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Sodium Fluorescein

Sodium fluorescein is a fluorescent xanthene dye that emits a yellow-green color under blue (490 nm) or ultraviolet light, visible even at very low concentrations in urine. In GU practice, low-dose IV sodium fluorescein is an off-label aid for cystoscopic visualization of ureteral jets during pelvic surgery; it was described as an alternative during the indigo-carmine shortage.[1][3]

Pharmacology​

PropertyValue
ClassXanthene fluorescent dye
ColorYellow-green (visible), intensifies under blue/UV light
RouteIV (studied for ureteral efflux); intravesical use is not standardized
Renal excretionIn five women given 50 mg IV fluorescein, urine color changed in an indwelling catheter at a median of 5 minutes (range 3–9); the study did not time cystoscopic jets.[4]
DurationUrine stays discolored for 24–36 hours; skin discoloration fades in 6–12 hours[3]
FDA approvalFLUORESCITE 10% (500 mg/5 mL vial): diagnostic fluorescein angiography or angioscopy of the retina and iris vasculature; GU use is off-label[3]

GU Applications​

1. IV dye for cystoscopic ureteral-efflux assessment​

  • 25–100 mg IV (0.25–1 mL of the 10% solution) produces a bright yellow ureteral jet within minutes, visible with the standard white-light cystoscope[1]. In a prospective observational series of 54 women after total laparoscopic hysterectomy given 100 mg IV, mean time to stained efflux through at least one ureteral meatus was 7.5 minutes (95% CI 6.3–8.7).[10]
  • IV fluorescein can aid white-light cystoscopic visualization of ureteral efflux when indigo carmine is unavailable.[1]
  • Doyle et al. 2015 described 0.25–1 mL of 10% (25–100 mg) IV; Cohen 2017 used 0.5 mL (50 mg) and Grimes 2017 used 25 mg.[1][2][4] These are off-label regimens, well below the labeled 500 mg ophthalmic dose.[1][2][4]
  • Comparative data: urine color changed in catheter drainage at a median of 5 minutes after IV fluorescein (n = 5) versus 70 minutes after oral phenazopyridine (n = 7); this nonrandomized cohort did not time cystoscopic jets.[4] In the Grimes RCT (n = 130; oral phenazopyridine, IV fluorescein, mannitol distention, saline distention), surgeons rated mannitol bladder distention most satisfactory (median VAS 0 versus 20 for fluorescein; lower is better), with no difference in cystoscopy time or adverse events.[2] In a randomized trial enrolling 176 pelvic-surgery patients, IV fluorescein and 10% dextrose bladder distention each improved ureteral-jet visibility and surgeon satisfaction versus saline distention.[11] In a 2023 randomized trial of women undergoing pelvic reconstruction, oral riboflavin (n = 117) versus 5% dextrose distention (n = 119) yielded accurate bilateral-jet detection of 97.4% versus 90.8% (p = 0.051) and fluorescein rescue in 3.4% versus 11.8% (p = 0.025).[12] Fluorescein remains a reasonable IV option for cystoscopic ureteral-efflux assessment. A visible jet indicates urine passage at cystoscopy but should not end evaluation when ureteral injury remains suspected: thermal lesions can be subtle and delayed, and the 2023 WSES emergency digestive surgery guideline calls diagnostic cystoscopy with retrograde pyelography the gold standard for suspected intraoperative ureteral injury .[1][6] In a prospective series of 30 women after laparoscopic hysterectomy, one ureteral jet appeared six minutes after the other and was less densely colored; partial obstruction was diagnosed 13 days later.[7]

2. Intravesical applications​

Intravesical use is off-label and lacks a standardized regimen established by the cited IV-efflux studies. Do not transfer an IV or ophthalmic preparation into the bladder without an appropriate local protocol and pharmacy review.

3. Perfusion / angiography (limited GU use)​

  • Widely used in ophthalmology for retinal angiography
  • Occasional intraoperative use for flap perfusion assessment in plastic surgery
  • Rare in GU reconstruction (ICG preferred for perfusion)

Dosing​

  • IV ureteral identification: 25–100 mg (0.25–1 mL of 10%) IV, through a well-functioning line; published series report doses of 25, 50 and 25–100 mg[1][2][4]
  • Intravesical leak testing: use a locally reviewed protocol; the IV studies do not establish a bladder dose.
  • Verify the supplied concentration: FLUORESCITE 10% is 100 mg/mL (500 mg/5 mL vial). The labeled adult angiography dose is 500 mg IV (pediatric 7.7 mg/kg, maximum 500 mg), injected rapidly into an antecubital vein; GU studies used far less. For FLUORESCITE, do not mix or dilute with other solutions or drugs, and flush the IV line before and after injection.[3]

