Assessment for UTI in People with Urostomy
In patients with a urostomy, assess for UTI only when specific symptoms are present—fever (≥100°F/37.8°C), new dysuria-like discomfort, gross hematuria, or signs of systemic infection—and obtain urine specimens via catheterization directly through the stoma after rigorous antiseptic preparation, never from the collection bag. 1, 2
Clinical Presentation: When to Suspect UTI
The key principle is that asymptomatic bacteriuria should not be tested or treated in urostomy patients, as colonization of the urinary diversion is universal and does not indicate infection. 3, 1
Specific Symptoms That Warrant Evaluation:
- Fever: Single oral temperature ≥100°F (37.8°C), repeated temperatures ≥99°F (37.2°C), or increase of ≥2°F (1.1°C) over baseline 1, 4
- Systemic signs of infection: Shaking chills, hypotension (systolic BP ≤100 mmHg), altered mental status, or signs of organ dysfunction 5, 1
- Gross hematuria: New onset visible blood in urine 1, 4
- Flank pain or suprapubic discomfort: Suggesting upper or lower tract involvement 3, 1
Critical Pitfall to Avoid:
Do not order urinalysis based solely on nonspecific symptoms such as confusion, decreased appetite, functional decline, or cloudy/malodorous urine from the pouch—these are not reliable indicators of UTI in urostomy patients. 1, 4
Proper Specimen Collection Technique
The collection method is critical because contamination from stomal mucosa colonization will lead to false-positive cultures and inappropriate treatment. 3, 2
Step-by-Step Collection Protocol:
Never collect urine from the drainage bag or pouch—this will be contaminated with colonizing bacteria 3, 2
Remove the existing appliance and clean the stoma and peristomal skin with antiseptic solution using rigorous technique 3, 2
Catheterize directly through the stoma using sterile technique:
Transport specimen to laboratory within 1 hour or refrigerate if delayed to prevent bacterial multiplication 3
Laboratory Evaluation Algorithm
Initial Screening (When Symptoms Present):
Step 1: Urinalysis with dipstick and microscopy 1, 4
- Test for leukocyte esterase and nitrite 1, 4
- Perform microscopic examination for WBCs (pyuria defined as ≥10 WBCs/high-power field) 1, 4
Step 2: Interpret results 1, 4
- If negative for both leukocyte esterase AND nitrite: UTI is effectively ruled out (96% negative predictive value)—stop further testing 1, 4
- If pyuria present OR positive leukocyte esterase/nitrite: Proceed to urine culture with antimicrobial susceptibility testing 1, 4
Step 3: Additional testing for suspected urosepsis 5, 4
- Obtain paired blood and urine cultures simultaneously before starting antibiotics 5
- Request Gram stain of uncentrifuged urine for rapid pathogen identification 5
- Obtain CBC with differential within 12-24 hours: Look for WBC ≥14,000 cells/mm³ or left shift (bands ≥6% or ≥1,500 cells/mm³) 5, 4
High-Risk Situations Requiring Lower Threshold for Evaluation
Certain clinical scenarios warrant more aggressive assessment even with subtle symptoms: 3, 5
- Recent urologic surgery or manipulation of the urostomy 3
- Suspected urinary obstruction or conduit complications 3
- Immunocompromised patients (transplant recipients, neutropenia) 3
- Signs of sepsis: Hypotension, altered mental status, organ dysfunction (use qSOFA score: respiratory rate ≥22, altered mental status, systolic BP ≤100 mmHg) 5
Key Differences from Standard UTI Assessment
Unlike patients with intact bladders, urostomy patients present unique challenges: 6, 2
- Bacteriuria is expected and normal—the conduit mucosa is always colonized 3, 6
- Typical lower urinary tract symptoms (frequency, urgency) are absent due to the diversion 6
- Specimen contamination is extremely common if proper collection technique is not followed 3, 2
- Skin complications around the stoma may mimic or coexist with infection but are usually unrelated to UTI 6, 7