Cloudy & Foamy Urine: Is It Proteinuria?

Normal urine is suppose to be clear, with mild yellow or straw colour. When you notice your urine is cloudy (frothy) and/or foamy (bubbles), you may be anxious and want to know whether there is anything wrong with your kidneys.

Urine contains water and all sorts of solubles waste products that are excreted by our kidneys. In common sense, when the waste products in the urine is more concentrated, or there are abnormal particles in the urine, the urine may become cloudy or foamy.

     Normal urine: clear

Here is a list of possible causes of:

Cloudy Urine

• dehydration  (more concentrated urine)
• proteinuria (protein in the urine)
• phosphate crystals (after phosphate-rich meal)
• vitamins B/C (excessive intake excreted through kidneys)
• urinary tract infection (pus from bladder/kidney infection)
• prostatitis (infection or inflammation of prostate)
• kidney stone
• vaginal discharge (contaminate the urine)
• gonorrhoea (pus contaminate the urine)
• retrogade ejaculation (only cloudy after ejaculation)

Foamy Urine

• forceful urination into toilet bowl
• dehydration
• proteinuria
• urinary tract infection

From the list above, dehydration may be the most common cause and proteinuria may be the most important cause. 

When you complain of cloudy urine, at least you need to get a urine sample to check for the presence of protein in your urine. If it is positive for protein, then you may need to have further investigation. However, not all proteinuria especially mild proteinuria is harmful. If your urine do not contain protein, then it is good but you should repeat it at other time and also look for other causes.

    Urine dipstick test: easy for self-check

If the cloudy urine is intermittent and not frequent, then the chance of significant proteinuria is less.

Dehydration, phosphate crystals and vitamin B/C in the urine are totally harmless. Infection usually produce pain when passing urine or pain at the lower abdomen or flank. Urine dipstick and microscopy can help to identify infection. Kidney stones can be diagnosed with ultrasound scan.

Food rich in phosphate include milk, cheese, beans, nuts, corn, chocolate, meat, egg yolk, mushrooms, wheat, oat etc and some processed food with additives such as soft drink, processed meat/hot dogs, biscuits, ketchup etc.

Not every cloudy or foamy urine means kidney problem. If you have this problem, you can check your urine using a dipstick or see your doctor if you are in doubt.

Raised CA-125: What are the Causes?

CA-125 is a protein found mostly in certain types of cancer cells. CA stands for cancer antigen and CA-125 is known as a tumour-marker especially for ovarian cancer.

CA-125 is traditionally done to measure the success of ovarian cancer treatment or when a pelvic mass is found. It is not suggested to be used as a screening test for ovarian cancer because it is not accurate with high probability of false positive and false negative results. CA-125 can be high in certain cancers other than ovarian cancer, and in other non-cancerous condition as well.

     Female reproductive organs

Here is a list of conditions which can cause a raised CA-125:

Cancer

• Ovary
• Uterus/endometrium
• Fallopian tube
• Breast
• Pancreas
• Liver
• Lungs
• Bowel
• Bladder
• Cancer with peritoneum involvement

Non-cancer (gynecological)

• Benign ovarian cyst
• Endometriosis
• Fibroid
• Pelvic inflammatory disease
• Pregnancy (first trimester)
• Menstruation

Non-cancer (non-gynecological)

• Pancreatitis
• Liver cirrhosis/failure
• Renal failure
• Nephrotic syndrome

The normal value of CA-125 is <35 u/ml. If you have a level higher than 35, then you should have an ultrasound scan to check your ovaries and uterus. Your doctor will take relevant history from you and examine you thoroughly. If nothing can be found, usually you are only required to repeat the test at an interval and follow up with the doctor.

If a pelvic/ovarian mass is found, depends on its characteristic, a surgery may be required to confirm whether it is cancerous or not. Sometimes it can just be a benign (non-cancerous) ovarian tumour or endometriod cyst.

However, not everyone with confirmed ovarian cancer will have an abnormal CA-125 results. Only about 50% of stage I ovarian cancer patients have raised CA-125. For stage II, III, IV ovarian cancer patients, 80% will have raised CA-125 while for the rest of 20% of these patients, their CA-125 level remain normal.

A study done in 1999 by IJ Jacobs screen about 10,000 post-menopausal women over 45 years old using the CA-125 test alone. Results of this study showed a false positive rate of about 80%. (only 20% of these women with abnormal CA-125 had ovarian cancer)

Another study screened 11,000 post-menopausal women over 45 years old with CA-125. As a result, 468 of them were found to have raised CA-125 and ultrasound scan were done. Of these 468 women, 29 underwent surgical procedure and noted:

• 6 had ovarian cancer (1.3% - 6 out of 468)
• 2 had adenocarcinoma of unknown origin
• 14 had benign tumour
• 4 had fibroids
• 3 had no abnormality

We can see that the false positive rate of CA-125 test varies from different studies, but we know that the chance of ovarian cancer with a raised CA-125 is not very high. However, this should not be the reason for us to ignore the positive result. To improve the accuracy of the test, a serial CA-125 tests should be done to see the trend, and ultrasound scan should be performed.

Testicular Microlithiasis: Can It Cause Cancer?

Testicular microlithiasis is usually diagnosed during ultrasound scan done as screening or for suspected testicular mass. Those many white dots which appear in the ultrasound image are calcium deposits. However, it has no relation with how much calcium you eat. Should a man worry if he is told to have testicular microlithiasis?

