Health‐Related Quality of Life Among Patients With Ostomy Intestinal Stoma According to Sex and Ostomy Permanence: A Systematic Review and Meta‐Analysis

ABSTRACT

Colon cancer (RC) patients holding an intestinal stoma recorded lower health‐related quality of life (HRQOL) levels. Intestinal stoma leads to several difficulties, like travel, work, and sporting activities. Patients with an intestinal stoma frequently experienced changes in their HRQOL. The COH‐QOL‐Ostomy questionnaire comprehensively measured these changes across physical, psychological, social, and spiritual domains. We reviewed literature in order to assess any differences in HRQOL between females and males and between intestinal stoma permanence among these patients. We conducted a literature review from: British Nursing Collection, Embase, MEDLINE, Nursing & Allied Health Database, PubMed, Scopus and Web of Science databases, without any time limits. The protocol was registered with PROSPERO no. CRD420251040414. A total of 492 records were identified. Of these, 362 records were removed, obtaining 130 potential records. However, 126 of these were excluded as they did not meet the inclusion criteria including only 4 records for further analysis. The COH‐QOL‐Ostomy questionnaire has been considered to assess HRQOL total score and its related sub dimensions, specifically physical, psychological, social and spiritual well‐being. For each item, a Likert scale has been associated raging from zero (worse outcome) to 10 (good outcome). A total of 915 observations were collected, specifically 401 related to females and 514 to males. Additionally, a total of 670 observations were recorded: 338 belonging to the temporary group and 332 to the permanent one. Data reported a significant difference in the Psychological Well Being dimensions between the two groups, in favour of the female group (t = −3.66; p = 0.035). Considering the ostomy permanence, the temporary group reported a significant and better total quality of life score (t = −7.53; p = 0.017), Psychological Well Being dimension (t = −5.24; p = 0.035), and in social dimension (t = −8.09; p = 0.015), too. Sex‐related differences in HRQOL assessments could help patients to achieve the most appropriate interventions to ameliorate QOL perceptions. Permanence criteria for ostomy could better address healthcare professionals for a specific clinical pathway to improve, especially in social support, which could positively contribute to better self‐care for these patients.

Summary

• The COH‐QOL‐Ostomy questionnaire measure changes related to health‐related quality of life in patients holding an intestinal stoma.

• Significant differences are observed between females and males for psychological well being in favour of the group of females.

• Patients with temporary ostomia presented better quality of life in the psychological and social domain compared to patients holding a permanent ostomia.

1. Introduction

Globally, colorectal cancer (CRC) represents the second leading cause of cancer‐related mortality, with more than 1.9 million new diagnoses and over 930 000 deaths reported each year. The highest prevalence rates are observed in Europe and in Australia and New Zealand, and global forecasts estimated a 63% increase in CRC incidence and a 73% increase in mortality by 2040 [1]. A substantial proportion of individuals with CRC require the creation of an intestinal stoma (ostomy) as part of their surgical management. An ostomy involves surgically externalising a segment of bowel through the anterior abdominal wall and may be temporary or permanent, involving either the small intestine (ileostomy) or the large intestine (colostomy). Although the overall number of ostomy procedures has decreased in recent years, the growing incidence of CRC suggests that the number of permanent ostomies is likely to rise [1].

Patients living with an ostomy frequently report reduced Health‐Related Quality of Life (HRQOL). The presence of an ostomy has been linked to limitations in travel, employment, and participation in physical activities [2, 3]; disturbances in sexual functioning [4, 5]; heightened psychological distress [6, 7]; challenges related to spiritual well‐being [8]; and diminished body image satisfaction, often influenced by concerns such as gas, odour, and loss of bowel control [9]. These multi‐dimensional effects underscore the importance of investigating HRQOL in this population to inform targeted supportive care strategies and optimise long‐term outcomes.

Thus, the HRQOL assessment among stoma patients may be useful for healthcare professionals to guide the most appropriate shared decision‐making to control disease, complications, and their related treatments.

