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The color purple
Author(s)
Abhinav Sood, MBBS, MD
Ashhar Ali, DO
Adarsh Bhimraj, MD

A 58-year-old man with a history of cystoprostatectomy for prostate cancer, end-stage renal disease on hemodialysis, and distal ureteral obstruction requiring bilateral nephrostomy tubes noticed that one of the nephrostomy bags looked “purple” (Figure 1). A specimen collected from one bag was reddish purple (Figure 2). The urine in the other bag was normal. The condition was diagnosed as purple urine bag syndrome.

PURPLE URINE BAG SYNDROME

Reddish-purple discoloration in one nephrostomy bag
Figure 1. Reddish-purple discoloration in one nephrostomy bag.

Purple urine bag syndrome, a relatively rare condition that appears after 2 to 3 months of indwelling urinary catheterization, is usually asymptomatic, the only signs being the purplish urine and staining of the urinary bags and catheters. However, it should be considered a sign of underlying urinary tract infection, which can disseminate causing local complications (Fournier gangrene), systemic complications (septicemia), and death.1–3

Specimen taken from one nephrostomy bag
Figure 2. Specimen taken from one nephrostomy bag.

The syndrome, first described in 1978 in children with spina bifida and urinary diversion,4 is more prevalent in women than in men, possibly because of the shorter urethra and closer proximity to the anus, which predispose women to bacterial colonization of the urinary tract. Predisposing conditions include dementia,5 female sex, increased dietary tryptophan, bacteriuria, urinary tract infection, constipation, older age, immobility, and alkaline urine.6–8

The cause of the discoloration

The purple color is from indigo and indirubin compounds in the urine, the result of the breakdown of dietary tryptophan. The color varies depending on the proportions of the two pigments.

Dietary tryptophan is broken down into indole by colonic bacteria. After reaching the portal circulation, it is excreted into the urine as indoxyl sulfate, which is broken down to indoxyl by sulfatase-producing bacteria (eg, Klebsiella pneumonia, Proteus mirabilis, Pseudomonas aeruginosa, Escherichia coli, Providencia species, Morganella morganii). Indoxyl is then oxidized to indigo and indirubin.

These compounds do not discolor the urine directly, but rather precipitate after interacting with the lining of the urinary catheter and bags, thereby imparting a purple color.1,9–13

Management

Effective initial measures are improved urinary hygiene (eg, frequent, careful changing of the urinary catheter) and management of constipation, as constipation leads to increased colonization of the intestine by bacteria that metabolize dietary tryptophan into indoxyl. Antibiotics should be given for symptomatic urinary tract infection (fever, increased urinary frequency, dysuria, abdominal pain) but not for color change alone. Coverage should be for gram-negative bacilli, although methicillin-resistant Staphylococcus aureus, which is gram-positive, has also been reported to cause purple urine bag syndrome.

In most cases, purple urine bag syndrome is benign and requires no therapy other than that mentioned above.3,13–15 However, in rare cases, immunocompromised patients (eg, people with diabetes) can develop local complications and sepsis from dissemination of bacterial infection, requiring aggressive therapy.14 Therefore, purple urine bag syndrome should be recognized as an indicator of an underlying urinary tract infection and should be treated if symptomatic. Nevertheless, the long-term prognosis is generally good.

OUR PATIENT’S MANAGEMENT

Our patient was confirmed to have urinary colonization with P aeruginosa and E coli, and alkaline urine. He underwent replacement of the nephrostomy tubes and urinary bag during his hospital stay (he was already in the hospital for another indication), but he continued to produce purple-colored urine from his right side and normal-colored urine from his left side. The unilateral involvement was likely from selective colonization of the right-sided nephrostomy tube with gram-negative bacteria.

