Chyluria is a condition characterized by the presence of chyle or fatty lymph in the urine, causing it to appear milky white. It is most commonly caused by filarial infections in parts of Africa and India. The condition results from obstruction or insufficiency of the lymphatic system, causing retrograde flow of lymph into the urinary tract. Diagnosis involves urine tests to detect triglycerides and lymph. Treatment options include medication to treat underlying causes, sclerotherapy to scar lymphatic vessels, and surgery such as lymphatic disconnection or lymph node-vein anastomosis if more conservative treatments fail.

1. CHYLURIA
Dr rajendra prasad ray, mch
urology,IPGMER,kolkata,westbengal

2. Def:- Chyluria is recognized as a urological manifestation of
lymphatic system abnormality characterized by presence
of chyle in urine which results white appearing urine.
Epidemiology-
• Prevalent among of Africa& Indian subcontinent.
• Mostly due to filariasis.
• Rare in Western countries and mostly due to post-
operative.
• Common age group- 2nd or 3rd decade of life.
• Male: female- 6: 1.
• Left sided kidney is mostly affected.

3. History of hypothesis-
• Prout (1841)-secretion of fat from blood through
kidney.
• Ackerman (1863)- Blockage of major lymphatics
or thoracic duct- retrograde flow of lymph from
gut into lumen of urinary tract.
• Wucherer (1869)- Presence of microfilaria in
blood and urine.
• Manson-Bahr (1954)-Rapture of lymph varix
anywhere in urinary tract leading to escape of
lymph in urine.

4. • Sen & Elappan (1968)- parasitic/bacterial
infections-fibrosis-reduced lymphatic bed-
lymphatic HT- lymph stasis and shunt
formation.
• Recent Theory: Inflamatory reaction due to
parasitic/ bacterial infection> obliterative
lymphangitis> lymphatic HT> vulvular
incompetence> retrograde flow &
varicosities> rapture & fistula formation.

5. Etiopathogenesis

6. • It is basically a disease of lymphatic system.
• Sceondarily involves Urinary system.
• Obstruction or insufficiency of vulvular system
> retrograde flow of lymph >vericosities >
rapture of lymphatic channel to pyelocaleceal
system.

7. Etiology
Classification of chyluria based on
etiological factors
Parasitic (primary-tropical)
• Wuchereria bancrofti (90%)
• Taenia echinococcus
• Taenia nana
• Ankylostomiasis
• Trichiniasis
• Malarial parasites

8. Non-parasitic (secondary-nontropical)
•Congenital
• Lymphangioma of urinary tract
• Megalymphatics & urethral/vesical fistulae
• Stenosis of thoracic duct
•Retroperitoneal lymphangiecatasia
•Traumatic lymphangiourinary fistulae
•Obstruction of thoracic duct/ lymphatics (tumor,
granulomas, aortic aneurysm)
•Other causes (pregnancy, diabetes, abscess)
•Nephrotic syndrome

9. Clinical presentation
• Passage of milky urine-most common.
• Clot colic / passage of chylous clots.
• Passage of bloody & milky urine.
• Dysuria, frequency, urgency.
• Acute urinary retension (chylous clot retension).
• Constitutional symptoms- fever, wt.loss, back
pain.
• Genital manifestation- filarial scrotum & penis.
• Lower limb oedema- filarial lower limb.

10. Grading
1. Mild chyluria- Intermittent milky urine.
-No clot colic/ AUR/ wt. loss.
-Involvment of single calyx on RGP.
2.Moderate chyluria-Intermittent milky urine.
-occasional clot colic/no AUR or wt.loss.
-Involvment of 2or more calyx on RGP.
3.Severe chyluria- Continuous milky urine.
-presence of clot colic/AUR/wt. loss.
-Involvment of most of calyx with or without
involvment of ureter on RGP.

11. INVESTIGATION
• Aims- Confirmation of presence of chyle in urine.
-Identification of communication.
-Findout the etiology.
Modalities: 1.urine examination.
2.blood examination.
3.cystourethroscopy.
4.RGP.
5.lymphangiography.
6.lymphangioscintigraphy.
7.USG/IVU/CT scan/ MRI.

