Urine Examination

Kholoud Essokni

Baca- Laboratory Medical , Mas- Bio Medical , Dip-

Infection Control
Introduct
ion to
Urinalysis
 1- What is the specimen of choice for routine
urinalysis?
 A. Fasting specimen
 B. First morning specimen
 C. Random specimen
 D. 24-Hour specimen
 2- Three types of urine specimens that would be
acceptable? for culture to diagnose a bladder
infection include all of the following except:
 A. Catheterized
 B. Midstream clean-catch
 C. Random
 D. Suprapubic aspiration
 3- A negative urine pregnancy test
performed on a random specimen may
need to be repeated using a:
 A. Clean-catch specimen
 B. Fasting specimen
 C. First morning specimen
 D. 24-Hour specimen
 4-What three changes will affect the results of the
microscopic examination of urine if it is not tested
within 2 hours?

 A. Decreased bacteria, decreased red blood cells,

 decreased casts
 B. Increased bacteria, increased red blood cells,
 increased casts
 C. Increased bacteria, decreased red blood cells,
 decreased casts
 D. Decreased bacteria, increased red blood cells,
 increased casts
 5- What type of urine specimen should be collected
from a patient who complains of painful urination
and the physician has ordered a routine urinalysis
and urine culture?
 A. Random
 B. First morning
 C. Fasting
 D. Midstream clean-catch
Urine Composition
 In general, urine consists of urea and other
organic and inorganic
 chemicals dissolved in water. Urine is normally
95%
 water and 5% solutes, although considerable
variations in the
 concentrations of these solutes can occur
owing to the influence of factors such as
dietary intake, physical activity, body
metabolism, endocrine functions, and even
body position.
 Urea, a metabolic waste product produced in the
liver from the breakdown of protein and amino
acids, accounts for
 nearly half of the total dissolved solids in urine. Other
organic :
 substances include primarily creatinine and uric
acid.
 The major inorganic solid dissolved in urine is
chloride, followed by sodium and potassium.
 theurine also may contain formed elements, such
as cells, casts, crystals, mucus, and bacteria.

 Increased amounts of these formed elements are

often indicative of disease.
Urine Volume
 Urine volume depends on the amount of water that the kidneys
excrete.
 Water is a major body constituent; therefore, the amount excreted
is usually determined by the body’s state of hydration.

 Factors that influence urine volume include fluid intake, fluid loss
from nonrenal sources, variations inthe secretion of antidiuretic
hormone, and need to excrete
 increased amounts of dissolved solids, such as glucose or salts.

 Taking these factors into consideration, although the normal daily

urine output is usually 1200 to 1500 mL, arange of 600 to 2000 mL is
considered normal.
 Diabetes mellitus and diabetes insipidus produce
polyuria (an increase in daily urine volume (greater
than 2.5 L/day)
 in adults and 2.5–3 mL/kg/day in children), is often
associatedwith diabetes mellitus and diabetes
insipidus; however,

 itmay be artificially induced by diuretics, caffeine,

or alcohol, all of which suppress the secretion of
antidiuretic hormone.
 analysis of the urine is an important step in the
differential diagnosis Diabetes mellitus is caused by
a defect either in the pancreatic production of
insulin or in the function of insulin, which results in an
increased body glucose concentration.
 a urine specimen from a patient with diabetes
mellitus has a high specific gravity because of the
increased glucose content
 Diabetes insipidus results from a decrease in the
production or function of antidiuretic hormone;
thus, the waternecessary for adequate body
hydration is not reabsorbed fromthe plasma filtrate.
In this condition, the urine is truly dilute and has a
low specific gravity
 Specimen Collection:
 The recommended capacity of the container is
50 mL, which allows 12 mL of specimen needed
for microscopic analysis, additional specimen for
repeat analysis.
 Sterile containers are also suggested if more than 2
hours elapse between specimen collection and
analysis.
Types of Specimens
 Random Specimen ( R/E ) :
 This is the most commonly received
specimen because of its ease of
collection , its ease of collection
 random specimen is useful for routine
screening tests to detectobvious
abnormalities.
First Morning Specimen
 Itis essential for preventing false-negative
pregnancy tests and for
 evaluating orthostatic proteinuria. The first
morning specimen, or 8-hour specimen, is
a concentrated specimen, thereby

