• Users Online: 171
  • Print this page
  • Email this page


 
 
Table of Contents
LETTER TO THE EDITOR
Year : 2018  |  Volume : 29  |  Issue : 6  |  Page : 307-310

The effect of dextrose instillation on a man with chylous hematuria: A case report


1 Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
2 Department of Anatomic Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan

Date of Web Publication22-Nov-2018

Correspondence Address:
Hao Lun Luo
Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, No.123, Da-Pi Road, Niaosong Dist., Kaohsiung
Taiwan
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_18_17

Get Permissions

  Abstract 

Chyluria is a morbid condition and sclerotherapy is a minimally invasive treatment modality in treatment of chyluria. The benefit of sclerosing agents have been analyzed in previous studies; however, our patient has iodine allergy and silver nitrate is not available at our institution. So we chose 50% dextrose as sclerosing agents. We found that chyluria was cured without any complication. This result might offers a simple and safe modality of treatment.

Keywords: Chyluria, slecrotherapy, dextrose


How to cite this article:
Liu YL, Huang SC, Luo HL. The effect of dextrose instillation on a man with chylous hematuria: A case report. Urol Sci 2018;29:307-10

How to cite this URL:
Liu YL, Huang SC, Luo HL. The effect of dextrose instillation on a man with chylous hematuria: A case report. Urol Sci [serial online] 2018 [cited 2018 Dec 13];29:307-10. Available from: http://www.e-urol-sci.com/text.asp?2018/29/6/307/232250


  Introduction Top


Chyluria is the presence of chyle in urine that is prevalent in tropical countries such as India, Africa, and South America. Efficacy of renal pelvic instillation sclerotherapy (RPIS) using silver nitrate for chyluria has been demonstrated in various studies, but the silver nitrate instillation is not a harmless therapy. The complications including severe perinephric hematoma, arterial hemorrhage, acute necrotizing ureteritis with obstructive uropathy, and ureteral stenosis have been reported.[1],[2],[3],[4] Cases of death also have been reported after silver nitrate instillation.[5] We report a case of chyluria from left kidney in a 51-year-old man treated by retrograde instillation of 50% dextrose water. No complication was recorded during the follow-up of 6 months. We suggest that urothelial sclerotherapy using 50% dextrose water in chyluria offers a simple and safe modality of treatment.


  Case Report Top


A 51-year-old male without relevant comorbidities came to our clinic because of milky urine in the recent 2 weeks. The urine was getting thicker associated with blood clot passage. He denied traveling history or trauma history in the recent 1 year. Physical examination revealed low-abdominal distension and obvious tenderness. Urinary retention was impressed, and catheterization showed strawberry milk-like content [Figure 1]. [Table 1] shows the patient's initial laboratory testing. Urine analysis showed obvious proteinuria and hematuria [Table 2]. Computer tomography found no retroperitoneal lesions. Cystoscopic removal of intravesical content was performed, and no obvious intravesical lesion was noted. Bilateral ureteral catheter was placed, and retrograde pyelography found left renal pyelolymphatic backflow [Figure 2]. The collected urine was stained by Sudan III to confirm triglyceride content [Figure 3]. We performed 50% dextrose 20 cc instillation twice daily for 3 days and repeated retrograde pyelography. The left pyelolymphatic backflow was much regressed, and urine was gradually getting clear [Figure 4].
Figure 1: Catheterization showed strawberry milk-like urine

Click here to view
Table 1: Patient's laboratory values

Click here to view
Table 2: Urine analysis

Click here to view
Figure 2: Retrograde pyelogram showing fistulous connection between urinary collecting system and lymphatic system

Click here to view
Figure 3: Photomicrograph of patient's urine stained with Sudan III showing triglyceride content (×400)

Click here to view
Figure 4: Retrograde pyelogram showing pyelolymphatic backflow was much regressed

