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Urostomy And Urinary Tract Infections

Our natural filtering system eliminates urine through the urinary tract. Kidney disease, stomach cancer or surgery patients may require a surgical modification in a procedure called urostomy, either a diversion of the conduit or a pouch drained via a catheter. An urosotmy has multiple risks, including potential urinary tract infections due to bacterial contamination. 

“The number of people with a urostomy in America is not clearly known; reports estimate the range from 150,000 to 250,000. One of the most common complications associated with a urostomy are urinary tract infections. Due to the small number of people with a urostomy, clinicians may not be familiar with the correct technique to obtain a urine sample from a stoma to test for a urinary tract infection. Incorrect sampling techniques may lead to inaccurate culture results and then lead to inappropriate diagnosis and treatment.”1

“The most important cause of morbidity and mortality in patients in whom a urostomy was created is complications related to bacterial contamination. When the intestine is anastomosed to the urinary tract, local bacterial growth is facilitated, and these bacteria serve as a source for systemic spread. A urostomy may expose the body to infections, especially in the urinary tract, largely due to the proximity of the bowel and its nearby abundance of bacteria.”2

Sources of urinary tract infections in ostomy patients

“Many classifications have been proposed to assess factors that expose the individual at risk for UT (Urinary Tract). Genetic predisposition, behavioral factors, host factors and risk for UTIs (Urinary Tract Infections) results from a complex interaction between all of these elements. The higher susceptibility of the female sex is firstly due to anatomical characteristics with the proximity of the female urethra to the vaginal cavity to the rectum. This increases the probability of colonization of the periurethral mucosa by potential uropathogens and thus facilitating the ascending route of infection to the bladder of the kidney. Specific behaviors have been associated with UTIs. Studies among college women have shown that sexual intercourse, use of spermicides and diaphragms and number of sexual partners increase risk of acquiring UTIs.”3

 Sexual activity

“Urinary tract infections are more common among women than among men (with a ratio of men to women of 1:3:9), although the prevalence in elderly women and men is similar. The presentation can include different forms of cystitis, pyelonephritis, and urethral syndrome, with the most common complaints being dysuria and flank or back pain. Although there are a number of potential causes of urinary tract infection in women, risk factors include sexual intercourse, use of spermicidal products and diaphragm use […]

Because sexual abstinence is unlikely among most women, particularly for those in an established sexual relationship, someplace themselves at risk of recurrent infection. For women presenting a first urinary tract infection by E. coli, vaginal intercourse increased the risk of a second urinary tract infection with both a different and same uropathogen, as did using a diaphragm, cervical cap, and spermicide. These findings emphasize the importance of considering the context of sexual interactions and/or involving in sexual partners and/or in developing a treatment plan.”4

Diabetes

“For a long time, it had been controversial whether the frequency of bacteriuria is higher in diabetic patients, but there has never been any doubt that symptomatic UTIs are more severe and more aggressive in diabetic individuals. […]

While doing a clinical evaluation of diabetic patients with suspected nephrologic involvement certain aspects have to be specially considered. Patients with diabetes mellitus may have a renal function with minimal localizing symptoms or signs. Conditions such as Emphysematous Pyelonephritis (EPN) and renal abscess should be considered in the event of non-response to appropriate antibiotic therapy for urinary infection in diabetic patients.

Diabetic patients with urinary infections are more likely to be bacteremic or urosceptic than nondiabetic patients. These patients are also five times more likely to develop acute pyelonephritis than non-diabetic patients. Diabetic patients with systemic signs of urinary infection should be studied with abdominal radiography to detect renal EPN. Ultrasound or computerized tomography should be performed in an obstruction or abscess is suspected.

The urinary tract is implicated as the source of bacteremia more frequently in diabetic than non-diabetic patients. Women with type 2 diabetes and history of UTI (especially upper UTI) are at increased risk for renal scarring and damage as demonstrated by renal cortex scans. Most of the bacteria responsible for urosepsis in diabetics are gram-negative rods, with E. coli and Klebsiella Sp. Accounting for about 70%. Klebsiella sp. It is isolated twice as frequently in diabetic patients with bacteremic urinary infections, especially in those with indwelling urinary bladder catheters. Symptomatic UTIs definitely run a more aggressive course in diabetic patients. Recent studies show that in multivariate analysis diabetes and poor glycemic control are independent factors associated with upper urinary tract involvement.”5

