In theatre, an appropriately sized transparent drainable appliance should be applied. This should be left on for approximately 2 days. For the first 48 hours post‐operatively, the stoma should be observed for signs of ischaemia or necrosis, and stoma colour (a pink and healthy appearance indicates a good blood supply), size and output should be noted, as should the presence of any devices, such as ureteric stents or a bridge with a loop stoma (Boyles and Hunt [33]).

Table 6.13 recommends the most appropriate bag type to use on each type of stoma and the expected output. The drainable appliance should always be emptied frequently and gas should be filtered out of the pouch via the filter; however, if gas builds up, allow it to be emptied from the pouch to prevent ballooning. The appliance should not be allowed to get more than half full with effluent. If the appliance becomes too full, leaks may occur and the weight from the effluent or the pressure from gas may cause the appliance to fall off. A leak‐proof, odour‐resistant, well‐fitted appliance does much to promote patient confidence at this time (Black [28]). The first time a bowel stoma acts, the type, appearance, quantity and consistency of the matter passed should be recorded; this includes any flatus that may be passed (Black [24]).

Immediately post‐operatively, patients should not be expected to perform their own stoma care. However, if appropriate, teaching begun pre‐operatively can be put into practice within the first 24–48 hours following surgery. During appliance changes, observations should be made of the following:

Any abnormalities should be reported to the stoma care nurse and medical staff (Black [25]). Viewing the stoma may be difficult for the patient, who may be very aware of other people's reactions to it. The patient's reaction to their stoma should be observed and recorded.

Stoma formation creates many issues for patients and many struggle with body image. Studies suggest that this is often overlooked (Wallace [240]). The circumstances in which the stoma is formed will influence psychological recovery (Di Gesaro [67]). Communication is key and it is important to allow the patient and their family to discuss their concerns and anxieties. Therefore, stoma care nurses play a vital role in supporting the patient and their family. It is important to promote patient independence and acceptance.

Initially, all patients will start with sips of water, then move on to free fluids, and then to a light diet. In the absence of nausea and vomiting, they can proceed with building up their dietary intake. Colostomists and urostomists should be encouraged to eat a wide variety of foods and drink 1.5–2 L of fluids each day. People's digestive systems react in individual ways to different foods and so it is important that patients try a wide range of foods on several occasions and that none should be specifically avoided (Burch [40]). Patients can then make decisions about different foods based on their own experiences. Explanations should be given of how the gut functions, how it has been changed since surgery and the effects certain foodstuffs may cause.

However, patients with an ileostomy should use caution with foods that will increase output as these may cause a high‐output stoma. A person with an ileostomy should also be aware of what to do if the output is watery for longer than 24 hours (Goodey and Colman [90]). The normal output from an ileostomy should be toothpaste‐like or porridge‐like in consistency and the patient should empty the pouch approximately six to eight times a day (approximately 600–800 mL in 24 hours) (Cronin [56]). If the patient has watery stool for over 12 hours, they should consider increasing the amount of starch in their diet, such as white bread, white pasta, white rice, noodles and potatoes. They should avoid fibre, and in particular they should reduce their intake of fruit (including fruit juice) and green leafy vegetables. In addition, they can stagger eating and drinking so that they are not doing both at the same time, spacing them at least half an hour apart (Goodey and Colman [90]).

The patient should have been prescribed some medication to reduce diarrhoea, such as loperamide. They should take this in accordance with instructions from their prescriber. Loperamide needs to be taken half an hour before each meal to slow the bowel down (Goodey and Colman [90]).

If a person with an ileostomy has had a watery output for more than 24 hours or consistently has a watery output, they should contact their stoma care nurse or doctor. They must be aware of the symptoms of dehydration, such as headaches, dizziness, thirst, reduced and darker‐coloured urine, cramps and tingling in the hands (Goodey and Colman [90]). Patients may be at risk of acute kidney injury if the dehydration continues. In particular, their electrolytes (sodium, potassium and magnesium) are likely to be outside normal parameters.

An ileostomy patient can help to rehydrate themselves by making up a rehydration solution (Box 6.5) and drink a litre of this during the course of 24 hours. They should reduce their intake of tea and coffee and not take any fizzy drinks (Goodey and Colman [90]).

