Sigh.

Hi there,

Sounds like you must have an ileostomy? I always instruct my patients to cut the wafer approximately 1/8" larger than their stoma. This allows for it to expand and contract, as well as prevents the moisture from the stoma itself from wearing away the wafer. The caveat is though that if you have an ileostomy, it's very important to cover that exposed skin with a paste product, like others have said either paste ring or tube paste.

You didn't mention what you were using for your irritated skin, but prior to applying the wafer, you could dust ostomy powder. It will stick to the wet irritated skin. Then coat over top that with a NON-STING barrier wipe or spray. Depending on the severity of the irritation, I do anywhere from 1-3 layers. Then put your wafer/paste on. This will coat the skin so it can heal. But your nurse is probably right that changing more frequently will be better because the powder/wipe mixture will cause the wafer to not last as long.

Best of luck in your journey!
Ashley

I think I'm correct in thinking any stoma output will damage bare skin.  If we cut the wafer 1/8" larger than the stoma, that 1/8" of bare skin will get damaged unless it's protected by some other means.  Stomahesive paste might be OK but, for me, Eaken seals work better.  That's after a skin prep like Cavilon barrier wipes or spray or Smith & Nephews protective spray.  There CANNOT be any unprotected skin next to the stoma.  That's my thought.  If I'm wrong I apologize and thanks in advance for the education.

Respectfully,

Mike

Hi Mike,

The amount of damage ostomy output creates really depends on how enzymatic the drainage is. Typically, the higher up the bowel the ostomy is made, the more enzymes will be in the output. And more enzymes equal more damage. For instance, a sigmoid colostomy (down near the rectum) won't have the enzymes that a high ileostomy (made from the small bowel) has. The lower in the gut the stoma is made, the more "normal" the stool should be, and the less caustic to the skin (but there are always exceptions). So I think that is why Eakins work for some people and others are able to get away with just paste. Good thoughts! And I personally love the Cavilon wipes. Another one that I've found interesting is the Marathon skin protectant (I think Medline makes it). I just tested some on my hand and it stayed on for like 3 days! And that was through washing frequently, of course.

Ashley

Have you tried putting an Adapt ring snugly around your stoma before putting the wafer on? I put it on and then press it up against the stoma, down against my skin, put the wafer on, press more around the stoma to be sure the ring stays snug, and that should take care of any gaps. Then I put my hands over the wafer for about 5 minutes to help the adhesive firmly attach to my skin. Hope this helps.

Hi,
I highly recommend the ConvaTec Moldable Technology 2-piece system available in flat or convex. I was having all the same problems that you have described. I heard about this system and ordered a trial packet directly from the company. I tried it out for 2 weeks and had virtually no problems with skin rashes, blow-outs, pancaking, leaks, and odors. It was easy because there was no cutting or guesswork, and it molds to your skin for a custom fit. You don't have to worry about adding any other skin barriers such as the Adapt rings because it is built into the system.
You have to see it to believe it and really understand what I am talking about. If you are ready for better, call ConvaTec and order a sample packet. YOU WILL NOT REGRET IT!!

Hey Ashley, I think we all learned something from your offering.  Thank you.  Also, like Suesong, I use the Convatec Moldable 2- piece stuff with Cavillon wipes.  If I didn't have that flexibility near the soma I would worry about the stoma getting squeezed.  Sometimes I use an Eaken seal but that's probably an overkill.

I think we'll all find what's best from sharing our thoughts and experiences.

Sincerely,

Mike

Tudibird,

I'm enclosing an info sheet I give to all the new ostomates I visit in hospitals.

Please pay close attention to the "1/8 inch leeway" mentioned.

If you have the opening too close to the wafer, there is a chance the wafer could cut your
stoma. On the other hand, too large of a hole leaves your stoma prone to leakage. An 1/8
inch around the stoma is recommended by most manufacturers.

Here's that info sheet I give out:

Steps For Changing Your Pouch

Wash your hands well and have all equipment available.

***Gently*** remove the pouch. ***Push the skin away from the seal.***
***Do not pull the ostomy wafer away from your skin.***

Wash your stoma and the skin around it carefully with soapy water.
* Do not use a soap that has perfume or lotion added to it.
* Use mild soap, such as Ivory, Safeguard, or Dial.

Look carefully at your stoma and the skin around it for any changes.
***Allow your stoma area to dry completely***
before connecting the new pouch.

Trace the shape of your stoma onto the back of the new pouch and
barrier or wafer (wafers are part of a 2-piece pouch system).

