Note: This information is for educational purposes only. It is not intended to replace the advice of your health care provider. If you have any questions, talk to your doctor.
The urinary tract includes your kidneys, ureters, bladder, and urethra. If you have a urostomy, you no longer get bladder infections. However, we can still experience urinary tract infections (UTI) driven by bacteria introduced in the ostomy pouch, stoma, conduit, ureters, and kidneys.
Figure 1. Urostomy, Urinary Tract
If physical symptoms are present, you should see your doctor, they will analyze your urine and blood and determine if antibiotics are prescribed and what type. They may culture the urine to determine what antibiotics are most effective, and they will let you know if a different antibiotic is more effective for treating your infection.
Antibiotic resistance is a real problem. According to the World Health Organization, "Antibiotic resistance is one of the biggest threats to global health, food security, and development today." It is important to know the difference between asymptomatic and symptomatic UTI's. You do not want to overuse antibiotics and develop a resistance when not necessary. While at the same time you do want to use antibiotics when necessary.
With physical symptoms any amount of bacteria in the urine can lead to a diagnosis of urinary tract infection. In general, bacteria counts between 100-100,000 colony-forming units (CFUs)/mL may be considered positive. 100 CFU/mL for people with symptoms or those who use catheters, and toward the higher end for people who are asymptomatic (without symptoms). [1]
There are things we can do to prevent symptomatic infections and even cure mild urinary tract infections ourselves.[2]
Signs You Should Pay Attention To (Possible Early Symptoms-See Strategy Below):
Cloudy Urine
Increased Odor
Change in Color (darker)
Symptomatic Signs: (Get Medical Attention)
Fever
Chills
Abdominal Cramping
Fatigue
Pressure/Pain in flanks (lower back)
Figure 2. Where Kidney Pressure / Pain Is Typically Felt
Research is being done to find new ways to treat urinary tract infections due to bacteria becoming resistant to antibiotics. While progress is being made, it is important to prevent urinary tract infections (UTIs) before they become a problem.
The most common causes for UTIs in people with Urostomies or Indwelling/Intermittent Catheters are the following, in order[3]:
*Uropathogenic Escherichia coli (UPEC) (E-Coli) 65%
*Enterococcus faecalis.
*Klebsiella pneumoniae
*Staphylococcus aureus
*Proteus mirabilis
*Pseudomonas aeruginosa
*group B Streptococcus
*All of these form a biofilm that protect the bacteria and allow bacteria to survive and grow in the urinary tract and on surfaces. [4],[5],[6],[7],[8],[9],[10].
Important Note: Bacteria growth is exponential. UPEC E. Coli has been shown to have a generational rate of 37 minutes in the human urinary tract and just over 20 minutes for people who have an active urinary tract infection.[11] In simple terms, bacteria populations can double every half hour.
Our strategy is simple:
Prevent Symptomatic Infection by pro-actively managing, influencing, and reducing the bacteria populations in our urinary tracts. Think of it as population control.
Develop habits that help us be successful and reduce occurrence of infection.
What are these habits? (Some of these are old news....)
Prioritize Prevention: Recurring infections are no fun. I have dealt with them my entire life due to urinary obstruction, and intermittent catheterization. For many years, monthly trips to the Emergency Room was my normal. Over time, the bacteria that caused most of my UTIs became resistant and the antibiotics I took had to be administered through a peripherally inserted central catheter (PICC) line. My urologist told me I needed to change the way I think about these infections and how we treat them. He is the one that got me to think about this as a personal experiment in bacteria population control. Minimize the population of bacteria, and give our immune systems a fighting chance to win the war. Make it a priority. It has been 5 years since I've been to the emergency room for an infection.
Drink More Water. As part of our strategy we want to drink more to help dilute the urine and help flush bacteria from the kidneys, ureters, conduit and stoma. You may be asking "how much is more?" We will revisit this below...
Always Empty Your Urostomy Pouch between 1/3 and 1/2 Full. This is recommended for normal use by Hollister, Coloplast, and Convatec. [12],[13],[14] This is a healthy habit and may limit the amount of bacteria with direct contact to your stoma, conduit, ureters and leaves open space to help ensure urine is not getting stuck up in our kidneys. In addition, overfilling your urostomy pouch can lead to leaks. [15]
Empty Your Urostomy Pouch "more" often. Emptying our pouches more often, flushes urine and the bacteria populating it out of our modified urinary tracts. Our goal is to reduce the bacteria population of the system. So, lets revisit the question of how much more water we should drink. My personal goal is to increase fluid intake to where I have to empty my bag more often than normal. That is my "more". If I feel like I am getting close to symptomatic infection I try to drink enough to have to empty my bag even more. Additionally, if we know bacteria populations can double every 20-30 minutes, emptying your pouch may not take the population to zero, but it will flush all the bacteria that's not clinging to the sides of the bag. If you are emptying when your bag is at 250ml, and you are at 100CFU's per mL, that's 25,000 bacteria that are no longer able to double in your bag.