Patients with colostomy or ileostomy formation do not have the same control as with an anal sphincter, so passage of wind cannot be controlled. High‐fibre foods such as beans and pulses produce wind as they are broken down in the gut; hence, individuals who eat large quantities of these foodstuffs may be troubled by wind. There are several non‐food causes of wind, such as chewing gum, eating irregularly and drinking fizzy drinks, and these should be considered before blaming a particular food. Eating yoghurt or drinking buttermilk may help to reduce wind for these patients. Green vegetables, pulses and spicy food are examples of foods that may cause colostomy and ileostomy output to increase or become watery. Boiled rice, smooth peanut butter, apple sauce and bananas are some of the foods that may help to thicken stoma output (Black [23], Burch [40]).

Some foods, for example tomato skin and pips, may be seen unaltered in the output from an ileostomy. Celery, dried fruit, nuts, fibrous fruit (such as mango) and potato skins are some of the foods that can temporarily block ileostomies (Burch [40]). The blockage is usually related to the amount eaten and the offending food can be tried at another time in small quantities, ensuring it is chewed well and not eaten in a hurry.

There are no dietary restrictions with a urostomy, although bowel activity may be temporarily affected if a portion of the ileum has been used for the stoma. It must be stressed, however, that an adequate fluid intake must be maintained to minimize the risk of urinary tract infection due to a shortened urinary tract. The recommended fluid intake for all individuals is 1.5–2 L per day (Burch [40]). Fluid intake should be increased in hot weather and at times when there is an increase in sweating, for example with exercise or fever. Patients should be made aware of certain foods that may cause a change to the usual character of the urine. For example, beetroot, radishes, spinach and some food dyes may discolour urine; some drugs may also have this effect, for example metronidazole and nitrofurantoin. Similarly, following consumption of asparagus or fish, urine may develop a strong odour.

This is a common fear for patients with bowel stomas, often based on hearsay or experience with other ostomates in hospital or the community. Appliances are odour free when fitted correctly. Flatus may be released via charcoal filters, and deodorizers are available. The individual must be reassured, however, that any problems that occur post‐operatively will be investigated, with a good possibility of their being solved by such means as the use of alternative appliances (Black [29]).

The possibility of sexual impairment for both men and women after stoma surgery depends on the nature of the operation and the ensuing damage to the nerves and tissues involved. The psychological impact of the surgery and its effect on the individual's body image must also be taken into consideration. Surgery that results in physical sexual disability will have psychological repercussions, while some sexual difficulties may be of psychological origin (Humphreys [104], Reese et al. [209], Williams [251]). Impairment may be permanent or temporary. In the latter case, resolution of the difficulty may take anywhere up to 2 years. Pre‐ and post‐operative counselling should be offered for both patient and partner.

All patients may experience loss of libido and sexual desire. Females having cystectomy for cancer will in most cases require anterior exenteration and vaginal reconstruction. This includes removal of the urethra and a vaginal reconstruction, which affects both vaginal length and blood supply to the vagina and clitoris. Consequent sexual dysfunction occurs and patients must be counselled accordingly in the pre‐operative period (Zippe et al. [261]). In males, ejaculatory disturbances occur following cystectomy so men facing this surgery should be offered sperm banking prior to surgery. Erectile dysfunction is a common complication of all pelvic surgery and there are a number of treatment options available. These include oral medications, such as phosphodiesterase type 5 inhibitors (PD5 inhibitors), sublingual apomorphine, intraurethral and intracavernosal injections, vacuum devices and penile implants (Broholm et al. [37], Geng et al. [85], NHSBSA [167], Park et al. [187]). Patients with persistent erectile dysfunction should be referred for penile rehabilitation.

Female sexual dysfunction after colorectal and pelvic surgery is common (Bregendahl et al. [35], Burch [42]). Typically, a loss of libido and satisfaction occurs. Female patients may experience dyspareunia; this may be due to narrowing or shortening of the vagina, a reduction in the volume of vaginal secretions or changes in genital sensations (Reese et al. [209]). The use of a lubricant, adopting different positions during penetrative intercourse or encouraging greater relaxation by extending foreplay may help to resolve painful intercourse (Humphreys [104]).

All NHS patients with a permanent stoma or cancer are entitled to free prescriptions for their stoma care products, and should complete the relevant forms for exemption from payment. Appliances can then be obtained from the local chemist or free home delivery services.