Bacterial infections (E. Coli, Staphylococcus or Pseudomonas)

“Gram negative bacilli of the family Enterobacteriaceae are responsible for 90% of urinary tract infections. Escherichia coli is the single most important organism and accounts for 80% to 90% of uncomplicated infections. Others include Klebsiella, Enterobacter, Serratia, Proteus, Pseudomonas, Providencia, and Morganella species. Pseudomonas aeruginosa infection is almost always secondary to urinary tract instrumentation. Staphylococcus saprophyticus is the second most common cause of cystitis and causes 10% of infections in sexually active females. Staphylococcus epidermidis is a nosocomial pathogen identified in patients with indwelling catheters. Staphylococcus aureus is less commonly isolated and is often secondary to hematogenous renal infection.

Other gram-positive organisms such as enterococci and Streptococcus agalactiae cause about 3% of episodes of cystitis. Enterococcus faecalis causes about 15% of nosocomial urinary infections, and Str. Agalactiae is more commonly the cause in patients with diabetes mellitus. Anaerobic bacteria, although abundant in fecal flora, rarely cause urinary tract infections. The oxygen tension in the urine probably prevents their growth and persistence in the urinary tract.”6

Viral or fungal infections 

“Bacteria are the cause of most urinary tract infections. Virus or fungal infection of the urinary tract is a rare event and suggests an underlying health problem in the affected patient. In most cases, a single pathogen is isolated from an infected urine sample. Isolation of more than one bacterial type, unless repeated over a course of time, would generally indicate that a specimen was contaminated rather than infected. Because urinary tract infections are so common, diagnostic microbiology laboratories put considerable effort into their diagnosis. Although only single pathogens are implicated in urinary tract infections, their diagnosis is complicated because of the difficulties of obtaining good quality specimens.”7

Potential causes of viral or fungal infections are:

  • Excess accumulation of urine in the ostomy bag (more than half -full).
  • Utilizing the wrong ostomy bag.
  • Age (past menopause).
  • Past medical history indicating urinary tract infections (UTIs).

“The stoma serves as a portal for pathogens to enter the urinary tract, causing infection. Urinary tract infections can have serious consequences, including kidney damage and septicemia. Pouch care is treated as a clean rather than sterile procedure because the stoma is not sterile. However, you must still take care to avoid introducing organisms to the area.

Yeast infections that sometimes develop around the stoma are characterized by a skin rash surrounding the stoma. These are usually treated with antifungal powder applied to the peristomal skin, and sealed with a skin barrier spray/wipe, then covered with the wafer.”8

Your physician may administer tests to confirm the presence of a UTI and recommend appropriate treatment (usually antibiotics).  

Ensuring Urinary System Health

Recommended countermeasures to ensure post-operation or normal urinary system health include:

  • Aseptic management of the parastomal area and handling of the urostomy bag or catheter after surgery.
  • Optimal fluid intake.
  • Use of a urostomy bag with a non-return valve to prevent urine reflux over the stoma. “Urostomy patients use specific urostomy pouches, which have a tap at the end to allow ease of emptying and which can attach to a two-liter night drainage bag at night. These pouches also have an anti-reflux valve which prevents the backflow of urine towards the stoma to reduce the risk of ascending infection. Some urostomy patients also use a leg bag to increase storage capacity and increase the time between toilet visits.”9
  • Connect a Night Drainage system to your ostomy bag every night.
  • Good nutrition and supplementation, especially with vitamin C rich foods and cranberry juice which acts as a natural antibiotic.  It is especially important to mention that vitamin C and cranberry juice (240 ml per day) have proven successful in preventing the onset of UTIs as well as aiding in the recovery after infection development.
  • A medically supervised pre-emptive or post-surgical antibiotic treatment. If you also have a colostomy or an ileostomy, consider attaining the right absorption levels. An ostomy resulting from any of these two procedures may affect the ability to fully benefit from a drug program.

Check your urostomy bag and contact your ostomy nurse or physician if you observe any or a combination of the following: unfamiliar or foul urine odor, abnormally high temperatures or chills, lower body pain,  and or urine mixed with pyuria or blood.

