Cloudy Urine

Urine is a waste that is produced by the kidneys. The main job of the kidneys is to filter the waste, reabsorb the important elements and get rid of the wastes. The colour of the urine is an indicator of various pathologies.

Normal urine of an individual who is well hydrated and healthy is clear. Depending on the level of hydration it can be colourless to yellowish in colour. The urine has minimal or no odour. Now let us understand different types of urine and what they indicate.

Normal Urine

What is Cloudy Urine?

The term cloudy urine refers to urine that is foggy, milky or opaque. The medical term used for it is nebulous urine. If the urine is very yellow or foamy, then also it is termed as cloudy urine. Many people refer to cloudy urine as white urine but actually it has a yellowish tinge to it and so it is better described as cloudy yellow rather than cloudy white.

Cloudy Urine Image Source lechupechen.ru

Causes of Cloudy Urine

The urine tends to become cloudy when the mineral concentration, amount of white blood cells (leukocytes) and fat increase in the urine. The common causes of cloudy urine are mucous discharge from the prostrate and semen in males, vaginal discharge in females, stress, some types of drugs, foods and health supplements Cloudy urine is not caused by pregnancy, ovulation, gylcosuria in diabetics or by taking milk of magnesia. The medical reasons for cloudy urine are-

Causes in Males:

There are some disease which affect the male reproductive and urinary system which can give rise to cloudy urine and they are as follows-

• Prostrate cancer is cancer of the prostrate gland and it can lead to lower abdominal pain, bloody and cloudy urine and weight loss
• Prostatitis is the infection of the prostrate gland due to which the person has a frequent urge to pass urine. There is fever and the urine is cloudy.
• Epididymitis is the swelling in the scrotum and can cause groin pain and blood in the urine.
• Sexually transmitted diseases like gonorrhoea or Chlamydia can also lead to cloudy urine or purulent discharge from the penis along with other general symptoms.

Causes in Females:

The causes of cloudy urine in females are as follows-

• Infections: Yeast or candida infections can cause vaginitis with increase discharge called leucorrhoea. This discharge mixes with the urine and makes it cloudy.
• Sexually transmitted disorders like gonorrhoea and clamydia can cause infection and thick vaginal discharge which then leads to cloudy urine.
• Pregnancy leads to many changes in the body of a female. Increased levels of blood sugar in pregnancy can cause proteinuria which makes the urine cloudy. If the blood pressure levels rise as in ecclampsia and preeclampsia, then the urine can become cloudy

High Calcium and Phosphate Levels:

If there is a high excretion of phosphate(phosphaturia) and calcium(hypercalciuria) in the urine then it can lead to cloudy urine. If you want to confirm the phosphate content in urine, then add a few drops of acetic acid or vinegar and it will clear up the cloudy urine immediately and confirm the presence of phosphate. Calcium and phosphate imbalance can occur due to-

• An increase in the intestinal absorption of calcium.
• Large doses of supplements like vitamin D
• Taking or eating large amounts of calcium supplements, milk, antacids or canned fish.
• Medical conditions like Fanconi syndrome, hyperparathyroidism, leukaemia, lymphoma, sarcoidosis, Paget’s disease and bone marrow cancer like multiple myeloma.

High Oxalic Acid Levels:

• Excessive amounts of oxalic acid in the urine is called hyperoxaluria and it can happen because of-
• Taking vitamin C in high doses as supplements
• Diseases of the intestines like Crohns disease.
• Chronic pancreatitis
• Consuming foods like cocoa, spinach, black tea, swiss chard, chocolates etc in large amounts.
• Hereditary primary hyperoxaluria

High Uric acid Levels:

Uric acid levels can increase when an individual consumes a lot of proteins. Foods with high purine content like organ meats especially liver, kidneys, pulses, bakers yeast and other yeast supplements can raise the levels of uric acid in the urine. Patients with high uric acid are advised to avoid red meat, spinach, tomatoes and pulses in their day to day diet.

Protein Levels:

If protein is present in the urine, then the urine will appear cloudy. Protein can appear in the urine because of unusual stress to the body as in heart failure, renal diseases or after very heavy exercise. To confirm the presence of protein in urine, heat it and the urine will become more cloudy.

