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- Wolters Kluwer Health
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- Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc.
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- 1661-7657
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- 1661-7657
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- 10.1097/cu9.0000000000000044
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Abstract
Background: Purple urine bag syndrome (PUBS) is an unusual condition in which a purple discoloration of urine and bag occurs in peo- ple with urinary catheters. People with purple urine usually do not complain of any symptoms. The purple discoloration of the urine bag is often the only finding, frequently noted by caregivers. Materials and methods: This prospective observational study was conducted at our tertiary care institute from June 2018 to May 2020. A total of 46 patients with PUBS were included in this study. The objective of our study was to record the prevalence of each pre- disposing factor and to correlate the pathological mechanism through which the PUBS is manifested. Results: The mean age of PUBS patients was 67.4years and 67.4% were males. Most patients of PUBS (60.9%) had a urethral catheter, while there was percutaneous nephrostomy in 26.1% patients and 13% patients had a percutaneous suprapubic cystostomy catheter. Among the patients, 69.65% were bedridden or in an institutionalized situation, 73.9% were suffering from chronic constipation, 21.7% were associated with dementia, and 47.8% were cerebrovascular accidents with hemiparesis patients. In addition, 93.5% of patients presented with alkaline urine and 3 patients with acidic urine. The most common bacteria isolated in urine culture were E coli and Pseudomonas. Conclusions: Urinary catheter associated urinary tract infection and PUBS is most commonly documented in females, but our study showed that it is more common in males. The appearance of a purple bag does not depend on the material and type of the catheter or the catheterization method. In addition, no correlation was found between the microorganisms isolated from the environment and patients’ urine. Keywords: Constipation; Percutaneous nephrostomy; Purple urine bag syndrome; Tryptophan; Urinary catheterization; Urinary tract infection 1. Introduction renal disease, dehydration, patients with an indwelling catheter and recurrent urinary tract infection (UTI), and those with catheter [2,4] Purple urine bag syndrome (PUBS) is an unusual condition in which bags and tubes made of certain types of plastic. Some believe purple discoloration of urine and bag occurs in people with urinary that different bacteria in urine create the purple color, in combina- [1] catheters. PUBS was first reported in 1978, and since then there is tion with the above factors, facilitating the development of PUBS. no scientific evidence to explain why this happens. Research does It is important to note that catheter-associated UTI is the most com- [5] not show its relation to the type or brand of urine bags or catheters mon cause of infection in all healthcare facilities. Unlike traditional used, as it can occur in all types of catheters. People with PUBS usu- UTIs, those associated with PUBS are more likely to be asymptomatic ally do not complain of any symptoms. Purple discoloration of the but on culture may show significantly higher bacterial loads (1–2logs) [2] urine bag is often the only finding, frequently noted by caregivers. than those without the syndrome. This latter point is important, Although it is uncommon, the prevalence of PUBS has been reported as this leads to greater levels of bacterial sulfatases and phospha- to be as high as 9.8% in institutionalized patients with long-term in- tases necessary for PUBS. Purple urine bag syndrome is mostly be- [2,3] dwelling urinary catheters. Purple urine bag syndrome have been nign, although it causes great concern for patients, family mem- shown to be associated in high-risk patients such as elderly, female bers, and healthcare workers when encountered. It usually resolves gender, alkaline urine, constipation, poor hygiene, institutionaliza- with removal of the offending agent. tion, and a bedridden situation with immobilized patients, end-stage The aim of our case series was to record the prevalence of each predisposing factor in our institute. Therefore, we can draw safe conclusions about its recognition and propose a method to prevent * Corresponding Author: Vishal Kumar Neniwal, Department of Urology and Renal misdiagnosis and effective prevention and management. Transplant, SCB Medical College Cuttack, Odisha, 753007, India. E-maii address: vishalneniwal@gmail.com (V.K. Neniwal). Current Urology, (2023) 17, 2, 125–129 Received October 7, 2020; Accepted January 4, 2021. 