chyle is composed of albumin , emulsified fat and fibrin . in tropical country like india , chyluria is a chronicsequelae of filariasis . up to 10% patient with filariasis may experience chyluria in tropical countries ( 1 ) . chyluria has no sex predilection ; but young adult male from poor socio - economic background are mainly affected ( 2 ) . it is recognized as tropical disease associated with spontaneous remissions and exacerbation ( 3 ) . in our state , it is not uncommon to find pregnant females with chyluria . the study aims to present our experience of managing 43 cases with chyluria during pregnancy over a period of ten years from july 2003 to june 2014 . forty three pregnant female patients , who presented to the department of urology , igims , patna , from july 2003 to june 2014 , were evaluated for chyluria ( tables 1 - 3 ) . all the patients were evaluated by history , physical examination , routine examination of urine for chyle and chylomicron , culture sensitivity of urine , complete blood count ( cbc ) tests , blood sugar , renal function test , post prandial glucose test for chyle in urine , zeihl - nelson staining for acid fast bacilli , ultrasonography , cystourethros copy for lateralization and to exclude other pathology . all the patients were managed initially by conservative means - bed rest , high protein diet , and avoidance of fat , oil , milk , and milk product . all patients were administered isoxsuprine hydrochloride ( 10 mg ) 1 tab twice daily for two days prior to the procedure and continued two days after completion of procedure . ceftriaxone l gwas injected just before the procedure . under local an aesthesia ( 2% xylocaine jelly instilled in urethra ) , cystoscope was passed into the bladder , bladder washed and cleared of clots and side of chylus efflux determined . with the help of ureteric catheter 10 ml solution of sclerosant ( 5 ml of 10% povidone iodine was mixed with normal saline in equal amount to make it 10 ml ) instilled slowly into renal pelvis . after eight hours , 5 ml of 25% dextrose mixed with normal saline in equal amount to make it 10 ml was again instilled . ureteric catheter was left indwelling and for next two days and same solution was instilled alternately at an interval of eight hours . two patients underwent mtp after failure of sclerotherapy or because of personal preference in desperate cases . in overall , 67.44% of patients were in the age group of 20 to 30 years followed by 30.23% in the age group of 30 to 40 years . 74.41% of the patients were referred to us in their second trimester followed by third trimester ( 13.95% ) and least in first trimester . thirteen patients ( 30.33% ) hadchyluria before pregnancy . in our series , about half ( n = 21 ) patient presented with chyluria only while others presented with other associated symptoms like dysuria ( n = 6 ) , chyluria mixed with hematuria ( n = 3 ) , urinary retention ( n = 10 ) , fever / uti ( n = 4 ) , and decreased fetal movement ( n = 4 ) ( table 4 ) . after one course of sclerotherapy thirteen patients improved , 19 patients needed second course of sclerotherapy , while two patients who presented in first trimester underwent medical termination of pregnancy at their own choice . caesarian section was done in three patients , two of them at 37 weeks of pregnancy and one at 40 weeks of pregnancy after failure of sclerotherapy . one patient who did not improve even after caesarean section responded to conservative management and four weeks course of diethyl carbamazine ( 100 mg three times a day ) . colicky pain developed in eight patients just after sclerosant instillation and in four patient urine output decreased while four patients developed transient fever and two patients developed urinary tract infection ( table 4 ) . chyluria is a state of lymphourinary reflux via fistulous communications secondary to lymphatic stasis caused by obstruction of the lymphatic flow ( 10 ) . it is a form of chronic filarial syndrome , caused by intermittent discharge of intestinal lymph ( chyle ) into the renal pelvis and finally into the urine ( 2 ) . chyluria is generally thought as harmless conditions in majority but in our part of state fatal outcome has been seen when not properly managed . persistent chyluria can lead to malnutrition due to loss of protein and lipid ( 12 ) . it becomes more important to diagnose and aggressively treat pregnant patient to prevent morbidity and mortality of mother and child . chyluria is a urological manifestation of lymphatic system disease which may lead to nutritional deficiency , recurrent clot colic , urinary retention , urinary tract infection , hematuria and a state of compensated immunosuppression . chyluria may lead to serious immunological and hemostatic deficit due to igg and iga deficiency ( 13 ) . there are various theories regarding development of chyluria ; but nowadays , two theories have been implicated as causative factors them : obstructive theory [ aye and aung , 1975 ( 14 ) ] regurtitative theory [ ngan and leong , 1977 ( 15 ) ] this is the commonest form in india and mainly associated with wuchereria bancrofti infection . non parasitic causes includes tuberculosis , congenital lymphangioma of urinary tract , trauma , pregnancy , malignant infiltration of lymphatics ( 13 ) . the most common etiological factor for chyluria is filariasis and should be considered filarial unless proven otherwise particularly in filarial belt ( 10 ) . chyluria is the end result of impairment of retroperitoneal lymphatics due to vicious cycle of infection sclerosis obstructive retrograde dilatation , stasis backflow and spontaneous rupture with fistualisation into the urinary tract . in the present study we encountered half of the patients ( n = 21 ) were suffering from chyluriaalone followed by urinary retention ( n = 10 ) dysuria ( n = 6 ) fever and decreased fetal movement ( n = 4 each ) and hematuria ( n = 3 ) . there are so many investigations for diagnosis and management of chyluria apart from routine examination of blood and urine . specialized tests are test for chyle in urine i.e. ether test , methylene blue test , afb in three consecutive morning sample of urine . detection of microfilaria is described in centrifuged preparations of cystoscopically catheterized urine , but very rarely in normally voided urine samples specially the chylous sample ( 16 ) . other tests are radiological i.e. retrograde pyelography , lymphangiography , lymphangioscintigraphy , intravenous pyelography , ct - scan , mri , ultrasonography , enzyme linked immunosorbent assay ( elisa ) for filarial antigen in blood and antibodies specific to recombinant filarial antigen wbsxp - i have been used to develop in elisa for detecting circulating antigen filarial in serum of patient with filariasis ( 17 ) . another elisa to detect specific igg4 antibodies in un - concentrated urine has been developed ( 18 ) . recently , triglyceride has been demonstrated to be universally present in chyluria , even in clear urine . the amount of triglyceride has been found to be directly proportional to haziness of chylous urine . we tailored investigation to routine examination of urine , acetic acid test , afb in three morning sample of urine , investigation to test for chyle in urine after injestion of 75 g of butter on night before the test and send first morning sample of urine ( ether test ) and urethrocystos copy and lateralization . addition of few drops of 10% acetic acid in 1 ml of chylous urine clears the opacity in cases of phosphaturia , while opacity persists in chyuria ( 20 ) . equal part of chylous urine and ether mixed in a test tube and shaken vigorously . hematinic multivitamins some patients improve ( n = 6 ) but this should not be tried for more than two weeks . if symptoms not improve , because of devastating squeal due to loss of protein and immunoglobulinssclero therapy should started without delay . diethyl carbamazine should not be used in pregnant patient because its safety has not been established in pregnancy ; although , it is being used by some physician in these cases without reported ill effect on foetus . in our study we found that most of the patient ( 32/37 ) improved by three day regimen of sclerotherapy with 10% povidone iodine mixed with equal amount of normal saline and 25% dextrose . outcome of pregnancy was not affected with this regime and all the patient deliver full term healthy baby . there are various agent used for sclerotherapy such as agno3 , povidone iodine , dextrose and radiographic contrast material in different concentrations . severe and fatal complications such as interstitial nephritis , papillary necrosis , acute tubular necrosis are associated with use of silver nitrate as sclerosant in chyluria . mortality has been reported due to acute tubular necrosis on instillation of silver nitrate in both ureters ( 21 , 22 ) . it is as effective as 1% agno3 but not associated with severe and fatal complications such as interstitial nephritis , papillary necrosis and acute tubular necrosis . combination of sclero therapy using a 5% povidone iodine and 50% dextrose solution has been found to be safe and cost - effective minimally - invasive therapy for chyluria refractory to conservative treatment . a 5 ml of 50% dextrose combined with 5 ml 0.2% povidone iodine provides stronger and better fibrotic response ( 9 ) . different workers ( 8 , 9 , 23 , 24 ) found 87 - 100% success rate of sclerotherapy with betadine alone or in combination with dextrose . our success rate with combination sclerotherapy of betadine and dextrose was 86.2% , which is similar to result of other workers ( table 5 ) . complications of sclerotherapy was transient hematuria ( n = 10 ) which developed after two days of sclerotherapy , which was managed by abandoning the procedure , hydration of patient and antibiotic coverage . colicky pain developed in 8 patients just after instillation of sclerosant which subsided in 10 minutes period . few patients required antispasmodic decreased urine output developed in 4 patients which was managed by of of diuretics for two to three days and adequate hydration . nausea and vomiting developed in two patients managed by antiemetic drugs . by dietary restriction and bed sclerotherapy with 10% povidone iodine and 25% dextrose is a safe and effective method with high cure rate . non parasitic causes includes tuberculosis , congenital lymphangioma of urinary tract , trauma , pregnancy , malignant infiltration of lymphatics ( 13 ) . non parasitic causes includes tuberculosis , congenital lymphangioma of urinary tract , trauma , pregnancy , malignant infiltration of lymphatics ( 13 ) . the most common etiological factor for chyluria is filariasis and should be considered filarial unless proven otherwise particularly in filarial belt ( 10 ) . chyluria is the end result of impairment of retroperitoneal lymphatics due to vicious cycle of infection sclerosis obstructive retrograde dilatation , stasis backflow and spontaneous rupture with fistualisation into the urinary tract . pregnant female with chyluria may present as monosymptomatic or may be polysymptomatic . in the present study we encountered half of the patients ( n = 21 ) were suffering from chyluriaalone followed by urinary retention ( n = 10 ) dysuria ( n = 6 ) fever and decreased fetal movement ( n = 4 each ) and hematuria ( n = 3 ) . there are so many investigations for diagnosis and management of chyluria apart from routine examination of blood and urine . specialized tests are test for chyle in urine i.e. ether test , methylene blue test , afb in three consecutive morning sample of urine . detection of microfilaria is described in centrifuged preparations of cystoscopically catheterized urine , but very rarely in normally voided urine samples specially the chylous sample ( 16 ) . other tests are radiological i.e. retrograde pyelography , lymphangiography , lymphangioscintigraphy , intravenous pyelography , ct - scan , mri , ultrasonography , enzyme linked immunosorbent assay ( elisa ) for filarial antigen in blood and antibodies specific to recombinant filarial antigen wbsxp - i have been used to develop in elisa for detecting circulating antigen filarial in serum of patient with filariasis ( 17 ) . another elisa to detect specific igg4 antibodies in un - concentrated urine has been developed ( 18 ) . recently , triglyceride has been demonstrated to be universally present in chyluria , even in clear urine . the amount of triglyceride has been found to be directly proportional to haziness of chylous urine . we tailored investigation to routine examination of urine , acetic acid test , afb in three morning sample of urine , investigation to test for chyle in urine after injestion of 75 g of butter on night before the test and send first morning sample of urine ( ether test ) and urethrocystos copy and lateralization . addition of few drops of 10% acetic acid in 1 ml of chylous urine clears the opacity in cases of phosphaturia , while opacity persists in chyuria ( 20 ) . equal part of chylous urine and ether mixed in a test tube and shaken vigorously . cleared urine indicates chyluria . by conservative management with rest , high protein diet , hematinic multivitamins some patients improve ( n = 6 ) but this should not be tried for more than two weeks . if symptoms not improve , because of devastating squeal due to loss of protein and immunoglobulinssclero therapy should started without delay . diethyl carbamazine should not be used in pregnant patient because its safety has not been established in pregnancy ; although , it is being used by some physician in these cases without reported ill effect on foetus . in our study we found that most of the patient ( 32/37 ) improved by three day regimen of sclerotherapy with 10% povidone iodine mixed with equal amount of normal saline and 25% dextrose . outcome of pregnancy was not affected with this regime and all the patient deliver full term healthy baby . there are various agent used for sclerotherapy such as agno3 , povidone iodine , dextrose and radiographic contrast material in different concentrations . severe and fatal complications such as interstitial nephritis , papillary necrosis , acute tubular necrosis are associated with use of silver nitrate as sclerosant in chyluria . mortality has been reported due to acute tubular necrosis on instillation of silver nitrate in both ureters ( 21 , 22 ) . it is as effective as 1% agno3 but not associated with severe and fatal complications such as interstitial nephritis , papillary necrosis and acute tubular necrosis . combination of sclero therapy using a 5% povidone iodine and 50% dextrose solution has been found to be safe and cost - effective minimally - invasive therapy for chyluria refractory to conservative treatment . a 5 ml of 50% dextrose combined with 5 ml 0.2% povidone iodine provides stronger and better fibrotic response ( 9 ) . different workers ( 8 , 9 , 23 , 24 ) found 87 - 100% success rate of sclerotherapy with betadine alone or in combination with dextrose . our success rate with combination sclerotherapy of betadine and dextrose was 86.2% , which is similar to result of other workers ( table 5 ) . complications of sclerotherapy was transient hematuria ( n = 10 ) which developed after two days of sclerotherapy , which was managed by abandoning the procedure , hydration of patient and antibiotic coverage . colicky pain developed in 8 patients just after instillation of sclerosant which subsided in 10 minutes period . few patients required antispasmodic decreased urine output developed in 4 patients which was managed by of of diuretics for two to three days and adequate hydration . nausea and vomiting developed in two patients managed by antiemetic drugs . by dietary restriction and bed sclerotherapy with 10% povidone iodine and 25% dextrose is a safe and effective method with high cure rate .