Wikipedia

Purple urine bag syndrome

Purple urine bag syndrome (PUBS) is a medical syndrome where purple discoloration of urine occurs in people with urinary catheters and co-existent urinary tract infection. PUBS mostly occurred in elderly females with constipation.[1]High bacterial counts in urine are the most important factor causing PUBS.[2] Bacteria in urine produce the enzyme indoxyl sulfatase. This converts indoxyl sulfate in the urine into the red and blue colored compounds indirubin and indigo.[3] In other words, the purple discoloration is caused by using plastic catheters and urine bags reacting with the red and blue colored compounds( indirubin and indigo). The most commonly implicated bacteria are Providencia stuartii, Providencia rettgeri, Klebsiella pneumoniae, Proteus mirabilis, Escherichia coli, Morganella morganii, and Pseudomonas aeruginosa.[4]

Purple urine bag syndrome
A urine bag containing purple liquid
Purple urine bag syndrome usually presents as urine with a purplish discoloration accumulating in a catheterized person's collection bag.

Signs and symptoms

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People with purple urine bag syndrome usually do not complain of any symptoms. Purple discoloration of urine bag is often the only finding, frequently noted by caregivers. It is usually considered a benign condition, although in the setting of recurrent or chronic urinary tract infection, it may be associated with drug-resistant bacteria.[5]

Pathophysiology

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Purple urine bag syndrome (PUBS) is caused by tryptophan from the diet being metabolized by bacteria in the gastrointestinal tract to produce indole. Indole is absorbed into the blood by the intestine and passes to the liver. There, indole is converted to indoxyl sulfate, which is then excreted in the urine. In purple urine bag syndrome, bacterial enzymes that colonize the urinary catheter , specifically sulfatases and phosphotases, convert indoxyl sulfate to the colored compounds indirubin and indigo.[3] Indirubin is a reddish color while indigo is blue. Combined, they create the signature purple seen in PUBS.[6]

The change in tryptophan metabolism is theorized to be due to diminished gut motility resulting in prolonged transit times. This will lead to a bacterial overgrowth in the bowel. The overabundance of bacterial will facilitate the conversion of tryptophan into indole.[7]

PUBS has also been linked to long term laxative use. A common side effect of overuse of laxatives is damage to the colorectal mucosal lining and changes to the normal intestinal microbiota.[6] This will once again allow bacteria to accumulate.

Risk Factors and Causes

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Purple urine bag syndrome can be a side effect of having a urinary tract infection. Many other risk factors can increase how likely it is for someone to develop a urinary tract infection. A common risk factor is using a catheter for a long period of time.[8]A catheter is a small, flexible tube that can be inserted into a patient's bladder by a medical professional to allow the patient to easily empty their bladder. This is commonly used before/after surgeries, for those who have a blockage preventing them from urinating, to assist those with bladder weakness that is impacting their ability to urinate, etc. Having a urinary catheter increases a patient's risk of developing a urinary tract infection.[9]

Beyond using a catheter for long periods of time, some risk factors for a urinary tract infection include being of female gender, constipation, and chronic renal failure.[8]

Diagnosis

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Purple urine bag syndrome is a clinical diagnosis, the cause of which may be investigated using a variety of laboratory tests or imaging.

Treatment

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This image depicts the molecular structure of the antibiotic cefuroxime used in treatment of purple urine bag syndrome.

Generally, purple urine bag syndrome is treated with antibiotics. In the case of an elderly woman with limited mobility due to a previous fracture, she was put on a catheter, a tube that provides hospital patients with fluids and nutrients as they recover.[10] She also had significant trouble defecating, a further risk factor for the development of purple urine bag syndrome.[10] The woman was treated with one class of antibiotics, cefuroxime, by mouth before being transitioned over to two different antibiotics, ceftriaxone and gentamicin, by way of intravenous injection, a catheter that delivers important compounds such as nutrients and medications, specifically into the bloodstream.[10]

Another case focuses on the development of purple urine bag syndrome within a middle aged Pakistani woman who exhibited several risk factors such as enduring constipation (a long-lasting health issue indicating decreased excretion of fecal matter), use of a catheter for an extended period of time, as well as being female.[11] The woman was also treated with antibiotics. Specifically, she was given cefixime, a class of antibiotic, by mouth, and did not receive the other specific antibiotics that the previously mentioned patient did.[11] She was only given oral medications and not switched to intravenous injections of antibiotics.[11] She was continued on the antibiotic for a little over a week and her UTI issue was revisited about ten days later after completing the treatment with antibiotics.[11] By that time, it was found that her symptoms had completely resolved.[11]