Literature suggested that females holding an intestinal stoma recorded lower levels in HRQOL than males, more specifically in physical and role functioning accompanied with worse body image perception and greater sexual and emotional difficulties than male ostomates [10, 11]. A similar pattern has been observed among cancer patients with a permanent intestinal stoma, who generally recorded lower HRQOL scores than those with temporary stomas. Permanent stoma carriers often induced more persistent disruptions to body image, intimacy, lifestyle, and self‐identity, contributing to reduced psychological and social well‐being over the long term. Collectively, these findings highlight the significant and gender‐sensitive impact of stoma status on HRQOL outcomes [12, 13].

1.1. HRQOL Assessments

Several tools have been developed to assess HRQOL among ostomy patients, including the Stoma Care Quality of Life Index, the City of Hope Quality of Life–Ostomy Questionnaire (COH‐QOL‐Ostomy), the Ostomy Adjustment Scale, the Ostomy Adjustment Inventory‐23, the Coping Strategies Inventory, the Quality of Life Index, the Survey of Preoperative Factors of Ostomy Adjustment, and the Stoma‐QOL instrument [14]. However, many of these instruments have not been specifically validated for use in patients with intestinal stomas, and some lack comprehensive assessment of condition‐specific domains such as stoma care, body image, and adaptation challenges [15, 16]. Among these tools, the COH‐QOL‐Ostomy questionnaire stands out as one of the few ostomy‐specific instruments that has undergone systematic psychometric evaluation [17]. The original COH‐QOL‐Ostomy questionnaire was developed from a study conducted in 1983 to explore quality of life among individuals living with an ostomy. In 2004, Grant et al. [14] revised and further validated the instrument using a large, multicenter sample of ostomy patients. The COH‐QOL‐Ostomy questionnaire represented a multidimensional tool comprising 43 items divided into four subdimensions: physical well‐being (items 1–11), psychological well‐being (items 12–24), social well‐being (items 25–36), and spiritual well‐being (items 37–43). Each item was scored on a Likert scale ranging from 0 (worst outcome) to 10 (best outcome). Subscale scores were calculated by summing the items within each dimension, and the overall HRQOL score was derived by summing the subscale totals [18]. Psychometric analyses have demonstrated strong internal consistency across the questionnaire's domains, with Cronbach's α coefficients typically ranging from 0.82 to 0.96, indicating excellent reliability. Construct validity has been supported through correlations with established HRQOL instruments, demonstrating expected associations with measures of physical functioning, psychological distress, and social adaptation. Content validity was ensured through expert review and patient feedback, while factor‐analytic studies have confirmed the four‐domain structure. Additionally, test–retest reliability assessments have shown stable scores over time, further supporting the instrument's usefulness for both clinical practice and research [14].

1.2. Aim

The present systematic review and meta‐analysis aimed to assess any differences in HRQOL between:

• Female and male cancer patients with intestinal stomas;

• Ostomy permanence, like temporary and permanent

2. Evaluation Methodology

2.1. Research Strategy

We conducted a literature review from: British Nursing Collection, Embase, MEDLINE, Nursing & Allied Health Database, PubMed, Scopus, and Web of Science databases, without any time limits and only considering English language records according to the PRISMA checklist (Supporting Information S1) [19]. The protocol was registered with PROSPERO no. CRD420251040414.

Keywords according to the MeSH terminology were adopted thanks to the PIO methodology. Search terms were mixed thanks to Boolean operators (Table 1).

TABLE 1.

The PIO tool for the present systematic review and meta‐analysis.

Population	Cancer patients differentiated between females and males and ostomy permanence, as permanent and temporary
Intervention	Intestinal Ostomy
Outcome	HRQOL

2.2. Selection Criteria

The review included all interventional and observational studies which recorded sex and ostomy differences in health‐related quality of life among cancer adults with an intestinal stoma. Thus, data expressed with mean ± standard deviation between females and males in cancer patients with an intestinal stoma were taken into account to assess both sex and permanence assessment in health‐related quality of life (HRQOL).

2.3. Selection Process

During the first phase of the present systematic review and meta‐analysis, a total of 492 records were identified. Among these, 362 records were removed, as 10 were duplicates and 352 were removed for other reasons. After screening, a total of 130 potential records were obtained. However, 126 of these were excluded as they did not meet the inclusion criteria. Finally, only 4 records were selected in the present systematic review and meta‐analysis (Figure 1).

