Explore Ostomate - Compatible Toilets

As part of an out-of-hospital practice program conducted by the Department of Coloproctological Surgery, we investigated the facilities for ostomates together with Malaysian medical students from British colleges. We visited Asakusa and Kamakura to search for ostomate-compatible toilets. We had paid little attention to the ostomate symbol. Actually, there were not only ostomate-compatible toilets in hospitals, but also in many public places. An ostomate-compatible toilet was equipped with a large and deep sink at waist height, which allows the ostomate to dispose of feces from the stoma pouch. Some ostomate-compatible toilets also had a hand shower for cleaning the skin around the stoma. Since there has been an increase of ostomates, it is an urgent necessity to also increase the number of ostomate-compatible toilets and raise public awareness. However, there is a larger number of ostomate-compatible toilets in Japan, compared with other countries. This tour provided our first experience with ostomate-compatible toilets. We were able to identify a larger than expected number of ostomate-compatible toilets during out-of-hospital practice.


Introduction
We had an opportunity to participate in clinical clerkship conducted by the Department of Coloproctological Surgery and encounter colostomy patients. Although we had knowledge of artificial anuses, this was our first time to see them. We also attended lectures on artificial anuses and learned about ostomate-compatible toilets that have been specially developed for ostomates 1) . We became interested in artificial anuses and ostomate-compatible toilets.
This paper reports our findings on ostomatecompatible toilets obtained during out-of-hospital practice.

Out-of-hospital practice
Our medical advisor assigned us the task of finding ostomate-compatible public toilets in order to gain better knowledge of them with the Malaysian students who came from British colleges to study during the clinical clerkship period.
The ostomate symbol was posted at the entrance to ostomate-compatible toilets ( Figure-1).
We visited Asakusa and Kamakura to carefully search for ostomate-compatible toilets, and it was not difficult for us to identify the ostomate symbol in shopping areas and sightseeing spots.
In Asakusa, we were able to identify a larger than expected number of ostomate-compatible toilets (Figure-2). There were ostomate-compatible toilets at the entrance to the Asakusa Culture Tourist Information Center in the front of Kaminarimon Gate.
In Kamakura, ostomate-compatible toilets were located at Kamakura Station, Tsurugaoka Hachimangu Shrine, Enoshima Island, and other famous sightseeing spots. The ostomate-compatible toilets at Kamakura Station were particularly spacious and clean.
As one of its characteristics, an ostomate-compatible toilet was equipped with a large and deep sink at waist height, which allows the ostomate to dispose of feces from the stoma pouch. The users can place devices required to exchange the stoma on a shelf (clean and wide space where the devices can be placed) and use a mirror (which allows the users to view the stoma while changing their appliances) on a wall. Some ostomate-compatible toilets also had a hand shower for cleaning the skin around the stoma (Figure-3).
This tour provided our first experience with ostomate-compatible toilets.

Discussion
An ostomate is a person who has undergone surgery to create an abdominal stoma because of trauma or disease. Japan has approximately 200,000 Ostomates have a mean age of 71 years, and there are twice as many male ostomates as female ostomates 2) . An ostomate attaches a pouch to his/her stoma and exchanges it for a new pouch when it becomes filled with feces. However, it is difficult for an ostomate to exchange the pouch comfortably in a common toilet with little space. Although toilets for the disabled and multipurpose toilets are more spacious, they do not have the facilities required for exchanging pouches. Ostomate-compatible toilets have special facilities, so that ostomates can dispose of feces and used equipment, remove and attach stoma pouches, and clean the skin surrounding the stoma 2) 3) . Most of the toilets for ostomates that we viewed on the tour were relatively clean and had these facilities.
Interestingly, there were more ostomate-compatible toilets than we had expected. The number of ostomate-compatible toilets installed in Tokyo was 1, 182, and the number was approximately three times as large as that in Kanagawa (471), Saitama (405), and Chiba (385) Prefectures, respectively (https: //www. ostomate. jp/). Although we were familiar with the symbol indicating a toilet for people with physical disability, we had paid little attention to the ostomate symbol. Actually, there were not only ostomate-compatible toilets in hospitals, but also in many public places such as train stations and parks. There has also been an increase of ostomate-compatible toilets at highway rest areas and in Shinkansen bullet trains. Online services are also available to provide information, including the locations of ostomate-compatible toilets 4) . We learned that the places with ostomatecompatible toilets can be identified by performing an online search. However, even if stations and other facilities with ostomate-compatible toilets were identified through online searches, some of them had only one such toilet, and it was difficult to locate it. The number of ostomate-compatible toilets is far smaller than that of multipurpose toilets and remains insufficient for the needs of ostomates. Furthermore, according to a survey conducted by the Japan Ostomy Association, the public facilities in approximately 30% of Japanese municipalities have no ostomate toilet 2) . Since there has been an increase of ostomates, it is an urgent necessity to also increase the number of ostomatecompatible toilets and raise public awareness 2) 3) .
As part of an out-of-hospital practice program, we investigated the facilities for ostomates together with medical students from British colleges. Interaction with people who have different views and customs inspired us significantly and helped us to develop an international perspective. It also increased our motivation to study medicine. We felt more confident because we were able to communicate with the Malaysian students in English.
Furthermore, we learned about differences between British and Japanese public toilets. Medical students from British colleges stated that an estimated one in 500 people living in Britain has a stoma, and that the out-of-hospital practical training raised their awareness of the necessity of meeting ostomatesʼ needs. We could not obtain information on the exact status of ostomatecompatible toilets, including their numbers, in Britain through online searches. However, they were also impressed by the significantly larger number of ostomate-compatible toilets in Japan, which are referred to as stoma-friendly-accessible toilets in Britain, and their excellent functions, compared with those in Britain. As a primary difference between the two countries, toilets in Britain are not as clean as those in Japan, in which ostomatecompatible and other toilets in most places are always clean. Caring for public conveniences is an example of the Japanese"spirit of hospitality,"and this experience re-emphasized to us that Japan is a wonderful country.
As a limitation of the present report, there is a marked demand for ostomate-compatible toilets in the center of cities and bustling areas visited by many people, and we chose Asakusa and Kamakura as the survey areas to examine the status of responses to these needs. Although the results of online searches provided the number of ostomatecompatible toilets available outdoors, we have few experiences of using them to examine their size and convenience, and it is difficult to describe the status of responses to the above-mentioned needs.
In conclusion, we were able to gain better knowledge about ostomate and ostomate-compatible toilet in this out-of-hospital practice. We also found that there are more ostomate-compatible toilets installed in Japan than in Britain through discussions with British medical students. However, the needs of ostomate-compatible toilets are not yet satisfied. Increasing the number of ostomatecompatible toilets in all over Japan is our top priority issue.
We would like to thank the doctors of the Department of Coloproctological Surgery for providing us with such a valuable opportunity.