aka Unusual Urine 010
Differential for green urine
DrugsAmitriptyline
B vitamins
Cimetidine
Doxorubicin
Indomethacin
Methylene blue
Promethazine
Propofol
Rinsapine
Sildenafil
Triamterene
InfectionPseudomonas urinary tract infection; producing pyocyanin and pyoverdin pigments
MetabolicIndicanuria: Hartnup disease; Blue diaper syndrome
Bilverdin(uria) e.g. with chronic obstructive jaundice
IngestantsFood dyes
Asparagus
Chlorophyl: e.g. Clorets with actizol
Wilisan pills: traditional Chinese medicine – found to contain methylene blue
OtherVesicoenteric 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

Cite this article as: Jeremy Rogers and Mike Cadogan, "Green urine," In: LITFL - Life in the FastLane, Accessed on May 18, 2022, https://litfl.com/green-urine/.

Unusual Urine

Clinical cases

Physician in training. German translator and lover of medical history.

Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM with a 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 |

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.