White (Milky) Urine- Differential Diagnosis Approach Chart

One of the scary symptoms is having white pee all of a sudden. White or Milky urine can be the potential cause of a number of conditions. We have summarized the causes with an approach. In this post, we will guide you on White (Milky) Urine- Differential Diagnosis- Approach with Flowchart.

Differential Diagnosis


This happens because of passage of chylomicrons in urine.


It refers to passing out of large amount of phosphates (amorphous or crystalline) in urine.


It is presence of fat droplets in urine.

Pseudochyluria (milky or gold paint)

This means passage of large amount of protein, desquamated cells may turn the urine milky (there is mixed cellularity with cholesterol excess).


It simple means that urine is full of pus cells as in urinary tract infection.


A. Blockage of lymph channels or thoracic duct

This can happen due to parasite. The causes of duct blockage are:

a. Parasites: filariasis, ascariasis, cysticercosis, taenia and H. nana infection.

b. Non-parasitic: trauma to thoracic duct, tumors, obstruction of thoracic duct, pregnancy, tuberculosis, retroperitoneal fibrosis, congenital malformation of lymph channels or lymphangiectasia.

B. Idiopathic

Some causes are still unknown.

White (Milky) Urine- Diagnosis Algorithm

Through a simple approach, one can establish the diagnosis by ruling out other possibilities. The steps are for algorithm of white or milky urine are summarized in infographic below:

Key Notes


Commonest cause is filariasis (e.g. W. bancrofti-induced), especially in India. A state of lymphatic hypertension with cavernous malformations of lymph channels at hilum of pelvis prevails which ultimately ruptures into the urinary passage (may be in the bladder or urethra too). The colour of the urine is milky or creamy and the fat globules may be demonstrated microscopically by staining with Sudan III. Reassurance and treatment of the cause are the mainstay of management.


Urine clears with the addition of acetic acid. Oral aluminium hydroxide (antacid) may alleviate the problem.


Fat droplets usually float on the top of the urine or may be separated as a layer on top after ultracentrifugation. Conditions associated with lipiduria are diabetes mellitus, nephrotic syndrome, eclampsia, arsenic poisoning.


Usually turbid urine as a result of large number of degenerated cells or tumour cells. Turbidity clears on addition of alkali.


Large number of pus cells make the urine turbid and is commonly associated with pyelonephritis, cystitis or urethritis. Broad-spectrum antibiotics cure the ailment.

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