* Use a stoma guide with different sizes and shapes, if you have one.
Or, draw the shape of your stoma on a piece of paper. You may want to cut
out your drawing and hold it up to your stoma to make sure it is the right
size and shape. The edges of the opening should be close to the stoma,
but they should not touch the stoma itself.

*** (Leave 1/8" leeway).***

Trace this shape onto the back of your new pouch or wafer. Then cut the
wafer to the shape.

* The skin around your stoma should be completely dry and smooth.
There should be no wrinkles in the skin around the stoma.
(I use a hair dryer, on low setting, to completely dry)

Remove the backing from the pouch. Make sure the opening of the new
pouch is centered over the stoma and pressed firmly onto your skin.

* Hold your hand over the pouch and barrier for about 30 seconds after
you have placed it. This will help seal it better. Warming the skin also helps.
(Again, I use a hair dryer on low setting)

I hope this helps!

I have had similar problems and yes, any exposed skin around the stoma can cause problems. My ostomy nurse said if I can thicken my output, this will also be a big help to the watery acid output penetrating around the stoma. I cut mine very close to the stoma, and I purchased a piece of PVC plastic cap from the hardware store that fits inside the wafer, and I use this to apply pressure when installing the wafer. It is difficult to get your fingers close enough to the stoma while pressing down the wafer. Good luck, I know it can be frustrating. Rod

Hey Rod,

That's a good idea. Here's a cheaper one... The ladies in my support group use the plastic top of a "hair spray" can. I tried it with the top of my shaving cream can and it works perfectly!

The PVC caps are less than $2.00 at any hardware store. The hairspray cap is a good one too, but the PVC cap will catch any output while you are pressing the wafer on. The cap is open on the bottom and closed on top. I am very excited as I just finished my prototype for a stoma flow-guard that will help with seat belt pressure, pant/belt waistline pressure. This device allows continuous flow into the pouch. I tried a few that are on the market, but they did not work very well. Rod

Hi, obtain some adhesive washers from your supplier, lay the bag cut to size on a flat surface, peel the protective plastic nearly off, fold underneath the bag, take the washer out of its protection, stretch it to approximately the size, place it on the bag adhesive, shiny side down, fold the plastic backing back over the bag/washer making sure all the glue is covered. Put it on the floor, cover it with a plastic disposal bag, and stand on it 4/5 times. Place it under the arm to keep warm until needed, spray on skin protector when dry, put a finger in the hole and mold the washer to the bag hole, spin the finger around the hole where the stoma will enter to make sure it is smooth, remove the plastic backing and fit it to the stoma, press the washer from the outside so it molds and fills in the gap between the stoma and the bag, still keeping warm with a flat hand until done.

Best of luck...Les.

Hi ostomyvisitor, kudos to you for your volunteering.  Now, I need to pursue the 1/8" thing.  With all due respect to you and Ashley, the bare skin surrounding the stoma is subject to damage.  Since you (OV) are not differentiating between illeostomies and colostomies and maybe even urostomies, I need to wonder about the enzyme levels relative to damage.  Suesong and I do the same thing and it works for us.  

I'm sticking with NO UNPROTECTED SKIN anywhere near the stoma regardless of where the stoma is.

Now Penguin, I'm with you on the PVC stuff except my stoma is a little too long for a cap.  Instead I use a 1/2" and 3/4" PVC coupling.  Their inside diameters are about 15/16"" and 1-1/8" respectively.  I slide the smaller one over the stoma and apply a slight pressure for about a minute.  Sometimes, I slide the larger one over and hold it for about a half minute.  I don't know why.  I guess it's just to better seal more of the wafer to my skin.  I never had a leak and don't ever want one.  BTW I heat my wafer with a hair dryer before applying it.

And Penguin, we're both from New Jersey but I'm older so I must be right.

Respectfully,

Mike

Thank you everyone for the helpful tips. I had my two-week follow-up today at Hopkins and my ostomy nurse stopped in to check on me. She did measure my stoma at 1" with a small amount of room to spare, so she said the wafer I had on was too big. She was not happy with how my skin looked and also said one of my problems is that my stoma is sinking in some, so she switched me to a convex 2-piece system with a 1" stoma opening. She said this should help me considerably. I hope she is right.

