URINE- GENERAL CHARACTERISTICS.

PHYSICAL EXAMINATION OF URINE.

WHY STUDY URINE?

The purposes of performing a routine urinalysis are (1) to aid in the diagnosis of disease;
(2) to screen for asymptomatic, congenital, or hereditary diseases; (3) to monitor disease
progression; and (4) to monitor therapy effectiveness or complications.
Urine is actually a fluid biopsy of the kidney and provides a "fountain" of information.
The kidney is the only organ with such a non-invasive means by which to directly evaluate its
status. In addition, because urine is an ultrafiltrate of the plasma, it can be used to evaluate and
monitor body homeostasis and many metabolic disease processes.

1. SPECIMEN TYPES
The type of specimen selected and the collection procedure used are determined by the health
care provider and depend on the tests to be performed. The three basic types of urine specimens
are first morning, random, and timed:

FIRST MORNING SPECIMEN

To collect a first morning specimen, the patient voids before going to bed and
immediately on rising from sleep the patient collects a urine specimen. Because this urine
specimen has been retained in the bladder for approximately 8 hours, the specimen is ideal to
test for substances that require concentration or incubation for detection (e.g., nitrites and
protein) and to confirm postural or orthostatic proteinuria. Formed elements such as white
blood cells, red blood cells, and casts are more stable in these concentrated acidic urine
specimens. In addition, these specimens are often ideal for cytological studies because the
number of epithelial cells present can be significant. The morphology of cellular components
and casts actually is enhanced by the high osmolality of first morning specimens.
The first morning urine is usually the most concentrated and is frequently the specimen
of choice, but the specimen must be preserved if it is not going to be analyzed within 2 hours
of collection.
RANDOM URINE SPECIMEN
A urine specimen collected at any time, day or night, without prior patient preparation.
Random specimens are usually satisfactory for routine screening and are capable of detecting
abnormalities indicating a disease process.
TIMED COLLECTION
Because of the circadian or diurnal variation in excretion of many substances and functions
(e.g., hormones, proteins, and glomerular filtration rate) and the effect of exercise, hydration, and
body metabolism on excretion rates, quantitative urine assays often require a timed collection.
These timed collections, usually 12-hour or 24-hour, eliminate the need to determine when excre-
tion is optimal and allow comparison of excretion patterns from day to day. Timed urine
specimens can be divided into two types: those collected for a predetermined length of time (e.g.,
2 hours, 12 hours, 24 hours) and those collected during a specific time of day (e.g., 2 to 4 RM. ).
For example, a 4-hour or 12-hour specimen for the determination of urine albumin, creatinine,
and the albumin-to-creatinine ratio can be collected anytime, and are ideal specimens to screen for
microalbuminuria. In contrast, a 2-hour collection for the determination of urinary urobilinogen
is preferably collected from 2 to 4 P.M., the time when maximal excretion of urobilinogen is known
to occur.

Collection protocol for a 24-hour (timed) urine specimen

!!!Discuss specimen collection procedure with patient, as well as provide him or her with written
instructions.
On Day 1 at the start time (e.g., 8 A.M.), patient empties bladder in the toilet. All subsequent urine is
collected for the next 24 hours in the container provided.
On Day 2 at the end lime (e.g., 8 A.M.), the patient empties bladder and includes this specimen in
the collection.
After transport to the laboratory, the entire specimen is mixed well, and the total volume excreted
is accurately measured and recorded.
 A sufficient aliquot, one that allows for repeal or additional testing, is removed. The remaining
urine may be discarded.

MIDSTREAM CLEAN CATCH

If the possibility of contamination (e.g., from vaginal discharge) exists or if a bacterial
culture is desired, a midstream "clean catch" specimen should be obtained "clean catch"
specimen: a urine specimen obtained after thorough cleansing of the glans penis in the male or the
urethral meatus in the female. Following the cleansing procedure, the patient passes the first
portion of the urine into the toilet, stops and collects the midportion in the specimen container, then
passes any remaining urine into the toilet. Used for routine urinalysis and urine culture, the specimen
is essentially free of contaminants from the genitalia and distal urethra.

2. COLLECTION GUIDELINES STORING

Containers for urine specimen collections must be clean, dry, and made of a clear or
translucent disposable material such as plastic or glass. They should stand upright, have an
opening of at least 4 to 5 cm, and have a capacity of 50 to 100 mL. To eliminate spillage, even if
no transporting of the specimen is necessary, a cover should be provided.
Sterile, individually packaged urine containers are also available from commercial sources for
the collection of specimens for microbial culture. However, if a specimen must be stored for a
period of time before testing (i.e., more than 2 hours), the use of a sterile container is
recommended, regardless of the tests ordered, because of changes that can occur in unpreserved
urine.
Various large containers are available for the collection of 12-hour and 24-hour urine
specimens for quantitative analyses. These containers have a capacity of approximately 3000 mL
and have a wide mouth and a leakproof screw cap.
3. LABELING
All specimen containers must be labelled before or immediately following collection.
Because lids are removed, the patient identification label is always placed directly on the
container holding the specimen. However, the following minimal information should be
provided on all labels: the patient's full name, a unique identification number, the date and
time of collection, the patient's room number (if applicable), and the preservative used, if any.