References
  1. Kang KH, Jeong KH, Baik SK, et al. Purple urine bag syndrome: case report and literature review. Clin Nephrol 2011; 75:557–559.
  2. Ribeiro JP, Marcelino P, Marum S, Fernandes AP, Grilo A. Case report: purple urine bag syndrome. Crit Care 2004; 8:R137.
  3. Robinson J. Purple urinary bag syndrome: a harmless but alarming problem. Br J Community Nurs 2003; 8:263–266.
  4. Barlow GB, Dickson JAS. Purple urine bags. Lancet 1978; 1:220–221.
  5. Ga H, Kojima T. Purple urine bag syndrome. JAMA 2012; 307:1912–1913.
  6. Ishida T, Ogura S, Kawakami Y. Five cases of purple urine bag syndrome in a geriatric ward. Nihon Ronen Igakkai Zasshi 1999; 36:826–829. Japanese.
  7. Gautam G, Kothari A, Kumar R, Dogra PN. Purple urine bag syndrome: a rare clinical entity in patients with long term indwelling catheters. Int Urol Nephrol 2007; 39:155–156.
  8. Shiao CC, Weng CY, Chuang JC, Huang MS, Chen ZY. Purple urine bag syndrome: a community-based study and literature review. Nephrology (Carlton) 2008; 13:554–559.
  9. Chong VH. Purple urine bag syndrome: it is the urine bag and not the urine that is discolored purple. South Med J 2012; 105:446.
  10. Chung SD, Liao CH, Sun HD. Purple urine bag syndrome with acidic urine. Int J Infect Dis 2008; 12:526–527.
  11. Wu HH, Yang WC, Lin CC. Purple urine bag syndrome. Am J Med Sci 2009; 337:368.
  12. Achtergael W, Michielsen D, Gorus FK, Gerlo E. Indoxyl sulphate and the purple urine bag syndrome: a case report. Acta Clin Belg 2006; 61:38–41.
  13. Hadano Y, Shimizu T, Takada S, Inoue T, Sorano S. An update on purple urine bag syndrome. Int J Gen Med 2012; 5:707–710.
  14. Tasi YM, Huang MS, Yang CJ, Yeh SM, Liu CC. Purple urine bag syndrome, not always a benign process. Am J Emerg Med 2009; 27:895–897.
  15. Ferrara F, D’Angelo G, Costantino G. Monolateral purple urine bag syndrome in bilateral nephrostomy. Postgrad Med J 2010; 86:627.
Article PDF
Sood_PurpleUrine.pdf
Author and Disclosure Information

Abhinav Sood, MBBS, MD
Department of Internal Medicine, Cleveland Clinic

Ashhar Ali, DO
Department of Neurology, Cleveland Clinic

Adarsh Bhimraj, MD
Head, Neurological Infections Clinic, and Department of Infectious Disease, Cleveland Clinic

Address: Abhinav Sood, MBBS, MD, Department of Internal Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail: sooda@ccf.org

Issue
Cleveland Clinic Journal of Medicine - 82(11)
Publications
Cleveland Clinic Journal of Medicine
Topics
Geriatrics
Hospital Medicine
Nephrology
Infectious Diseases
Page Number
721-722
Legacy Keywords
purple urine bag syndrome, urinary tract infection, catheterization, Abhinav Sood, Ashhar Ali, Adarsh Bhimraj
Sections
The Clinical Picture
Author(s)
Abhinav Sood, MBBS, MD
Ashhar Ali, DO
Adarsh Bhimraj, MD
Author(s)
Abhinav Sood, MBBS, MD
Ashhar Ali, DO
Adarsh Bhimraj, MD
Author and Disclosure Information

Abhinav Sood, MBBS, MD
Department of Internal Medicine, Cleveland Clinic

Ashhar Ali, DO
Department of Neurology, Cleveland Clinic

Adarsh Bhimraj, MD
Head, Neurological Infections Clinic, and Department of Infectious Disease, Cleveland Clinic

Address: Abhinav Sood, MBBS, MD, Department of Internal Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail: sooda@ccf.org

Author and Disclosure Information

Abhinav Sood, MBBS, MD
Department of Internal Medicine, Cleveland Clinic

Ashhar Ali, DO
Department of Neurology, Cleveland Clinic

Adarsh Bhimraj, MD
Head, Neurological Infections Clinic, and Department of Infectious Disease, Cleveland Clinic

Address: Abhinav Sood, MBBS, MD, Department of Internal Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail: sooda@ccf.org

Article PDF
Sood_PurpleUrine.pdf
Article PDF
Sood_PurpleUrine.pdf
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Is antibiotic treatment indicated in a patient with a positive urine culture but no symptoms?

