http://doi.org/10.33698/NRF0141 – Sukhpal Kaur, Karobi Das, Rajesh Gupta
Abstract : Ostomy patients face number of challenges due to their pouch. The formation of a stoma can have a profound negative impact on people’s lives. It affects a person’s quality of life and can cause unnecessary sufferings. Patients with stoma have significant physical, nutritional and sexual problems postoperatively. Various studies have revealed the problems encountered and the impact of the ostomy on the daily lives of the patients. The current study was conducted with the objective of exploring the physical, nutritional and sexual problems of the patients with colostomy/ileostomy. The researcher took the medium of ‘Phenomenological Research Design’ to unmask their minds and interpret them. Using purposive sampling technique, 40 patients were included in the study. In-depth interviews were conducted with a semi structured interview schedule. Colaizzi’s procedural steps were adopted to analyze the data as it gives clear cut steps of analysis for the transcripts of recorded data. The study leads the researcher to explore the physical, nutritional and sexual problems encountered by the subjects.
The conversation between the researcher and the subject was recorded side by side. The various subthemes which emerged under the physical problem were lack of adjustment in activities of daily living, altered sleep pattern related to fear of leakage, pain or discomfort and altered skin integrity related to irritation by the stoma contents. The subthemes which emerged under the sexual problem were feeling of embarrassment, anxiety, refraining from sexual act and adjustment towards sexual life, Impact on sexual desires, sexual behavior and sexual health due to ostomy bag, rejection by the spouse in relation due to ostomy bag and acceptance of the spouse with the ostomy appliance. The subthemes which emerged under the nutritional problem were discomfort and avoidance with the certain food items and modification with the certain foods. It was concluded that there is a need to provide counseling services to the subjects so that they can better adjust in their life.
Key Words : Ostomy, Phenomenological study, physical, nutritional and sexual aspect.
Correspondence at Shaffy, S. Atma Singh
Urban Estate PUDA Colony, Jalandhar Road, Kapurthala.
Colostomy or ileostomy is the surgical creation of a stoma for the evacuation of bodily waste.1 Though the purpose of ostomy is to treat and reduce patient’s pain and discomfort, however in many cases it may lead to intensified distress and suffering for patients, and can cause severe stress.2The common problems experienced by the subjects have been reported to be skin irritation (76%), pouch leakage (62%), offensive odor (59%), reduction in pleasurable activities (54%), and depression/anxiety (53%).3The creation of an ostomy leads to various physiological, problems for patients.4 Ostomy patients are apprehensive about leakage and odor from the ostomy, and might therefore avoid interactions with people, become introverted, and seek solitude. Over time, this insecurity in social situations and lack of trust could lead to total social isolation.5
In physical terms, ostomates face number of problems.Ostomates have feared that ostomy bag might leak or smell or pass flatus, especially when away from home. This includes the fear of not waking up before a leak happens. Often the fear of leaking is worse than the actual experience of having an accident. Many see the stoma as a sanitary nuisance for themselves and others, feeling dirty and unclean.People with fecal stomas no longer have control over flatulence from the stoma, lacking a voluntary sphincter such as the anus provides.6
The existence of opening in the anterior abdominal wall creates problems because of the lack of sphincter control and irritant effect of fecal efflux on the surrounding skin. There is also the problem of the collection, storage, sight, sound and the odor of the fecal stream. In addition, the projecting bowel mucosa needs protection from external trauma.7In one of the study, the ostomates has complained of irritation and rash around the ostomy site, with sleep disturbance, bad breath, and gas emission in the presence of others. Moreover, they reported that they could not lift objects weighing more than 5 kg.8
Patients with an ileostomy face many dietary challenges relevant to the location of the stoma. Without the colon, absorption of electrolytes, water, vitamin K, and biotin are affected.9There are different problems which are faced by patients with ostomy i.e gas, odor, obstructive foods, constipation, socio- economic, sexual, psychological problem and other complications related to stoma. A descriptive survey collected data related to individual dietary recommendations and restriction for people with ostomies.The findings revealed that 88.4% of respondents were not following a special diet, 11.6% had modified their diet. The foods because of the ostomy included fresh fruits, nuts, coconut, and vegetables such as corn, popcorn, cabbage, beans, and onions. The major problems repor ted were blockage and increased gas.10 Sexuality is a complex phenomenon affecting body image, feelings, and interpersonal relationships.11A person’s sexuality is closely associated to their body image.12Many people with stomas have concerns that their sexual attractiveness has been diminished.13
People with stomas experience some uncertainty about their sexual attractiveness and manage this difficulty in different ways. Some want to expose themselves and see how their partner responds. If their partner does not see the stoma as a problem, they could more easily accept the stoma as a part of themselves. Some hide their stoma bag when undressing; keeping it out of their partner’s sight believing that their body is ‘destroyed’. Some are afraid of discussing sex with their par tner, worried about their reactions. They fear that ultimately the relationship will fail.14,15,16A person’s body image and sexuality are major factors in determining the effect of a stoma on a person’s quality of life.
