3.UROLOGIC LABORATORY EXAMINATION (1)

UROLOGIC LABORATORY
EXAMINATION
Sopheap Bou, MD
Urologist (SHCH)
International University 1
Examination of Urine
• Urinalysis (UA) is one of the most important
and useful urologic test available.
• Routine UA as a screen in asympt individuals,
those admitted to hospitals or those
undergoing elective surgery.
• UA is not cost-effective.
• Pt presenting with urinary tract st or sings,
should undergo UA.
Examination of Urine
• If macroscopic UA (dip-strip) is normal,
microscopic UA is not necessary ,
• If the pt has signs or st suggestive of urologic
disease, or dipstick is positive for protein,
heme, leukocyte esterase, or nitrite, a
complete UA, including microscopic
examination of the sediment, should be
completed.
Urine Collection
A-Timing of Collection
Best urine ex has been properly obtained in
the office
First voided morning specimens are helpful
for . Qualitative protein testing (orthostatic
proteinuria)
.specific gravity as a presumptive test of
renal function (minimal renal disease ←
diabetes mellitus or sickle cell anemia or in
those with suspected diabetes
International University
insipidus). 4
B-Method of Collection
-Proper collection of the specimen is
particularly important ( hematuria or proteinuria
or UTI).
-A urine specimen collection in several
containers may help to identify the site of origin
of hematuria or UTI
-The specimen should be obtained before a
genital or rectal examination in order to prevent
contamination.
-A collecting device’s urine ( a condom, chronic
catheter, or intestinal conduit drainage bag), is
not a proper specimen
Internationalfor UA.
University 5
1-Men :
-collect a clean voided midstream urine sample:
a-retraction of the fore skin and cleansing of the
meatus with benzalkonium chloride or
hexachlorophene;
b-passing the 1st part of the stream(15-30ml)
without collection;
c-collecting the next portion (~50-100ml) in a
sterile specimen container, capped immediately
afterward;
1-Men :
d-completely emptying the bladder into the
toilet.
A portion of the specimen is prepare
immediately macro and microscopic exam, the
rest is saved in sterile container for culture.
With this midstream clean-catch method, the
contaminated specimen by meatal or urethral
secretions is decreased.
In adult, it’s rare to collect urine by catherization
unless urinary retention is present or
assessment of residual urine is required.
2-Women :
-The best method for collecting a clean-voided
midstream specimen :
a-lithotomy position.
b-The vulva and urethral meatus are cleansed.
c-The labia are separated.
d-The pt is instructed to initiate voiding into the
container held close to the vulva. After she has
passed the 1st 10-20ml of urine, the next 50-
100ml collected in a sterile container that is
immediately capped .
2-Women :
e-The pt is allowed to complete emptying of the
bladder.
It’s acceptable to have the pt provide an initial
specimen in a non sterile container in the office.
If results of UA are normal, no further study;
If abnormal, a urine specimen must be obtained by the
more exacting technique.
If a satisfactory specimen cannot be obtained :
-suprapubic needle aspiration;
-catheterization (8Fr catheter attached to a centrifuge
tube).
3-Children :
Obtaining a satisfactory urine specimen from
young child can be particularly challenging
-UA : obtain from males or females by covering
the cleansed urethral meatus with a plastic bag.
-culture:
*catherization (not routinely in boy)
*suprapubic needle aspiration (preferable
in either sex).
Macroscopic Examination
A-Color and Appearance :
-generally urine color : a clear light yellow
-phenazopyridine (Pyridium) →the urine
orange;
-rifampin→ yellow-orange;
-nitrofurantoin→ brown;
-L-dopa, α-methyldopa, and metronidazole →
reddish-brown.
*Red urine does not always signify hematuria
A-Color and Appearance
-A red discoloration unassociated with intact
erythrocytes in the urine (←beta-cyanin
excretion after beet ingestion, phenolphthalein
in laxatives, ingestion of vegetable dyes,
concentrated urate excretion, myoglobinuria ←
significant muscle trauma, or hemoglobinuria
following hemolysis).
*Serratia marcescens bacteria→ “red diaper”
sd.
-whenever red urine is seen, hematuria must be
ruled out by microscopic analysis.
A-Color and Appearance
-Claudy urine is commonly thought to
represent pyuria but more often cloudiness←
large amounts of amorphous phosphates
(disappear with the addition of acid, or urates,
which dissolve with the use of alkali).
-The odor of urine is rarely clinically