A 58-year-old man with a history of cystoprostatectomy for prostate cancer, end-stage renal disease on hemodialysis, and distal ureteral obstruction requiring bilateral nephrostomy tubes noticed that one of the nephrostomy bags looked “purple” (Figure 1). A specimen collected from one bag was reddish purple (Figure 2). The urine in the other bag was normal. The condition was diagnosed as purple urine bag syndrome.

PURPLE URINE BAG SYNDROME

Reddish-purple discoloration in one nephrostomy bag
Figure 1. Reddish-purple discoloration in one nephrostomy bag.

Purple urine bag syndrome, a relatively rare condition that appears after 2 to 3 months of indwelling urinary catheterization, is usually asymptomatic, the only signs being the purplish urine and staining of the urinary bags and catheters. However, it should be considered a sign of underlying urinary tract infection, which can disseminate causing local complications (Fournier gangrene), systemic complications (septicemia), and death.1–3

Specimen taken from one nephrostomy bag
Figure 2. Specimen taken from one nephrostomy bag.

The syndrome, first described in 1978 in children with spina bifida and urinary diversion,4 is more prevalent in women than in men, possibly because of the shorter urethra and closer proximity to the anus, which predispose women to bacterial colonization of the urinary tract. Predisposing conditions include dementia,5 female sex, increased dietary tryptophan, bacteriuria, urinary tract infection, constipation, older age, immobility, and alkaline urine.6–8

The cause of the discoloration

The purple color is from indigo and indirubin compounds in the urine, the result of the breakdown of dietary tryptophan. The color varies depending on the proportions of the two pigments.

Dietary tryptophan is broken down into indole by colonic bacteria. After reaching the portal circulation, it is excreted into the urine as indoxyl sulfate, which is broken down to indoxyl by sulfatase-producing bacteria (eg, Klebsiella pneumonia, Proteus mirabilis, Pseudomonas aeruginosa, Escherichia coli, Providencia species, Morganella morganii). Indoxyl is then oxidized to indigo and indirubin.

These compounds do not discolor the urine directly, but rather precipitate after interacting with the lining of the urinary catheter and bags, thereby imparting a purple color.1,9–13

Management

Effective initial measures are improved urinary hygiene (eg, frequent, careful changing of the urinary catheter) and management of constipation, as constipation leads to increased colonization of the intestine by bacteria that metabolize dietary tryptophan into indoxyl. Antibiotics should be given for symptomatic urinary tract infection (fever, increased urinary frequency, dysuria, abdominal pain) but not for color change alone. Coverage should be for gram-negative bacilli, although methicillin-resistant Staphylococcus aureus, which is gram-positive, has also been reported to cause purple urine bag syndrome.

In most cases, purple urine bag syndrome is benign and requires no therapy other than that mentioned above.3,13–15 However, in rare cases, immunocompromised patients (eg, people with diabetes) can develop local complications and sepsis from dissemination of bacterial infection, requiring aggressive therapy.14 Therefore, purple urine bag syndrome should be recognized as an indicator of an underlying urinary tract infection and should be treated if symptomatic. Nevertheless, the long-term prognosis is generally good.

OUR PATIENT’S MANAGEMENT

Our patient was confirmed to have urinary colonization with P aeruginosa and E coli, and alkaline urine. He underwent replacement of the nephrostomy tubes and urinary bag during his hospital stay (he was already in the hospital for another indication), but he continued to produce purple-colored urine from his right side and normal-colored urine from his left side. The unilateral involvement was likely from selective colonization of the right-sided nephrostomy tube with gram-negative bacteria.

A 58-year-old man with a history of cystoprostatectomy for prostate cancer, end-stage renal disease on hemodialysis, and distal ureteral obstruction requiring bilateral nephrostomy tubes noticed that one of the nephrostomy bags looked “purple” (Figure 1). A specimen collected from one bag was reddish purple (Figure 2). The urine in the other bag was normal. The condition was diagnosed as purple urine bag syndrome.

PURPLE URINE BAG SYNDROME

Reddish-purple discoloration in one nephrostomy bag
Figure 1. Reddish-purple discoloration in one nephrostomy bag.

