Green urine

aka Unusual Urine 010

Differential for green urine

Drugs	Amitriptyline B vitamins Cimetidine Doxorubicin Indomethacin Methylene blue Promethazine Propofol Rinsapine Sildenafil Triamterene
Infection	Pseudomonas urinary tract infection; producing pyocyanin and pyoverdin pigments
Metabolic	Indicanuria: Hartnup disease; Blue diaper syndrome Bilverdin(uria) e.g. with chronic obstructive jaundice
Ingestants	Food dyes Asparagus Chlorophyl: e.g. Clorets with actizol Wilisan pills: traditional Chinese medicine – found to contain methylene blue
Other	Vesicoenteric fistula

Propofol-induced green urine

Green urine is a rare and benign side effect of propofol administration, and while often described in patients on prolonged propofol infusions, can occur with short durations of use such as with induction for general anaesthesia. It is thought to occur in less than 1% of cases of propofol administration.

Propofol is primarily metabolised in the liver to phenolic metabolites predominantly involving 1-glucuronide, 4-glucuronide and 4-sluphate conjugates of 2,6 diisopropyl-1,4-quinol.  These phenolic metabolites are thought to cause green discoloration of the urine. Urinary alkalinsation can increase the formation of these phenolic metabolites, therefore green urine may be more commonly observed in patients who develop respiratory alkalosis while ventilated.

While propofol is classically associated with the risk of green urine (and hair!), it can also induce a PINK urine syndrome thought to be due to propofol-induced increased urinary uric acid excretion coupled with heme oxygenase-1 activity; as well as a transient white urinary appearance thought to be due to propofol’s lipid emulsion.

The green urinary discolouration will generally spontaneously resolve following discontinuation of propofol, although consideration of alternative causes of the appearance is required. While alarming, green urine is not associated with propofol infusion syndrome – a serious syndrome of acute refractory bradycardia leading to asystole in the presence of metabolic acidosis, rhabdomyolysis, hyperlipidaemia and enlarged or fatty liver.

References

• Shim Y, Gil H, Yang J, Lee E, Kim S, Hong S. A case of green urine after ingestion of herbicides. Korean J Intern Med 2008;23:42–4.
• Iyer VN, Hoel R, Rabinstein AA. Propofol infusion syndrome in patients with refractory status epilepticus: an 11-year clinical experience. Crit Care Med. 2009 Dec;37(12):3024-30
• Lam CW, Wong SY. A case of green urine due to a traditional Chinese medicine containing methylene blue. N Z Med J. 2010 Apr 9;123(1312):71-6. 
• Torka P, Sharma R. Green coloured urine. Neth J Med. 2012 Aug; 70(6): 282, 285
• Meng QH, Handy B, Wagar EA. It’s not easy being blue-green. Ann Lab Med. 2013 Nov; 33(6): 457-8
• Loh N, Nair P. Propofol infusion syndrome, Continuing Education in Anaesthesia Critical Care & Pain, 2013; 13(6): 200–202
• Rawal G, Yadav S. Green Urine Due to Propofol: A Case Report with Review of Literature. J Clin Diagn Res. 2015 Nov;9(11):OD03-4.
• Kim GE et al. Green urine after general anesthesia with propofol: different responses in the same patient. Anesthesia and Pain Medicine 2017;12(1):32-36
• Barros Pinto MP. Green urine – understanding its importance. Laboratoriums Medizin 2018
• Tucker BM, Perazella MA. Pink Urine Syndrome: A Combination of Insulin Resistance and Propofol. Kidney Int Rep. 2018 Oct 13;4(1):30-39.
• Pulos BP, Sviggum HP, Sharpe EE. Propofol-associated Green Hair Discoloration. Anesthesiology. 2019 Mar;130(3):445.
• Cadogan M. Verdant waste. LITFL
• Cadogan M. How green is my urine. LITFL