The aim of this study was to investigate the effects of ostomy on body, health, nutrition and sexuality of the patients.
Material and Methods
Phenomenological design is selected to describe the life experiences of the subjects under study. The study was conducted in the surgical OPD of Nehru Hospital in Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh. Study sample consisted of 40 patients with colostomy/ileostomy attending the surgical OPD with minimum time period of six weeks after surgery. Purposive sampling technique was used in this study.
The tool used for data collection was consisted of two parts. First part consisted of sociodemographic data sheet of the patients which had items such as name, age, sex, CR.no, type of surgery, educational status, occupation, total family income, total family members, per capita income. etc.
The second part consisted of semi structured interview schedule which was developed by reviewing literature and had given to experts for validity from the field of nursing and department of general surgery for judging its clarity, relatedness, meaning and contents. Semi structured interview schedule consisted of open ended questions related to physical, nutritional and sexual domain. A written permission was obtained from the Head department of General surgery, PGIMER. Ethical permission was obtained from the institutional ethics committee.
To assess the feasibility of the study, pilot study was conducted on five subjects in the surgical OPD, Nehru Hospital, PGIMER, Chd. The various themes analyzed under the pilot study were Physical problems, Nutritional problems, Sexual problems, Psychological problems and Effect on the social, religion, economy and family relationships. These findings were incorporated in the main study.
The written consent was taken from the subjects. The subjects were told that all the conversation would be kept confidential. The interview was recorded in the stoma room adjacent to the surgical OPD by maintaining the privacy during the interview procedure. The interviews were recorded and audio taped side by side. The data was collected between 10am to 5pm. The time spent for each interview varies from half an hour to one hour, according to the willingness of clients to talk. Some preferred to talk elaborately, while others wanted to stop it sooner. The data was transcribed into verbatim forms and was analyzed using Colaizzi’s steps for analysis. Firstly the data was recorded and then it was typed. After that reading and re- reading of participant’s descriptions were done. Then significant statements were extracted followed by formulating the meaning for each significant statement. Then categorizing of formulated meanings into cluster of themes were done. Then the extracted meaning and statements were validated by experts in the field of psychiatry and psychology.After careful analysis of the transcript of the in-depth interview, so many subthemes have been emerged. These subthemes were coded under the grouped analytical coding sheet by final description and categorizing the essence of phenomenon.
Socio- demographic data of the subjects
Mean age (yrs) of the subjects was 33.6±13.1, with the range of 16-66 yrs. About one third of the subjects (35%) were between 26-35 years. Two third (67.5%) were male. Approximately half of the subject had ileostomy and one four th (22.5%) had colostomy. 35% of subjects each had undergone surgery 3 months and 9 months prior more than half were working (57.5%)& 35% had monthly family income of Rs. 5,000.
