chyle is composed of albumin , emulsified fat and fibrin . in tropical country like india , chyluria is a chronicsequelae of filariasis .
up to 10% patient with filariasis may experience chyluria in tropical countries ( 1 ) .
chyluria has no sex predilection ; but young adult male from poor socio - economic background are mainly affected ( 2 ) .
it is recognized as tropical disease associated with spontaneous remissions and exacerbation ( 3 ) . in our state , it is not uncommon to find pregnant females with chyluria .
the study aims to present our experience of managing 43 cases with chyluria during pregnancy over a period of ten years from july 2003 to june 2014 .
forty three pregnant female patients , who presented to the department of urology , igims , patna , from july 2003 to june 2014 , were evaluated for chyluria ( tables 1 - 3 ) .
all the patients were evaluated by history , physical examination , routine examination of urine for chyle and chylomicron , culture sensitivity of urine , complete blood count ( cbc ) tests , blood sugar , renal function test , post prandial glucose test for chyle in urine , zeihl - nelson staining for acid fast bacilli , ultrasonography , cystourethros copy for lateralization and to exclude other pathology . all the patients were managed initially by conservative means - bed rest , high protein diet , and avoidance of fat , oil , milk , and milk product .
all patients were administered isoxsuprine hydrochloride ( 10 mg ) 1 tab twice daily for two days prior to the procedure and continued two days after completion of procedure .
ceftriaxone l gwas injected just before the procedure . under local an aesthesia ( 2% xylocaine jelly instilled in urethra ) , cystoscope was passed into the bladder , bladder washed and cleared of clots and side of chylus efflux determined . with the help of ureteric catheter 10 ml solution of sclerosant ( 5 ml of 10% povidone iodine was mixed with normal saline in equal amount to make it 10 ml ) instilled slowly into renal pelvis .
after eight hours , 5 ml of 25% dextrose mixed with normal saline in equal amount to make it 10 ml was again instilled .
ureteric catheter was left indwelling and for next two days and same solution was instilled alternately at an interval of eight hours .
two patients underwent mtp after failure of sclerotherapy or because of personal preference in desperate cases .
in overall , 67.44% of patients were in the age group of 20 to 30 years followed by 30.23% in the age group of 30 to 40 years .
74.41% of the patients were referred to us in their second trimester followed by third trimester ( 13.95% ) and least in first trimester .
thirteen patients ( 30.33% ) hadchyluria before pregnancy . in our series , about half ( n = 21 ) patient presented with chyluria only while others presented with other associated symptoms like dysuria ( n = 6 ) , chyluria mixed with hematuria ( n = 3 ) , urinary retention ( n = 10 ) , fever / uti ( n = 4 ) , and decreased fetal movement ( n = 4 ) ( table 4 ) .
after one course of sclerotherapy thirteen patients improved , 19 patients needed second course of sclerotherapy , while two patients who presented in first trimester underwent medical termination of pregnancy at their own choice .
caesarian section was done in three patients , two of them at 37 weeks of pregnancy and one at 40 weeks of pregnancy after failure of sclerotherapy .
one patient who did not improve even after caesarean section responded to conservative management and four weeks course of diethyl carbamazine ( 100 mg three times a day ) .
colicky pain developed in eight patients just after sclerosant instillation and in four patient urine output decreased while four patients developed transient fever and two patients developed urinary tract infection ( table 4 ) .  
chyluria is a state of lymphourinary reflux via fistulous communications secondary to lymphatic stasis caused by obstruction of the lymphatic flow ( 10 ) .
it is a form of chronic filarial syndrome , caused by intermittent discharge of intestinal lymph ( chyle ) into the renal pelvis and finally into the urine ( 2 ) .
chyluria is generally thought as harmless conditions in majority but in our part of state fatal outcome has been seen when not properly managed .
persistent chyluria can lead to malnutrition due to loss of protein and lipid ( 12 ) .
it becomes more important to diagnose and aggressively treat pregnant patient to prevent morbidity and mortality of mother and child .