2. Materials and methods http://dx.doi.org/10.1097/CU9.0000000000000044 Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. This is This prospective observational study was conducted at our tertiary an open-access article distributed under the terms of the Creative Commons care institute from June 2018 to May 2020. The study was con- Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it ducted in adherence to the ethical guidelines of the Declaration of is permissible to download and share the work provided it is properly cited. The Helsinki and its amendments. We included all urological patients work cannot be changed in any way or used commercially without permission from the journal. who presented to us with PUBS during this period. The patient profile, 125 Neniwal et al. Volume 17 Issue 2 2023 www.currurol.org disease profile, comorbidities, clinical presentation, investigations, Table 1 and characteristics of the catheter were recorded in all patients. All pa- Categorical variable summary of our study. tients were managed with a catheter and urobag replacement, antibi- otics according to urine culture, and a few cases received symptomatic Categorical variable treatments. All patients were followed-up for 21 days during catheter S. No summary Number Percentage, % p replacement and any recurrence was noted. We also sent aerobic and 1 Sex 0.00084 anaerobic swab samples from different area in our procedure room Male 31 67.4 along with air samples by Koch’s sedimentation settle plate technique Female 15 32.6 to culture microorganism, and this was correlated to microorganisms 2 Comorbidity 0.06724 found in the present study. Dementia 10 21.7 Statistical analysis was performed using SPSS version 25 (Armonk, Chronic constipation 34 73.9 NY, IBM Corp.). Written consent was taken from all patients prior Cerebrovascular accident with 22 47.8 to the procedure and for use of clinical details for academic pur- hemiparesis pose. Patients who refused to give consent or were lost to Obstructive uropathy with CKD 11 23.9 follow-up were excluded from this study. We confirm availability Cardiovascular disease 4 8.69 Bedridden 21 45.6 and access of all original data reported in this study. Institutionalization 11 23.9 3 Type of catheter material <0.00001 PVC plastic catheter 39 84.7 3. Results Silicone catheter 7 15.2 4 Type of catheter 0.00078 A total of 46 patients with PUBS were included in this study. The Per urethral bladder catheter 28 60.8 mean age of the patients was 67.4 years (range, 34–87years). Most Nephrostomy catheter 12 20.08 of the patients were males (67.4%) as compared to females. This Percutaneous suprapubic 613.04 was statistically significant. We found purple discoloration with catheter the urethral Foley catheters was most common (60.9%), with per- 5 Type of catheterization 0.00018 Permanent 32 69.5 cutaneous nephrostomy in 26.1% of the patients, and with 13% of Temporary 14 30.4 patients with percutaneous suprapubic cystostomy catheter. This 6 Symptom at time of presentation <0.00001 was statistically significant. Six patients of PUBS had both a ure- Symptomatic 11 23.9 thral catheter and a nephrostomy catheter out of 28 patients of Asymptomatic 35 76.08 PUBS with a urethral catheter (Fig. 1). 7 Urinary catheter <0.00001 In our study, the duration between the last catheter placement Changed 38 82.6 and PUBS appearance was on average 65 days (range, 7–130 days). Removed 8 17.3 Around 70% patients who were on permanent catheterization due 9 Procedure room-air/swab culture Organism isolated to chronic illness developed PUBS in our study. Overall, 45.6% Dressing trolley No growth bedridden patients, 24% institutionalized patients, and 73.9% Procedure table Enterococcus Spp. Procedure room-walls Staphylococcus aureus chronic constipation patients were found with PUBS. We found ce- rebrovascular accidents with hemiparesis (47.8%) were the most CKD = chronic kidney disease. common comorbidity in our study, along with dementia present in 21.7% patients. This was statistically not significant. We also and the other 3 patients showed acidic. Out of 46 patients, 37 found that most patients had PVC plastic catheter material (84.8%) (80.5%) patients on urine microscopy revealed many pus cells and and 7 patients had silicon catheters associated with PUBS and this phosphate crystals. Urine culture was sent for all PUBS patients. was statistically