Clean and Disinfect Your Night Drainage Bag and Tubing Daily: If you use a night drainage bag and tubing, or carry a urinary drainage bag with you be sure to sanitize them on a daily basis. Cleaning and disinfecting should be two steps and each has a distinct purpose. Cleaning prepares the surfaces to enable disinfectants to do their job: Cleaning removes organic substances that can impede disinfectants from working. Clean and then remove as much residual water as possible from the tubing and bag. As, residual water may dilute the disinfectant. Note: When using disinfectants, it is critical to follow the instructions and guidance for wet time, or contact time, required to be effective. [16] This note also applies to enzyme based cleaners. Follow the directions on the label.
Keep Your Changing Area Clean: Sometimes we are forced to change our urostomy bags in an emergency and do not get to choose when or where. We should carry cleaner and sanitizer in our day bags. At home, keep surfaces clean and sanitized, especially in our changing areas. Many of us change in the bathrooms of our homes. Shower doors, sink faucets, counter tops, bath tubs, toilet seats, and any area where you take care of your night drainage bag should be kept clean and sanitized before you change your pouch and after. We do not want to introduce our bacteria to others who may share the same bathroom.
Wash Soiled Linen, Hand Towels, Bath Towels, and Clothing Immediately: When soiled linen comes in contact with washing machine doors, etc, those surfaces should be cleaned and sanitized as well. If you are forced to change in non-clean environment like a porta-potty, public restroom, etc, you can make sure to change again when you are in your home location. I use Lysol Laundry Sanitizer Additive and Odor Eliminator. It works great at getting urine smells out of your laundry.
Change Your Urostomy Pouch More Frequently: If you normally change your pouch once or twice per week and feel like you need to boost your efforts to reduce the level of bacteria in your urinary tract, temporarily increase the frequency of changing your bag. Whatever the bacteria level is inside your bag, you can take it close to zero by removing the old bag and replacing it with a new bag. If you use a two piece you may start by just replacing the bag and keeping the flange in place. This will get rid of all the bacteria in the bag and those clinging to the sides. People with bladders can't do this...but we sure can!
Exercise and Stretch Regularly and Move Throughout the Day: Moving throughout the day may help flush residual urine and is a healthy habit for a number of reasons. But, for bacteria control, my system flushes better when I am standing or laying down with my upper torso slightly elevated. When seated urine tends to not flush as quickly and I feel the effects over time.
Supplements: Always talk to your doctor before taking a supplement to prevent UTIs. There are two supplements that come up consistently when discussing UTI prevention. D-Mannose and Cranberry. Research seems to indicate both have some ability to help prevent UTIs. However, cranberry appears to come with the most cautions and uncertainty[17][19]. High acidity can be tough on stomach, sugar content of juice form can be a problem for those controlling blood sugar, high oxalate content can be a driver for kidney stone formation, and if you take a blood thinner definitely talk to your doctor first. I was always told that it was the acidity of cranberry that made it effective in preventing UTI. However, current research seems to indicate it has some ability, similar to D-Mannose to prevent bacteria from sticking to the lining of the urinary tract, making it more difficult to colonize. Some studies indicated D-Mannose alone, or D-Mannose with antibiotics are more effective than antibiotics alone in treating UTI's. [18],[19] For our strategy I am going to recommend D-Mannose over cranberry due to the risks associated with cranberry. Vitamin C also has conflicting studies. [19] However, consult with your doctor, do your research, determine for yourself if you take a supplement or not.
Bathing: It is important to practice good hygiene. This post is focuses on protecting ourselves from bacteria. However, we can help protect other people including those that are close to us by practicing good habits, as well. Soaking in water sources without your urostomy bag clearly gives any bacteria in the water direct access to your urinary tract. We can be diligent in our efforts to reduce bacteria after exposing our urostomy bag to environments high in bacteria. Clean the urostomy bag and your skin after the activity and prior to changing the bag. If you feel that an infection is close, be extra diligent and possibly choose showering over bathing until you feel the risk is again low. As always, showering prior to entering hot tubs or public pools help prevent contamination of those areas.
Closing Thoughts On Cleaning: Keep it simple. The purpose of cleaning is to eliminate organic matter so the disinfectant can make contact with the bacteria. My ultimate goal is to reduce bacteria but also prolong the use of my urinary drainage bags and tubing. Initially, I was concerned about oxidizing cleaners on plastic for fear of damaging the bags, and tubing. I use an enzyme cleaner called Puracy Laundry Stain Remover. I know, it sounds weird. But, it contains all 6 enzymes and so I feel confident it works. After I rinse and drain my tubing/bag each morning, I use the Puracy Enzyme Cleaner and let it work all day. Then, when I get home I drain, rinse and disinfect. If you are looking for an animal friendly, environmentally friendly, affordable enzyme cleaner, check it out.
Closing Thoughts On Disinfecting: Again, simple is best for building sustainable long term habits. Make it easy for you. My goal is to reduce bacteria, but I want to do it safely (for me and the environment), and affordably. In doing my own research I've decided against Vinegar and Bleach, except in emergency situations. But, you may prefer those. Just be sure to follow the dilution and contact time data that is available. If you are spraying on and immediately wiping or rinsing off, it is likely wrong and not going to be effective. For disinfecting I use PUREROX superoxidized water, it is a hospital grade, non-toxic, residue free, safe for environment disinfectant. Contact time is 3 minutes. Safe for all surfaces.