Problems experience by patients grouped under following subthemes
The theme of the study was found to be as physical problem, nutritional problem and sexual problem experienced by all the participants at different level. In the theme of physical problem one third of the responses (32.3%) were clubbed under the subtheme of ‘Altered sleep pattern related to fear of leakage, pain or discomfort’, 29.4% under the subtheme of ‘Lack of adjustment in activity of daily living’, followed by ‘Impact on the overall health’15.7%, 11.8% were under the subtheme of ‘Altered skin integrity related to irritation by the stoma contents’, 10.8% had’Effect on the clothes worn.’
Table 1: Socio-demographic data of the subject N=40
Mean age (yrs) ±SD:33.6±13.1. Range: 16-66 yrs Mean Per capita Income Rs. ±SD:3492.3 ±6331.27. Range Rs: 250/-39991/-
Table 2 : Problems experienced by patients
|Cluster of themes||Frequency of responses(%)|
|° Altered sleep pattern related to fear of leakage, pain or discomfort||33(32.3)|
|° Lack of adjustment in activity of daily living.||30(29.4)|
|° Impact on the overall health||16(15.7)|
|° Altered skin integrity related to irritation by the stoma contents.||12(11.8)|
|° Effect on the clothes worn.||11(10.8)|
|° Impact on sexual desires, sexual behaviour and sexual health|
|due to ostomy bag.||16(57.1)|
|° Feeling of embarrassment, anxiety, refraining from sexual act|
|and adjustment towards sexual life.||7(25.0)|
|° Acceptance of the spouse with the ostomy appliance||3(10.7)|
|° Rejection by the spouse in relation due to ostomy bag.||2(7.2)|
° Discomfort and avoidance with the certain food items.
° Modification with the certain foods.
In the theme of sexual problems more than half of the (57.1 %) responses were grouped under the subtheme of ‘Impact on sexual desires, sexual behavior and sexual health due to ostomy bag’, one fourth (25%) of the responses had ‘Feeling of embarrassment, anxiety, refraining from sexual act and adjustment towards sexual life’, 10.7% had ‘Acceptance of the spouse with the ostomy appliance’ and 7.2% had ‘Rejection by the spouse in relation due to ostomy bag.’Under the theme of nutritional problems more than half of the responses (58.8%) were grouped under the subtheme of ‘Discomfort and avoidance with the certain food items’, and 41.2 % had ‘Modification with the certain foods.’
Descriptions of the identified subthemes are as follows:
One hundred two formulated responses were revealing physical problems due to various reasons. The physical problems are divided into five subthemes according to the problems identified. They are as follows.
1. Lack of adjustment in activity of daily living.
This subtheme analyzed that patients with ostomy had lack of adjustment in activities of daily living. It has affected the person’s life style and leads to lag in all the self care activities. Thir ty formulated responses were analyzed under this subtheme.
One of the clients said ‘I am not taking bath since the bag is placed. I do sponge bath daily with towel. I had fear in my mind that my bag will be spoiled if I take bath.’ Patient had the fear in their mind that the stoma was hindering for taking the bath. One of the client added ‘I feel a tremendous problem with bag. e.g. in the morning I have to go for Physical therapy (PT). Then it is very difficult for me to attend the PT. I feel weakness in my body and fear of leakage.’ Another client said ‘Yes there is a tremendous change in my daily routine. Now I am not able to go for work. I remain at home. In my free time I chat with my friends.’Patient reported that he was not able to go to the job and was at home all the time. In his free time he chitchats with his friends.
The other client said ‘When it is time to change the bag then only I take full bath. I change the bag after a week.’ It reflected the lag in the personal hygiene of the patient.
2. Altered sleep pattern related to fear of leakage, pain or discomfort
Most of the par ticipants had the problems related to sleep because of fear of leakage of the bag at night, pain or discomfort. One of the clients said ‘I am in tension while sleeping with ostomy. I am not able to sleep soundly. My sleep is very superficial. I have to get up at night and then only take side lying position.’ The other client said ‘I experience a lot of problem during sleep. I am not able to sleep comfortably in side position because of fear of leakage. I mostly lie on a side, where the bag is placed because if I sleep on side then the bag is hanging and more prone to leakage.’
