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Purple urine bag syndrome is an uncommon condition seen in patients with indwelling urinary catheter and urinary infection.
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Characteristic purple color results from the metabolism of tryptophan in the presence of urinary bacteria.
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The condition is usually benign and requires no further treatment than bacteria-directed antibiotic.
1. Indication
A 83-year-old man with a history of arterial hypertension, diabetes mellitus, chronic obstructive pulmonary disease, and benign prostatic hyperplasia was admitted to our center for a surgical repair of abdominal hernia. He was on a long-term urinary catheter. The surgical procedure was performed without immediate complications. 48 h after the procedure, the urine bag showed a very distinctive purple color (Fig. 1). The patient remained clinical and hemodynamically stable without urinary symptoms; he complained of mild abdominal pain in the area of the surgical incision. The physical exam showed no abnormal findings. Urinalysis revealed a pH of 9.0, density of 1010, presence of nitrites, leukocytes 25–50 per field, and bacteria (+++). Urine culture was also collected. 24 h after, Klebsiella pneumoniae (more than 100,000 CFU/mL) was isolated. Urinary catheter was replaced, and the patient began treatment with ciprofloxacin (500 mg bid) He was discharged 24 h later. After 14 days of treatment, the color of the urine bag was normalized and patient outcome was favorable.
Fig. 1Plastic urine bag with a striking purple color.
Purple urine bag syndrome (PUBS) is an uncommon condition observed in patients with long-term urinary catheter and co-existent urinary tract infection, where the urine bag and tubing turn purple. Risk factors for the development of PUBS include female gender, old age, indwelling urinary catheter, prostration, chronic constipation, chronic kidney disease, azotemia, and protein-rich diet.
The characteristic purple color results from metabolism of tryptophan in the presence of urinary tract infection. Intestinal bacteria such as Proteus mirabilis convert tryptophan to indole which is later metabolized to indoxyl sulfate in the liver. Bacterial phosphatases or sulfatases catalyze indoxyl sulfate to indoxyl. In urine, indoxyl is converted into two pigments, indigo (blue) and indirubin (red). Interaction of these two pigments with the plastic bag or catheter creates a purple color [
]. Several bacteria have been associated with PUBS including Pseudomonas aeruginosa, Proteus mirabilis, Klebsiella pneumoniae, Morganella morganii, Escherichia coli, Providencia species, Enterococcus species, etc. [
]. Although urinary tract infections are very common, not all bacteria produce these enzymes, explaining the rare finding of this condition. Situations that induce bacterial overgrowth (e.g. constipation) may induce increased metabolism of tryptopahn into indole [
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