 

References:

(1) Mahoney, M., Baxter, K., Burgess, J., Bauer, C., Downey, C., Mantel, J., … & Sheppard, S. (2013). Procedure for obtaining a urine sample from a urostomy, ileal conduit, and colon conduit: a best practice guideline for clinicians. Journal of Wound Ostomy & Continence Nursing, 40(3), 277-279. Available online at https://nursing.ceconnection.com/ovidfiles/00152192-201305000-00009.pdf 

(2) Temiz, Z., & Cavdar, I. (2018). The effects of training and the use of cranberry capsule in preventing urinary tract infections after urostomy. Complementary therapies in clinical practice, 31, 111-117. Available online at https://www.researchgate.net/publication/322904400_The_effects_of_training_and_the_use_of_cranberry_capsule_in_preventing_urinary_tract_infections_after_urostomy 

(3) Tonolini, M. (Ed.). (2018). Imaging and intervention in urinary tract infections and urosepsis. Springer International Publishing. Available online at https://books.google.co.ve/books?id=er5GDwAAQBAJ&pg=PA10&dq=Bacterial+infections+(E.+Coli,+Staphylococcus+or+Pseudomonas)+Urinary+tract+infections&hl=es-419&sa=X&ved=0ahUKEwj98c3137TiAhXHs1kKHTtPCgkQ6AEIJzAA#v=onepage&q=Bacterial%20infections%20(E.%20Coli%2C%20Staphylococcus%20or%20Pseudomonas)%20Urinary%20tract%20infections&f=false 

(4) Meston, C. M., Goldstein, I., Davis, S., & Traish, A. (2005). Women’s sexual function and dysfunction: study, diagnosis and treatment. CRC Press. Available online at https://books.google.co.ve/books?id=3J7TnwpbZQwC&pg=PA298&dq=sexual+activity+urinary+tract+infections&hl=es-419&sa=X&ved=0ahUKEwjJiN605rTiAhUCyFkKHZdRALcQ6AEIJzAA#v=onepage&q=sexual%20activity%20urinary%20tract%20infections&f=false 

(5) Dakshinamurty, K. V. (Ed.). (2013). Diabetic Kidney Disease-ECAB. Elsevier Health Sciences. Available online at https://books.google.co.ve/books?id=PXEEbZnlsE8C&pg=PA66&dq=diabetes+and+urinary+infections&hl=es-419&sa=X&ved=0ahUKEwj_rfWquLTiAhVvvFkKHcpWCKUQ6AEINzAC#v=onepage&q=diabetes%20and%20urinary%20infections&f=false 

(6) Walters, M. D., & Karram, M. M. (2014). Urogynecology and Reconstructive Pelvic Surgery E-Book. Elsevier Health Sciences. Available online at https://books.google.co.ve/books?id=9dpb-v6usoMC&pg=PA414&dq=Bacterial+infections+(E.+Coli,+Staphylococcus+or+Pseudomonas)+Urinary+tract+infections&hl=es-419&sa=X&ved=0ahUKEwj98c3137TiAhXHs1kKHTtPCgkQ6AEIZzAI#v=onepage&q=Bacterial%20infections%20(E.%20Coli%2C%20Staphylococcus%20or%20Pseudomonas)%20Urinary%20tract%20infections&f=false 

(7) Heritage, J., Evans, E.G.V., Killington, R.A. Microbiology in Action. Available online at https://books.google.co.ve/books?id=n9x6zLqdjOYC&pg=PA140&dq=Viral+or+fungal+infections+and+urinary+infections&hl=es-419&sa=X&ved=0ahUKEwiZ_rzquLTiAhULj1kKHXcbBIsQ6AEIQzAD#v=onepage&q=Viral%20or%20fungal%20infections%20and%20urinary%20infections&f=false 

(8) Linton, A. D., & Matteson, M. A. (2019). Medical-Surgical Nursing E-Book. Elsevier Health Sciences. Available online at https://books.google.co.ve/books?id=DA-IDwAAQBAJ&pg=PA314&dq=urostomy+urinary+tract+infections&hl=es-419&sa=X&ved=0ahUKEwiLx67XrbTiAhUhxVkKHdyfAVAQ6AEIUDAF#v=onepage&q=urostomy%20urinary%20tract%20infections&f=false 

(9) Moore, S. (2015). The practice nurses guide to new stoma care products. Available online at https://www.lenus.ie/bitstream/handle/10147/582817/art6.pdf?sequence=1&isAllowed=y 

 

María Laura Márquez
13 October, 2018

Written by

María Laura Márquez, general doctor graduated from The University of Oriente in 2018, Venezuela. My interests in the world of medicine and science, are focused on surgery and its breakthroughs. Nowadays I practice my profession...read more:

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