Adverse Events​

  • Skin yellowing. Transient; the label reports fading in about 6–12 hours. Transient scleral and palmar yellowing occurred in the Doyle series.[1][3]
  • Yellow urine. Expected, lasting 24–36 hours per the label[3]
  • Nausea, vomiting, GI upset. Listed as common adverse reactions at the labeled dose; less well characterized at GU doses
  • Hypotension. In a prospective series of 30 women given 25 mg IV near the end of laparoscopic hysterectomy, during vaginal cuff closure, 3 developed hypotension within five minutes and required ephedrine.[7]
  • Hypersensitivity, including fatal anaphylaxis. Known fluorescein or component hypersensitivity is a contraindication; reactions are unpredictable and more frequent after prior adverse reactions, and the label calls for an emergency tray. Anaphylactic shock has been reported after 25 mg IV for cystoscopic efflux assessment; the incidence of severe reactions at GU doses is unknown, so review allergy history before administration.[3][5]
  • Extravasation can cause severe tissue damage; confirm a functioning IV.[3]
  • Pregnancy and lactation. The FLUORESCITE label advises use in pregnancy only if clearly needed and reports transfer into human milk for up to four days after IV administration.[3]
  • Laboratory assays. After 500 mg IV fluorescein for angiography, one case report found falsely increased urine protein by a benzethonium chloride method.[8] In four adults undergoing fluorescein angiography, method-dependent serum assays were affected at sampled times through 12 hours.[9] Ask the laboratory to review unexpected blood or urine results after fluorescein.

Sodium Fluorescein vs. Indigo Carmine vs. Methylene Blue​

FeatureSodium FluoresceinIndigo CarmineMethylene Blue
ColorYellow-greenBlue-violetDeep blue
Visible in urineYes, in white light; enhanced under UV/blueYesYes
Best useAlternative to indigo carmine when unavailableCystoscopic ureteral-efflux aidFistula / orifice / anastomotic leak
AvailabilityCheck local supplyBLUDIGO marketed; check local supplyCheck local supply
CostLowLowVery low
Need for special imagingEnhanced by blue filter (optional)NoneNone

See Also​

References​

1. Doyle PJ, Lipetskaia L, Duecy E, Buchsbaum G, Wood RW. Sodium fluorescein use during intraoperative cystoscopy. Obstet Gynecol. 2015;125(3):548–550. doi:10.1097/AOG.0000000000000675

2. Grimes CL, Patankar S, Ryntz T, et al. Evaluating ureteral patency in the post-indigo carmine era: a randomized controlled trial. Am J Obstet Gynecol. 2017;217(5):601.e1–601.e10. doi:10.1016/j.ajog.2017.07.012.

3. FLUORESCITE. US prescribing information, revised June 2026. DailyMed.

4. Cohen SA, Chaudhry Z, Oliver JL, et al. Comparison of Times to Ureteral Efflux after Administration of Sodium Fluorescein and Phenazopyridine. J Urol. 2017;197(2):519-523. doi:10.1016/j.juro.2016.07.099

5. Lee T, Sanderson D, Doyle P, Buchsbaum G. Anaphylactic Shock After Intravenous Fluorescein Administration for Intraoperative Cystoscopy. Obstet Gynecol. 2018;131(4):727-729. doi:10.1097/AOG.0000000000002519

6. de’Angelis N, Schena CA, Marchegiani F, et al. "2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries (IUTIs) during emergency digestive surgery." World J Emerg Surg. 2023;18:45. doi:10.1186/s13017-023-00513-8

7. Delbos L, Gareau-Labelle AK, Langlais EL, et al. "Sodium Fluorescein for Ureteral Jet Detection: A Prospective Observational Study." JSLS. 2018;22(3):e2018.00019. doi:10.4293/JSLS.2018.00019

8. Bouman AC, de Kruijf D, Emmen JMA, Rettig TCD, Kooijman-de Groot MJC, Faes MC. "Systemic reaction to and interference with urine protein measurements after intravenous fluorescein injection." BMC Ophthalmol. 2019;19(1):261. doi:10.1186/s12886-019-1276-x

9. Bloom JN, Herman DC, Elin RJ, et al. "Intravenous fluorescein interference with clinical laboratory tests." Am J Ophthalmol. 1989;108(4):375–379. doi:10.1016/S0002-9394(14)73304-5

10. Morgan-Ortiz F, Morgan-Ruiz FV, Báez-Barraza J, Ortiz-Bojórquez JC, Martínez-Félix JI, Peraza-Garay FJ. "Time of ureteral ejection of sodium fluorescein in the cystoscopic assessment of ureteral patency in patients undergoing total laparoscopic hysterectomy." J Turk Ger Gynecol Assoc. 2020;21(1):10–14. doi:10.4274/jtgga.galenos.2019.2019.0091

11. Espaillat-Rijo L, Siff L, Alas AN, et al. "Intraoperative cystoscopic evaluation of ureteral patency: A randomized controlled trial." Obstet Gynecol. 2016;128(6):1378–1383. doi:10.1097/AOG.0000000000001750

12. Zhao ZY, Lovatsis D, Gagnon L, Wang S, Huszti E, McDermott CD. "Comparing vitamin B2 versus 5% dextrose in water for optimal ureteric jet visualisation at the time of pelvic reconstructive surgery: a randomised controlled trial." BJOG. 2023;130(6):610–618. doi:10.1111/1471-0528.17363