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.

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.

PSA: Is it a good prostate cancer marker?

Prostate specific antigen (PSA) is a protein produced by cells in the prostate glands. Thus only male has PSA. PSA has been widely used as a screening tool for prostate cancer.

   Location of prostate gland

It is still controversial whether PSA is suitable to be used to screen for prostate cancer. Studies have shown that while most prostate cancer sufferers have raised PSA level, this test is somehow not specific. This means that the false positive rate is quite high. Even though one has high level of PSA, he may not have prostate cancer.

There are a few recognized causes for raised PSA, all of them are associated with irritation of the prostate:

1. Benign Prostatic Hyperplasia – enlarged prostate due to aging
2. Prostatitis – inflammation of prostate (can be infection or non-infection)
3. Prostate cancer
4. Recent ejaculation (avoid testing PSA in 48 hours)
5. Recent prostate biopsy (avoid testing PSA in 6 weeks)
6. Recent prostate surgery
7. Recent digital rectal examination (avoid testing PSA in 1 week)
8. Recent urinary cathetherization
9. Urinary retention
10. Recent rigorous exercise esp bicycle riding

 

   Benign Prostatic Hyperplasia

Generally the cut off point for PSA value is set at 4.0ng/ml. Since PSA level is age-dependent as prostate gland will increased in size with age, some authorities suggest to modify it according to age.

Age	“Normal” PSA (ng/ml)
40-49	<2.5
50-59	<3.5
60-69	<4.5
70-79	<6.5

Although PSA <4.0ng/ml is widely considered as normal, there is still a possibility of prostate cancer (about 20% chance) in these people. PSA between 4.0 and 10.0ng/ml is considered borderline (25% chance of prostate cancer), while PSA >10.0ng/ml has higher risk (67% chance of prostate cancer).

Since the false positive rate is quite high, PSA may not be a good cancer marker as it can cause unnecessary further investigation and anxiety. Digital rectal examination (a finger is inserted into rectum) is usually done to feel for abnormality in the gland. For men with higher risk of prostate cancer such as old age and positive family history, further test such as prostate ultrasound and biopsy may be needed. For those with low risk, other causes of raised PSA should be looked for and treated accordingly. The PSA level can be repeated after 6-12 weeks to see the trend. If it continues to rise significantly, then further investigation is warranted. Another blood test that can be done is free/bound PSA ratio. More free PSA compared to bound PSA is good news. The standard PSA test is total PSA (free + bound).

Whether you should have your PSA checked depends on you. One one hand it may save your life by detecting prostate cancer early, on the other hand it may cause unnecessary anxiety, loss of money and complication from further investigation.