chyluria is a urological manifestation of lymphatic system disease which may lead to nutritional deficiency , recurrent clot colic , urinary retention , urinary tract infection , hematuria and a state of compensated immunosuppression .
chyluria may lead to serious immunological and hemostatic deficit due to igg and iga deficiency ( 13 ) .
there are various theories regarding development of chyluria ; but nowadays , two theories have been implicated as causative factors them : obstructive theory [ aye and aung , 1975 ( 14 ) ] regurtitative theory [ ngan and leong , 1977 ( 15 ) ] this is the commonest form in india and mainly associated with wuchereria bancrofti infection .
non parasitic causes includes tuberculosis , congenital lymphangioma of urinary tract , trauma , pregnancy , malignant infiltration of lymphatics ( 13 ) .
the most common etiological factor for chyluria is filariasis and should be considered filarial unless proven otherwise particularly in filarial belt ( 10 ) .
chyluria is the end result of impairment of retroperitoneal lymphatics due to vicious cycle of infection sclerosis obstructive retrograde dilatation , stasis backflow and spontaneous rupture with fistualisation into the urinary tract .
in the present study we encountered half of the patients ( n = 21 ) were suffering from chyluriaalone followed by urinary retention ( n = 10 ) dysuria ( n = 6 ) fever and decreased fetal movement ( n = 4 each ) and hematuria ( n = 3 ) .
there are so many investigations for diagnosis and management of chyluria apart from routine examination of blood and urine .
specialized tests are test for chyle in urine i.e. ether test , methylene blue test , afb in three consecutive morning sample of urine .
detection of microfilaria is described in centrifuged preparations of cystoscopically catheterized urine , but very rarely in normally voided urine samples specially the chylous sample ( 16 ) .
other tests are radiological i.e. retrograde pyelography , lymphangiography , lymphangioscintigraphy , intravenous pyelography , ct - scan , mri , ultrasonography , enzyme linked immunosorbent assay ( elisa ) for filarial antigen in blood and antibodies specific to recombinant filarial antigen wbsxp - i have been used to develop in elisa for detecting circulating antigen filarial in serum of patient with filariasis ( 17 ) .
another elisa to detect specific igg4 antibodies in un - concentrated urine has been developed ( 18 ) .
recently , triglyceride has been demonstrated to be universally present in chyluria , even in clear urine .
the amount of triglyceride has been found to be directly proportional to haziness of chylous urine .
we tailored investigation to routine examination of urine , acetic acid test , afb in three morning sample of urine , investigation to test for chyle in urine after injestion of 75 g of butter on night before the test and send first morning sample of urine ( ether test ) and urethrocystos copy and lateralization .
addition of few drops of 10% acetic acid in 1 ml of chylous urine clears the opacity in cases of phosphaturia , while opacity persists in chyuria ( 20 ) .
equal part of chylous urine and ether mixed in a test tube and shaken vigorously .
hematinic multivitamins some patients improve ( n = 6 ) but this should not be tried for more than two weeks .
if symptoms not improve , because of devastating squeal due to loss of protein and immunoglobulinssclero therapy should started without delay .
diethyl carbamazine should not be used in pregnant patient because its safety has not been established in pregnancy ; although , it is being used by some physician in these cases without reported ill effect on foetus . in our study
we found that most of the patient ( 32/37 ) improved by three day regimen of sclerotherapy with 10% povidone iodine mixed with equal amount of normal saline and 25% dextrose .
outcome of pregnancy was not affected with this regime and all the patient deliver full term healthy baby .
there are various agent used for sclerotherapy such as agno3 , povidone iodine , dextrose and radiographic contrast material in different concentrations .
severe and fatal complications such as interstitial nephritis , papillary necrosis , acute tubular necrosis are associated with use of silver nitrate as sclerosant in chyluria .
mortality has been reported due to acute tubular necrosis on instillation of silver nitrate in both ureters ( 21 , 22 ) .
it is as effective as 1% agno3 but not associated with severe and fatal complications such as interstitial nephritis , papillary necrosis and acute tubular necrosis .
