Support garments don’t actually prevent hernias.
It might come as a surprise to learn that there is no conclusive evidence from randomised controlled trials proving that support garments can prevent hernias.
The lifetime risk of developing a parastomal hernia is anything between 50-70%. In fact, formation of a stoma, is in fact formation of a hernia, when the bowel is pulled through the abdominal wall. Surgeons readily agree that when they make a stoma, they’ve made us a hernia.
However, whether we go on to develop a significant bulge, problematic or prominent hernia around our stoma is another matter. There are many factors involved in hernia development, many of which (surgical technique, infection, number of surgeries etc) are outside of our control. The biggest factors within our control are body weight, abdominal fat, obesity, smoking and weakness of the abdominal wall muscles and muscle loss of the entire body. Support garments are only a tiny part of the puzzle, and probably don’t do as much as we think.
So with this in mind. What do we, as patients, do? does it mean that support garments don’t have any benefit?
We ultimately need to take a more nuanced approach to the role of support garments and view garments and belts as one tool in our toolbox.
Garments definitely have a place and purpose, but we need to reframe the narrative around them. Why do we wear them? what’s the purpose and goal? what are they doing for us?
Some questions to consider:
- What are you trying to achieve by wearing the garment? – what’s the purpose? support of a hernia? aesthetics? Confidence? Support of the bag and holding things in place? manage pain or discomfort? Remember they all do different things and be really clear about what you goals and needs.
- Does your garment do what you want it to? Is it really solving the problem? Is it really working for you?
- Are you wearing it simply because you’ve been told to?
- Is it comfortable? Can you breathe properly in it and move around without restriction?
- Does it create other problems (leakage, pancaking, getting hot and sweaty)?
- Are there other alternatives? Does it have to be a specific stoma garment or will something else work equally well?
- Do you feel you need support, but are resistant to wearing a garment? Could you try some different items and do more research?
Going through these questions you might uncover some answers, but also more questions. So take the opportunity to investigate other alternatives and try different items. Have a discussion with your stoma nurse or contact a garment manufacturer, such as Vanilla Blush, for impartial evidence based advice.
Either way, I’d encourage you to honestly and critically appraise your decisions and choice of garment and advocate for your own needs and choices. Don’t be pushed into support wear if you don’t want it or don’t feel you need it.
We need to move away from the narrative of wearing ‘support garments to prevent hernia’ and being fearful of movement or exercise unless we’re wearing a garment. And instead, move towards a more multi-factorial approach to hernia prevention and management including lifestyle factors.
“The pants are only part of the picture”
How to choose the right garment
With so many products available, how do you make the right choice?
It’s important not to lump all ‘support garments’ into the same bucket. There are so many different styles, types and levels of support offering different benefits, levels of comfort and purpose. Some provide significant levels of support for large hernias, whilst others provide lighter support and more of an aesthetic benefit, simply creating a flatter profile and holding the bag in place under clothing or during exercise. There are belts, boxers, bands, vests and pants to choose from, so pick what is best for you and your lifestyle.
The position of your stoma on your abdomen is often a key driver of what sort of garment to wear. Stomas above the waist line are more tricky, so choose high waisted pants, boxers or vests to provide a smooth line and hold the bag flat and in place. It might be that have different garments for different activities too.
Summary of support garment use:
Hernia prevention – There is a lack of strong evidence that support garments have a role in preventing hernias. There are too many factors involved. Hernia prevention is multifactorial – check out the list below.
Aesthetics/holding bag in place/comfort – High waisted leggings, underwear, tights or stoma specific garments and belts and light support can provide what you need to create a smooth line under clothing and ‘hold things in place’.
Confidence – A correctly fitting and comfortable support garment can increase confidence to work, engage in physical activity and improve quality of life. This could be either a stoma specific product or normal clothing which can do the same role.
Hernia support – If you HAVE a hernia, it’s likely that some sort of stronger firmer support will provide some comfort and support, especially for a large uncomfortable hernia. Seek advice from your stoma nurse and garment manufacturer. Check the list below for hernia management strategies such as core exercises and weight loss.
What are the benefits of support wear?
Confidence, a feeling of support and being ‘held in’ are the most common benefits noted, and for many it’s a way to hold the bag in place under clothing and improve the appearance of the tummy.
