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BMJ 2003; 326 doi: (Published 29 May 2003) Cite this as: BMJ 2003;326:1222

Soaring caesarean section rates in the United States provide food for thought. The rate in 2001 reached an all time high of 24.4%, while that of women having a vaginal delivery after a previous section dropped to an all time low of 16.5%. An editorial in the Journal of Obstetric, Gynecologic, and Neonatal Nursing (2003;32: 283-4) asks whether this situation has arisen because the demand for perfection forces unnecessary intervention, and calls for a return to common sense guided by evidence rather than fear of litigation.

An elderly woman presented with obstructive uropathy requiring a nephrostomy. After ureteric stenting the urinary catheter bag turned purple but the nephrostomy bag remained clear. Reports suggest that the discoloration is due to a mixture of indirubin dissolved in the plastic and indigo on its surface. Organisms in the urine that possess indoxyl sulphatase activity, such as Providencia and Klebsiella, metabolise urinary indoxyl sulphate to indigo leading to purple urine bag syndrome. This is often seen with elderly patients as they have high levels of urinary indoxyl sulphate. No organism was identified in this patient, but she had cystitis without evidence of ascending infection.

Stephen G Riley, specialist registrar, Prem Thurairajah, senior house officer, Bryonie F Read, senior …

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