Urinary Drainage System Research Articles

Purple Urine Bag Syndrome: A Rare Clinical Entity in a Female Patient with a Long-term Indwelling Urethral Catheter

Background: Discoloration of urine is commonly encountered in clinical practice and this at times may indicate significant pathology. Nevertheless, the majority of instances are benign. Blue and purple dye discoloration of the urinary catheter drainage system israre and can be alarming to both patients and health care workers who are not aware of the condition which is called Purple-Urine-Bag-Syndrome (PUBS). PUBS, is associated with urinary tract infections occurring in catheterised patients, generally elderly females with significant co-morbidities and constipation. The urine is usually alkaline. Gram-negative bacteria that produce sulfatase and phosphatase are involved in the formation of pigment, indigo which gives a blue coloration and indirubin which gives a purple coloration. Tryptophan metabolism is involved in the pathogenesis. Case Report: A 60-year-old lady who had a long-term urethral catheter for four years went to see her General Practitioner on few occasions with a report that her urine has been draining blue dye into her urine bag which was followed by drainage of purple dye into the catheter bag. The General practitioner did not know the cause of the problem but gave the patient antibiotic on each occasion and the blue/purple dye urine discoloration cleared each time she was given empirical antibiotic treatment. Her urine culture grew E coli at the time of the discoloration.Conclusion: PUBS occurs in long-term catheterised patients; is associated with UTI; presents with symptom-less blue/purple discoloration of urine; resolves with appropriate antibiotic treatment.

S100A1 expression characterizes terminally differentiated superficial cells in the urothelium of the murine bladder and ureter.

The urothelium is a stratified epithelium that lines the inner surface of the components of the urinary drainage system. It is composed of a layer of basal cells, one or several layers of intermediate cells, and a layer of large luminal superficial or umbrella cells. In the mouse, only a small set of markers is available that allows easy molecular distinction of these urothelial cell types. Here, we analyzed expression of S100A1, a member of the S100 family of calcium-binding proteins, in the urothelium of the two major organs of the murine urinary tract, the ureter and the bladder. Using RNA in situ hybridization analysis, we found exclusive expression of S100a1 mRNA in luminal cells of the ureter from embryonic day (E)17.5 onwards and of the bladder from E15.5 to adulthood. Immunofluorescence analysis showed that expression of S100A1 protein is confined to terminally differentiated superficial cells of both the ureter and bladder where it localized to the nucleus and cytoplasm. We conclude that S100A1 is a suitable marker for mature superficial cells in the urothelial lining of the drainage system of the developing and mature mouse.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00418-022-02120-1.

A biogeographic 16S rRNA survey of bacterial communities of ureolytic biomineralization from California public restrooms.

In this study, we examined the total bacterial community associated with ureolytic biomineralization from urine drainage systems. Biomineral samples were obtained from 11 California Department of Transportation public restrooms fitted with waterless, low-flow, or conventional urinals in 2019. Following high throughput 16S rRNA Illumina sequences processed using the DADA2 pipeline, the microbial diversity assessment of 169 biomineral and urine samples resulted in 3,869 reference sequences aggregated as 598 operational taxonomic units (OTUs). Using PERMANOVA testing, we found strong, significant differences between biomineral samples grouped by intrasystem sampling location and urinal type. Biomineral microbial community profiles and alpha diversities differed significantly when controlling for sampling season. Observational statistics revealed that biomineral samples obtained from waterless urinals contained the largest ureC/16S gene copy ratios and were the least diverse urinal type in terms of Shannon indices. Waterless urinal biomineral samples were largely dominated by the Bacilli class (86.1%) compared to low-flow (41.3%) and conventional samples (20.5%), and had the fewest genera that account for less than 2.5% relative abundance per OTU. Our findings are useful for future microbial ecology studies of urine source-separation technologies, as we have established a comparative basis using a large sample size and study area.