 assuring detection of chemicals and

formed elements that maynot be present
in a dilute random specimen
Fasting Specimen (Second
Morning)
 differsfrom a first morning specimen
bybeing the second voided specimen
after a period of fasting.
 This specimen will not contain any
metabolites from foodingested before the
beginning of the fasting period. It is
recommended for glucose monitoring.
2-Hour Postprandial Specimen
 The patient is instructed to void shortly
before consuminga routine meal and to
collect a specimen 2 hours after eating.
 The specimen is tested for glucose, and
the results are used primarily for
monitoring insulin therapy in persons with
diabetes mellitus.


Glucose Tolerance Specimens
 are sometimes collectedto correspond
with the blood samples drawn during a
glucose tolerance test (GTT).
 The number of specimens varies with the
length of the test. GTTs may include
fasting, halfhour, 1-hour, 2-hour, and 3-
hour specimens, and possibly4-hour, 5-
hour, and 6-hour specimens. The urine is
tested for glucose and ketones,
24-Hour (or Timed) Specimen
A carefully timed specimen must be used
to produce accurate quantitative results
 On its arrival in the laboratory, a 24-hour
specimen must be thoroughly mixed and
the volume accurately measured and
recorded.
Catheterized Specimen
 Thisspecimen is collected under sterile
conditions by passing a hollow tube
(catheter) through the urethra into the
bladder.

 The most commonly requested test on a

catheterized specimen is a bacterial
culture.
Midstream Clean-Catch
Specimen
 Asan alternative to the catheterized
specimen, the midstream clean-catch
specimen provides a safer, less traumatic
method for obtaining urine for bacterial
culture and routine urinalysis.
Pediatric Specimen
 Collection of pediatric specimens can
present a challenge.
 Soft, clear plastic bags with
hypoallergenic skin adhesive to attach to
the genital area of both boys and girls are
available for collecting routine
specimens.
Physical
Examination
of Urine
1- The concentration of a normal urine specimen can
be estimated by which of the following?

 A. Color
 B. Clarity
 C. Foam
 D. Odor
 2- Specimens from patients receiving
treatment for urinary tract infections
frequently appear:
 A. Clear and red
 B. Viscous and orange
 C. Dilute and pale yellow
 D. Cloudy and red
 3- Microscopic examination of a clear urine
that produces a pink precipitate after
refrigeration will show:
A. Amorphous urates
 B. Porphyrins
 C. Red blood cells
 D. Triple phosphate crystals
Color :
 The color of urine varies from almost
colorless to black.
 These variations may be due to normal
metabolic functions, physical activity,
ingested materials, or pathologic
conditions.
Urine specimens of varying
color.
Normal Urine Color:
 Common descriptions include pale
yellow, yellow, dark yellow, and amber.
 Care should be taken to examine the
specimen under a good light source,
looking down through the container
against a white background.
Abnormal Urine Color
 Dark Yellow/Amber/Orange:
 Dark yellow or amber urine may not
always signify a normal concentrated
urine but can be caused by the presence
of the abnormal pigment bilirubin.
 If bilirubin is present, it will be detected
during the chemical examination;
 Normal urine produces only a small amount of
rapidly disappearing foam when shaken,
 large amount of white foam indicates an increased
concentration of protein.
 A urine specimen that contains bilirubin may also
contain hepatitis virus.
 The photo-oxidation of large amounts of excreted
urobilinogen to urobilin also produces a yellow-
orange
 Photo-oxidation of bilirubin imparts a yellow-green
color to the urine.
Red/Pink/Brown
 Red is the usual color that blood produces
in urine, but the color may range from
pink to brown, depending on the amount
of blood, the pH of the urine, and the
length of contact.
 A fresh brown urine containing blood may
also indicate glomerular bleeding
resulting from the conversion of
hemoglobin to methemoglobin
Clarity :
 Clarity is a general term that refers to the
transparency/turbidity of a urine specimen.
 Common terminology used to report clarity
includes clear, hazy, cloudy, turbid, and milky.
 Normal Clarity:
 Freshly voided normal urine is usually clear,
particularly if it is a midstream clean-catch
specimen. Precipitation of amorphous
phosphates and carbonates may cause a
white cloudiness.
 Nonpathologic Turbidity :
 Thepresence of squamous epithelial cells and
mucus, particularly in specimens from women, can
result in a hazy but normal urine .
Pathologic Causes
of Urine Turbidity
 RBCs
 WBCs
 Bacteria
 Yeast
 Nonsquamous epithelial cells
 Abnormal crystals
 Lymph fluid
 Lipids
Nonpathologic Causes
of Urine Turbidity
 Squamous epithelial cells
 Mucus
 Amorphous phosphates, carbonates, urates
 Semen, spermatozoa
 Fecal contamination
 Radiographic contrast media
 Talcum powder
 Vaginal creams
Specific Gravity
 Specificgravity is defined as the density
of a solution.
Chemical Examination
of Urine
 1-Screening tests for urinary infection
combine the leukocyte esterase test with
the test for:
 A. pH
 B. Nitrite
 C. Protein
 D. Blood
Reagent Strips
 Routine chemical examination of urine has
changed dramatically since the early days of
urine testing, owing to the development of
the reagent strip method for chemical
analysis.