FIGURE 1.

The selection process.

2.4. Data Recruitment

Articles were identified through a systematic database search and uploaded to a reference management software where duplicate studies were removed. Then, two independent reviewers (E.V. and L.M.) assessed the title and abstract of the identified studies for inclusion and unsuitable reports were removed. After that, articles were uploaded, and the full text was assessed more closely for eligibility. Disagreements about whether a study should be included or not were resolved by discussion and consensus. If the disagreement remained, arbitration from another reviewer was provided. Data collection included extraction of study characteristics (author, year of publication, aim, design, sample size, setting), participants (age, cancer stage), and HRQOL scores between females and males and permanent and temporary stomas.

2.5. Risk of Bias (Quality) Assessment

The presence of Risk of Bias was investigated using the risk of bias in observational studies of exposures (ROBINS‐E) tool [20]. The tool consisted of seven domains through which the presence of bias in the results could be investigated. These domains were identified based on empirical evidence and theoretical considerations and cover all types of bias that could influence the results of observational studies of exposures (Figure 2). The seven areas assessed were:

1. Bias due to confounding:

2. Bias arising from measurement of the exposure;

3. Bias in selection of participants into the study (or into the analysis);

4. Bias due to post‐exposure interventions;

5. Bias due to missing data;

6. Bias arising from measurement of the outcome;

7. Bias in selection of the reported result

FIGURE 2.

Quality assessment of the included studies.

2.6. Strategy for Data Synthesis

Studies were assessed for quality as per protocol recommendations. The information retrieved from the final selected studies will be exposed using both a narrative approach and tables. Statistical analysis is performed using R Studio (version 4.5). For each study, standardised mean differences (SMD) were calculated using Hedges' g method [21]. For both the sex comparison and the ostomy permanence one, separate meta‐analyses were conducted for each of the outcomes of interest (total quality of life, physical well‐being, psychological well‐being, social well‐being, and spiritual well‐being). In each of the meta‐analyses, Cochrane's total Q test was used to assess heterogeneity. A significant Q value (p < 0.05) indicates the presence of heterogeneity among studies. Additionally, to assess the consistency across studies, the Tau‐squared coefficient (τ ²) and the I ² statistic are adopted, with I ² values of less than 25%, 50%, and 75% suggesting low, moderate, and high heterogeneity degrees, respectively [22]. Since I ² should be presented and interpreted cautiously in small meta‐analyses, the 95% confidence intervals (95% CI) are presented in addition to the point estimate. Data were pooled using a random‐effects model with the Knapp‐Hartung adjustment method (HKSJ), and Forest Plots were generated for each meta‐analysis [23]. Publication biases were assessed by performing contour‐enhanced Funnel Plots together with Egger's t‐test [24].

3. Results

3.1. Health‐Related Quality of Life Among Patients With Ostomy. Study Description

Only four studies satisfied our aim [25, 26, 27, 28]. Table 2 displayed the main features of each study included in the present systematic review and meta‐analysis (Author(s), publication year, study design, sample size, sex‐related outcome).

TABLE 2.

The main features of the included studies (n = 3).

References	Study design	Simple size	Sex difference	Permanence difference
Alenezi et al. [25]	Descriptive Cross‐sectional	421patients: 182 female 239 male 206permanent 211temporary	Females recorded lower QOL scores than males in all 4 QOL dimensions. It could also depend on female related self‐care, organisational practices and tendency to focus more on their body images.	Significant differences were recorded between patients with permanent and temporary ostomies; those with Temporary ostomies had a lower and significant overall QOL score (mean = 6.8; SD = 1.1) than permanent ones (mean = 8.2; SD = 2.5), also in all 4 sub dimensions.
Diniz et al. [26]	Descriptive Cross‐sectional	152patients: 75 female 77 male 78permanent 74temporary	No significant differences were recorded between females and males in all the sub dimensions investigated.	Definitive stomas presented significant improvements in the psychological (p = 0.002) and social (p = 0.001) dimensions and total QOL (p = 0.006).
Krouse et al. [27]	Matched cross‐sectional	246 patients: 99 female 147 male	Differences for females in the psychological and social sub dimensions exceeded the MID.	Not assessed
Silva et al. [28]	Cross‐sectional descriptive	96 patients 45 female 51 male	None statistical significant differences were recorded between males and females in overall HRQOL, physical, psychological, social and spiritual sub dimensions.	Length of stoma recorded a significant association with the physical well‐being (p = 0.018), psychological well‐being (p = 0.009), and total (p = 0.010) dimensions. Temporary stoma induced a feeling of anxiety for the closing of the stoma.