A National Intervention to Reduce Undesirable Urinary Tract Events in Internal Medicine Wards

Background: Catheter-associated urinary tract infection (CAUTI) is considered a preventable healthcare-associated infection. Many local and national interventions using multimodal prevention measures have targeted CAUTI incidence as the primary outcome. Other undesirable events related to urinary catheters and infections such as overuse of urine culturing and antimicrobial prescribing for asymptomatic bacteriuria, are not captured by CAUTI surveillance, and may not be the targets of such interventions. The aim of this study was to assess the impact of expanded national surveillance targeting various aspects of urinary tract infections, culturing and treatment practices, and catheter use in internal medicine wards. Methods: The Israeli National Center for Infection Control (NCIC) issued CAUTI prevention guidelines and initiated in 2016 a urinary tract event surveillance system that targets the incidence of CAUTI, urinary catheter utilization ratio, and the proportion of urine cultures sent and patients treated in the absence of symptoms. The surveillance is conducted for 1 month 3 times per year. Hospitals are required to report all positive urine cultures (>100,000 CFU) collected in internal medicine wards, along with the following data: admission date, symptoms of infection, dates of urinary catheter use, and antibiotic treatment. These data enable the NCIC to validate hospital classifications of each event. In addition, during each surveillance month, hospitals conduct point-prevalence surveys of compliance with CAUTI prevention measures. An electronic data collection form with built-in algorithms supports the local teams during the surveillance process. Results: Between 2016 and 2019, a total of 3,028 positive urine cultures not present on admission were reported by internal medicine wards in 30 hospitals. A significant decrease was observed in the incidence of CAUTI (from 4.7 to 2.9; P < .001) and in the proportion of asymptomatic bacteriuria treated with antibiotics (from 31% to 20%; P = .02) (Table 1). The catheter utilization ratio decreased from 0.25 to 0.23 (P < .001). The rate of cultures sent from asymptomatic patients decreased from 1.5 to 1.1 (P < .01). Point-prevalence surveys in internal medicine wards detected a significant increase in the use of closed urinary drainage systems (from 79% to 97% in 2018, P < .001) and documentation of a daily nurse assessment of the need for a catheter (from 74% to 81%, P < .001). Conclusions: National surveillance of undesirable urinary tract events resulted in a significant reduction in CAUTI, antibiotic treatment for ASB, and the rate of cultures sent from asymptomatic patients. A small decrease was observed in catheter utilization ratio. CAUTI surveillance programs should include other undesirable urinary tract events.Funding: NoneDisclosures: None

Purple Urine Bag Syndrome in a Critically Ill Patient: Case Report

Purple urine bag syndrome (PUBS) is a rare manifestation characterized by purple discoloration of the urine drainage system. It may appear as a disconcerting finding for patients and healthcare workers not aware of this condition. It’s mostly seen in patients with long-term urine catheterization and a coexisting urinary tract infection (UTI); however, this is not always the case. We describe the case of a 43-year-old patient with cervical cancer and end-stage renal disease who presented to the emergency room with fever and urinary retention which required catheterization. Three hours later, purple urine was noted in the bag. She was diagnosed with bacteremia and a urinary tract infection which were treated with intravenous antibiotics, eventually presenting an unfavorable clinical evolution. Although usually considered benign, it does not always run a harmless course. It’s important to assess this finding on a patient-specific basis to uncover a possible underlying UTI, considering that some may not be able to adequately communicate symptoms, as is the case of the critically ill or patients with communication difficulties. This report contributes to raising awareness and a better comprehension of this unusual entity.

The Role of Bacterial Biofilms in Infections and Effective Prevention Strategies for Biofilm Formation in Urinary Catheters