Another client added ‘Sometimes my bag bursts at night. I took side when I was in sound sleep then it started leaking and my sleep was disturbed.’
3. Altered skin integrity related to irritation by the stoma contents.
This subtheme represented that the patients had the skin problem because of the effluents coming out from the ostomy. This subtheme cannot be ignored as it is going to affect them so badly. Twelve responses were analyzed under this subtheme. One of the clients said ‘My skin was reddened and I had wound on the skin around ostomy. I had this problem when my bag was leaking.’
The other client said ‘I had itching and redness on the skin around the ostomy. I poured the powder on the skin. I mostly had itching on the skin in summer season.’ In summer season the patient had itching because of increased perspiration. Another client said ‘Doctors had advised me to pour powder on the skin around the ostomy. My skin had burnt with the discharge from the bag.’
4. Effect on the clothes worn.
Eleven formulated responses showed that the patients had the change in the wearing of dresses after the ostomy. One of the client said ‘Yes stoma had affected the choices of clothes. I wear loose clothes like salwar kameej. I am not able to wear jeans.’ There was a change in the dressing after the ostomy The other client said ‘I have to wear loose clothes only. Before the operation I could also wear the tight dresses but now it is totally restricted.’. Another client said ‘Yes, stoma had limited the choices of clothes. Previously I wore the good quality clothes. But after the operation I wore only the loose night suits only. When people saw my bag then they showed irritation towards the bag. I have seen a lot of problems in my life. But now I feel good after the operation (restoration of bowel continuity).’
5. Impact on the overall health.
This problem is significant by itself. It represented the overall impact on the health after the ostomy surgery. Sixteen formulated responses supported this subtheme. One of the clients said ‘I feel that my body is weakened as compared to before. I am not able to do work properly.’ Another client said ‘I feel that I am tired after the operation. Now if I sit for half an hour then I feel that I have to take rest. I am also not able to walk for a longer time. I felt this type of problem for 15 days after the operation but now I feel comfortable.’
One of the clients quoted that ‘I feel tired after the operation. Most of the time in the day I remain on the bed.’ One of the client said ‘It is a bad experience of my life. I was operated many times. After the stoma operation I feel a lot of weakness. I think that I am not able to do any work now.’
- Feeling of embarrassment, anxiety, refraining from sexual act and adjustment towards sexual
Many people with stomas have concerns that their sexual attractiveness had been diminished. They had embarrassment and anxiety during sexual act and hence led to refraining from sexual act while some had made adjustment towards sexual life. Seven responses were analyzed under this context. Self-consciousness and shame are overlapping, integral components to an individual’s body image. But it was felt by the researcher that participants were feeling shy to explore view and feeling related to this subtheme. They wanted to hide their feelings related to sex. One of the client said ‘I feel very awkward to have sex because of bag. I control my mind a lot. We are not able to do sex normally. I am not able to do the sexual act in a proper manner. I have a relationship in a modified positions only e.g. in a standing position.’ Here patient felt awkward to have the sexual relationship with his wife but he has made adjustment by having sex in a modified positions. Another client quoted that ‘I don’t want to discuss about this topic(sexual discussion). I am continuously worried about my disease.’ Patient tried to avoid the discussion on the sex.
Another client said ‘I feel some problem during the sexual relationship. My sex life is affected a lot. According to my view every person has different types of sex powers. I think that 95% of my sexual urge is destroyed due to ostomy. I think that when the rectum is removed then sex organs are destroyed.’
2. Impact on sexual desire, sexual behaviour and sexual health due to ostomy bag.
This subtheme can’t be ignored as some of the participants had reported the changes in sexual drive, sexual behavior and sexual health after the ostomy surgery. Sexual dysfunction, a loss of pleasure and diminution in sexual ability and activity, are common problems experienced by the participants. Sixteen responses gave the clue regarding this subtheme.