WBC Levels:

If white blood cells or leucocytes increase in number then the urine can become cloudy. If the leucocytes increase without the presence of infection, it is called sterile pyuria. The following conditions can have raised WBC levels- Renal diseases like polycystic kidneys, cancer of tuberculosis of the kidneys, renal stones etc. Other conditions are SLE (systemic lupus erthymatosus) which is an autoimmune disease, Kawasaki disease and interstitial cystitis.

Infections:

Infections occurring anywhere in the urinary tract can lead to cloudy urine along with foul smell. The infection of the urethra is called urethritis, bladder is called cystitis and kidney is called pyelonephritis.

The presentation of urinary infection is frequent urination with burning and urgency. There may fever and low back pain. In some cases nausea and vomiting may also occur.

The diagnosis of urinary tract infection is done by urine analysis which shows a marked increase in the levels of WBC and pus cells. Few RBCs may also be present.

Coloured Urine – Types and Causes

Red\Pink or Brown Urine

Red Urine

 

“Pinkish urine” | Image Source Wikipedia

The urine can appear pinkish red or brown in the following conditions

Hematuria (Blood in the urine): The presence of blood in the urine is responsible for giving it a reddish colour. Depending on the amount of blood present it may appear pinkish to red or even brown in colour. The causes of blood in urine are:

• Post heavy exercise like running a marathon
• Menstruation in females-where the uterine lining is shed off under the effect of hormones each month. The blood mixes with the urine and makes it appear red and may also cause some amount of contamination.
• Affections of the urinary tract like UTI, renal or ureteric stones, post catheter injury to the urethra, polycystic renal disease.
• Blood disorders like reduced platelet count can lead to spontaneous bleeding. Prolomged clotting time, haemochromatosis, sickle cell anaemia and haemochromatosis may also lead to blood in the urine.
• Certain drugs like aspirin tend to make the blood thin and increase the bleeding tendency. So aspirin is stopped before all surgical procedures. Other medications are cyclophosphamide, heparin, rifampin and penicillin.
• Vitamin C deficiency
• Bleeding inside the body as in bacterial endocarditis, cancer or vasculitis.

Blood in The Urine Picture – Source Wikipedia

Food substances: There are many foods that can lead to a reddish colour in the urine. They are beets-boiled or in the form of juice, fava beans, blackberries, aloe vera and rhubarb. Some drug supplements with added permitted colours may also make the urine reddish or brown in colour.

Porphyria: Porphyria is categorised as a disorder of genetic origin where the production of haemoglobin is affected and so the destruction of the untimely destruction of the haemoglobin makes the urine red or dark brown.

Rhabdomyolysis: Muscle breakdown or rhadomyolysis is another cause of reddish brown urine. When the muscle breaks down, the protein present in it called myoglobin escapes into the urine and imparts it the colour. The common causes of muscle breakdown are:

• Prolonged and excessive physical exertion like the one after a marathon. Long standing immobilization that can occur due to fractured leg or pressure on the limbs after an episode of alcohol intoxication. Other causes are muscle tremors, burns, sever trauma and convulsions.
• Some medicines like tricyclic antidepressants, SSRIs, barbiturates, methadone, protease inhibitors that are used in the treatment of HIV/AIDS, ketamine, propofol infusion, cholesterol lowering medicines and statins can alter the colour of the urine.
• Reduced levels of phosphate in the blood
• Infections like influenza, cytomegalovirus infection, Epstein Barr virus infection, Genital herpes, skin disease like shingles etc
• Food poisoning with vomiting and diarrhoea caused by Salmonella, Ecoli and shigella organisms.
• Dengue fever
• Consumption of illegal drug substances like heroin, amphetamine, LSD, methadone, phencyclidine can make the urine reddish brown in colour.