Biofilm formation is a complicated microbiological process and one of the distinctive features of pathogenic bacteria. Biofilms are a cluster of bacterial cells enclosed in extra polymeric substances and irreversibly attached onto a surface. Biofilms have a major impact on public health as biofilm associated bacteria are able to survive and populate in indwelling medical devices, causing severe nosocomial and recurrent infections. Biofilm-embedded bacteria have unique characteristics which are harder to destroy than the planktonic forms. Especially biofilm bacteria are highly resistant to antimicrobial agents. Treating patients undergoing long term urinary catheterization is becoming complicated by encrustation and blockage due to crystalline biofilm formation inside the lumen of catheters. Further, all types of indwelling catheters including silver or nitrofurazone‐coated devices are vulnerable to biofilm formation. Therefore, there is an urgent requirement to develop either urinary catheters with other alternative coatings or new urinary drainage systems which may lead to reduction of infections and morbidity. Other than that, controlling biofilm formation is a necessary requirement during both manufacturing and usage of catheters. Antifouling and biocidal coatings on the catheters are currently being investigated and it is proved that herbal products also express anti-biofilm activity. This review is largely based on previous literature describing biofilm formation and their role in catheter associated urinary tract infection. Further, mechanism of biofilm formation in indwelling urinary catheters, antibiotic resistance patterns, and the detection methods of biofilm are briefly described. Understanding the mechanisms of biofilm formation and the antibiotic resistance patterns is of utmost importance which will result in the development of new remedies for biofilm infection.

Urinary Tract Aspergillosis in a Patient With Diabetes Who Underwent Total Abdominal Hysterectomy

Urinary tract aspergillosis is uncommon even in the era of increased frequency of invasivemycoses. Experience is largely from isolated case reports and few case series or reviews.The majority of cases involve transplant recipients predominantly following renaltransplantation but is also reported in other immunocompromised states such as AIDS anduncontrolled diabetes mellitus. Most cases represent haematogenous spread to renalparenchyma, often in the absence of recognized focus of infection, presenting as small orlarge abscesses, infarcts, renal insufficiency or urinary drainage system fungal balls withobstructive uropathy. Diagnosis is usually made on the basis of renal tissue aspiration, urinecultures or by histopathology of the suspicious mass passed through urinary tract. Theeffective management of invasive aspergillosis includes strategies to optimize preventionand early antifungal treatment, immunomodulation, and, in some cases, surgery. Neweranti-Aspergillus drugs notably voriconazole offer less toxic therapeutic options and are quitesuccessful in combination with drainage measures to relieve urinary stasis. This reportdescribes a case of primary urinary tract aspergillosis with fungal bezoars formation in a 37years old female, diabetic, hypertensive, who presented with intermittent urinary tractobstruction and was successfully managed by oral voriconazole for six weeks as itraconazolewas found refractory.
 Bangladesh J Obstet Gynaecol, 2018; Vol. 33(1) : 74-77

Prevention of catheter-associated urinary tract infection in neurological post-operation patients: a best practice implementation project

The objective of this evidence based implementation project was to promote evidence based practice in the prevention of catheter-associated urinary tract infection (CAUTI) in the neurology and neurosurgery units of a Taipei hospital. Catheter-associated urinary tract infection has been associated with increased morbidity, mortality, hospital costs and length of stay. Urinary drainage systems are often reservoirs of infection in patients, thus effective prevention of CAUTI requires an evidence-based approach. The CAUTI incidence in the neurosurgery units of the hospital was 1.86-2.69% urinary catheter days, which ranked as medium when compared to the entire hospital. A clinical audit was undertaken using the Joanna Briggs Institute Practical Application of Clinical Evidence System tool, based on eight audit criteria that represented best practice recommendations for CAUTI. A baseline audit of the neurology and neurosurgery units was performed, followed by the implementation of multiple strategies throughout a 20-week period. A follow-up audit was undertaken after this to assess changes in practice. The post strategy implementation audit results indicated that compliance with clinical guideline recommendations improved considerably. Proper utilization of an appropriate closed drainage system and training of persons maintaining catheters achieved 100% compliance. The guideline recommendation that catheter and drainage bags be changed only when clinically indicated reached 94% compliance. Catheters removed within 24 hours postoperatively improved by more than 50% compliance. Compliance with systemic antimicrobials being clinically indicated and their use justified improved by 25% and documentation on a clinically appropriate indication for ongoing urinary catheterization improved by almost 33.3%. The implementation project was successful in improving nurses' knowledge and skills related to the prevention of CAUTI. A variety of strategies, such as an education program, simple and clear instruments, collaboration with physicians in caring for patients with a high risk of CAUTI, and multiple educational materials can facilitate implementation of evidence based procedures in clinical practice.