 Reagent strips currently provide a simple,

rapid means for performing medically
significant chemical analysis of urine,
including pH, protein, glucose, ketones,
blood, bilirubin, urobilinogen, nitrite,
leukocytes, and specific gravity.
 Reagent Strip Technique:
 Testingmethodology includes dipping the reagent
strip completely, but briefly, into a well-mixed
specimen, removing excess urine from the strip by
running the edge of the strip on the container when
withdrawing it from the specimen, waiting the
specified length of time for reactions to take place,
and comparing the colored reactions against the
manufacturer ’s chart using a good light source.
pH:

A healthy individual usually produces a

first morning specimen with a slightly
acidic pH of 5.0 to 6.0; amore alkaline pH
is found following meals
 The pH of normal random samples can
range from 4.5 to 8.0.
Clinical Significance:
 In respiratory or metabolic acidosis not
relatedto renal function disorders, the
urine is acidic; conversely, if respiratory or
metabolic alkalosis is present, the urine is
alkaline.
Causes of Acid and
Alkaline Urine

 Acid Urine:
 Emphysema , Diabetes mellitus ,
Starvation , Dehydration , Diarrhea ,
Presence of acid-producing bacteria
(Escherichia coli) , High-protein diet ,
Cranberry juice , Medications
Alkaline Urine :
 Hyperventilation , Vomiting , Renal tubular
acidosis , Presence of ureaseproducing
 Bacteria , Vegetarian diet , Old
specimens .
Protein:
 Ofthe routine chemical tests performed
on urine, the most indicative of renal
disease is the protein determination. The
presence of proteinuria is often
associated with early renal disease,
making the urinary protein test an
important part of any physical
examination.
Glucose:
 Because of its value in the detection and
monitoring of diabetesmellitus, the
glucose test is the most frequent chemical
analysis performed on urine