combination of sclero therapy using a 5% povidone iodine and 50% dextrose solution has been found to be safe and cost - effective minimally - invasive therapy for chyluria refractory to conservative treatment .
a 5 ml of 50% dextrose combined with 5 ml 0.2% povidone iodine provides stronger and better fibrotic response ( 9 ) .
different workers ( 8 , 9 , 23 , 24 ) found 87 - 100% success rate of sclerotherapy with betadine alone or in combination with dextrose .
our success rate with combination sclerotherapy of betadine and dextrose was 86.2% , which is similar to result of other workers ( table 5 ) .
complications of sclerotherapy was transient hematuria ( n = 10 ) which developed after two days of sclerotherapy , which was managed by abandoning the procedure , hydration of patient and antibiotic coverage .
colicky pain developed in 8 patients just after instillation of sclerosant which subsided in 10 minutes period .
few patients required antispasmodic decreased urine output developed in 4 patients which was managed by of of diuretics for two to three days and adequate hydration .
nausea and vomiting developed in two patients managed by antiemetic drugs . by dietary restriction and bed
sclerotherapy with 10% povidone iodine and 25% dextrose is a safe and effective method with high cure rate .
non parasitic causes includes tuberculosis , congenital lymphangioma of urinary tract , trauma , pregnancy , malignant infiltration of lymphatics ( 13 ) .
non parasitic causes includes tuberculosis , congenital lymphangioma of urinary tract , trauma , pregnancy , malignant infiltration of lymphatics ( 13 ) .
the most common etiological factor for chyluria is filariasis and should be considered filarial unless proven otherwise particularly in filarial belt ( 10 ) .
chyluria is the end result of impairment of retroperitoneal lymphatics due to vicious cycle of infection sclerosis obstructive retrograde dilatation , stasis backflow and spontaneous rupture with fistualisation into the urinary tract .
pregnant female with chyluria may present as monosymptomatic or may be polysymptomatic . in the present study we encountered half of the patients ( n = 21 ) were suffering from chyluriaalone followed by urinary retention ( n = 10 ) dysuria ( n = 6 ) fever and decreased fetal movement ( n = 4 each ) and hematuria ( n = 3 ) .
there are so many investigations for diagnosis and management of chyluria apart from routine examination of blood and urine .
specialized tests are test for chyle in urine i.e. ether test , methylene blue test , afb in three consecutive morning sample of urine .
detection of microfilaria is described in centrifuged preparations of cystoscopically catheterized urine , but very rarely in normally voided urine samples specially the chylous sample ( 16 ) .
other tests are radiological i.e. retrograde pyelography , lymphangiography , lymphangioscintigraphy , intravenous pyelography , ct - scan , mri , ultrasonography , enzyme linked immunosorbent assay ( elisa ) for filarial antigen in blood and antibodies specific to recombinant filarial antigen wbsxp - i have been used to develop in elisa for detecting circulating antigen filarial in serum of patient with filariasis ( 17 ) .
another elisa to detect specific igg4 antibodies in un - concentrated urine has been developed ( 18 ) .
recently , triglyceride has been demonstrated to be universally present in chyluria , even in clear urine .
the amount of triglyceride has been found to be directly proportional to haziness of chylous urine .
we tailored investigation to routine examination of urine , acetic acid test , afb in three morning sample of urine , investigation to test for chyle in urine after injestion of 75 g of butter on night before the test and send first morning sample of urine ( ether test ) and urethrocystos copy and lateralization .
addition of few drops of 10% acetic acid in 1 ml of chylous urine clears the opacity in cases of phosphaturia , while opacity persists in chyuria ( 20 ) .
equal part of chylous urine and ether mixed in a test tube and shaken vigorously . cleared urine indicates chyluria .
by conservative management with rest , high protein diet , hematinic multivitamins some patients improve ( n = 6 ) but this should not be tried for more than two weeks .
if symptoms not improve , because of devastating squeal due to loss of protein and immunoglobulinssclero therapy should started without delay .