Using Nursing Digital Technology to Reduce the Rates of Catheter-Associated and Non-Catheter-Associated Urinary Tract Infection

Urinary tract infection (UTI), the most common type of healthcare-associated infection, may result from negligence of care regardless of the presence or absence of catheterization. The UTI rate in our unit was .069%, which was the highest among all of the wards in the hospital. This project aimed to reduce the UTI rate to 0.37%. In order to achieve this goal, we amended the SOPs and audit table of catheterization, enhanced access to catheterization and perineal-wash-related instructional videos using quick response (QR) codes, encouraged and reminded patients to drink plenty of water, maintained the urinary drainage system free to avoid the growth of bacterial colonies, revised related healthcare education pamphlets and posters, and organized on-the-job training sessions for nursing staff. The UTI rate fell from .069% to 0.030%. Moreover, patients and their families responded well to the QR code method of accessing relevant videos, which enhanced technical knowledge and made the new information easy to learn. The use of QR code scanning enabled patients and their families to easily and conveniently watch videos on catheterization and perineal washing on demand. Nurses may employ QR codes in health education more frequently in order to provide higher quality nursing care.

Normal Functioning Fused Pelvic Kidney: A Very Rare Renal Anomaly

This study highlights two cases having fused pelvic kidneys who were referred at this institute by clinicians/nephrologists for 99mTechnetium (99mTc) DMSA and DTPA renal scintigraphy. One case was 24 year old female and the other case was 21 year old male. Both cases were undergone ultrasonographic examination for correlative purpose before renal scintigraphy. Their urinary drainage system was assessed with DMSA and DTPA renal scintigraphy, showing normal functioning fused pelvic kidneys. The authors also used diuretic during DTPA renogram to exclude the true obstructive feature of urinary tract.TAJ 2016; 29(1): 55-57

An engineering approach towards a more discrete and efficient urinary drainage system.

Modern urinary catheter-to-leg-bag systems suffer from a number of shortcomings. Drainage tubing of current urinary leg bags is perceived as unnecessarily bulky compared to the indwelling catheters to which it is connected, and catheter designs are prone to the formation of biofilms, leading ultimately to encrustation and blocking. We used analytical and experimental engineering methodologies, aligned with current international (International Standards Organisation) and European standards, to optimise drainage tube size and flow efficiency and characterise tube kinking behaviour. Using computational fluid dynamics, we studied the influence of modern Foley catheter design on urodynamics and explored its potential influence on biofilm formation and encrustation. Results indicate that tubing diameters could be reduced by 40%-50% and still satisfy current International Standards Organisation flow rate standards for leg bags; this might also reduce the likelihood of tube kinking. The computational study showed how current catheter design may promote the development of lower velocity recirculating flows and high shear in proximity of regions known to be affected by bacterial adhesion and biofilm formation. If confirmed, these findings will give manufacturers greater flexibility to develop less obtrusive and more encrustation-resistant products for end users.

Impact of an aseptic procedure for breaking the integrity of the urinary drainage system on the development of catheter-associated urinary tract infections in the intensive care unit

Catheter associated urinary tract infections (CAUTI) are a common complication in the hospital, especially in intensive care units (ICU). These infections are directly linked to the use of an indwelling urinary catheter. One commonly identified factor related to the development of CAUTI has been thought to be violating the integrity of the closed drainage system. However, a paucity of research exists to support or refute this practice. The primary purpose of this observational study was to assess if there is a relationship between CAUTI incidence and breaking the closed drainage system using an aseptic procedure. A process improvement effort was developed to ensure an aseptic technique was utilised when there was a need to break the integrity of the urinary drainage system. Because this was a new practice and not supported by the Centres for Disease Control (CDC) recommendations, this change in practice was evaluated as an observational study. In an eight month period there were 53 documented breaks in the urinary drainage system. There were 28 total cases of CAUTI overall during this same time period. Only four patients with a system break developed a CAUTI (7.5%). In almost 93% of the patients where aseptic technique was used for breaks in the drainage system, there was no occurrence of CAUTI. A follow-up evaluation was performed after a year of this practice in three adult ICUs. During this three month evaluation period, there were 47 documented cases of breaking this system using aseptic technique. Of the patients who had a documented break in their drainage system, none developed subsequent CAUTIs. One commonly identified factor related to the development of CAUTI has been thought to be violating the integrity of the closed drainage system. However, a paucity of research exists to support or refute this practice. This observational study found that utilising an aseptic technique to break the integrity system did not result in an associated increase in CAUTI.