significant (Table 1). On urine microbiological analyses, 4 patients out of 46 showed Most patients who presented with PUBS seemed to be largely more than 1 microorganism and the remaining 42 patients showed asymptomatic (76%), while the remaining 11 (24%) patients of single microorganisms in their urine culture. The urine culture was PUBS were symptomatic and this was statistically significant. Routine positive for E. coli in 20 (47.6%) out of 42 patients. The second most urine examination of most patients showed clear urine with no purple common organism was Pseudomonas aeruginosa seen in 11 pa- discolorations. Urine dipsticks of 43 patients showed alkaline urine tients (26%) followed by Proteus mirabilis (11.9%) and Klebsiella pneumoniae, Providencia stuartii, Enterococcus, and Morganella morgannii were the bacteria most frequently isolated (Fig. 2). This was statistically significant. Replacements of catheters and urobags were done. Lactulose was prescribed for constipation. All 46 pa- tients were started on antibiotic according to the urine culture sensitiv- ity report. Forty two patients were treated with 1 antibiotic and 4 with a combination of 2 antibiotics. None of the patient reported recur- rence of a new purple bag to the followup visit at 3 weeks. No growth in repeat urine culture was seen in any patient. None of the patient had any symptoms suggestive of UTI on follow-up. 4. Discussion Figure 1. A 74-year-old female, left percutaneous nephrostomy and per urethral All patients in our study presented with discoloration of tubing and catheter bag both have purple discoloration. urobags which was purple in color, so patient and their family 126 Neniwal et al. Volume 17 Issue 2 2023 www.currurol.org Most study data suggested that PUBS affects chronically debili- tated females and is associated with alkaline urine, dementia, chronic constipation, and comorbidity with chronic catheterization. A thor- ough literature review revealed that PUBS affects females more than [4,5,10] males. In our study, we maintain a procedure register, as per that register we had 220 patients during the study that came for reg- ular per urethral catheter replacements with 160 males and 60 fe- males; in which31males and15females developedPUBS. So,we found more males as compared to females and this was statistically significant (Fig. 3). This finding contradicts various literatures. This finding may be due to more male patients attending urology Outpa- tient Department. But, we recommended further study with a larger sample size. Most PUBS patients use long-term catheters because of immobili- zation, such as patients who are chair bound or are completely bed- [10] Figure 2. Urine culture shows number of microorganism. ridden. In our study, we also found 69.6% patients had mobiliza- tion problems as they were ether bedridden or institutionalized. members were worried about this sudden change in urine color There are only a few cases reported in the literature of PUBS and came to the hospital. Purple urine bag syndrome was usually with underlying nephrostomy and a suprapubic cystostomy cath- [12–14] benign and harmless without serious consequences in our study. eter. In our study, we also found cases of PUBS in the setting Purple urine bag syndrome is a rare phenomenon in which the con- of nephrostomy tubes and percutaneous suprapubic cystostomy tubes tents of urine bags and tubing turn purple or blue following (Fig. 4). Most patients had a urethral bladder catheter (60.9%), while long-term urinary catheterization. The first case of PUBS was de- 26.1% had a nephrostomy catheter, and 13% had a percutaneous [1] scribed in 1978 by Barlow and Dickson. However in 1812, the suprapubic cystostomy catheter. These numbers suggested that PUBS [6] English King George III was believed to have purple bag syndrome. not only develop in urethral catheters but also in other type of The PUBS can be easily identified and treated but it remains a draining catheter, such as nephrostomy catheters and cystostomy neglected entity, in spite of the fact that it implies a considerable un- catheters. This was statistically significant. derlying pathology. Pathophysiology of PUBS is a chain reaction The duration from the last catheterization and PUBS appearance regarding the metabolism of tryptophan that leads to urinary was on average 65 days. Most studies suggested that prolonged [1,7] byproducts of indirubin and indigo. Tryptophan is an a-amino urinary catheterization led to increased chances of PUBS. acid used in the biosynthesis of proteins. This tryptophan is metab- Our study also found the same, but