So I'm admitting a 103 year old lady who fell at home and is too weak to go home. In the words of ER doctors all across this country, hospitals with emergency rooms have famously become known as the defacto senior safe haven drop off point for elderly in our country. As I'm just finishing up her admission to the hospital, I hear a commotion in the background.
ED doctor: I wonder what's going on with that guy. He's got green urine.
You want to make a hospitalist show some interest? Tell them the guy in room 12 has green urine. After five hundred admissions for COPD and heart failure, green urine sounds a bit more exciting. I've never seen it before. I've only read about it. The only thing I could remember that could cause green urine was propofol.
So I called my partner to ask her what she knew about green urine:
Happy: Hey, it's me, Happy
Partner: What's up
Happy: What do you know about green urine? There's a guy in our ER down here with green urine. It doesn't look dirty. Just a really deep green.
Partner: How about propofol?
Happy: Well, I thought of that, but he's in the ER not the ICU and his name isn't Michael Jackson.
Partner: Beats me.
So I decided to do a little investigating. It just so happened that the daughter walked into the room of this 78 year old man who's chief complaint was increasing frequency of urination.
Happy: Hi there. You must be his daughter. That's pretty crazy urine over there. Our nurse thinks he's doing this to prepare for St Patrick's Day. What do you think?
Daughter: Laughing Well, he is Irish. But his doctor said five days ago not to be alarmed because this new pain medicine will turn his urine green.
Happy: Pain medicine?
Daughter: Yeah, it starts with a P. I gave the list to the nurse.
Happy: Checking on the list. There it was: Prosed.
Beings as I'd never heard of Prosed, I looked it up in my Pharmacopoeia. Prosed is a combination medication. It contains
- Methenamine 81.6 mg
- phenyl salicylate 36.2 mg
- methylene blue 10.8 mg
- benzoic acid 9.0 mg
- hyoscyamine .12 mg
And there is was. Methylene blue. That's why his urine was green. In addition to methylene blue and propofol, amitritypline can give you green urine as well. I bet you didn't know that. As is often the case in internal medicine, when in doubt, the sign or symptom is probably due to a medication. In this case his green urine was due to the methylene blue. He wasn't Michael Jackson reincarnated. He didn't come in on propofol. He wasn't playing a St Patty's Day trick. His doctor made him the coolest patient in the ED that day.
Are you wondering what other conditions, foods and medications can give you other colored urine conditions. Here is a differential diagnosis of the different urine colors?
- Black urine that turns black after sitting in direct sunlight is a sign of ochronosis. It's one of the cool diseases I remember from medical school. Ochronosis (often called alkaptonuric ochronosis) causes a build up of homogentisic acid in the urine. This compound turns black when exposed to direct sunlight.
- Blue urine may be a sign of tryptophan malabsorption. Familial hypercalcemia, also known as blue diaper syndrome can also turn your urine blue.
- Pink urine could be a sign of hematuria, or blood in the urine.
- Port wine colored urine may be a sign of porphyria.
- Intense yellow or orange urine could be do to conditions that increase uric acid production. Asparagus can do it. Pyridium and rifampin, warfarin as well as some laxatives can do it as well. So can an increasing bilirubin, a sign of liver disease.
- Dark brown or tea colored urine may also be a sign of liver disease, hemolysis or rhabdomyolysis. A dipstick strongly positive for blood but a microsopy showing no red blood cells can often indicated a process of rhabdo or hemolysis due to the cross reactivity of pigment in the urine.
- White urine could be a cause of infection, phosphate crystals, propofol or chyluria. Chyluria is caused by filariasis, specifically the nematode Wuchereria bancrofti. Crazy stuff.
- Purple urine may be caused by bacteria in an indwelling catheter.
While not related to the color of the urine, urine smell can also give you clues to the underlying conditions. Some smells include
- Acrid, sweaty feet smell may be a sign of glutaric acidemia II or isovaleric acidemia
- Cabbage smell may indicate a tyrosinemia
- Fishy smell could be trimethylaminuria or dimethylglycinuria
- Maple syrup or curry smell may be a sign of maple syrup urine disease
- A sweet smell may indicate a beta-ketothiolase deficiency
- A swimming pool smell may indicate Hawkinsuria is present
Have you every seen any crazy urine findings?