.
Ketones:
 Normally,
measurable amounts of ketones
do not appear in the urine, because all
the metabolizedfat is completely broken
down into carbon dioxide and water.
Blood:
 Blood may be present in the urine either in
the form of intact Blood may be present in
the urine either in the form of intact red
blood cells (hematuria) or as the product
of red blood cell destruction, hemoglobin
(hemoglobinuria).
 blood present in large quantities can be
detected visually; hematuria produces a
cloudy red urine, and hemoglobinuria
appears as a clear red specimen
 any amount of blood greater than five
cells per microliter of urine is considered
clinically significant,
 Urine Bilirubin and
Urobilinogen in Jaundice
Urine Bilirubin Urine
Urobilinogen
Bile duct +++ Normal
obstruction
Liver damage + or - ++
Hemolytic Negative +++
disease
 Clinical Significance
of Urine Urobilinogen
 1. Early detection of liver disease
 2. Liver disorders, hepatitis, cirrhosis, carcinoma
 3. Hemolytic disorders
Nitrite:
 Thereagent strip test for nitrite provides a
rapid screening test for the presence of
urinary tract infection (UTI).
Clinical Significance
of Urine Nitrite
 1. Cystitis
 2. Pyelonephritis
 3. Evaluation of antibiotic therapy
 4. Monitoring of patients at high risk for
urinary tract infection
 5. Screening of urine culture specimens
Leukocyte Esterase:
 Prior to the development of the reagent
strip leukocyte esterase (LE) test,
detection of increased urinary leukocytes
required microscopic examination of the
urine sediment
Clinical Significance
of Urine Leukocytes
 1. Bacterial and nonbacterial urinary tract
infection
 2. Inflammation of the urinary tract
 3. Screening of urine culture specimens
Specific Gravity:
 1. Monitoring patient hydration and
dehydration
 2. Loss of renal tubular concentrating
ability
 3. Diabetes insipidus
 4. Determination of unsatisfactory
specimens due to low
 concentration
Microscopic
Examination of Urine
 Red Blood Cells: Normal RBCs
Air bubble:
 Yeast. The presence of budding forms aid in
distinguishing
 from RBCs
 Dysmorphic RBCs:
 epithelial cells and oil droplets
 RBCs and one WBC:
White Blood Cells:
 WBCs are larger than RBCs, measuring an
average of about 12 mm in diameter The
predominant WBC found in the urine
sediment is the neutrophil. Neutrophils are
much easier to identify than RBCs
because they contain granules and
multilobed nuclei
 WBCs. Notice the multilobed nucleoli:
 WBC clump:
Epithelial Cells:
 Itis not unusual to find epithelial cells in
the urine, because they are derived from
the linings of the genitourinary system.
 Unless they are present in large numbers
or in abnormal forms, they represent
normal sloughing of old cells.
 Three types of epithelial cells are seen in
urine: squamous, transitional
 (urothelial), and renal tubular
 Phenazopyridine-stained sediment showing
squamous epithelial cells :
 Squamous epithelial cells identifiable:
 Clump of squamous epithelial cells:
Squamous epithelial cells
 are easily recognized as large, flat,
irregularly shaped cells. They contain small
central nuclei and abundant cytoplasm
 Transitional cell (A), Renal
epithelial cells (B) and WBCs
(C)
A
B

C
Transitional Epithelial Cells
 are two to four times as large as white
cells. They may be round, pear-shaped
 these cells may contain two nuclei.
Transitional cells line the urinary tract from
the pelvis of the kidney to the upper
portion of the urethra.
demonstrates the size of a
transitional cell :
Renal tubular epithelial cells
 are slightly larger than leukocytes and
contain a large round nucleus.
 Increased numbers of tubular epithelial
cells suggest tubular damage.
ACIDIC URINE
 Those crystals which are frequently found
in acidic urine are uric acid, calcium
oxalate, and amorphous urates
Uric Acid Crystals:
 crystals can occur in many different
shapes, but the most characteristic forms
are the diamond , which consists of many
crystals clustered together.
 The presence of uric acid crystals in the
urine can be anormal occurrence.
Uric Acid Crystals:
Uric Acid Diamond
Uric acid crystals in rosette
formation
Six-sided uric acid crystal
Calcium Oxalate Crystals:
 crystals are colorless octahedral or
“envelope”- shaped crystals which look like
small squares crossed by intersecting
diagonal lines