Abbreviations: MID, minimally important difference; QOL, quality of life.

3.2. Health‐Related Quality of Life Among Patients With Ostomy. Meta‐Analysis According to Sex

Data were pooled from 4 studies [25, 26, 27, 28], for a total of 915 observations, of which 401 related to the female group of patients and 514 related to the male group.

3.2.1. Total Quality of Life

Heterogeneity among the studies was low and not significant (p = 0.353; τ ² = 0.01; I ² = 8% with a 95% CI: [0%; 85.9%]). No significant differences in the total quality of life score according to group (t = −2.86; p = 0.064) were assessed (Figure 3). Both the Funnel Plot (Supporting Information S2) and the Eggers' test (β = 3.42; 95% CI = [2.56; 4.28]; p = 0.016) indicated that some publication bias was present. However, the small number of studies available may not have the statistical power to detect bias.

FIGURE 3.

Forest Plot for Total Quality Of Life in sex difference.

3.2.2. Physical Well Being

No heterogeneity was present among the studies (p = 0.561; τ ² = 0.01; I ² = 0% with a 95% CI: [0%; 84.7%]) From the results of the meta‐analysis presented by means of Forest Plot (Figure 4), we could observe that there was no significant difference in the Physical Well Being dimension between the two groups (t = −1.86; p = 0.160). The Funnel Plot (Supporting Information S3) indicated that no publication bias was present, also confirmed by the results of Eggers' test (β = 0.97; 95% CI = [−2.57; 4.51]; p = 0.645).

FIGURE 4.

Forest Plot for Physical Well Being in sex difference.

3.2.3. Psychological Well Being

No significant heterogeneity was found between the studies (p = 0.610; τ ² = 0.004; I ² = 0% with a 95% CI: [0%; 84.7%]). The Forest Plot (Figure 5) suggested that there was a significant difference in the Psychological Well Being effect between the two groups (t = −3.66; p = 0.035) in favour of the group of females. Additionally, the Funnel Plot (Supporting Information S4) indicated that there was no publication bias, also confirmed by the results of Egger's test (β = 0.44; 95% CI = [−3.08; 3.95]; p = 0.830).

FIGURE 5.

Forest Plot for Psychological Well Being in sex difference.

3.2.4. Social Well Being

The results showed the presence of homogeneity between the studies (p = 0.746; τ ² = 0.002; I ² = 0% with a 95% CI: [0%; 84.7%]). The Forest plot (Figure 6) suggested that there were no significant differences between the effects for the two groups (t = −1.96; p = 0.145). Egger's test and Funnel Plot (Supporting Information S5) showed that no publication bias was present (β = 0.51; 95% CI = [−2.33; 3.36]; p = 0.757).

FIGURE 6.

Forest Plot for Social Well Being in sex difference.

3.2.5. Spiritual Well Being

The heterogeneity present between the studies was high (p = 0.015; τ ² = 0.08; I ² = 71.2% with a 95% CI: [17.9%; 89.9%]). The Forest Plot (Figure 7) indicates that no significant differences were present between the two experimental groups (t = −0.58; p = 0.605). The Funnel plot (Supporting Information S6) and the Egger's test indicate the presence of publication bias (β = 4.82; 95% CI = [−0.45; 10.07]; p = 0.215).

FIGURE 7.

Forest Plot for Spiritual Well Being in sex difference.

3.3. Health‐Related Quality of Life Among Patients With Ostomy. Meta‐Analysis According to Ostomy Permanence

Data were pooled from 3 studies [25, 26, 28], for a total of 670 observations, of which 338 related to the temporary group of patients and 332 related to the permanent group.