Medications: There are some drugs that can cause red urine and they are:

• Paracetamol (acetaminophen)
• Antibiotics like metronidazole, furazolidone, rifampin etc
• Anti malarial drugs like chloroquine and primaquine
• Laxatives
• Chlorpromazine
• Propofol
• Sulfasalazine
• Warfarin

Poisonings: Poisonings can cause red or brown black urine. Acute poisoning can occur with ethanol, iodine, ethylene glycol, cyanide, phenol, methanol etc. Chronic poisoning can occur with lead, mercury and copper.

Deep Yellow or Orange Urine

Deep Yellow \ Orange Urine | Source Wikipedia

Normal urine is pale yellow. Dark yellow, amber coloured or orange urine can be seen in the following conditions:

Dehydration: The commonest cause of dark coloured urine is dehydration and water loss from the body. The level of dehydration will decide whether the urine is yellow, orange or tea colour .This can also occur in very hot weather when you do not drink sufficient water and you lose water through sweat. If the dehydration is moderate or due to heat, then replenishing it with good amount of water will correct the condition. If the water loss is server as in case of diarrhoea or vomiting, then the water needs to be replaced externally in the form of IV fluids.

Food Substances: Foods that are rich in beta carotene can impart a yellow colour to the urine. These vegetables are carrots, butternut squash, pumpkin, spinach, sweet potatoes, kale and collards. Fruits those are rich in vitamin C like guava, pumpkin, kiwi, orange and lemon juice also make the urine dark.

Artificial food colouring is added to certain foods like flavoured yogurt, energy drinks candies and soft drinks. These foods and drinks can make the urine yellowish orange.

Drug supplements: The commonest drug supplement that makes the urine dark yellow is vitamin B2 also called riboflavin. Vitamin C supplements and foods rich in vitamin c also tend to alter the colour of the urine.

Liver disorders: The liver produces bilirubin which is a yellow compound. It gets excreted in the bile and the urine. So any disorder of the liver such as hepatitis, gall stones, cirrhosis of liver etc will block the normal flow of bile and lead to cholestasis. This causes an increase in the bilirubin levels of the blood and the urine giving rise to a condition called jaundice. The urine is typically deep yellow or amber and foamy where as the stools are pale.

Urine & liver disease | Image Source

Hyperuricosuria: An increase in the levels of uric acid in the body can lead to a urine that is dark yellow in colour. Uric acid can rise in acute renal failure, leukaemia, haemolytic anaemia, lymphoma, chemotherapy and some genetic disorders. To confirm the presence of urates, the urine can be heated and you will see that it clears up.

Medicines: Certain drugs that have added permitted colours can make the urine yellow. They are allopurinol that is used in the treatment of gout, ethoxazene, methyldopa, phenacetin, tetracycline etc.

Orange urine can occur due to the drugs used for chemotherapy like isoniazid,rifampin and warfarin.

Greenish Blue Urine

The causes of greenish blue urine are:

• Green or blue food colouring
• Drugs like amitriptylline, methylene blue, promethzine, propofol and some drug supplements.
• Urinary infection caused by Psedomonas Aeruginosa
• Porphyria
• Poisonings with tetrahydronaphthalene or imazosulfro.
• Hartnup disease
• Consuming foods like asparagus and black licorice.

Purple Urine

Purple urine is seen mostly in individuals with porphyria. Their urine can go from red to purplish colour when it is exposed to sun rays.

Another condition is called purple urine bag syndrome where the urine appears purplish in the urine bag of patients who have catheters. Urinary tract infections are very common in hospitalised patients with catheters.

Black Urine

There are some drugs like iron supplements, metronidazole, L dopa, nitrofurantoin and laxatives that can cause black urine.

A metabolic disorder called alkaptonuria and malignant skin cancer (melanoma) are two conditions where the urine can turn black within few hours in the lavatory bowl.

Foamy Urine – Causes

The urine may be frothy or foamy due to an underlying pathology. Here are the causes of foamy urine.