Prevention of Catheter-Associated Urinary Tract Infections

With a share of 22.4%, nosocomial urinary tract infections (nUTIs) are among the most frequent infections acquired in hospitals, along with surgical site infections (24.7%), pneumonia (21.5%), clostridium difficile infections (6.6%) and primary sepsis (6%) 1. 80% of all nUTIs are associated with indwelling urinary catheters, with 12-16% of all hospitalised patients and up to 81.8% of all intensive care patients receiving an indwelling urinary catheter during their hospital stay 2 3. Therefore, profound knowledge about the basics of catheter-associated nUTIs and the correct management of urinary catheters are of utmost individual and socio-economic importance 4 5. It is estimated that up to 70% of all nUTIs occurring in Germany may be avoided by using appropriate preventative measures 6 7.In 2012, the authors Conway and Larson compared 8 recommendations in English language for the prevention of UTIs and noticed that they have been largely consistent over a period of 30 years 8. Special issues have rarely been addressed in valid studies, and study results are rather heterogeneous. For example, the 2008 SHEA (Society of Hospital Epidemiologists of America) guideline contains only 3 recommendations and 4 prohibitions which are based on more than one randomised controlled clinical study 9 10 11.The confirmed recommendations on the prevention of UTIs are consistent in the following aspects 12 13 14 15 16 17: · Every insertion of a urinary catheter must be based on a well-founded medical indication.. · Well-founded medical indications include acute urinary retention, interventions lasting several hours with a high fluid turnover, surgery involving the urinary tract, the necessity to record fluid turnover especially in critically ill patients, comfort for the dying, facilitating wound healing in the external genitals in the presence of urinary incontinence. Examples of unnecessary use of urinary catheters include prescriptions based on urinary incontinence alone and prolongation of use, e. g. after surgical procedures or after intensive care monitoring/recording has been completed.. · The insertion technique as well as catheter care and the detection of catheter-associated complications must be trained continuously.. · Catheterisation must be performed under sterile precautions.. · Only sterile and closed urinary drainage systems may be used.. · Catheters must be removed as early as possible..

Prevalence of dependent loops in urinary drainage systems in hospitalized patients.

The purpose of this study was to measure the prevalence and configuration of dependent loops in urinary drainage systems in hospitalized, catheterized adults. The study sample comprised 141 patients with indwelling urinary catheters; subjects were hospitalized at an academic health center in northern Florida. We measured the prevalence of dependent loops in urine drainage systems and the incidence of urine-filled dependent loops over a 3-week period. We measured the heights of the crest (H(c)), trough (H(t)), and, when urine-filled dependent loops were present, the patient-side (H(p)) and bag-side (H(b)) menisci with a laser measurement system. All variables were measured in centimeters. The majority of observed urine drainage systems (85%) contained dependent loops in the drainage tubing and 93.8% of the dependent loops contained urine. H(c) and H(t) averaged 45.1 ± 11.1 and 27 ± 16.7 cm, respectively. Meniscus height difference (H(b) - H(p)) averaged 8.2 ± 5.8 and -12.2 ± 9.9 cm when H(p) < H(b)(65.3%) and H(p) > H(b) (32.7%), respectively. We found that dependent loops are extremely common in urinary drainage systems among hospitalized patients despite the manufacturer recommendations and nursing and hospital policies. Maintaining the urine drainage tubing free of dependent loops would require incorporation into nursing care priorities and workflow as inadvertent force on the tubing, for example, patient movement or nurse contact can change tubing configuration and allow excess drainage tubing to re-form a dependent loop.

Upk3b is dispensable for development and integrity of urothelium and mesothelium.