Click here to view



  Discussion Top


Chyluria is described as the passage of milky white chylous urine due to the leakage of chylous material into the pelvicalyceal system. The causative factors have been divided into two groups: parasitic and nonparasitic. In tropical countries, more than 90% of parasitic chyluria is caused by Wuchereria bancrofti infestation. The parasite is spread by mosquitoes. Other parasites such as Taenia echinococcus, Taenia nana, ankylostomiasis, trichiniasis, and malarial parasites can also cause chyluria.[6] Nonparasitic chyluria is rare and commonly occurs secondary to trauma, tumors, abscesses, pregnancy, congenital conditions, and following surgery. Most of these causes can result in lymphatic obstruction, leading to dilatation and proliferation of reno-lumber lacteals. Thus, a fistulous connection with the collecting system was developed. The severity of chyluria can be graded into (1) Grade I: Milky white urine passage; (2) Grade II: With whitish clots or episodes of clot retention; and (3) Grade III: Hematochyluria passage.[7] The duration of chyluria symptoms may vary from 2 to 11 years. The disease is significantly higher in males (86%) compared to females (14%) and occurs more frequently on the left side.[6]

Diagnosis

The urinary sample is like milk, usually containing fibrin and blood clots. A fatty diet before voiding can enhance the phenomenon. Erythrocytes and lymphocytes may appear in a microscopic examination and chyluria can be confirmed by ether test, methylene blue test, and Sudan III test.[6] Abnormal pyelolymphatic channels can be confirmed by intravenous urography, retrograde pyelography, and lymphangiography. The preoperative findings of retrograde pyelography may not affect the outcome but help plan treatment.[8] The lymphangiography is the most powerful diagnostic modality, but it is not routinely done because it is a technically demanding, time-consuming, and invasive procedure.[6] Other noninvasive techniques such as magnetic resonance imaging and lymphangioscintigraphy also can provide detailed anatomical information about the source of chyluria.

Treatment

Conservative treatment may include watchful waiting and treatment with high protein and medium-chain triglyceride-rich diets(coconut oil). Antifilarial drugs (diethylcarbamazine, ivermectin, and albendazole) are useful against lymphatic filariasis.[6] RPIS which causes sclerosis of the fistulous connection is a minimally invasive treatment for chyluria resistant to conservative treatment. Sclerosing agents including silver nitrate (0.1%–3.0%), 0.2% povidone-iodine, 15%–25% sodium iodide, 10%–25% potassium iodide, 50% dextrose, 76% hypertonic saline, and combination therapy are used. The patient was placed in the head-down (20°) position and 7–10 ml sclerosant was instilled through an ureteric catheter. The following edema, inflammatory reaction, and fibrosis will lead to symptoms remission.

Silver nitrate is the most commonly used agent with a high success rate and a relative low recurrent rate. Silver nitrate has sensitivity to light, so the solution must be freshly prepared each time and stored in a dark bottle. In addition, when the silver nitrate and normal saline are mixed, insoluble silver chloride salt forms and can lead to ureteric obstruction.[6] Side effects caused by silver nitrate instillation include severe perinephric hematoma, arterial hemorrhage, acute necrotizing ureteritis, and ureteral stenosis. Even a 30-year-old woman death has been reported following bilateral simultaneous 3% silver nitrate instillation.[5]

Povidone-iodine is another safe and effective agent with similar success rate to silver nitrate. Goel et al.[9] reported that 0.2% povidone-iodine is as effective as 1% silver nitrate with no side effects. Nandy et al.[10] mentioned about the combination sclerotherapy using 5% povidone-iodine and 50% dextrose of chyluria which caused 87% complete remission. In other study,[11] a combination of 10% povidone-iodine plus 10% dextrose solution was used in two patients, and recurrence was noted in one patient after 6-month follow-up. Sclerotherapy with povidone-iodine is an alternative therapy in addition to silver nitrate, but the long-term efficacy is still unclear. Although povidone-iodine is an alternative and a relatively safe agent, patients still have the risk of allergic reaction. Goel et al.[9] found a relatively high recurrent rate of sclerotherapy with 50% dextrose alone. However, for patients with povidone-iodine allergy history, it should be considered as a safe and alternative treatment choice. Fifty percent dextrose is a hypertonic solution that may cause thrombosis when infused through peripheral veins. Fifty percent dextrose infusion is thought to induce an inflammatory reaction and then fibrosis within the pyelolymphatic fistula, leading to the closure of lymphatic pelvic channel.