Protein: The commonest cause of the urine being frothy is the presence of protein in it. The froth appears in every urine and tends to remain for at least one minute. Proteinuria or increased urinary protein excretion can happen due to-

• Fever
• Exposure to extreme cold climate
• Stress in the form of physical exertion or emotional stress

• Congestive cardiac failure is a condition where the heart fails to function normally and the blood flow through the kidneys in greatly increased.
• Renal diseases like glomerulonephritis or nephritic syndrome where the functioning of the kidney is disturbed and so urine contains protein.
• Orthostatic proteinuria is a physiological condition where the urine tends to become cloudy if the person stays upright for a long time. It is seen more commonly in young boys and girls. Cloudy urine alternates with normal urine.
• Medical conditions where there is an increase in the production of protein in the body like rheumatoid arthritis, sarcoidosis, lymphoma, muscle damage or rhabdomyolysis, syphilis, HIV/AIDS, amyloidosis etc.
• Poisonings with heavy metals like lead or mercury.
• Certain drugs like aspirin, penicillamine, antibiotics, NSAIDs and ACE inhibitors(angiotensin converting enzyme inhibitors)

Semen: Semen contains sperms that can be released into the urinary tract after sex or due to having a wet dream. In either cases the semen mixes with the urine and makes it frothy. This is seen mostly in the morning. The froth or foam will disappear on its own within few seconds.

Bilirubin: Bilirubin is a liver pigment which can escape into the blood and urine when there is a liver disease. It makes the urine dark yellow and frothy.

Dehydration caused by water loss due to diarrhoea or vomiting, drinking less water in very hot weather can make the urine dark yellow and frothy. The colour and the foam will disappear if you take a good amount of water and the water loss is corrected.

Other causes: At times there is a fistula formation between the urinary bladder and the bowel or at times between the bladder and the vagina. This fistula is an abnormal opening through which there can be passage of air into the urine. This gas can make the urine frothy.

Causes of Strong Odour in Urine

Foods and Drinks: Taking some kind of foods and beverages can make the urine odour stronger than normal.

• Urine smelling of sulphur, the smell being similar to that of rotten eggs is seen when you eat cabbage, garlic, asparagus, brussel sprouts,cheese etc
• Ammonia smell in the urine can be because of a high protein diet with lots of meat. Citrus fruits and vinegar can also cause this kind of smell.
• The urine can have a medicinal smell which is imparted by b complex supplements or other foods that are fortified with vitamin B6.
• Sweet smell in the urine may be a result of eating puffed wheat or fenugreek. Long fasting can cause release of ketones in the urine which are responsible for the sweetish smell.
• Alcoholic beverages can impart a peculiar odour to the urine.

Medical conditions: Some medical conditions can also cause strong smelling urine and they are:

• Dehaydration
• Ketonuria in uncontrolled diabetes
• Urinary tract infections
• Prostatitis

Diagnosis of Cloudy Urine

There are a few simple tests that can be used to asses the cause of the cloudy urine.

1. If you add a little bit of acid in the form of lemon or vinegar and the urine clears up, then it confirms the cloudy urine is due to presence of calcium, phosphates or oxalates.
2. Cooling the urine in the fridge may cloud the urine. This means that the cloudy urine is due to the presence of phosphates, oxalates and urates.
3. When heating the urine clears it up, it confirms that the cloudy urine is caused by urates and the protein levels are quite high.
4. Add ether to a urine sample and if the urine clears up then it indicates the presence of fat in the urine.(chyluria)

Other urine abnormalities like coloured urine or strong smelling urine will be diagnosed by the history. The doctor will ask you the foods, supplements and drinks that you have taken the previous day.

The investigations that may be required depending on the symptoms are

• Urine examination-urine routine and microscopic tests
• CBC-complete blood count
• X-ray KUB(kidney, ureters, bladder)
• Urine culture
• Testing for Sexually transmitted diseases
• USG or CT scan of the kidneys.

Treatment Methods

The treatment will depend mainly on the basis of the underlying cause. The cloudy urine that is caused by dehydration or consuming certain foods or drinks is temporary and corrects itself within a day or two. If there is a serious medical problem like a blood disorder then timely diagnosis is very important. Drinking plenty of water can correct the cloudy urine.

In infants, dark urine can occur due to neonatal jaundice which will correct itself in a few weeks. If the jaundice persists then phototherapy may be required.