Purple urine bag syndrome, a relatively rare condition that appears after 2 to 3 months of indwelling urinary catheterization, is usually asymptomatic, the only signs being the purplish urine and staining of the urinary bags and catheters. However, it should be considered a sign of underlying urinary tract infection, which can disseminate causing local complications (Fournier gangrene), systemic complications (septicemia), and death.1–3

Specimen taken from one nephrostomy bag
Figure 2. Specimen taken from one nephrostomy bag.

The syndrome, first described in 1978 in children with spina bifida and urinary diversion,4 is more prevalent in women than in men, possibly because of the shorter urethra and closer proximity to the anus, which predispose women to bacterial colonization of the urinary tract. Predisposing conditions include dementia,5 female sex, increased dietary tryptophan, bacteriuria, urinary tract infection, constipation, older age, immobility, and alkaline urine.6–8

The cause of the discoloration

The purple color is from indigo and indirubin compounds in the urine, the result of the breakdown of dietary tryptophan. The color varies depending on the proportions of the two pigments.

Dietary tryptophan is broken down into indole by colonic bacteria. After reaching the portal circulation, it is excreted into the urine as indoxyl sulfate, which is broken down to indoxyl by sulfatase-producing bacteria (eg, Klebsiella pneumonia, Proteus mirabilis, Pseudomonas aeruginosa, Escherichia coli, Providencia species, Morganella morganii). Indoxyl is then oxidized to indigo and indirubin.

These compounds do not discolor the urine directly, but rather precipitate after interacting with the lining of the urinary catheter and bags, thereby imparting a purple color.1,9–13

Management

Effective initial measures are improved urinary hygiene (eg, frequent, careful changing of the urinary catheter) and management of constipation, as constipation leads to increased colonization of the intestine by bacteria that metabolize dietary tryptophan into indoxyl. Antibiotics should be given for symptomatic urinary tract infection (fever, increased urinary frequency, dysuria, abdominal pain) but not for color change alone. Coverage should be for gram-negative bacilli, although methicillin-resistant Staphylococcus aureus, which is gram-positive, has also been reported to cause purple urine bag syndrome.

In most cases, purple urine bag syndrome is benign and requires no therapy other than that mentioned above.3,13–15 However, in rare cases, immunocompromised patients (eg, people with diabetes) can develop local complications and sepsis from dissemination of bacterial infection, requiring aggressive therapy.14 Therefore, purple urine bag syndrome should be recognized as an indicator of an underlying urinary tract infection and should be treated if symptomatic. Nevertheless, the long-term prognosis is generally good.

OUR PATIENT’S MANAGEMENT

Our patient was confirmed to have urinary colonization with P aeruginosa and E coli, and alkaline urine. He underwent replacement of the nephrostomy tubes and urinary bag during his hospital stay (he was already in the hospital for another indication), but he continued to produce purple-colored urine from his right side and normal-colored urine from his left side. The unilateral involvement was likely from selective colonization of the right-sided nephrostomy tube with gram-negative bacteria.