Unfortunately, though testicular microlithiasis is widely recognized and diagnosed, we still do not understand it well. The cause of it is still unknown, and its consequences are still very much debatable. The most worrying issue regarding testicular microlithiasis is its association with a type of testicular cancer called testicular germ cell tumour. 

     Microlithiasis: The "Stars" are the microliths

Opinion regarding the link between testicular microlithiasis and cancer varies between different countries and even between different doctors within the same country. However, if you have testicular microlithiasis, definitely you need to have it monitored regularly and should not just leave it alone.

For people with testicular microlithiasis, it is easier to divide them into 3 groups. How they should be followed up with their doctor depends on which group they are in.

• Testicular microlithiasis and asymptomatic (no symptoms and healthy)
• Testicular microlithiasis with symptoms of testicular dysgenesis syndrome
• subfertility (difficult to get baby)
• cryptorchidism (undescended testis)
• testicular atrophy (reduction in testis size)
• gonadal dysgenesis (abnormality in sexual organs development)
• Testicular microlithiasis with  concurrent germ cell tumour

For those who are asymptomatic and apparently healthy, you need to see a doctor to rule out the presence of testicular dysgenesis syndrome. If everything is fine, the risk of developing testicular germ cell tumour is not high. However, it is advisable to perform testicular self-examination regularly and see your doctor/urologist for examination or ultrasound scan annually. Biopsy is usually not required.

For those who have testicular dysgenesis syndrome, the risk of testicular germ cell tumour is said to be higher than others who do not have the symtoms. A condition called intratubular germ cell neoplasia with unclassified type (or testicular carcinoma in-situ), which is "pre-cancerous" condition , can be found in 11-18% of those with both testicular microlithiasis and testicular dysgenesis syndrome. In such case, you need to consult a urologist to discuss whether a testicular biopsy and further imaging studies are necessary. Monitoring of tumour markers such as AFP and hCG may be helpful.

For those who has concurrent unilateral (one-sided) germ cell tumour, the presence of microlithiasis may suggest that the risk of cancer in the other testis is higher. Thus, further management such as chemotherapy may differ.

It is wrong to say that testicular microlithiasis can cause cancer. However, it is related to testicular cancer. Having testicular microlithiasis does not mean that one will definitely develop testicular cancer in the future. As testicular microlithiasis is still considered inadequately studied, please liaise with your urologist as he/she will know the latest development regarding this condition.

Gallstones and Gallbladder Flush

There are generally 2 types of gallstone: cholesterol or pigment stones. It is believed that >80% of gallstones are caused by excessive cholesterol in the bile.

Gallstones can be easily diagnosed using an ultrasound scan. Most gallstones are diagnosed incidentally while doing ultrasound scan for screening or other purposes, as most gallstones do not produce any symptoms. When they do, the most common symptoms they produce is pain at the right upper region of the abdomen which may radiate to the right shoulder, especially after a fatty meal.

The stones can irritate the gallbladder and cause inflammation of the gallbladder referred to as "cholecystitis". Sometimes the stone can pass through the bile duct and get trapped half way. It will result in severe pain and jaundice (yellow eyes & skin). If left untreated, serious complication such as pancreatitis can occur. Both these two conditions are common gallbladder disorders and need emergency surgery to remove the gallbladder (cholecystectomy).

     Gallbladder at your right upper abdomen

If you find out that you have gallstones and you still have not experience any symptoms, then usually nothing need to be done. Some doctors may recommend surgery to remove the gallbladder straight away as when problems arise, surgery will have higher risk. Other doctors may recommend medication such as ursodeoxycholic acid to dissolve the cholesterol stones. However, this drug is not commonly given nowadays as it takes many years to dissolve the stones and the stone may reform after that.

If you have gallstones with no symptoms or only mild infrequent discomfort, you may want to try an alternative treatment called gallbladder flush. This method is not 100% effective and it depends on how well you follow the plan.

There are many version of gallbladder flush available, but their principle are almost the same. Here is an example.

2-4 weeks before:

Eat healthy diet rich in fruits & vegetables, with no meat and no refined food. Make sure there is no constipation.

Day 1-5:

Continue with the healthy diet. Drink at least 2 glasses of apple juice a day. 

Day 5:

Do not eat anything after lunch. Take 1 teaspoon of epsom salts at 4pm and then another teaspoon at 6pm.

From 8pm, take 15ml of olive oil mixed with 15ml of lemon juice every 15 minutes for 8 times (total 120ml of olive oil & 150ml of lemon juice taken in 2 hours time).

Then go to bed lying on your right side with right knee bend.

Day 6-7:

You may pass out greenish/yellowish stones if successful. To confirm it, just see your doctor to do an ultrasound scan.

    Gallstones

Plenty of fruits and vegetables help to cleanse the bowel in preparation for the stones to pass out. Apples are rich in malic acid which can help to soften or break the cholesterol gallstones. Epsom salt or magnesium sulfate helps to relax smooth muscle within the bile ducts so that the stones can pass through easily. Olive oil will make the gallbladder contract forcefully to flush out the stones, while lemon juice just make the olive oil better to drink.

There is a possibility that the stones may trapped halfway and causes pain which may need intervention by doctors. Other than this, gallbladder flush is a safe practice for healthy adults. Even if it is not successful, your body will still benefit from a few weeks of healthy diet.