Despite all of this, it is important to note that purple urine bag syndrome is generally harmless and does not require immediate treatment usually unless progressing to a painful state within the patient.[12] This tendency to be more susceptible to the effects of the condition can happen in particular among those who are immunocompromised.[12]

Prevention

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Purple urine bag syndrome is associated with longer periods using a catheter as well as has greater prevalence among those who have trouble with making bowel movements or are dehydrated (lacking adequate fluid).[13] Other significant risk factors include being of the female sex, being elderly, and/or being immobile, which refers to the inability to move.[11] Pregnant women are also at higher risk of developing UTI's, and in pregnant women, the development of UTI's can be quite dangerous; thus, it is highly advised for pregnant women to seek immediate care if experiencing significant signs and symptoms of a UTI.[14] Purple urine bag syndrome typically occurs as a result of bacterial infections. Thus, taking precautions against the development of bacterial infections can minimize the risk of purple urine bag syndrome.

 
Drinking lots of water can help with preventing the development of UTI's that promote the growth of bacteria involved in purple urine bag syndrome.

To prevent bacterial infections like UTI's that can lead to purple urinary bag syndrome, it is advised to drink lots of water and avoid things like "sugar, caffeine, and alcohol" ("Purple Urine Bag" 2020). There is some research that points to cranberry pills as a means of reducing the occurrence of urinary tract infections, an infection caused by the accumulation of bacteria in the urinary system which includes the bladder and kidneys. Cranberry juice on the other hand has too much sugar to be as beneficial as the cranberry pill.[13] In terms of bowel movements, it is encouraged to promote gut health, by doing certain activities like exercising and consuming lots of fluids and fiber. Besides consuming large amounts of fluid and fiber, avoiding sugar, caffeine, and alcohol, taking cranberry pills, and exercising, it is recommended to frequently use the restroom to clear the bladder, urinate after sexual intercourse, and lastly wipe your underside thoroughly to prevent the spread of bacteria to your private parts; all of these tips will ultimately prevent the development of UTI's and furthermore decrease the likelihood of attaining purple urine bag syndrome.[15] Some sources note that taking probiotics too can help with promoting the growth of good bacteria and edging out the bad bacteria involved in UTI's.[14] Finally, it is helpful to consistently change the catheter and drainage bag, which is a bag that receives urine from the catheter, in order to inhibit the formation of harmful bacteria that can cause this condition of purple discoloration of the urine.[12]

Epidemiology

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Purple urine bag syndrome is more common in female nursing home residents. Other risk factors include alkaline urine, constipation, and polyvinyl chloride catheter use.[16] When compared to the non-elderly patient population, PUBS is more prevalent among the elderly population.[17]

History

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This rare syndrome was first described by Barlow and Dickson in 1978.[18] PUBS has commonly been found among patients with long-term urinary catheters, those that are bedridden, diagnosed with chronic kidney disease (CKD), or has chronic constipation.[19] The most common related condition to PUBS would be urinary tract infections (UTIs).[19]

In 1812, King George III of England was reported to have a bluish tinge in his urine and bouts of constipation. Along with the King's many other illnesses, this discolored urine lead to the diagnosis of acute porphyria.[20]

In the first two PUBS patient cases in 1978 and 2003, it was reported that the patients had a purple-colored urine bag for a long period of time ranging from hours to days, after their urinary catheterization.[4] A specific patient case involved an 85-year-old female living in nursing home with a long-term urinary catheter, who had been experiencing urine discoloration of violet-colored urine over the past 4 weeks.[21] This rare phenomenon was centered around this patient that had a history of recurrent UTIs, and was admitted for initial diagnosis of UTI and constipation.[10] The patient was given the following medication regimen: oral cefuroxime, then changed to ceftriaxone IV and gentamicin IV, and oral glycerol for constipation.[10]