Hi Tudibird,
I am assuming you are in the USA? Here in the UK, the company I get my supplies from cuts the hole to my stoma. I have it slightly larger than the stump but not too much. Around the ileostomy stump, I have a special aloe vera powder which I first put on and then just take the excess with a tissue. I then spray Cavelon onto the powder. Coloplast makes extension strips for the outside of the bag, but I cut one in half and then apply this to the raw site where I have just put the powder on. Then I use a Cavelon stick all around my skin where my bag will go and then make sure the stump is in the middle when applying. One secret is to make sure that you have a small amount of air in the bag when you close it or it will suck itself to the stoma, and that is when you get pancaking and leakage. I then fit 2 extension strips on the edge of the bag and heyho! I have not had a leak for a long time, the skin around the stoma is a little raw but not sore. I work in the operating theatre as an assistant to the colorectal surgeons, and this was such a nightmare as I would always leak during surgery and I had to leave the operation and could not finish suturing the patient and had to leave this to the surgeon. They were very understanding as they had done the surgery for me, but it has really been trial and error with the bag and now I am happy. I am very lucky as in the UK all the products including disposable bags, wet and dry wipes, etc., are all free, and I have been able to try various products until I got it right, but try and leave some air in the bag on closure.
Good luck, and I know how you feel, but things will be alright in the end.

Regards
Stomafart

Mike, I am from Michigan but since you are older then I will give you the wiser part. Penguin

That's a great tip about the PVC cap! I've got to check that out the next time I'm at the hardware store!

We'd love to hear more about your stoma flow-guard. New products are always exciting.

Sorry, Penguin.  Obviously, my "wisdom" took a detour.  Thanks for the free pass.  Special thanks for sharing your research.



Mike

Follow-up to my post about switching to a convex wafer. Wow, what a difference 2 days made. A home health nurse came today to replace the appliance. My skin has already improved by 50%. I was amazed and so happy. My stoma, however, is taking on an entirely new shape, and one side has sunk considerably (almost down to my belly level), and this is where my opening is, so I don't know how things will play out. But for now, I'm very happy my skin is healing with the convex wafer. To Stomafart, I must say I love the username, and lucky you to have free supplies to try. It's definitely been trial and error with me. The fold and lock bags seem to give me a heck of a time getting the opening open, even though it says just squeeze the sides. I must be clumsy because half the time I can't get the dang thing to open. To all others, I love all the feedback. So many good ideas. This site has been so helpful to me as I begin my journey with an ileostomy. I'm now 3 weeks post-op and coming to terms better with all of this.

Hi Tudibird,

It sounds like your stoma and mine could be twins. I had a heck of a time learning to cut the wafer correctly to fit over my oval stoma. I use the Coloplast Assura 2-piece system, and having tried many different products, I find this to be the one which works best for me. I do have to get a little creative sometimes with the stencil for the wafer. I place one guide over the upper part and mark either side where the stoma starts to go oval. I tape this to my body and then I use another guide and place it on the stoma at the bottom, then tape it to the other guide. When I remove it, I have an oval guide which I use to cut the wafer. I save the plastic backing so that I don't have to go through all of that again until my stoma decides to change shape slightly. I always cut it as close to my stoma as possible without causing pain. You can smooth any rough edges just by rubbing or cutting them away. I use skin barrier wipes, and that's all unless I start having problems, then I might layer on the spray or the Nystop powder if my skin gets irritated. Also, I've suggested this in the past to another ostomate on this site, but if you are having problems with stinging or irritation under the wafer, when removing, I use the wax removing oil that I find at Sally's in the waxing/hair removal section. It works great and doesn't sting and is good for your skin. You just have to be sure to rinse all of it off before applying your wafer or it won't stick. Remember, it takes a while for your stoma to finally find its true shape, and even then it can decide to change on you. Lol! You just gotta roll with it. Good luck, and I hope this helps.

There is an ostomy company that has oval stencils to use when measuring your stoma.
It's called Nu-Hope Laboratories in California. Their website is:
www.nu-hope.com

**** Or you can call 1-800-899-5017

Incidentally, there should be a 1/8 inch leeway around your wafer.
Don't cut the wafer/flange too close, leave a one-inch leeway.

It seems you have excoriated skin from feces laying on it... Here are directions for changing one's pouch

Steps For Changing Your Pouch
Wash your hands well and have all equipment available.

***Gently*** remove the pouch. ***Push the skin away from the seal.*** ;
***Do not pull the ostomy wafer away from your skin.***

Wash your stoma and the skin around it carefully with soapy water.
* Do not use a soap that has perfume or lotion added to it.
* Use mild soap, such as Ivory, Safeguard, or Dial.
Look carefully at your stoma and the skin around it for any changes. ***Allow your stoma area to dry completely*** before connecting the new pouch.