3.3.1. Total Quality of Life

There was no heterogeneity among the studies (p = 0.366; τ ² = 0.01; I ² = 0.4% with a 95% CI: [0%; 89.6%]). The result of the analysis, reported via Forest Plot (Figure 8), suggested that there was a significant difference in the total quality of life score according to ostomy permanence, in favour of the temporary group (t = −7.53; p = 0.017). The Funnel Plot (Supporting Information S7) and the Eggers' test (β = 2.17; 95% CI = [−0.76; 5.1]; p = 0.384) indicated that no publication bias was present.

FIGURE 8.

Forest Plot for Total Quality Of Life in ostomy permanence difference.

3.3.2. Physical Well Being

No heterogeneity was present among the studies (p = 0.068; τ ² = 0.03; I ² = 62.8% with a 95% CI: [0%; 89.4%]). The Forest Plot (Figure 9) suggested that there was no significant difference in the Physical Well Being results between the two groups (t = −3.41; p = 0.077). The Funnel Plot (Supporting Information S8) indicated that no publication bias was present. This hypothesis could not be confirmed by the results of Egger's test due to the small number of available studies.

FIGURE 9.

Forest Plot for Physical Well Being in ostomy permanence difference.

3.3.3. Psychological Well Being

No significant heterogeneity was found between the studies (p = 0.382; τ ² = 0.01; I ² = 0% with a 95% CI: [0%; 89.6%]). The Forest Plot (Figure 10) showed that there was a significant difference in the Psychological Well Being effect between the two groups (t = −5.24; p = 0.035) in favour of the temporary group. The Funnel Plot (Supporting Information S9) and the Eggers' test (β = −2.39; 95% CI = [−3.78; −0.99]; p = 0.185) showed no publication bias.

FIGURE 10.

Forest Plot for Psychological Well Being in ostomy permanence difference.

3.3.4. Social Well Being

The results showed the presence of homogeneity between the studies (p = 0.488; τ ² = 0.01; I ² = 0% with a 95% CI: [0%; 89.6%]). The Forest plot (Figure 11) suggested that there was a significant difference between the effects for the two groups (t = −8.09; p = 0.015) in favour of the temporary group. Funnel Plot (Supporting Information S10) and the Eggers' test (β = 2.17; 95% CI = [1.23; 3.11]; p = 0.139) showed the absence of publication.

FIGURE 11.

Forest Plot for Social Well Being in ostomy permanence difference.

3.3.5. Spiritual Well Being

Homogeneity was present between the studies (p = 0.062; τ ² = 0.03; I ² = 64.1% with a 95% CI: [0%; 89.7%]). The Forest Plot (Figure 12) indicated that no significant differences were present between the two groups (t = −2.12; p = 0.168). The Funnel plot (Supporting Information S11) and the Eggers' test (β = 3.09; 95% CI = [−2.97; 9.15]; p = 0.500) indicate the absence of publication bias.

FIGURE 12.

Forest Plot for Spiritual Well Being in ostomy permanence difference.

4. Discussion

The present systematic review and meta‐analysis aimed to assess any differences in HRQOL among patients holding an intestinal ostomy both according to sex and the ostomy permanence.

A total of 915 observations were collected, specifically 401 related to females and 514 to males. Additionally, a total of 670 observations were recorded, like 338 belonging to the temporary group and 332 to the permanent one. Our analysis revealed a significant difference in the Psychological Well Being dimensions between sexes, in favour of females (t = −3.66; p = 0.035). However, our findings were in disagreement with Gautam and Poudel's study [29] who reported no significant sex‐related differences in psychological sub‐dimensions. In their study, males demonstrated lower psychosocial scores compared with females, opposite to the trend observed in our meta‐analytic data. Nonetheless, several further studies suggested the direction of our results [30, 31], indicating that females typically reported higher levels of anxiety, depression, psychological distress [32, 33] and body image disturbance [34, 35]. Moreover, literature suggested deeper gender‐related differences in contemporary societies, suggesting the need to develop sex‐specific supportive programs tailored to each domain of health [36]. Our review focused only on biological sex differences, without accounting for factors such as differential access to health services, utilisation of care, family support, and experiences within the healthcare system, all of which may shape HRQOL perceptions among men and women [37]. For example, cultural expectations often assign women the bulk of domestic responsibilities—including childcare, food preparation, and home management—which may influence their HRQOL after ostomy surgery [38]; however, evidence on these dynamics remained inconclusive [29]. Some studies suggested that women demonstrate more adaptive coping styles than men [36], being more likely to internalise stress and engage in coping strategies to address health‐related challenges [36]. Grant et al. [39], in their investigation of gender differences in HRQOL among rectal cancer patients, observed that depression and body image concerns were reported primarily by women, whereas men tended to experience greater difficulty in articulating their perceptions and emotional states [40, 41, 42].