One of the client said ‘I don’t have any relationship with my wife because I have pain.’ Here patient avoids the relationship because of feeling of pain during sexual act. One of the client added ‘Ostomy has affected my sexual life. I felt that after the ostomy my sexual desire was reduced.’ The other client said ‘My sex life has nearly stopped. We have the sexual relationship but it is only time pass. I feel the weakness in making sexual relationship.’
3. Rejection by the spouse in relation due to ostomy bag.
This subtheme represented the serious effect on the patient’s sexual life. It focuses on the disturbed relationship between the patient and his/her spouse. It reflects the rejection by the spouse in relation to the ostomy bag. However proportion of the statements studied under this subtheme is negligible but it represented the serious mental dilemma in context to patient’s sexual life. Two responses of same patient were analyzed under this subtheme.
One of the client said ‘My wife felt very awkward towards bag. She cooks the food. My sister helped me a lot. My sister had done a great job. She is the only person who changes my bag at home. She also does my dressing but my wife didn’t want to look at the ostomy site.’ He added that ‘She tells me that there are women in the world whose husbands are no more. She tells me that it would be good if I was all right soon, then only it would be fine.’
4. Acceptance of the spouse with the ostomy appliance.
Acceptance of the spouse was one of the core elements of the sexual relationship. This subtheme reflects the coping strategies used by the patient and his /her spouse to cope with the ostomy. It represents that there was acceptance by the spouse towards the ostomy appliance. Only three responses were studied under this subtheme.
One of the client said ‘I feel very awkward to have sex because of bag. I control my mind a lot. We are not able to do sexual act normally. I made a relationships only in a modified positions only e.g. in a standing position.’ Another client added ‘My husband is helping me at home. I have a good relationship with my husband. He knows everything about my disease. I am totally dependent upon my husband. I think sexual life depends upon husband. It is based on the understanding and interaction between the thinking level of husband and wife.’ One of the client quoted that ‘No there is no problem in my sex life. We are doing sex but in a modified positions. My husband is not putting his body pressure on my body because I have bag and also I am weak.
- Discomfort and avoidance with the certain food
Some of the participants had reported the discomfort and problems related to some of the food items. Some of them reported that after taking specific type of food items the stoma was blocked or experienced the discomfort like belching, nausea or gas formation. Ten responses were analyzed under this context. One of the client said ‘I avoid the gas forming food groups like brinjal and some of the pulses. I feel belching, nausea and gas formation.’ Another client says ‘I experience a lot of problem after eating fried food. My stool is becoming thinner and sometimes I have bleeding.’
One of the client said ‘I am not able to take milk and curd. I feel some problem with some of the pulses, pumpkins, white and black channa. Otherwise I take all types of foods.’ Another client said ‘I eat all types of food. But I carefully choose the food items. Once my stoma was blocked. So I avoid gas forming food items like black and white channa, black pulses, ladyfingers and rajmah.’
2. Modification with the certain foods.
Seven responses were analyzed under the above mentioned subtheme. It reflected that there was a change in the liking of the food items after the ostomy. Participants had to adjust with the simple and bland diet which would not irritate their stoma. One of the client said ‘I am unable to eat spicy food. I have to take soft and digestive food only. I like rice and khichdi. I am drinking a lot of water. When I don’t eat or drink anything for a long time then I feel weakness and craving for food.’ Another client said ‘I liked spicy food before operation but now I have to take the food items which are available at home. Mostly I take the non vegetarian food items but I don’t take rajhmah and rice. Once I took rajhmah then my stoma was stuck. So I avoided taking rajhmah. But before the operation rajhmah and rice was my favorite dish. When I take non vegetarian food at night then I have a lot of smell in the ostomy drain.’ The other client said ‘Now, I have to eat food according to doctor’s prescription. Before the operation I was vegetarian and did not even drink milk but now I am eating non vegetarian food also. I avoid green vegetables because of increased pesticides used.’