Trace the shape of your stoma onto the back of the new pouch and barrier or wafer (wafers are part of a 2-piece pouch system).

* Use a stoma guide with different sizes and shapes, if you have one. Or, draw the shape of your stoma on a piece of paper. You may want to cut out your drawing and hold it up to your stoma to make sure it is the right size and shape. The edges of the opening should be close to the stoma, but they should not touch the stoma itself. *** (Leave 1/8" leeway).***

Trace this shape onto the back of your new pouch or wafer. Then cut the wafer to the shape.

* The skin around your stoma should be completely dry and smooth. There should be no wrinkles in the skin around the stoma. (I use a hairdryer, on low setting, to completely dry)

Remove the backing from the pouch. Make sure the opening of the new pouch is centered over the stoma and pressed firmly onto your skin.

* Hold your hand over the pouch and barrier for about 30 seconds after you have placed it. This will help seal it better. Warming the skin also helps. (Again, use a hairdryer on low setting).

CARING FOR EXCORIATED SKIN
If after removing your wafer you find your skin to be red, denuded of skin, painful or sensitive, you have Excoriated Skin.

Excoriated skin is often caused by pulling at your wafer too vigorously, along with moisture under the wafer. Use the 'Push Pull' method below.

When removing your wafer, use a non-alcohol adhesive remover. Simply hold down your skin with the adhesive remover pad and going from side to side, gently pull your wafer down and away from your skin.

After gently washing the stoma and surrounding skin with warm water, dry the skin thoroughly. Sprinkle the skin with stomahesive powder, dust off the excess and seal the powder in with a non-alcohol containing skin prep, i.e. Cavilon spray.

Wipe the skin with the skin prep until you can't see any more powder. Then instead of placing your wafer squarely on your skin, put it on a diamond shape. The next wafer change put it on your skin squarely [ ] and rotate every other change.

This gives at least part of your excoriated skin a good chance to heal. Remember, be gentle with your skin and it will be good to you!

A quick fix (as long as it's not fungal in origin) is to get some Maalox (not the mint kind!). Don't shake the bottle, skim the watery bit off the top and dab the thicker mixture onto your irritated skin. Wait for it to dry and put your wafer on over the top (it will still stick!). It helps soothe and heal the sore irritated skin.
(If you have trouble locating Maalox, it may have been discontinued, use the generic brand).

I hope this helps

Copyright 2007 Larry Pilarski All rights reserved

To bmeup - I just received some samples from Coloplast and I spoke to a rep about applying the wafer and can't remember if she said to heat it up before applying or not. Do you heat yours up and how do you do it? Thanks.

You can use a hair dryer set on low to warm the wafer up... Slowly go around the wafer. You can also warm the skin around your stoma this way... BUT be sure to have the hair dryer on low.

Another way if no hair dryer is present... After centering and placing the wafer over the stoma, just hold your hand over the wafer and apply gentle pressure for about a minute ~~ the heat from your hand will also bring heat through the wafer to the skin.

I chose the hair dryer because I can aim where I want the heat.

One more thing, if you have gained or lost weight you may have some "Nooks Crannies" (little crevices in/on your skin). If you have this problem it is best to use a wafer that is very thin. The pliability of this type of wafer will work itself into crevices -- I use wafers that seem like a band-aid (That's how thin they are).

Most of the people in my support group use this type of wafer when running into leakage problems.

I hope this helps. . .

Good Luck,

Lawrence (Larry) Pilarski
The Ostomy Visitor

Don't feel too bad as I have the same problem and it has been four years and I still don't get it right. My biggest problem is I can't touch the stoma as it makes me sick and I start gagging, so I have to judge. I get it okay most of the time now. My other problem is the colostomy was misplaced and I can't see it without holding a hand mirror close. Do you have any ill feeling touching the stoma? Well, keep at it. You will get it right most of the time. Joyce

Hi VO, The PVC caps work great for applying pressure, plus the cap catches any output so it doesn't get around the stoma and ruin the new wafer before it is properly adhered. I got my first prototype for the stoma flow guard and it works great. I drive a lot for my job and it really keeps seat belt pressure off the stoma. Plus, it allows flow into the pouch from restricting waistbands and belts. I tried a few products on the market and did not like the results. Take care. Penguin