12. • Urine:
Macroscopic- milky white in colour.
-on standing- 3 layers, upper
fat,middle fibrin,lower cells.
-Ether test- positive.
-Sudan 3 test- positive.
Microscopic- To exclude pyeuria
,tuberculosis(AFB),phosphaturia.
Biochemical- presence of triglycerides: confirm
-Albuminuria

13. • BLOOD: eosinophilia
: TLC-raised
:ELISA- for detection of filarial
antibodies.
:LFT-hypo albuminemia.

14. • CYSTOURETHROSCOPY:
-help to localize the side of lesion.
-ureteric catheterization and split urinanalysis
may be done.
-Rarely chylous efflux may be seen from
bladder or post. Urethra.

15. • RGP:
-Help to demonstrate pyelo-lymphatic back
flow.
-ureteric catheterization upto pelvis should be
done.
-spot film should be taken.
-patient is placed in head down position.
-Gravity propagated contrast instillation should
be done.

16. • LYMPHANGIOGRAPHY:
-previously it was the investigation of choice.
-At present it is not done routinely as it is time
consuming & invasive.
LYMPHANGIOSCINTIGRAPHY:
-It is useful, noninvasive,safe procedure.
-Localizes communication site.
-Indicated when RGP fails to demonstrate.

17. • USG/ IVU/ CT SCAN/ MRI:
-Not routinely recommended.
-MR urography recommended in low down
fistula (lower ureter/bladder/urethra)

24. MANAGMENT
• Chyluria should be considered as filarial cause untill prove
otherwise.
MEDICAL MANAGEMENT:
-Bed rest
-Dietary Modification
-Nutritional support if required
-Analgesic & antipyretic if needed
-Antifilarial drugs: DEC-6mg/kg-14d
:Ivermectin-400micgm/kg
:Albendazole-400mg
-Usage of abdominal belt
Spontaneous remission occurs within 6 months- mostly

25. SCLEROTHERAPY:
Indication: Failed conservative/ medical
therapy.
Agents used- Silver nitrate (0.1-3.0%)
-Povidone Iodine (0.2%)
-Dextrose (50%)
-Hypertonic saline (76%)
-Combination therapy

26. Mechanism

27. • PROCEDURE:
- Cystoscopy with ureteric catheterization.
- Catheter must reach renal pelvis.
-Should be done aseptically with antibiotic coverage.
- Patient should be placed head down position.
- Gravity propagated instillation of sclerosant should be
done.
- Catheter is clamped for 45 min.and then released.
- Patient should be monitored closely.
- Done 8 hourly for 3 days.

28. • Complications: -pain abdomen
-Vomiting
-Fever
-Haematuria
- Papillary necrosis
-ATN

29. • SURGERY:
Indication- Failed sclerotherapy (3 courses).
PROCEDURE- 1. Surgical lymphatic disconnection.
2.Renal auto transplantation.
3.Nephrectomy.
4.Micro surgery
-Lymphovenous anastomosis.
-Lymphonodovenous anastomosis.

30. SURGICAL LYMPHATIC DISCONNECTION:
Consist of –Nephrolympholysis
-Ureterolympholysis
-Hilar vessels stripping
-Gerota fasciectomy
-Nephropexy.

31. Lympho-venous anastomosis
This is the most physiological method of surgical correction for
recurrent chyluria.
• The procedure increases the drainage of lymph into venous
system, which rapidly decreases the intralymphatic pressure.
Thus facilitating the healing of pyelo-lymphatic fistulae.
• The procedure is technically cumbersome as lymphatics are
difficult to identify, lymphatic channels are thin, brittle and
liable to collapse, which requires microsurgical expertise.
Retro-peritoneal lympho-venous anastomosis
The technique was described by Cockett and Goodwin
Trans-inguinal spermatic lympho-venous anastomosis
Xu et al shows 60% while Zhao et al reported 76.3% success
rate.

33. Inguinal lymph node-saphenous vein
anastomosis
lymphnodo-venous anastomoses is made according to the
principles of lymphovenous shunt.
• A conical tissue of lymph node close to the greater
saphenous vein in the inguinal region is removed and the
remaining tunnel-shaped node is anastomosed to the vein to
drain the lymph into the venous system.
• Hou et al 85.7% effective rate.
• This operation avoids damage to both the afferent and
efferent lymphatic vessels and affords a large anastomotic
stoma for free passage of the lymph into the vein.
• .

34. Thank you