few patients presented within [7,8] olized into indole by gut flora. Afterwards it is diffused into the a few days of catheter placement with purple urine bag. These portal blood circulation and reaches the liver where it is converted findings suggest that not only the duration of catheter placement [9] into 3-hydroxyindole through cytochrome P450 2E1 (CYP2E1). is responsible for PUBS but other factors also play a role in its Following that, 3-hydrox- yindole is sulfonated through the liver development. SULT1A1 isoform, leading to indoxyl sulfate (indican) forma- Most of the time alkaline urine is an important factor encoun- [10,11] tion. This indoxyl sulfate (indican) is excreted from the circu- tered in the phenomenon of PUBS as observed but some studies [15,16] lation into the urinary tract. There, under the influence of bacterial have also reported PUBS in acidic urine. In our study, we also enzymes such as indoxyl sulphatases and indoxyl phosphatases, found 3 case had acidic urine while the rest had alkaline urine. mostly in an alkaline environment, indoxyl sulfate oxidation in Urine culture report showed in our study that Enterobacter- the urinary tract results in the production of 2 pigments: indirubin iaceae such E. coli accounted for almost half of cases; P aeruginosa [3,4] (red) and indigo (blue). The mixture of indirubin and indigo was the second most common and was implicated in almost 26% pigments are responsible for giving urine or the urine bag the pur- of cases. The presence of bacteria in urine culture is not always as- ple color. However, we could not confirm these associations as the sociated with PUBS and no causative relationship between specific [16] urinary bacterial load was not available in most of the studies. types of bacterial species and PUBS can be documented. A Figure 3. A 55-year-old male present with purple discoloration of perurethral Figure 4. A 34-year-old male present with purple urine bag syndrome of suprapubic catheter bag. catheter plastic tube and bag. 127 Neniwal et al. Volume 17 Issue 2 2023 www.currurol.org thorough review of the literature revealed that the most common adherence to the ethical guidelines of the Declaration of Helsinki bacteria associated with PUBS are Providentia stuartii, Providentia and its amendments. Written consent was taken from all pa- rettgeri, K pneumoniae, E. coli, P. mirabilis, Paeruginosa, Entero- tients prior to the procedure and for use of clinical details for [3,17] coccus species, and M. morgannii. academic purpose. Development of PUBS also depends on the type of catheter ma- terial. In our study we found 84.8% PUBS patients had a PVC fo- Conflict of interest statement ley catheter. Literatures have suggested that silver-impregnated Foley catheters and hydrogel urinary catheters pretreated with The authors report no conflicts of interest. antibiotics can significantly reduce biofilm formation and therefore [18,19] reduce the chance of UTI and PUBS. Funding source Most patients were asymptomatic in our study, and around 24% patients presented with UTI along with PUBS. So initially em- None. pirical antibiotics were prescribed in symptomatic patients and urine culture was sent. Purple urine bag syndrome may be benign Author contributions but is of great concern for patients and their relatives. However, PUBS may only reflect asymptomatic bacteriuria, so aggressive VKN: Concept, design, definition of intellectual content, literature management with antibiotics is not initially advised in all pa- [20,21] search, data acquisition, data analysis, statistical analysis, manu- tients. Since urine microscopy showed plenty of pus cells script preparation, manuscript editing, and manuscript review; and urine culture showed microorganism and a high bacterial load, SS: Concept, definition of intellectual content, data acquisition, the chance of serious complication in the future could not be ruled manuscript editing, and manuscript review; out. So, in all patients, replacement of urinary catheters, urobags SKR: Literature search, data acquisition, data analysis, statistical and tubes was done along with antibiotics according to the urine cul- analysis, and manuscript preparation; Datteswar Hota: Concept, ture report and correction of constipation was done to reduce recur- manuscript editing, and manuscript review; rence. Hygiene, good nutrition with higher fiber diets and appropri- PA: Data acquisition, data analysis, statistical analysis, and manu- ate hydration, good bowel habits and catheter sanitation must be script preparation; addressed with the removal of unnecessary catheters if required. PKY: