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Urostomy Complication – Stomal Infection

Overview

A stomal infection is an infection that develops at the site where a urostomy stoma (the surgically created opening for urine diversion) connects to the abdominal skin. The infection may involve the skin, sub‑cutaneous tissue, or deeper structures around the stoma. Stomal infections are among the most common early‑post‑operative complications of a urostomy, occurring in 5‑15 % of patients depending on the surgical technique, patient comorbidities, and postoperative care practices [1][2].

Urostomies are performed for a variety of urologic conditions—most frequently bladder cancer, neurogenic bladder, severe urinary incontinence, or traumatic injury. Anyone with a newly created urostomy or a long‑standing stoma can develop an infection, but certain populations are at higher risk (see “Causes and Risk Factors”). Prompt recognition and treatment are essential to prevent progression to cellulitis, abscess, or sepsis.

Symptoms

Stomal infection can present with a range of local and systemic signs. Look for any of the following:

• Redness (erythema) around the stoma – may spread outward in a halo pattern.
• Swelling or edema – the skin may feel warm and puffy.
• Pain or tenderness – especially when the stoma is touched or when changing the pouch.
• Purulent discharge – yellow, green or foul‑smelling fluid may ooze from the stoma or surrounding skin.
• Heat – the area feels hotter than the surrounding skin.
• Fever – temperature ≥ 38 °C (100.4 °F) suggests systemic involvement.
• Chills or rigors – often accompany fever.
• General malaise, fatigue or loss of appetite – indicate a broader inflammatory response.
• Changes in urine output or odor – infection can affect the urine that drains into the pouch.
• Skin breakdown or ulceration – the infection may erode skin, creating open sores.

Causes and Risk Factors

Primary Causes

• Bacterial contamination – skin flora (Staphylococcus aureus, Streptococcus spp.) or gut microbes (Enterobacteriaceae) can enter the incision during surgery or pouch changes.
• Moisture and maceration – prolonged contact of urine with the peristomal skin compromises the barrier, allowing bacteria to proliferate.
• Improper fitting of the ostomy appliance – gaps promote leakage and skin irritation.
• Trauma to the stoma – accidental pulling or crushing of the stoma during dressing changes.

Risk Factors

• Advanced age (> 65 years) – slower wound healing.
• Diabetes mellitus – impaired immune response and higher skin infection rates.
• Obesity – deeper skin folds increase moisture and make appliance sealing difficult.
• Smoking – vasoconstriction reduces tissue oxygenation.
• Immunosuppressive therapy (e.g., steroids, chemotherapy).
• Previous abdominal or pelvic radiation – damages skin integrity.
• Pre‑existing skin conditions (eczema, psoriasis) around the stoma site.
• Poor nutritional status (albumin < 3.5 g/dL) – hampers tissue repair.
• Inadequate postoperative education or lack of follow‑up with an ostomy nurse.

Diagnosis

Diagnosis is primarily clinical, supported by targeted investigations when needed.

Clinical Evaluation

• Inspection of the stoma and peristomal skin for erythema, edema, discharge.
• Palpation for warmth, tenderness, fluctuance (suggesting an abscess).
• Vital sign assessment – fever, heart rate, blood pressure.
• Review of recent pouch changes, hygiene practices, and systemic symptoms.

Laboratory & Imaging Tests

• Swab culture of any purulent drainage – guides antibiotic choice.
• Complete blood count (CBC) – leukocytosis (> 10,000 cells/µL) indicates infection.
• C‑reactive protein (CRP) or ESR – markers of inflammation.
• Blood cultures if systemic signs (fever, hypotension) suggest sepsis.
• Ultrasound or CT scan of the abdomen if an abscess, deep tissue infection, or fistula is suspected.

Treatment Options

Treatment aims to eradicate infection, protect the stoma, and prevent recurrence.