The mesothelium, the lining of the coelomic cavities, and the urothelium, the inner lining of the urinary drainage system, are highly specialized epithelia that protect the underlying tissues from mechanical stress and seal them from the overlying fluid space. The development of these epithelia from simple precursors and the molecular characteristics of the mature tissues are poorly analyzed. Here, we show that uroplakin 3B (Upk3b), which encodes an integral membrane protein of the tetraspanin superfamily, is specifically expressed both in development as well as under homeostatic conditions in adult mice in the mesothelia of the body cavities, i.e., the epicardium and pericardium, the pleura and the peritoneum, and in the urothelium of the urinary tract. To analyze Upk3b function, we generated a creERT2 knock-in allele by homologous recombination in embryonic stem cells. We show that Upk3bcreERT2 represents a null allele despite the lack of creERT2 expression from the mutated locus. Morphological, histological and molecular analyses of Upk3b-deficient mice did not detect changes in differentiation or integrity of the urothelium and the mesothelia that cover internal organs. Upk3b is coexpressed with the closely related Upk3a gene in the urothelium but not in the mesothelium, leaving the possibility of a functional redundancy between the two genes in the urothelium only.

Foley Drainage Tubing Configuration Affects Bladder Pressure: A Bench Model Study

A bench model was created to measure and analyze pressures in a simulated bladder and an actual urine drainage system. Fluid-filled dependent (generally U-shaped) loops in the urine drainage tubing generated back-pressure (in units of cm H2O), directly related to the difference in fluid meniscus heights (in units of cm) across the dependent loop that interfered with emptying of the simulated bladder. If the results obtained with a simulated bladder occur in actual bladders with indwelling urinary catheters, retained urine volume (that can promote urinary tract infection) will increase with larger differences in meniscus heights across the dependent loop due to increased back-pressure. Dependent loops in urine drainage tubing should be avoided. If the dependent loops cannot be avoided or a configuration without dependent loops cannot be maintained, they should be routinely emptied of urine, especially if the bag-side meniscus is higher than the bladder-side meniscus.

What we don't know may hurt us: Urinary drainage system tubing coils and CA-UTIs—A prospective quality study

Catheter-associated urinary tract infections account for >30% of infections in acute care hospitals. We hypothesized that coiling of/kinks in the indwelling urinary bladder catheter (IUBC) drainage bag tubing would increase the occurrence of infection/bacteriuria. Ninety-one patient events were evaluated over 60 days. All outcome variables trended with greater frequency among those with a coil in the IUBC tubing; only fever (temperature > 38.1°C) correlated significantly between groups (P = .003). If IUBC is unavoidable, strategies such as keeping collection bag below the level of bladder and avoiding any coiling in the drainage system should be employed. Further study of these phenomena is needed.

Catheters: a guide to selecting appropriate products

When a catheter is inserted as a comfort measure at the end of life, it is important to ensure that the patient receives a catheter of the correct size, length and material. This will minimise trauma, reduce catheter changes and improve quality of life.

Evaluating clinical indications for continued catheterisation

Evaluating clinical indications for continued catheterisation

New strategies to prevent catheter-associated urinary tract infections

Catheter-associated urinary tract infection (CAUTI) is the most common health-care-associated infection worldwide. Although not all cases of bacteriuria result in clinical infection, several hundred thousand episodes of CAUTI occur each year in the USA alone. The milieu in which the catheter is placed is highly conducive to bacterial colonization, biofilm formation on the catheter surface, and inevitable catheter-associated bacteriuria. A multitude of novel methods of CAUTI prevention have been described, including established approaches that are routinely recommended, such as the use of a secured, closed, silicone urinary catheter drainage system that mimics normal voiding, and newer strategies focusing on biocompatible catheter materials that cause minimal host inflammatory response and retard biofilm formation. Much recent research has focused on modification of the catheter surface by either coating or impregnation with antimicrobials or antiseptics. However, clinical trials that analyse cost-effectiveness and rates of antimicrobial resistance are awaited. More recently, innovative use of iontophoresis, vibroacoustic stimulation, bacterial interference and bacteriophage cocktails has been reported.