:
Bates, Brittany N. Pharma D; Interpretation of Urinalysis and Urine Culture for UTI Treatment. US Pharmacist, November 15, 2013 US Pharm. 2013;38(11):65-68
WebMD, Editorial Contributors, "Remedies for UTI", Medically Reviewed by Minesh Khari, MD, November 27, 2022, A to Z Guides.
Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary tract infections: epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol. 2015 May;13(5):269-84. doi: 10.1038/nrmicro3432. Epub 2015 Apr 8. PMID: 25853778; PMCID: PMC4457377.
Sharma G, Sharma S, Sharma P, Chandola D, Dang S, Gupta S, Gabrani R. Escherichia coli biofilm: development and therapeutic strategies. J Appl Microbiol. 2016 Aug;121(2):309-19. doi: 10.1111/jam.13078. Epub 2016 Mar 11. PMID: 26811181.
Zheng JX, Bai B, Lin ZW, Pu ZY, Yao WM, Chen Z, Li DY, Deng XB, Deng QW, Yu ZJ. Characterization of biofilm formation by Enterococcus faecalis isolates derived from urinary tract infections in China. J Med Microbiol. 2018 Jan;67(1):60-67. doi: 10.1099/jmm.0.000647. PMID: 29148361; PMCID: PMC5882073.
Seifi K, Kazemian H, Heidari H, Rezagholizadeh F, Saee Y, Shirvani F, Houri H. Evaluation of Biofilm Formation Among Klebsiella pneumoniae Isolates and Molecular Characterization by ERIC-PCR. Jundishapur J Microbiol. 2016 Jan 2;9(1):e30682. doi: 10.5812/jjm.30682. PMID: 27099694; PMCID: PMC4834130.
Archer NK, Mazaitis MJ, Costerton JW, Leid JG, Powers ME, Shirtliff ME. Staphylococcus aureus biofilms: properties, regulation, and roles in human disease. Virulence. 2011 Sep-Oct;2(5):445-59. doi: 10.4161/viru.2.5.17724. Epub 2011 Sep 1. PMID: 21921685; PMCID: PMC3322633.
Wasfi R, Hamed SM, Amer MA, Fahmy LI. Proteus mirabilis Biofilm: Development and Therapeutic Strategies. Front Cell Infect Microbiol. 2020 Aug 14;10:414. doi: 10.3389/fcimb.2020.00414. PMID: 32923408; PMCID: PMC7456845.
Mulcahy LR, Isabella VM, Lewis K. Pseudomonas aeruginosa biofilms in disease. Microb Ecol. 2014 Jul;68(1):1-12. doi: 10.1007/s00248-013-0297-x. Epub 2013 Oct 6. PMID: 24096885; PMCID: PMC3977026.
Patras KA, Derieux J, Al-Bassam MM, Adiletta N, Vrbanac A, Lapek JD, Zengler K, Gonzalez DJ, Nizet V. Group B Streptococcus Biofilm Regulatory Protein A Contributes to Bacterial Physiology and Innate Immune Resistance. J Infect Dis. 2018 Oct 5;218(10):1641-1652. doi: 10.1093/infdis/jiy341. PMID: 29868829; PMCID: PMC6173572.
Forsyth VS, Armbruster CE, Smith SN, Pirani A, Springman AC, Walters MS, Nielubowicz GR, Himpsl SD, Snitkin ES, Mobley HLT. Rapid Growth of Uropathogenic Escherichia coli during Human Urinary Tract Infection. mBio. 2018 Mar 6;9(2):e00186-18. doi: 10.1128/mBio.00186-18. PMID: 29511075; PMCID: PMC5844997.
Hollister PDF: "Understanding Your Urostomy";
Coloplast Web Page, "Changing and Emptying Your Urostomy Pouch"; https://www.coloplastcare.com/en-US/ostomy/the-basics/before-surgery/b2.3-changing-and-emptying-your-urostomy-pouch/
Convatec Web Page, "Product Basics", https://www.convatec.com/ostomy-care/before-surgery/product-basics/
Hollister Web Page; "6 Tips for Avoiding Ostomy Leakage"; https://www.hollister.com/en/ostomycare/ostomylearningcenter/maintaininghealthyskin/6tipsforavoidingleakage#
National Network of Public Health Institutes Interactive Learning: "Why Does Contact Time Matter for Disinfection?"
Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2012 Oct 17;10(10):CD001321. doi: 10.1002/14651858.CD001321.pub5. PMID: 23076891; PMCID: PMC7027998.
Kyriakides R, Jones P, Somani BK. Role of D-Mannose in the Prevention of Recurrent Urinary Tract Infections: Evidence from a Systematic Review of the Literature. Eur Urol Focus. 2021 Sep;7(5):1166-1169. doi: 10.1016/j.euf.2020.09.004. Epub 2020 Sep 22. PMID: 32972899.
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