significant, except that a pungent odor may
indicate that the specimen has been standing
too long to be diagnostically useful.
Simple Urinalysis
• Urine is usually tested using a dipstick, which
measures specific characteristics of the urine.
• The presence of glucosuria suggests diabetes mellitus
or a low renal threshold for glucose, and should be
investigated further with a fasting blood sugar or
formal glucose tolerance test.
*Specific Gravity :
• Normal : (1.003-1.030).
Simple Urinalysis
• Low specific gravity (<1008) suggests chronic
renal failure, high fluid intake, polyuria or
inapropriate antidiuretic hormone (ADH)
secretion.
• High specific gravity (>1020) is caused by
dehydration or administration of intraveinous
constrast medium.
Simple Urinalysis
• Dip testing detects more than five red blood
cells per microlitre. More than 2 blood cells
suggests a high risk of urothelial cancer and
should prompt full investigations.
• Anticoagulation at normal therapeutic levels
does not result in a positive urine test for blood.
• Normal urine pH : (4.5-8.0)
-higher levels (>7.5) suggests the presence of a
urease-splitting organism (Proteus vulgaris).
-pH <4.5 is suggestive
Internationalof high uric acid levels.
University 16
Simple Urinalysis
• Protein levels of more than 0.3g/L are detected
by dipstick. If persistent proteinuria is found,
more detailed quantification is necessary from a
24h urine collection.
* Nitrates and leucocytes in the urine suggest
the presence of infection . The persistence of
leucocytes in sterile urine (sterile pyuria) is
usually due to incompletely treated urinary
infection, urothelial malignancy or stone
disease and only rarely to tuberculosis.
Bacteria and Leukocytes
• Test strips to determine the number of bacteria
(nitrite) or leukocytes (leukocyte esterase) as
predictors of bacteriuria are as accurate as
microscpic sediment analysis in studies using
quantitative urine cultures as the standard.
• The nitrite reductase test depends on the
conversion of nitrate to nitrite.
• Many of bacteria responsible for UTI,
particularly enterobacteria, are capable of
reducing nitrate to nitrite and therefore
detectable by this test.
• When nitrite test is positive , it suggests the

presence of greater than 100,000
organisms/mL.
• Several factor→ false-negative results.
• The nitrite test positive only for coagulase-
splitting bacteria and thus when used alone is
only 40-60% accurate.
• Urine must be in the bladder for sufficient time
prior to sampling for the reduction of nitrate to
occur (>4h); therefore, this test is most likely to
be positive when fist-voided morning urine is
tested.
• A false-negative test will also result if the
bacteria present do not contain nitrate
reductase or if dietery nitrate is absent. A false-
negative nitrate study may occur in a pt tackig
vitamin C.
• The leukocyte esterase test is a widely used
chemical test that depends on the presence of
esterase in granulocystic leukocytes.
• The leukocyte esterase test is an indication of
pyuria and will remain positive even after the
leukocytes have degenerated.
• The test accurately identifies pt with 10-12
leukocytes per high-power field in a centrifuged
specimen.
• While this test is a good indicator of pyuria, it
does not necessary detect bacteriuria.
Therefore, it is often combined with the nitrate
test to detect both bacteriuria and inflammation
to maximize the chances of predicting UTI.
• Used together, the 2 tests are equally as
predictive as the microscopic analysis.
A false-negative leukocyte esterase study

can be caused by glucosuria, or by
phenazopyridine hydrocloride (Pyridium),
nitrofurantoin, vitamin C, or rifampin in the
urine.
Microscopy
• Urine microscopy may show red blood cells,
WBC, epithelial cells, casts, crystals, yeasts,
bacteria and parasitic ova.
• Normal urine : < 3 RBC per high powered field
(HPF).
• Glomerular red cells tend to be large and
dysmorphic, whereas red cells from the lower
urinary tract are usually eumorphic.
• Cellular casts suggest glomerular disease.
Microscopy
• Oxalate, urate and cystine crystals may be
seen in acidic urine (pH<5.5), while phosphate
crystallises in alkaline urine (pH>6.0).
• Significant bacteriuria is defined as five
organisms per HPF and equates to colony
counts of 100 000/mL.
3-container method for Hematuria
• In pt with microscopic hematuria, it can provide
information on the site of origin or erythrocytes
1-give the pt 3 containers, labeled 1,2 and 3 (or
initial, mid, and terminal).
2-instruct the pt to urinate and to collect the
initial portion of the urine stream (10-15ml) in
the first container, the mid portion (30-40ml) in
the second and the final portion (5-10ml) in the
third.
3-container method for Hematuria
• If erythrocytes predominate in
-the initial portion of specimen : from the ant
urethra;
-the terminal portion : from bladder neck or
posterior urethra and
-the presence of equal numbers of
erythrocytes in all 3 containers usually
indicates a source above the bladder neck
( bladder, ureters, or kidneys).
Culture and Sensitivity
• Urine for culture and sensitivity is usually
collected as a midstream or catheter specimen,
but suprapubic aspiration is sometimes used in
infants.
• Urine should be cultured within 1h of production
or refrigerated at 5˚c.
• The presence of >100 000 organisms/ml
confirms a significant urinary infection, whereas
levels of <10 000/mL suggest contamination.
Culture and Sensitivity
• If organisms are cultured from the urine,
Gram stain is performed to identify the
organisms and assess antibiotic sensitivity.
• Yeasts (eg. Candida albicans) may also be
cultured from the urine in susceptible
individuals.
• If tuberculosis is suspected, three early
morning urine samples (EMUs) should be
submitted for culture ( on Lowenstein Jensen
medium) and specific bacteriological staining
(Ziehl-Neelsen).
Biochemistry
Biochemical analysis of the urine is needed in
stone patients.
Persistent proteinuria is an indication for more
detailed quantification in a 24h urine collection.
Cystological Examination
• In suspected urothelial malignancy or in those
patients being followed for transitional cell
tumours, cytological examination of the urine is
essential.
• A freshly voided specimen is collected and
centrifuged to retrieve the cell containing
sediment; the sediment is then resuspended,
treated with Papanicolaou stain and examined
carefully for malignant cells.
Tumour Markers
Special assays are being developed to detect