In this case, a 51-year-old male developed chylous hematuria due to unknown etiology for 2 weeks. The patient has a history of contact dermatitis on povidone-iodine, and silver nitrate is not available at our institution. Hence, we chose 50% dextrose as sclerosing agents. A ureteral catheter was placed in the left renal pelvis, and six instillations of 50% dextrose solution were performed at 12-hourly intervals. Each dextrose instillation was stopped until this patient felt intolerable flank soreness. After treatment, the strawberry milk-like urine was cured completely. A repeat retrograde pyelography showed complete disappearance of the pyelolymphatic backflow. Postoperative follow-up about 1 year found no recurrence in such patients allergic to povidone-iodine. Although long-term follow-up is not reached, we present our experience of successful dextrose retrograde instillation in the management of chyluria.


  Conclusion Top


Sclerotherapy using 50% dextrose is an alternative technique for the treatment of pyelolymphatic fistula. This case illustrates a role for this sclerosing agent in treating chyluria. The dextrose is safe, cheap, and easy to obtain. However, further randomized controlled studies are needed to evaluate the long-term effectiveness of this sclerosing agent.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Vijan SR, Keating MA, Althausen AF. Ureteral stenosis after silver nitrate instillation in the treatment of essential hematuria. J Urol 1988;139:1015-6.  Back to cited text no. 1
    
2.
Su CM, Lee YC, Wu WJ, Ke HL, Chou YH, Huang CH, et al. Acute necrotizing ureteritis with obstructive uropathy following instillation of silver nitrate in chyluria: A case report. Kaohsiung J Med Sci 2004;20:512-5.  Back to cited text no. 2
    
3.
Srivastava DN, Yadav S, Hemal AK, Berry M. Arterial haemorrhage following instillation of silver nitrate in chyluria: Treatment by coil embolization. Australas Radiol 1998;42:234-5.  Back to cited text no. 3
    
4.
Dhabalia JV, Nelivigi GG, Suryavanshi M, Kakkattil S, Singh VK. An unusual complication of silver nitrate therapy for chyluria. Indian J Urol 2007;23:203-4.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Mandhani A, Kapoor R, Gupta RK, Rao HS. Can silver nitrate instillation for the treatment of chyluria be fatal? Br J Urol 1998;82:926-7.  Back to cited text no. 5
    
6.
Sachit Sharma AK. Chyluria – An overview. Int J Nephrol Urol 2009;1: 14-26.  Back to cited text no. 6
    
7.
Sinha RK, Ranjan N, Singh N, Amit K. Chyluria: A scourge of our region. BMJ Case Rep 2015;2015. pii: bcr2014209188.  Back to cited text no. 7
    
8.
Paul S, Kumar M, Singh V, Sankhwar S. Chyluria: Is retrograde pyelogram mandatory prior to endoscopic sclerotherapy? BMJ Case Rep 2014;2014. pii: bcr2013200550.  Back to cited text no. 8
    
9.
Goel S, Mandhani A, Srivastava A, Kapoor R, Gogoi S, Kumar A, et al. Is povidone iodine an alternative to silver nitrate for renal pelvic instillation sclerotherapy in chyluria? BJU Int 2004;94:1082-5.  Back to cited text no. 9
    
10.
Nandy PR, Dwivedi US, Vyas N, Prasad M, Dutta B, Singh PB, et al. Povidone iodine and dextrose solution combination sclerotherapy in chyluria. Urology 2004;64:1107-9.  Back to cited text no. 10
    
11.
Guttilla A, Beltrami P, Bettin L, Galantini A, Dal Moro F, Ficarra V, et al. Non-parasitic chyluria: Our experience with sclerotherapy with solution of povidone-iodine and destrose and A review of the literature. Urol Case Rep 2016;8:28-30.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed369    
    Printed30    
    Emailed0    
    PDF Downloaded29    
    Comments [Add]    

Recommend this journal