We should not wear support garments with the mindset of preventing hernia, or that it’s somehow mandatory when exercising. I hear a lot of people say they’ll only wear their support pants when they got to the gym or go running. What we actually need in this situation is a strong functional abdominal wall. Our ‘internal support pants’ – in other words our own muscles.
That said, support garments can facilitate physical activity for some people and get them out exercising when otherwise they may stay inactive. In this case, the reassurance provided by support wear makes engaging in exercise more comfortable and less stressful, which, in turn, supports better long-term outcomes. However, don’t let them become a ‘crutch’ and what’s likely to be more important is development of abdominal wall muscles. So work on your core, and start to reduce reliance on the pants.
Costs
A report by NHS Scotland in 2019 found annual spend on stoma support wear to be estimated to be £270,000 and in England to be around £1.4m.
This report led to NHS Scotland changing their prescription policy on support garments, so that support garments are no longer offered on prescription as a prevention measure. The report states that the evidence just doesn’t stack up to support such a cost. However, support wear for people with existing hernias are available on prescription.
In England, the picture is less clear. It is entirely down to the discretion of your GP and should be based on clinical need after assessment from a stoma nurse. So whilst you MAY be able to get items on prescription if needed and appropriate, it’s not an automatic entitlement. It’s worth bearing that in mind when you consider your needs and appropriate use of any garment.
We all need to do our bit in helping to reduce healthcare expenditure, so if you don’t think you need a garment or you don’t think you’ll wear it, you don’t need to receive support garments on prescription. Research has shown that many people get a product on prescription and then simply don’t wear it, resulting in wasted NHS money.
Things we can do to reduce the likelihood of hernia or manage an existing hernia:
Remember that support wear is only part of the picture when it comes to hernia prevention and management. There is a lot we can do to help ourselves. Whilst research is still ongoing, being active and doing the correct core exercises should be a fundamental part of your strategy. My classes at The Ostomy Studio are designed specifically for people with stomas and hernias.
Here are 10 top tips to prevent and manage a hernia:
- Keep weight down or lose weight – especially fat round the abdomen – try to avoid large weight changes post-surgery. Many surgeons feel this is the biggest risk factor of all
- Do not smoke or vape – make this a priority to stop
- Treat/medicate any cough, cold, hay fever or nose blowing issue straight away to reduce acute bouts of pressure around stoma
- Improve the muscle tone and strength of the abdominal wall through appropriate core exercises or clinical Pilates – this is a lifelong requirement
- Train your abdominal wall and core to a high level if you wish to do high level sporting activities – you need to be stronger than you ever were before surgery to do the same activities
- Learn how to manage and regulate intra-abdominal pressure through correct diaphragm breathing and deep abdominal muscle engagement – get help with this from a physio or clinical exercise specialist/Pilates teacher
- Stay fit and active and maintain good muscle strength throughout your whole body – especially as you age
- Learn how to lift correctly, engaging your abdominal muscles and exhaling on effort/exertion
- Consider wearing a support garment if it helps you feel more confident to be active and engage in exercise, but reduce reliance on it over time as you get stronger
- Wear an appropriate support garment to support an uncomfortable hernia
EXPASS Position Statement
The EXPASS expert panel who recently wrote the ASCN guidelines on exercise and physical activity after stoma surgery, wrote a position statement on support garments – page 36. Read the full statement here
Summary
Support garments have an incredibly important role, and can improve the confidence and wellbeing of people living with stomas and hernias. But we need to change the narrative.
We must move away from the thinking that everyone should ‘wear a support garment to prevent hernia, or when doing something strenuous’ and more towards an more nuanced and individual approach, considering why you wear one, the purpose of it and an honest appraisal of its pros and cons. Then make an individual and informed choice about what you wear, when and why.
References:
Hubbard G, Taylor C, Munro J, Dames N, Goodman W, Oliphant R, Beeken R. Experiences of support garments following bowel stoma formation: analysis of free-text responses in a cross-sectional survey. BMJ Open Gastroenterol. 2019 May 14;6(1)
Taylor C, Munro J, Goodman W, Russell S, Oliphant R, Beeken RJ, Hubbard G. Hernia Active Living Trial (HALT): an exercise intervention in people with a parastomal hernia or bulge. Br J Nurs. 2023 Dec 7;32(22):S4-S11.