The ostomy patients face an array of challenges due to the uniqueness and consequences of their ostomy bag. Purpose of ostomy is to treat and reduce patient’s pain and discomfort, but in many cases ostomy leads to intensified distress and suffering for patients, and causes severe stress2 as a result of skin irritation, pouch leakage, offensive odor, reduction in pleasurable activities, and depression/anxiety.6 In such circumstances, it is worthwhile to know the life experiences and the problems faced by the patients with the stoma and the effect of the stoma on their quality of life and the strategies used by the ostomates to manage with the bag.
The present study was conducted among patients with colostomy/ileostomy. The aim of the study was to explore the life experiences of the patients with colostomy/ ileostomy, and to interpret the phenomenon as experienced by them and to gain insight into the physical, nutritional and sexual problems experienced by the patients and the coping mechanisms adopted by patients in order to combat the stress.
An attempt was made to explore their fears in context to physical, nutritional and sexual problems for a prolonged period of time. Researcher wanted to explore their thoughts, problems and feelings and intrude into their psyche, though it was a tough task. Phenomenology was selected as a medium to enter into their personal world. Colaizzi’s method made analysis simple because it gives a systematic mode of dissecting data in clearly defined steps rather than just describing the lived experiences.
Participants in this study had lack of adjustment in the activities of daily living, altered sleep pattern related to fear of leakage, pain or discomfort, altered skin integrity which is related to irritation by the stoma contents, effect on wearing clothes and impact on the health status. Most of the participants reported the limitation in physical activity after their ostomy. They stated that they experienced a reduction in their usual activities and inability to do hard work. They often experienced the tiredness after doing some work.Most par ticipants complained of irritation and rashes around the ostomy site, with sleep disturbance, decreased or nil participation in every day’s activities, bathing problems, restricted clothing and tiredness.
The above findings were consistent with one of the study in which participants complained of irritation and rash around the ostomy site, with sleep disturbance, bad breath, and gas emission in the presence of others.17Mitchell et al further showed that leakage, odor, and noise from the appliance were the primary sources of embarrassment identified by patients.18
In the present study, married par ticipants encountered some sexual problems, particularly early on in the course of their disease or after surgery, which resolved gradually when they learnt how they could tackle this problem. Some of them had the normal sexual life but most of the par ticipants repor ted that there was a tremendous change in their sexual life. Feeling of anxiety and embarrassment with the stoma bag refrained many of the subjects from the sexual act. Some of them had adjusted by changing positions but most of them avoided the sexual act with the bag. They had decreased desire to indulge in the act because of feeling of weakness while few experienced rejection by the spouse. These findings were consistent in three of the studies in which participants sexual relationships were affected after the ostomy and reported the decreased desire to indulge in sexual act which ultimately resulted in inactive sexual life. 19,20,21
In one of the study the participants had gas, odor, constipation or diarrhea with certain food items like cauliflower, cabbage, yoghurt etc and hence they avoided that food items.22 In the present study nutritional problems were not less important. Majority of the participants reported that although they did not receive any education about their diet and nutritional status, they considered it to be an important issue and were doing their best to control it. The participants in the current study had reported the discomfort with certain food items which leads to modification of their routine diet. They complained of blockage of stoma with some of the food stuffs like beans and nuts. They complained of gas emission with certain food groups like cabbage and cauliflower. They avoided the spicy and oily food. They ate the food items according to their interest and found that some of the food items were discomforting. So they use to avoid these food items and focused on the high protein content food groups.Some of the participants used to skip the dinner and others had their dinner early to avoid emptying of the bag at night.
The findings of the study revealed that ostomy pouch led to serious maladjustment in everyday’s life of the patient. The findings of the study would be useful for health care providers when creating a suppor tive environment to improve quality of life in ostomy patients. Support groups in which therapists and patients could interact would provide an opportunity for participants to express their concerns about quality of life issues and ultimately it would lead the ostomates to better life.
