Article by Dr Manasa S, B.A.M.S
Chyluria is a medical condition characterized by the appearance of chyle in the voided urine. This issue is commonly seen in individuals who have been affected with filariasis at one or the other point of time in their life. The other non-infective causes of chyluria are infrequent but they cannot be ruled out completely.
The distinguishing feature of this condition is the presence of chyle in the voided urine along with microscopic blood and occasionally, with gross blood.
What is Chyle?
Chyle is a milky white coloured fluid which is formed in the small intestine during the digestion of fatty foods. Chyle is taken up by the lymph vessels, specifically lacteals. Then the chyle is transported to the cisterna chyli located anterior to the second lumbar vertebra – L2 and posterior and right of the abdominal aorta. Chyle consists of lymph and emulsified fats, or free fatty acids. After the food intake, it takes about two to three hours for the fat to be absorbed from the small intestine.
Overview of Chyluria
Chyluria is a condition associated with lymphatic fluid leak into the kidney, turning the voided urine milky white. It is mostly associated with the parasitic infection Wuchereria Bancrofti but non-infectious causes are also seen to be causal. When the normal flow of the lymph is disrupted or when lymph vessels are damaged because of infectious or noninfectious reasons there can be a leakage of lymphatic fluid into the kidneys.
It is most common to see parasitic chyluria in places like South America, sub-Saharan Africa and south-east Asia, especially India. Chyluria is typically common in age groups between 20 and 40 years. However, parasitic chyluria is also observed in children as young as 5 years of age.
Common causes of Chyluria
Common causes of Chyluria includes
Infectious causes
Parasitic infections due to Wuchereria bancrofti contribute to around 95% of cases.
The other 5 % of cases of chyluria are due to –
– Taenia echinococcus
– Taenia nana
– Ankylostomiasis
– Trichinosis
– Malaria
Non-infectious reasons
The non-infectious reasons for the causation of chyluria include –
– Tumours
– Trauma
– Congenital syndromes such as Gorham-stout, Noonan syndromes
– Congenital syndromes such as lymphatic malformations like lymphangiomatosis
– Injury to abdomen
– Surgeries like partial nephrectomy and scoliosis where there is accidental trauma to lymphatic vessels
– Radiation
– Abscesses
– Narrowing of thoracic duct
– Pregnancy
Pathophysiology of chyluria
The exact mechanism of chyluria is not clear, but two important theories behind the chyluria are –
– regurgitation of chyle from the lymphatic system into the renal tract or
– obstruction of the lymphatic system in the vicinity of the urinary tract resulting in the development of the fistula
In case of regurgitation of chyle from the lymphatic system there is either build-up of toxins or secondary inflammatory response to the parasitic infection results in the development of the lymphatic ectasia and varicosities. When the intestinal lymphatics dilate and then rupture, they release the chyle into the renal system leading to chyluria.
In case of obstructive cause secondary due to parasitic infections there is obliterative lymphangitis. This leads to collaterals and varicosities and due to which the chyle backflows.
Signs and symptoms
– Milky white appearance of voided urine
– Pain during urination
– Presence of microscopic blood or gross blood
– Frequent micturition
– Pain in the low back
– Weight loss
– Feeling fatigue all the time
– Complaints of chills
– Swelling in arms and legs
Though there is no universally accepted grading system for chyluria, presently the grading used in world literature has been accepted for all practical purposes. The grading of chyluria is as explained below –
a. Mild chyluria
– Intermittent episodes of milky white urine
– Involvement of only one calyx
b. Moderate chyluria
– Intermittent episodes of milky white urine with or without clot and colic
c. Severe chyluria
Persistent milky urine
One or more of the following
– Urinary retention
– Haematochyluria
– Systemic symptoms like weight loss
– Involvement of most of the calyces with possible ureteric involvement
Diagnosis of Chyluria
Health care professionals use both lab investigations and imaging techniques to diagnose the condition of chyluria.
Important tests may include
– X-ray
– Ultrasound
– Computer tomography
– MRI
Laparoscopy is a minimal invasive technique that provides information about the source of lymphatic leak.
Testing urine for the presence of lymph fluids
In addition to these, lymphatic imaging modalities such as intranodal lymphangiography and dynamic contrast magnetic resonance lymphangiography might be of great tools to check for the exact source of the lymphatic leak.
Treatment of Chyluria
Conservative line of treatment
– Rest
– Increase the hydration
– A well-balanced diet
– Limiting the amount of fat in the diet
– Parenteral nutrition may also be advised
– Internal medication to address the infection
Minimally invasive treatment
When a person suffering from chyluria is not responding well to conservative treatment approaches then minimal invasive treatment, sclerotherapy is a better option.
Sclerosant is a special solution which is injected into the centre of the kidney. The most common content of sclerosant is silver nitrate, but other common sclerosants include povidone iodine, sodium iodide, and potassium bromide, dextrose and hypertonic solution.
Preventive measures
Most cases of chyluria which are due to parasites typically spread through mosquito bites. The good way to prevent chyluria is to prevent mosquito bite and this includes –
– Wearing clothes which have long, thick pants and full sleeves
– Sleeping under the mosquito net
– Wearing mosquito repellents on the exposed part of the skin
– Clothes, tents and net coverings and surrounding areas where an individual resides should be treated with mosquito repellents
Ayurveda understanding of Chyluria
Pishta Meha
A condition called ‘Pishta Meha’ explained in Ayurveda treatises has been correlated to chyluria due to similarity in both conditions.
Pishta Meha is explained in the context of ‘Prameha’ which explains different kinds of urinary disorders and also includes diabetes mellitus. It is one among the ten types of kaphaja prameha i.e. pramehas caused due to predominant aggravation of kapha.
Pishta means flour. In this condition there is excessive urination in which urine appears like ‘flour mixed water’ and hence the name.
Symptoms of Pishta Meha
संसृष्टरोमा पिष्टेन पिष्टवद्बहुलं सितम्।वा.नि.१०।
saṃsṛṣṭaromā piṣṭena piṣṭavadbahulaṃ sitam|vā.ni.10|
In pishtameha the person would have horripilation while urinating. He voids excessive urine white in colour and mixed with white material resembling flour.
Sandra Meha
Master Charaka has not mentioned Pishta Meha. His explanation of Sandra Meha resembles the explanation of Chyluria. Charaka’s Pishtameha might be a representative of Vagbhata’s Pishta Meha.
यस्य पर्युषितं मूत्रं सान्द्रीभवति भजने।
पुरुषं कफ कोपेन तमाहुः सान्द्र मेहिनम्॥च.नि.४/१५॥
yasya paryuṣitaṃ mūtraṃ sāndrībhavati bhajane|
puruṣaṃ kapha kopena tamāhuḥ sāndra mehinam||ca.ni.4/15||
Symptoms of Sandra Meha
In a person having aggravation of kapha, the patient passes urine which when kept in a vessel gets solidified after some time.
Treatment
Pishta Meha and Sandra Meha are treated following –
– The general principles of treating Prameha
– The principles of treating Kaphaja Prameha
The same principles shall be followed while treating chyluria through Ayurveda measures.