 Calcium oxalate crystals can be present

normally in theurine especially after the
ingestion of various oxalate-richfood such as
tomatoes, spinach, rhubarb, garlic, oranges,
and asparagus
 Increased amounts of calcium oxalates
numbers include ethylene glycol
poisoning, diabetes mellitus, liver disease,
and severe chronic renal disease.
Calcium Oxalate
Calcium oxalate crystals
Calcium oxalate crystals. The “X”
of
each crystal is very prominent
Amorphous Urates
 Urate salts of sodium, potassium,
magnesium, and calcium are frequently
present in the urine in a non crystalline,
amorphous form. These amorphous urates
have ayellow–red granular appearance
 Amorphous urates have no clinical
significance.
Amorphous urates
Sodium Urates
 may be present as amorphous or cryst
forms Sodium urate crystals are colorless
or yellowish needles or slender prisms
occurring in sheaves or clusters.alline
 Sodium urates have no clinical
significance.
 Sodium urate crystals. These
needlelike
crystals are not pointed at the ends
Sulfonamide crystals, yeast, and WBCs. This
photograph demonstrates two typical formations of
sulfa crystals: the fan or sheaf formation and sheaves
with eccentric bindings
Cholesterol crystal with typical
notched
edges :
X-ray dye crystals
Cystine crystal
Bilirubin crystals
tyrosine crystals
ALKALINE URINE
 Those crystals which can be found in
alkaline urine include triple phosphates
(ammonium magnesium phosphates),
amorphous phosphates, calcium
carbonate, calcium phosphate, and
ammonium biurets, also called
ammonium urates
Triple Phosphates
 Triple phosphate crystals are colorless
prisms with from three to six sides that
frequently have oblique ends
 Pathologic conditions in which they may
be found include chronic pyelitis, chronic
cystitis, enlarged prostate, and when the
urine is retained in the bladder
Amorphous Phosphates
 These granular particles have no definite
shape and they are usually visibly
indistinguishable from amorphous urates.
The pH of the urine helps distinguish
between these two amorphous deposits
Calcium carbonate
 Calcium carbonate crystals are larger than
amorphous and, when in clumps, they may
 appear to have a dark color. The mass of
calcium carbonate crystals, as opposed to a
clump of amorphous phosphates, will also be
connected together around the edges.
 Calcium carbonate crystals have no clinical
significance
Calcium Phosphate
 Calcium phosphate crystals may also
form large, thin, irregular plates that may
float on the surface of the urine
Calcium phosphate plate or
phosphate
sheath
Ammonium biurate
 Ammoniumbiurates are yellow–brown
spherical bodies with long, irregular
spicules
Ammonium biurate crystals
without spicules
Casts
Hyaline casts
 are the most frequently occurring casts in the
urine.
 protein and may contain some inclusions
which were incorporated while in the kidney
 Since they are composed of only protein,
they have a very low refractive index and
 must be viewed under low light. They are
colorless, homogeneous,
 and transparent, and usually have rounded
ends
 Hyaline casts can be seen in even the
mildest kind of renal disease and are not
associated with any one disease
 in particular. A few hyaline casts may be
found in the normal urine, and increased
amounts are frequently present following
physical exercise and physiologic
dehydration.
RED BLOOD CELL CASTS
 mean renal hematuria and they are
always pathologic. They are usually
diagnostic of glomerular disease being
found in acute glomerulonephritis
White blood cell casts
 are
present in renal infection and in
noninfectious inflammation.
GRANULAR CASTS
 Granular casts almost always indicate
significant renal disease
 granular casts may be present in the urine
for a short time following strenuous
exercise
 Determining whether a cast is coarsely or
finely granular is of no clinical significance,
although the distinction is not hard to
make.
EPITHELIAL CELL CASTS
 form as the result of stasis and the
desquamation of renal tubular epithelial
cells. These casts are only rarely seen in
the urine because of the infrequent
occurrence of renal diseases which
primarily affect the tubules (necrosis)
 Epithelialcell casts may be present in
urine after exposure to nephrotoxic
agents or viruses
BACTERIA
 The urine is normally free of bacteria while
in the kidney and bladder, but
contamination may occur from bacteria
present in the urethra or vagina, or from
other external
sources.
 Some bacteria reduce nitrate to nitrite,
allowing for the detection of bacteria by
chemical methods. However, not all
pathogenic bacteria are nitrate reducers.
In addition, conditions exist which
influence the presence of nitrites. The
presence of leukocytes may provide
more accurate correlation with bacterial
infection than does
nitrite.
MUCOUS
 are long, thin, wavy threads of ribbon like
structures which may show faint
longitudinal striations
 Mucous threads are present in normal
urine in
 small numbers, but they may be very
abundant in the presence of
inflammation or irritation of the urinary
tract