- Silva MA, Ratnayake G, Deen Quality of life of stoma patients: temporary ileostomy vs colostomy. World J Surg, 2003;27:421-24.
- Krouse RS, Grant M, Rawl Coping and acceptance: The greatest challenge forveterans with intestinal stomas. J Psychosom Res 2009; 66:227- 232.
- Richbourg L, Thorpe JM, Rapp Difficulties experienced by the ostomate after hospital discharge. J Wound Ostomy Continence Nurs.2007;34:70-79.
- Kilic E, Taycan O, Belli KA, Ozmen The Effect of Permanent Ostomy on Body Image, Self-Esteem, Marital Adjustment, and Sexual Functioning. Turkish J of Psychiatry 2007; 18(4): 302- 10.
- Karadag A, Mentes BB, Uner ?mpact of stomatherapy on quality of life in patients with permanent colostomies or ileostomies. ?nt J Colorectal Dis,2003;18:234-38.
- Hornbrook MC, McMillan C, Grant M, Baldwin CM, Herrington L, Ramirez M, et The greatest challenges reported by long-term colorectal cancer survivors with stomas. J Support Oncol2008; 6(4):175- 82.
- Persson A new life with a stoma and quality of care among patients an their partners.University of Gothenburg;2004 Available at www.pubmed.com Accessed January 29,2011
- J, Beitz J. Sexuality and the person with a J of Wound, Ostomy and Continence Nursing 2005;32(2): 121-28.
- Corbin JM. The body in health and illness. Qualitative Health Research 2003;13:256-67
- Persson E, Hellstrom Experiences of Swedish men and women 6 to 12 weeks after ostomy surgery. Journal of Wound, Ostomy, and Continence Nursing 2002; 29 (2): 103-108.
- Salter What are the differences in body image between patients with a conventional stoma compared with those who had a conventional stoma followed by a continent pouch. J of Advanced Nursin 1992; 17(7): 841-48
- Carlsso E, Berglund B , Nordgren S. Living with an ostomy and shor t bowel syndrome: Practical aspects and impact on daily J of Wound Ostomy and Continence Nursing 2001; 28(2): 96-105.
- Kelly Coping with an ileostomy, Social Science of Medicine .Department of Public Health, University of Glasgow, Scotland.1991; 33(2): 115 25. (Cited on march,25 2011) Available from: http://www.sciencedirect.com.
- Kralik, D, Koch T, Telford Constructions of sexuality for midlife women living with chronic illness. 2001(2): 180-187
- McKenzie F, White C, Kendall S, Finlayson A, Urquhart M, Williams Psychological impact of colostomy pouch change and disposal Br J Nursing 2006; 15(6):308-16.
- Noone Pre- and postoperative steps to improve body image following stoma surgery. Gastrointest Nurs 2010 8(2): 34-39
- Dabirian A, Yaghmaei F, Rassouli M, Tafreshi Quality of life in ostomy patients: a qualitative study. Patient Prefer Adherence. 2011; 21(5):1-5.
- Mitchell KA, Rawl SM, Schmidt Demographic, clinical, and quality of life variables related to embarrassment in veterans living with an intestinal stoma. J Wound Ostomy Continence Nurs 2007;34(5):524-32.
- s SJ, Chongpison Y, Wendel CS, Grant M, Krouse RS. Overall quality of life and difficulty paying for ostomy supplies in the VA Ostomy Health- Related Quality of Life Study: An exploratory Med Care 2007; 45:891-95.
- Brown H, Randle Living with a stoma: A review of the literature. J Clin Nurs 2005;14(1):74-81
- Symms MR, Rawl SM, Grant Sexual health and quality of life among male veterans with intestinal ostomies Clin Nurse Spec 2008;22(1):30-40
- Nancy C. Nutritional Care of the Ostomy Patient January 2011:10-12. (Cited on March, 25, 2013) Available at URL: http:// o-wm.com wound management.