Regarding ostomy permanence, temporary ostomy holders reported significantly better total HRQOL scores (t = −7.53; p = 0.017), as well as superior Psychological Well‐Being (t = −5.24; p = 0.035) and Social Well‐Being scores (t = −8.09; p = 0.015), compared with those with permanent ostomies. These findings diverge from some existing studies, which have shown higher HRQOL in patients with permanent ostomies across all dimensions [29]. Other research has reported low‐to‐moderate HRQOL among patients with temporary ostomies—particularly within the psychological and social domains—underscoring the importance of social support and self‐management training provided by healthcare services [43, 44].

The present systematic review and meta‐analysis included several limitations since its related organization. Surely, to facilitate our work, we only considered the sex variable, while a future, more comprehensive work will include gender as a variable. Additionally, we included only HRQOL assessments adopting the COH‐QOL‐Ostomy since other data found in our research did not allow us to conduct a meta‐analysis of their related data.

5. Conclusion

In the present systematic review, we analysed differences in HRQOL sub dimensions considering sex and ostomy permanence. Understanding sex‐related variations in HRQOL could help clinicians tailor interventions that more effectively address the specific needs of patients improving QOL outcomes. Because current literature more frequently reports outcomes by sex, future research would benefit from defining more precise gender‐related outcomes as well. This would enhance the ability to identify which aspects of HRQOL are influenced by gendered experiences—beyond biological sex—and support the development of interventions that achieve comparable results across diverse populations. Similarly, considering the permanence of the ostomy could help healthcare professionals design more targeted clinical pathways. In particular, distinguishing temporary from permanent ostomies might guide the provision of psychosocial support, self‐management training, and follow‐up care. Such tailored approaches could strengthen social support systems and improve self‐care behaviours, ultimately contributing to better overall HRQOL in this patient population.

Disclosure

The authors affiliated to the IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, are responsible for the views expressed in this article, which do not necessarily represent the Institute.

Ethics Statement

The authors have nothing to report.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supporting Information: S1. Search strings carried out to perform this systematic and meta‐analysis study.

Supporting Information: S2. Contour‐enhanced funnel plot for total quality of life in sex difference.

Supporting Information: S3. Contour‐enhanced funnel plot for physical well being in sex difference.

Supporting Information: S4. Contour‐enhanced funnel plot for psychological well being in sex difference.

Supporting Information: S5. Contour‐enhanced funnel plot for social well being in sex difference.

Supporting Information: S6. Contour‐enhanced funnel plot for spiritual well being in sex difference.

Supporting Information: S7. Contour‐enhanced funnel plot for total quality of life in ostomy permanence difference.

Supporting Information: S8. Contour‐enhanced funnel plot for physical well being in ostomy permanence difference.

Supporting Information: S9. Contour‐enhanced funnel plot for psychological well being in ostomy permanence difference.

Supporting Information: S10. Contour‐enhanced funnel plot for social well being in ostomy permanence difference.

Supporting Information: S11. Contour‐enhanced funnel plot for spiritual well being in ostomy permanence difference.

Vitale E., Maistrello L., Cauli O., et al., “Health‐Related Quality of Life Among Patients With Ostomy Intestinal Stoma According to Sex and Ostomy Permanence: A Systematic Review and Meta‐Analysis,” International Wound Journal 23, no. 2 (2026): e70817, 10.1111/iwj.70817.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.