References
  1. Kang KH, Jeong KH, Baik SK, et al. Purple urine bag syndrome: case report and literature review. Clin Nephrol 2011; 75:557–559.
  2. Ribeiro JP, Marcelino P, Marum S, Fernandes AP, Grilo A. Case report: purple urine bag syndrome. Crit Care 2004; 8:R137.
  3. Robinson J. Purple urinary bag syndrome: a harmless but alarming problem. Br J Community Nurs 2003; 8:263–266.
  4. Barlow GB, Dickson JAS. Purple urine bags. Lancet 1978; 1:220–221.
  5. Ga H, Kojima T. Purple urine bag syndrome. JAMA 2012; 307:1912–1913.
  6. Ishida T, Ogura S, Kawakami Y. Five cases of purple urine bag syndrome in a geriatric ward. Nihon Ronen Igakkai Zasshi 1999; 36:826–829. Japanese.
  7. Gautam G, Kothari A, Kumar R, Dogra PN. Purple urine bag syndrome: a rare clinical entity in patients with long term indwelling catheters. Int Urol Nephrol 2007; 39:155–156.
  8. Shiao CC, Weng CY, Chuang JC, Huang MS, Chen ZY. Purple urine bag syndrome: a community-based study and literature review. Nephrology (Carlton) 2008; 13:554–559.
  9. Chong VH. Purple urine bag syndrome: it is the urine bag and not the urine that is discolored purple. South Med J 2012; 105:446.
  10. Chung SD, Liao CH, Sun HD. Purple urine bag syndrome with acidic urine. Int J Infect Dis 2008; 12:526–527.
  11. Wu HH, Yang WC, Lin CC. Purple urine bag syndrome. Am J Med Sci 2009; 337:368.
  12. Achtergael W, Michielsen D, Gorus FK, Gerlo E. Indoxyl sulphate and the purple urine bag syndrome: a case report. Acta Clin Belg 2006; 61:38–41.
  13. Hadano Y, Shimizu T, Takada S, Inoue T, Sorano S. An update on purple urine bag syndrome. Int J Gen Med 2012; 5:707–710.
  14. Tasi YM, Huang MS, Yang CJ, Yeh SM, Liu CC. Purple urine bag syndrome, not always a benign process. Am J Emerg Med 2009; 27:895–897.
  15. Ferrara F, D’Angelo G, Costantino G. Monolateral purple urine bag syndrome in bilateral nephrostomy. Postgrad Med J 2010; 86:627.
References
  1. Kang KH, Jeong KH, Baik SK, et al. Purple urine bag syndrome: case report and literature review. Clin Nephrol 2011; 75:557–559.
  2. Ribeiro JP, Marcelino P, Marum S, Fernandes AP, Grilo A. Case report: purple urine bag syndrome. Crit Care 2004; 8:R137.
  3. Robinson J. Purple urinary bag syndrome: a harmless but alarming problem. Br J Community Nurs 2003; 8:263–266.
  4. Barlow GB, Dickson JAS. Purple urine bags. Lancet 1978; 1:220–221.
  5. Ga H, Kojima T. Purple urine bag syndrome. JAMA 2012; 307:1912–1913.
  6. Ishida T, Ogura S, Kawakami Y. Five cases of purple urine bag syndrome in a geriatric ward. Nihon Ronen Igakkai Zasshi 1999; 36:826–829. Japanese.
  7. Gautam G, Kothari A, Kumar R, Dogra PN. Purple urine bag syndrome: a rare clinical entity in patients with long term indwelling catheters. Int Urol Nephrol 2007; 39:155–156.
  8. Shiao CC, Weng CY, Chuang JC, Huang MS, Chen ZY. Purple urine bag syndrome: a community-based study and literature review. Nephrology (Carlton) 2008; 13:554–559.
  9. Chong VH. Purple urine bag syndrome: it is the urine bag and not the urine that is discolored purple. South Med J 2012; 105:446.
  10. Chung SD, Liao CH, Sun HD. Purple urine bag syndrome with acidic urine. Int J Infect Dis 2008; 12:526–527.
  11. Wu HH, Yang WC, Lin CC. Purple urine bag syndrome. Am J Med Sci 2009; 337:368.
  12. Achtergael W, Michielsen D, Gorus FK, Gerlo E. Indoxyl sulphate and the purple urine bag syndrome: a case report. Acta Clin Belg 2006; 61:38–41.
  13. Hadano Y, Shimizu T, Takada S, Inoue T, Sorano S. An update on purple urine bag syndrome. Int J Gen Med 2012; 5:707–710.
  14. Tasi YM, Huang MS, Yang CJ, Yeh SM, Liu CC. Purple urine bag syndrome, not always a benign process. Am J Emerg Med 2009; 27:895–897.
  15. Ferrara F, D’Angelo G, Costantino G. Monolateral purple urine bag syndrome in bilateral nephrostomy. Postgrad Med J 2010; 86:627.
Issue
Cleveland Clinic Journal of Medicine - 82(11)
Issue
Cleveland Clinic Journal of Medicine - 82(11)
Page Number
721-722
Page Number
721-722
Publications
Cleveland Clinic Journal of Medicine
Publications
Cleveland Clinic Journal of Medicine
Topics
Geriatrics
Hospital Medicine
Nephrology
Infectious Diseases
Article Type
Article
Display Headline
The color purple
Display Headline
The color purple
Legacy Keywords
purple urine bag syndrome, urinary tract infection, catheterization, Abhinav Sood, Ashhar Ali, Adarsh Bhimraj
Legacy Keywords
purple urine bag syndrome, urinary tract infection, catheterization, Abhinav Sood, Ashhar Ali, Adarsh Bhimraj
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