References

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  1. ^ Sabanis N, Paschou E, Papanikolaou P, Zagkotsis G (November 2019). "Purple Urine Bag Syndrome: More Than Eyes Can See". Current Urology. 13 (3): 125–132. doi:10.1159/000499281. PMC 6944938. PMID 31933590.
  2. ^ Mantani N, Ochiai H, Imanishi N, Kogure T, Terasawa K, Tamura J (March 2003). "A case-control study of purple urine bag syndrome in geriatric wards". Journal of Infection and Chemotherapy. 9 (1): 53–57. doi:10.1007/s10156-002-0210-x. PMID 12673408.
  3. ^ a b Tan CK, Wu YP, Wu HY, Lai CC (August 2008). "Purple urine bag syndrome". CMAJ. 179 (5): 491. doi:10.1503/cmaj.071604. PMC 2518199. PMID 18725621.
  4. ^ a b Lin CH, Huang HT, Chien CC, Tzeng DS, Lung FW (December 2008). "Purple urine bag syndrome in nursing homes: ten elderly case reports and a literature review". Clinical Interventions in Aging. 3 (4): 729–734. doi:10.2147/cia.s3534. PMC 2682405. PMID 19281065.
  5. ^ Bhattarai M, Bin Mukhtar H, Davis TW, Silodia A, Nepal H (2013). "Purple urine bag syndrome may not be benign: a case report and brief review of the literature". Case Reports in Infectious Diseases. 2013: 863853. doi:10.1155/2013/863853. PMC 3705812. PMID 23864970.
  6. ^ a b Faia J, Martins AS, Martins M (December 2023). "Purple Urine Bag Syndrome: A Peculiar Presentation of a Urinary Tract Infection". Cureus. 15 (12): e49804. doi:10.7759/cureus.49804. ISSN 2168-8184. PMID 38161563.
  7. ^ Ga H, Park KH, Choi GD, Yoo BI, Kang MC, Kim SM, et al. (October 2007). "Purple Urine Bag Syndrome in Geriatric Wards: Two Faces of a Coin?". Journal of the American Geriatrics Society. 55 (10): 1676–1678. doi:10.1111/j.1532-5415.2007.01327.x. ISSN 0002-8614.
  8. ^ a b Pandey S, Pandey T, Sharma A, Sankhwar S (July 2018). "Purple urinary bag syndrome: what every primary healthcare provider should know". BMJ Case Reports. 2018: bcr2018226395. doi:10.1136/bcr-2018-226395. PMC 6058161. PMID 30021748.
  9. ^ "Urinary catheters". nhs.uk. 2017-10-20. Retrieved 2024-07-26.
  10. ^ a b c d e Al Montasir A, Al Mustaque A (January 2013). "Purple urine bag syndrome". Journal of Family Medicine and Primary Care. 2 (1): 104–105. doi:10.4103/2249-4863.109970. PMC 3894016. PMID 24479059.
  11. ^ a b c d e f Kumar R, Devi K, Kataria D, Kumar J, Ahmad I (July 2021). "Purple Urine Bag Syndrome: An Unusual Presentation of Urinary Tract Infection". Cureus. 13 (7): e16319. doi:10.7759/cureus.16319. PMC 8354832. PMID 34395107.
  12. ^ a b c Hadano Y, Shimizu T, Takada S, Inoue T, Sorano S (2012-08-22). "An update on purple urine bag syndrome". International Journal of General Medicine. 5: 707–710. doi:10.2147/IJGM.S35320. ISSN 1178-7074. PMC 3437914. PMID 22969302.
  13. ^ a b "Purple Urine Bag". Craig Hospital. Englewood, CO. November 2020. Retrieved July 23, 2024.
  14. ^ a b "What doctors wish patients knew about UTI prevention". American Medical Association. 2023-03-24. Retrieved 2024-07-24.
  15. ^ "5 tips to prevent a urinary tract infection". Mayo Clinic Health System. Retrieved 2024-07-24.
  16. ^ Su FH, Chung SY, Chen MH, Sheng ML, Chen CH, Chen YJ, et al. (September 2005). "Case analysis of purple urine-bag syndrome at a long-term care service in a community hospital". Chang Gung Medical Journal. 28 (9): 636–642. PMID 16323555.
  17. ^ Yang HW, Su YJ (March 2018). "Trends in the epidemiology of purple urine bag syndrome: A systematic review". Biomedical Reports. 8 (3): 249–256. doi:10.3892/br.2018.1046. PMC 5854937. PMID 29564123.
  18. ^ Sammons H, Skinner C, Fields J, Payne B, Grant A (March 1978). "Purple urine bags". Lancet. 1 (8062): 502. doi:10.1016/s0140-6736(78)90163-0. PMID 76045. S2CID 54340615.
  19. ^ a b Shaeriya F, Al Remawy R, Makhdoom A, Alghamdi A, Shaheen FA (April 2021). "Purple Urine Bag Syndrome". Saudi Journal of Kidney Diseases and Transplantation. 32 (2): 530. doi:10.4103/1319-2442.335466. ISSN 1319-2442.
  20. ^ Peters T (June 2011). "King George III, bipolar disorder, porphyria and lessons for historians". Clinical Medicine. 11 (3): 261–264. doi:10.7861/clinmedicine.11-3-261. ISSN 1470-2118. PMC 4953321. PMID 21902081.
  21. ^ Al-Jubouri MA, Vardhan MS (May 2001). "A case of purple urine bag syndrome associated with Providencia rettgeri". Journal of Clinical Pathology. 54 (5): 412. doi:10.1136/jcp.54.5.412-a. PMC 1731433. PMID 11328846.
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