Background <p>Continent ileostomy (Kock pouch, KP) is an established option after proctocolectomy, mostly for inflammatory bowel diseases or familial adenomatous polyposis (FAP). The indications in slow transit constipation (STC) are less common and the data situation is limited. Complications during the course, particularly valve failure, represent a surgical challenge in continent ileostomy.</p> Case presentation <p>We report the case of a 32-year-old female patient with severe treatment-refractory STC and multiple previous operations, including a primary complicated course of a KP placement and two unsuccessful external revision attempts. At the time of presentation in this hospital the patient showed a complete incontinence of the KP and a symptomatic rectovaginal fistula (RVF) after residual proctectomy. Intraoperatively, there was a substance defect and a lack of fixation of the valve. A successful revision of the KP was carried out with restoration of continence and resection of the rectal stump with closure of the fistula; however, a small RVF persisted postoperatively.</p> Conclusion <p>This case illustrates the complex challenges in patients with STC and KP. Even after multiple previous operations and complications, such as valve failure and fistula formation, a revision of the KP in an experienced center can be successful and substantially improve the quality of life. The treatment of persistent fistulas is still demanding. For selected patients with STC the Kock pouch can represent an option to be considered but requires understanding and commitment on the side of the patient and medical expertise in placement and management.</p>