1. Antibiotic Therapy

• Empiric oral antibiotics – often a first‑generation cephalosporin (e.g., cephalexin) or clindamycin for suspected Staphylococcus aureus. If MRSA risk is high, doxycycline or trimethoprim‑sulfamethoxazole may be used.
• Intravenous antibiotics – indicated for severe cellulitis, abscess, or systemic infection. Options include cefazolin, vancomycin (for MRSA), or piperacillin‑tazobactam if polymicrobial infection is suspected.
• Duration – typically 7‑10 days for uncomplicated infections; longer if deep tissue involvement.

2. Wound Care & Local Management

• Gentle cleansing with saline or a mild antiseptic solution (e.g., chlorhexidine wipes) twice daily.
• Apply a sterile, non‑adhesive dressing (e.g., silicone barrier) after cleaning.
• Use an ostomy appliance with a skin‑protective barrier (ring, paste, or wafer) that fits snugly without excess pressure.
• For purulent drainage, consider a small “drain” or foam dressing to wick moisture away.

3. Surgical Intervention

• Incision and drainage (I&D) of an abscess—performed under local or general anesthesia.
• Debridement of necrotic tissue if there is extensive skin breakdown.
• Rarely, revision of the stoma may be required if the infection compromises the stoma itself.

4. Lifestyle & Supportive Measures

• Optimize blood glucose in diabetic patients.
• Encourage smoking cessation.
• Maintain adequate protein intake (1.2‑1.5 g/kg/day) to support healing.
• Schedule regular follow‑up with an ostomy nurse for appliance fitting and skin assessment.

Living with Urostomy Complication (Stomal Infection)

Daily Management Tips

• Inspect the stoma each day—look for redness, swelling, or discharge.
• Change the pouch promptly if it becomes loose or leaks; avoid prolonged moisture exposure.
• Use a **skin barrier** (powder‑free powder, silicone paste, or hydrocolloid) around the stoma before applying the pouch.
• Keep the area **clean and dry**; after washing, pat the skin gently with a soft towel.
• Wear **loose‑fitting clothing** to reduce friction.
• Carry a **spare pouch, barrier supplies, and a small bottle of saline** when you’re out.
• Document any changes in a **stoma diary** (date, symptoms, pouch changes, medication).
• Stay **hydrated** (2‑3 L/day) unless your physician advises otherwise; adequate urine flow helps keep the pouch from backing up.
• Practice **hand hygiene** before and after pouch manipulation—wash with soap for at least 20 seconds.

Prevention

Most stomal infections are preventable with proper technique and vigilant care.

• Pre‑operative skin preparation – chlorhexidine showers the night before and the morning of surgery.
• Prophylactic antibiotics – a single dose of a first‑generation cephalosporin is standard for urostomy creation [3].
• Early postoperative education – instruction by an accredited ostomy nurse within 24‑48 hours of surgery.
• Proper appliance selection – choose a pouch system that matches stoma size and output volume.
• Barrier skin products – apply before each pouch change to protect against urine‑related maceration.
• Regular follow‑up – at least one visit with an ostomy specialist within the first month, then every 3‑6 months.
• Maintain good nutrition and glucose control – reduces infection risk.
• Smoking cessation programs – improve wound healing.

Complications

If a stomal infection is left untreated or inadequately managed, several serious problems can arise:

• Cellulitis – spreading skin infection that can progress to sepsis.
• Abscess formation – may require surgical drainage.
• Fistula development – abnormal tract between the stoma and surrounding tissue or organ.
• Stomal retraction or prolapse – infection weakens supporting tissue.
• Systemic sepsis – life‑threatening, especially in immunocompromised patients.
• Psychosocial impact – chronic infection can lead to anxiety, depression, and reduced quality of life.

When to Seek Emergency Care

References

1. American College of Surgeons. Complications of Ostomy Surgery. 2022.
2. Mayo Clinic. “Urostomy care: What to expect after surgery.” Updated 2023.
3. CDC. “Guideline for the prevention of surgical site infection, 2022.”
4. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). “Living with a urostomy.” 2021.
5. World Health Organization. “Infection prevention and control guidelines for health-care facilities.” 2023.

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