Data acquisition, data analysis, statistical analysis, manu- As the incidence of PUBS has increased in the last few years in script editing, and manuscript review. our institute, we have taken swab samples and air sample from differ- ent area in our procedure room to culture microorganism. We found References Enterococcus species from the procedure table, Staphylococcus aureus from the procedure room wall, while no organisms were iso- [1] Khan F, Chaudhry MA, Qureshi N, Cowley B. Purple urine bag syndrome: lated from the procedure trolley. All these environmental organisms An alarming hue? A brief review of the literature. Int J Nephrol 2011;2011: may lead to PUBS but we found no correlation between the microor- ganism isolated from the environment and patient’s urine in our study. [2] Lin CH, Huang HT, Chien CC, Tzeng DS, Lung FW. Purple urine bag syndrome in nursing homes: Ten elderly case reports and a literature review. Clin Interv Aging 2008;3(4):729–734. [3] Su FH, Chung SY, Chen MH, et al. Case analysis of purple urine-bag 5. Conclusions syndrome at a long-term care service in a community hospital. Chang Gung Med J 2005;28:636–642. The number of PUBS patients has increased in last few years in our [4] Lin HH, Li SJ, Su KB, Wu LS. Purple urine bag syndrome: A case report institute. Catheter-associated UTI and PUBS is most commonly and review of the literature. J Intern Med Taiwan 2002;13:209–3. [5] Kalsi DS, Ward J, Lee R, Handa A. Purple urine bag syndrome: A rare spot seen in females, but our studies showed they were more common diagnosis. Hindawi Dis Markers 2017;2017:9131872. in males. The appearance of a purple bag not only depends on [6] Arnold WN. King George Ill’s urine and indigo blue. Lancet 1996; the material of the catheter and the type of the catheter, but also 347 (9018):1811–1813. on the type of catheterization. In addition, no correlation was [7] Dealler SF, Hawkey PM, Millar MR. Enzymatic degradation of urinary found between the microorganism isolated from the environment indoxyl sulfate by Providencia stuartii and Klebsiella pneumoniae causes and patient’s urine. A delay in regular follow-up in a patient can the purple urine bag syndrome. J Clin Microbiol 1988;26(10):2152–2156. [8] Rossi M, Johnson DW, Morrison M, et al. Synbiotics easing renal failure lead to such complications. by improving gut microbiology (SYNERGY): A randomized trial. Clin J As PUBS is a clinical manifestation of underlying UTI if not timely Am Soc Nephrol 2016;11(2):223–231. managed, it is important that the drainage tubing and bags and in- [9] Banoglu E, Jha GG, King RS. Hepatic microsomal metabolism of indole to dwelling catheter may need to be changed on a regular basis. For indoxyl, a precursor of indoxyl sulfate. Eur J Drug Metab Pharmacokinet asymptomatic patients, treatment should be aimed at the underlying 2001;26(4):235–240. [10] Yang HW, Su YJ. Trends in the epidemiology of purple urine bag medical problem rather than purple bag, and to reduce the likelihood syndrome: A systematic review. Biomed Rep 2018;8(3):249–256. of this problem. This highlights the need of educating patients and [11] Banoglu E, King RS. Sulfation of indoxyl by human and rat aryl (phenol) their family members regarding the possibility of developing PUBS. sulfotransferases to form indoxyl sulfate. Eur J Drug Metab Pharma- cokinet 2002;27(2):135–140. Acknowledgments [12] Ferrara F, D’Angelo G, Costantino G. Monolateral purple urine bag syndrome in bilateral nephrostomy. Postgrad Med J 2010;86 (1020):627. [13] Hirzallah MI, D’Souza DL. 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JAmGeriatr Soc 2013;61(12):2240–2241. [17] de Bruyn G, Eckman CD, Atmar RL. Photo quiz. Purple discoloration [21] Robinson J. Purple urinary bag syndrome: A harmless but alarming in a urinary catheter bag. Clin Infect Dis 2002;34(2):210, 285–286. problem. Br J Community Nurs 2003;8(6):263–266. [18] LeuckAM, JohnsonJR, Hunt MA,etal. Safetyandefficacyofanovel silver- impregnated urinary catheter system for preventing catheter- associated bacteriuria: A pilot randomized clinical trial. Am J Infect Control 2015;43 How to cite this article: Neniwal VK, Swain S, Rulaniya SK, Hota D, (3):260–265. Agarwal P, Yadav PK. Purple urine bag syndrome: An unusual manifesta- [19] Lehman SM, Donlan RM. Bacteriophage-mediated control of a two- tion of urinary tract infection, our experience at a tertiary care center. Curr species biofilm formed by microorganisms causing catheter-associated Urol 2023;17(2):125–129. doi: 10.1097/CU9.0000000000000044
Journal
Current Urology – Wolters Kluwer Health
Published: Jun 2, 2023