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Analysis of risk factors in elderly patients with purple urine bag syndrome: A retrospective analysis in a medical center in northern Taiwan.

Byline: Tao-Chun. Peng, Chung-Ching. Wang, James. Chan, Shih-Ming. Huang, Tung-Wei. Kao, Yaw-Wen. Chang, Wen-Hui. Fang, Wei-Liang. Chen

Background: Purple urine bag syndrome (PUBS), an uncommon phenomenon that turns urine tubes or bags purple or blue, can be encountered in long-term-care facilities. A thorough literature review shows that East Asia has a high incidence of PUBS. It is important to recognize the clinical features and risk factors of this phenomenon. The aim of this study is to explore the characteristics of patients with PUBS and correlate the onset of PUBS symptoms with risk factors. Materials and Methods: We reported nine cases of clinically confirmed PUBS between January 2009 and June 2013. Pertinent clinical information was collected, including age, feeding type, renal function, type of Foley catheter, urine analysis, and bacteriological data. Results: All of patients with PUBS presented with stable vital signs without evidence of clinical infection, such as fever or chills. The mean age of the patients was 86.6 [+ or -] 10.1 years, with a preponderance of females (77%). Five PUBS patients (55%) had a history of chronic renal insufficiency. Six patients (66%) had constipation. A logistic regression univariate analysis demonstrated a statistically significant urine pH in patients with PUBS [odds ratio (OR), 3.078; P = 0.036]. Risk factors, such as gender, were found to be significant using logistic regression multivariate analysis (OR, 0.031; P = 0.021). During the follow-up, all of the patients had Foley catheters re-inserted, and all of the patients received health education. Conclusion: The incidence of PUBS in the elderly population is associated with asymptomatic bacteriuria, urine pH, and gender but not renal function, type of feeding, or type of Foley catheter used. To understand PUBS and maintain urological hygiene, it is important to educate families and health care workers about PUBS and to recognize that PUBS is not regarded as a symptom of severe disease.

Introduction

The first article on purple urine bag syndrome (PUBS) was published in 1978. [sup][1] The patient had a purple-colored urine bag after urinary catheterization was used for a period of time. [sup][2] PUBS is regarded as asymptomatic bacteriuria if there is no fever >38[degrees]C and no urgency or frequency of urination, dysuria, or suprapubic tenderness. Purple urine itself is not considered a symptom of urinary tract infection. [sup][3] Although the definitive risk factors for PUBS have not been established, the majority of authors believe that PUBS is associated with a bed-bound state, constipation, female sex, or dementia. [sup][4],[5],[6],[7],[8],[9] However, differences in study populations and institutions sustain the controversy surrounding the link between PUBS and those risk factors. Furthermore, there is a lack of sufficient epidemiological evidence from long-term-care facilities or home care. The objective of this study, therefore, was to identify the prevalence, clinical features, causative or associated factors, and potential risks of PUBS in long-term catheterized patients.

Materials and Methods

This retrospective study was conducted in the Tri-Service General Hospital (TSGH). This study was approved by the Institutional Review Board at TSGH in accordance with the revised Helsinki Declaration. We reviewed the medical records of all of the patients who had been diagnosed with PUBS and who lived in long-term-care facilities and home care served by TSGH from January 2009 to June 2013. The patients had been diagnosed with PUBS based on clinical findings (i.e., purple discoloration of urinary catheters and bags). [sup][1] These patients were cared for by families or foreign nursing workers. The patients were regularly visited by family doctors and home-care nurses and received regular changes of their nasogastric tubes and Foley catheters. We selected pertinent clinical information, including age, sex, feeding type, prior history, type of Foley catheter, the presence of bedsores or constipation, urine analyses, and bacteriological data. We used Fisher's exact test to compare categorical variables and Student's t -test to compare continuous variables. We used logistic regression (univariate and multivariate) to compare the positive PUBS group with the negative PUBS group. All of the statistical analyses were performed using SPSS statistical software version 19.0 for Windows (SPSS, Inc., Chicago, IL, USA). P < 0.05 was considered to be statistically significant. We also conducted a systematic literature review using the PubMed, Medline, Cochrane, and Embase databases. The predisposing factors, clinical presentations, prevalence, and therapeutic strategies were evaluated.

Results

Among 200 patients in home care who were served by TSGH, nine fulfilled the criteria for a clinical diagnosis of PUBS. Their urine bags were characterized by purple discoloration [Figure 1]. The mean age of the patients was 86.6 [+ or -] 10.1 years. The patients' demographic data, clinical characteristics, and laboratory findings are shown in [Table 1]. All of the patients were reported to have long-term catheter use and to be bed-bound. Seven (77%) of these patients were female. Five patients (55%) had chronic renal insufficiency, including patient nine, who had ESRD. Three patients (33%) had bedsores. Escherichia coli , Candida albicans , Enterococcus , Serratia marcescens , Pseudomonas aeruginosa , and Proteus mirabilis were identified in the patients' urine cultures. Six patients (66%) had long-term constipation. All of the patients had stable vital signs without evidence of infection (such as fever or chills) or renal or urologic system complications, despite persistent PUBS and bacteriuria in some cases. The prevalence of PUBS in our patients was 0.005 PUBS cases/catheterized patient-month during the survey period. The major variables in the two groups are shown in [Table 2]. The logistic regression univariate analysis demonstrated statistically significant findings on urine pH cultures in patients with PUBS [odds ratio (OR), 3.078; P = 0.036; [Table 3]. Risk factors, such as sex, were found to be statistically significant using logistic regression multivariate analysis (OR, 0.031; P = 0.021). Nine studies on PUBS were also identified [Table 4]. Most of the studies in the literature, with the exception of case reports, originated in East Asia. The predominant sex was female, and the mean age of the patients was older than 70 years. A high prevalence of constipation was also noted in the majority of the studies.{Figure 1}{Table 1}{Table 2}{Table 3}{Table 4}

