aka Unusual Urine 010
Differential for green urine
|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
Chlorophyl: e.g. Clorets with actizol
Wilisan pills: traditional Chinese medicine – found to contain methylene blue
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.
- 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
Associate Professor Curtin Medical School, Curtin University. Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM Sir Charles Gairdner Hospital. Passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | Twitter |