diethyl carbamazine should not be used in pregnant patient because its safety has not been established in pregnancy ; although , it is being used by some physician in these cases without reported ill effect on foetus . in our study
we found that most of the patient ( 32/37 ) improved by three day regimen of sclerotherapy with 10% povidone iodine mixed with equal amount of normal saline and 25% dextrose .
outcome of pregnancy was not affected with this regime and all the patient deliver full term healthy baby .
there are various agent used for sclerotherapy such as agno3 , povidone iodine , dextrose and radiographic contrast material in different concentrations .
severe and fatal complications such as interstitial nephritis , papillary necrosis , acute tubular necrosis are associated with use of silver nitrate as sclerosant in chyluria .
mortality has been reported due to acute tubular necrosis on instillation of silver nitrate in both ureters ( 21 , 22 ) .
it is as effective as 1% agno3 but not associated with severe and fatal complications such as interstitial nephritis , papillary necrosis and acute tubular necrosis .
combination of sclero therapy using a 5% povidone iodine and 50% dextrose solution has been found to be safe and cost - effective minimally - invasive therapy for chyluria refractory to conservative treatment .
a 5 ml of 50% dextrose combined with 5 ml 0.2% povidone iodine provides stronger and better fibrotic response ( 9 ) .
different workers ( 8 , 9 , 23 , 24 ) found 87 - 100% success rate of sclerotherapy with betadine alone or in combination with dextrose .
our success rate with combination sclerotherapy of betadine and dextrose was 86.2% , which is similar to result of other workers ( table 5 ) .
complications of sclerotherapy was transient hematuria ( n = 10 ) which developed after two days of sclerotherapy , which was managed by abandoning the procedure , hydration of patient and antibiotic coverage .
colicky pain developed in 8 patients just after instillation of sclerosant which subsided in 10 minutes period .
few patients required antispasmodic decreased urine output developed in 4 patients which was managed by of of diuretics for two to three days and adequate hydration .
nausea and vomiting developed in two patients managed by antiemetic drugs . by dietary restriction and bed
sclerotherapy with 10% povidone iodine and 25% dextrose is a safe and effective method with high cure rate .
 background : chyluria i.e. passage of chyle in urine , giving it milky appearance , is common in many parts of india but rare in west . 
 very few case of chyluria in pregnant female has been reported in literature . 
 persistence of this condition may have deleterious effects on health of child and mother . in the present study 
 43 cases of chyluria during pregnancy and their management seen over a period more than 10 years have been presented.objectives:the study aims to present our experience of managing 43 cases with chyluria during pregnancy over a period of ten years from july 2003 to june 2014.patients and methods : forty three pregnant patients with chyluria , who presented between july 2003 to june 2014 to the department of urology , indira gandhi institute of medical sciences , patna were included . 
 patients underwent conservative management and/or sclerotherapy after evaluation . 
 follow - up of all patients was done by observation of urine color , routine examination of urine and test for post prandial chyle in urine up to 3 months after delivery.results:conservative management by dietary restriction of fat and physical rest was successful in six patients . 
 thirteen patients improved after first course of sclerotherapy with 10% povidone iodine and 25% dextrose and 19 patients improve after second session . in non - responders , 
 three patients who were near term underwent caesarian section while two patients opted for medical termination of pregnancy at their own will . 
 after sclerotherapy , minor complications like clot retention , fever , hematuria , and abdominal pain were observed in small number of patients and managed symptomatically.conclusions:sclerotherapy for symptomatic relief of chyluria during pregnancy showed high response rate ( 86.2% ) in short term follow - up . 
 sclerotherapy with 10% povidone iodine and 25% dextrose combination have been proved safe and effective during pregnancy . 
 medical termination of pregnancy and cesarean section ( those near term ) may be the options in resistant cases not responding to sclerotherapy . 
1. Background
2. Objectives 
3. Patients and Methods
4. Results
5. Discussion
5.1. Classifications
5.1.1. Parasitic-Predominent Forms 
5.1.2. Non Parasitic
5.2. Etiopathogenesis
5.3. Clinical Features
5.4. Diagnosis
5.5. Acetic Acid Test
5.6. Ether Test
5.7. Management
5.8. Complications of Sclerotherapy