Discussion

In this study, the predisposing factors of nine cases of PUBS were investigated. All the patients with PUBS were catheterized because of significant disability, and they lived in long-term-care facilities or at home. Seven of the patients were female. The high incidence of PUBS in females has been previously reported. [sup][6],[7],[10] This high frequency of PUBS in females is assumed to be the result of the shorter female urethra. In general, alkaline urine is more likely to cause a proliferation of bacterial flora; consequently, alkaline urine is a risk factor for PUBS. [sup][11],[12] The finding that alkaline urine tends to be a factor that differentiates between the PUBS group and the control group was noted in our study (OR, 3.078; 95% confidence interval, 1.075-8.812; P = 0.036). Several articles have reported that PUBS was also found in patients with acid urine; [sup][13],[14] therefore, alkaline urine may not be an absolute requirement for PUBS. Although related enzyme (indoxyl phosphatase, sulfatase) activities were especially high in strongly alkaline urine, [sup][13] their occurrence in acidic urine is also likely, especially as a result of different bacteria. [sup][14]

This study focused primarily on home care and long-term-care populations. The prevalence of PUBS was 0.005 PUBS cases/catheterized patient-month. The precise prevalence of PUBS is uncertain because it varies among studies; the prevalence of PUBS was observed to be 8.3% (13/157) at a long-term-care service center, [sup][6] 26.67% (16/60) in geriatric wards, [sup][15] and as high as 42.1% (8/19) in urinary catheterized patients at a nursing home. [sup][9] The differences may be related to the different institutions (hospital wards, nursing homes, long-term-care facilities, home care), care quality, and study periods examined. PUBS was diagnosed clinically, and no confirmation method was used. Consequently, the color and the depth of the color purple are presumed to vary according to different people, thus contributing to a varied prevalence.

Several articles mentioned that PUBS has a higher prevalence in Taiwan than in other countries because Taiwan has a higher rate of dialysis-treated patients. [sup][16] In previous literature, 80% of those >70 years of age had a calculated creatinine clearance of <60 mL/min. [sup][17] All of the patients in our study were older than 70 years, and 5 patients (55%) had a calculated clearance of <60 mL/min (including ESRD in one patient). The prevalence of chronic renal failure was not higher than average in our study. Renal function was likely not a risk factor of PUBS. According to a thorough review of the literature, East Asia is one of the areas with a high incidence of PUBS. Potentially important but largely unknown factors include chronic disease, diet, residence, and care setting. Therefore, additional information is required to determine whether specific factors contribute to differences in PUBS prevalence among populations.

The high incidence of constipation in PUBS has been previously reported. [sup][10],[12],[18] Six (66%) of our patients had long-term constipation. Although constipation was highly prevalent in long-term-care facilities, there was no significant difference between the PUBS group and the control group. In one study, patients with PUBS had lower tryptophan levels. [sup][19] That finding offers indirect proof that constipation is commonly associated with decreased colonic motility, resulting in the increased metabolism of tryptophan and indole absorption. Tryptophan was converted to indole by intestinal bacterial metabolism. Indole was absorbed into the portal circulation and conjugates with SO [sub]4 to form indoxyl sulfate. Indoxyl sulfate was excreted into the urine and metabolized by bacteria to produce indigo (blue) and indirubin (red, [Figure 2]).{Figure 2}

In recent reports, PUBS was regarded as an asymptomatic bacteriuria. However, its potential relationship with urinary tract infection has been mentioned in publications. [sup][20],[21] Four of our patients had PUBS on and off for at least 1-week to several months. None of the patients received antibiotic treatment. We replaced their indwelling urinary catheters and drainage bags more frequently and encouraged the patients to drink cranberry juice to improve their catheter care quality. All of the patients with PUBS recovered without any complications. PUBS without abnormal findings is a benign symptom.

The Ministry of Health and Welfare of Taiwan estimated that elderly people will exceed 15% of the total population within the next decade. Therefore, long-term health care will pose a challenge in an era of aging populations. Caregivers, who are usually family members or foreigners, do not have the professional skills that nurses in hospitals provide. PUBS often perplexes these caregivers. They must send the patients to the hospital for additional evaluations, thus wasting time and money. Doctors must prove to the patients and caregivers that there is no problem and that nothing is wrong. These caregivers should be educated about PUBS; they should learn to regard PUBS as a benign problem, not a cause for fear. PUBS may be a quality indicator for health care facilities in the future.

Conclusion

We found that PUBS had a higher incidence in patients with alkaline urine and female gender. Prospective studies exploring the association between prognostic outcomes and PUBS were warranted to enable more specific interpretation of the findings.

Disclosure

The authors have no conflicts of interest to declare.

References

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Article Details
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Title Annotation:Original Article
Author:Peng, Tao-Chun; Wang, Chung-Ching; Chan, James; Huang, Shih-Ming; Kao, Tung-Wei; Chang, Yaw-Wen; Fan
Publication:Journal of Medical Sciences
Article Type:Clinical report
Geographic Code:1USA
Date:May 1, 2014
Words:2460
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