malignant cells in the urine (eg, bladder tumour
antigen, minichromosome maintenance protein
type 5); such tests are not routinely used and
remain under experimental assessment.
Blood tests
A-Biochemistry :
-Blood tests should be tailored to the individual
patient and to the primary st complex.
-Simple test of renal function (electrolytes, urea
and creatinine) are indicated for most pt, but
are insensitive indications of impaired renal
function.
-Prostate-specific antigen( PSA ) measurement
is indicated in men under the age of 70 years
with lower urinary tract st, and levels should be
interpreted according to age.
Serum Creatinine
Creatinine, the end product of the metabolism of
creatine in skeletal muscle, is normally excreted by the
kidneys. Because daily creatinine production is
amazingly constant, the serum level is a direct
reflection of renal function. Serum creatinine levels
remain within the normal range (0.8-1.2mg/dL in
adults; 0.4-0.8 mg/dL in young children) until
approximately 50% of renal function has been lost.
Unlike most other excretory products, the serum
creatinine level generally is not influenced by dietary
intake or hydration status.
Endogenous Creatinine Clearance
• Because creatinine production is stable and
creatinine is filtered through the glomerulus
(although a small amount is probably
secreted). Its renal clearance is essentially
equal to the glomerular filtration rate.
The endogenous creatinine clearance test
has thus become the most accurate and
reliable measure of renal function available
without resorting to infusion of exogenous
substances such as inulin or radionuclides.
• Determination of creatinine clearance requires
only the collection of a timed ( usually 24-h)
urine specimen and a serum specimen. The
clearance is calculated as follows :
Clearance = UV/P
where: U = creatinine in urine (in mg/dL)
P = creatinine in plasma (in mg/dl)
V = mL of urine excreted (per
minute or 24 h
• The resulting clearance is expressed in
milliliters per minute, with 90-110 mL/min
considered normal.
Because muscle mass differs among
individuals, further standardization has been
achieved by using the following formula:
UV/P = 1.73 m2 /Estimated surface area =

Corrected clearance
A corrected clearance level of 70-140mL/min
is considered normal.
Although creatinine is highly reliable as an
estimate of renal function, values may be
falsely low, particularly if only part of the urine
is collected over the timed period or if a serum
specimen is not collected concurrently.
The creatinine clearance can be predicted quite
accurately from the plasma creatinine
concentration using a formula developed by
Cockcroft and Gault :
Creatinine clearance =(140 – age) x weight in kg
72 x plasma
creatinine
Reduced by :
-15% for women, and spinal cord pt
-20% for paraplegics
-40% for quadriplegics.
Blood Urea Nitrogen (BUN)
• Urea is the primary metabolite of protein
catabolism and is excreted entirely by the
kidneys. The BUN level is therefore related to
the glomerular filtration rate. Unlike creatinine,
however, BUN is influenced by dietary protein
intake, hydration status, and gastrointestinal
bleeding.
• Approximately two-thirds of renal function must
be lost before a significant rise in BUN level
becomes evident. For this reason, an elevated
BUN level is less specific for renal insufficiency.
Blood tests
B-Haematology :
-A full blood count may detect anaemia,
polycythaemia and white cell abnormalities
(eg, leucocytosis). Erythrocyte sedimentation
rate (ESR) is rarely measured routinely but is
helpful in the follow-up of idiopathic
retroperitoneal fibrosis.
-Pt of Afro-Caribbean descent should undergo
screening for sickle cell disease before
anesthesia.
Blood tests
B-Haematology :
-Pt taking anticoagulants or those with clotting
disorders should undergo formal assessment
of their coagulation.
-Blood grouping and cross-matching is
necessary for pt who may require a blood
transfusion for anaemia or during urological
surgery.
Blood tests
C-Serology :
specific serological investigation may be
indicated in pt with STD.
Localisation of Infection
Stamey (1980)localisation for prostatic infection :
In pt with suspected chronic prostatic infection,
a stamey localisation test (fig.3) may help to
characterise the type and site of infection.
Four sterile containers are labeled :
VB1, VB2, EPS, and VB3 (VB= voided bladder
urine; EPS= expressed prostatic secretions).

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UROLOGIC LABORATORY

-The odor of urine is rarely clinically

• When nitrite test is positive , it suggests the

A false-negative leukocyte esterase study

Special assays are being developed to detect

UV/P = 1.73 m2 /Estimated surface area =

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