Changes in Unpreserved Urine

Urine specimens should be delivered to the laboratory immediately after collection. However,
this is not always possible; if delay in specimen transportation is to be 2 hours or greater,
precautions must be taken to preserve the integrity of the specimen, protecting it from the effects
of light and room temperature changes.

1. Physical Changes

Colour Changesdue to oxidation or reduction of substances (e.g., bilirubin to biliverdin,

haemoglobin to methaemoglobin, urobilinogen to urobilin)
Clarity Falsely decreaseddue to bacterial proliferation, solute precipitation
(crystals and amorphous materials). Falsely increaseddue to bacterial proliferation
Odor Decomposition of urea to ammonia.
2. Chemical Changes

pH Falsely increaseddue to bacterial decomposition of urea to ammonia; loss of CO,.

Falsely decreaseddue to bacterial or yeast conversion of glucose to metabolic acids.
Glucose Falsely decreaseddue to cellular or bacterial glycolysis.
Ketones Falsely decreaseddue to bacterial metabolism of acetoacetate to acetone.
Bilirubin Falsely decreaseddue to photooxidation to biliverdin and hydrolysis to free
bilirubin.
Urobilinogen Falsely decreaseddue to oxidation to urobilin.
Nitrite Falsely increaseddue to bacterial production following specimen collection

3. Microscopic Changes

Red blood cells, white blood cells, and casts Falsely decreased- disintegration of cellular and
formed elements, especially in dilute alkaline urine.
Bacteria Falsely increaseddue to bacterial proliferation following specimen collection.

!!!Refrigeration prevents bacterial proliferation, and the specimen remains suitable for culture up
to 24 hours if necessary.
Timed Collections
Timed specimens, particularly 12-hour and 24-hour collections, may require the addition of a
chemical preservative to maintain the integrity of the analyte of interest. Regardless of the
preservative necessary, urine collections should be kept on ice or refrigerated throughout the
duration of the collection. Timed urine collections should be transported to the laboratory as soon
as possible after completion of the collection. The total volume is determined, the specimen is
well mixed to ensure homogeneity, and aliquots are removed for the appropriate tests.

PHYSICAL EXAMINATION OF URINE

URINE VOLUME
Normally for the kidneys to eliminate the average daily load of solutes (600 to 700
mOsm), they produce a minimum urine volume of approximately 500 mL per day.
Normal urine volume varies from approximately 500 to 1800 mL/day.
Anuria (also called anuresis): the absence or cessation of urine excretion. Anuria usually
develops gradually, initially presenting as oliguria in progressive renal diseases. Anuria may
occur suddenly, however, as a result of a dramatic decrease in renal perfusion (e.g., haemorrhage)
or because of sudden extensive renal damage: Acute renal failure, Urinary tract obstruction,
Haemolytic transfusion reactions. Anuria is fatal if not immediately addressed because of the
accumulation of toxic metabolic products in the body.
Nocturia: excessive or increased frequency of urination at night (i.e., the patient excretes greater
than 500 mL per night); can be highly suggestive of chronic progressive renal failure.
Oliguria: a significant decrease in the volume of urine excreted (less than 400
L/day)- urinary obstruction, renal tubular dysfunction, or additional fluid loss can
result in a decrease in the amount of urine produced: shock, hypotension,
dehydration, end-stage renal disease, oedema.
Polyuria: the excretion of large volumes of urine (greater than 3 L/day)- Excessive fluid intake,
diabetes insipidus, diabetes mellitus, renal disease, ADH challenge , drugs (e.g., lithium), diuretic
therapy, caffeine, alcohol.

COLOR
Urine colournormally different shades of yellowcan range from colourless to amber
to orange, red, green, blue, brown, or even black. The specific yellow colour of normal urine is
due to the presence of the pigment urochrome.

Color Terms

Color Constituent Comments

Colorless, Fluid ingestion; polyuria

light yellow Dilute urine

Yellow Normal urine

Amber Concentrated urine (urochrome) Dehydration, fever

Urobilin No yellow foam

Dark Bilirubin Yellow foam if sufficient bilirubin

amber Biliverdin Imparts green hue

Orange Bilirubin Yellow foam if sufficient bilirubin

Urobilin No yellow foam
Medications (most often);
Red Haemoglobin, RBC
Myoglobin Muscle injury
Beets Foods

Pink Hemoglobin
Porphyrins
Brown Haemoglobin
Myoglobin Muscle injury
Methemoglobin Acid pH

Black Melanin On standing; rare

Homogentisic acid On standing; alkaline urine
Green, blue Indican Infections of small intestine
Chlorophyll Breath deodorizers
Pseudomonas s
Dyes and medications;
FOAM
If a normal urine specimen is agitated sufficiently, white foam can be forced to develop at its
surface that readily dissipates on standing. Moderate to large amounts of protein in urine cause
stable white foam to be produced when the urine is poured or agitated.
In contrast, bilirubin, when present in sufficient amounts, causes the foam to become
distinctly yellow.

CLARITY
Clarity describes the transperancy of the specimen. A normal clean catch urine specimen is
ussualy clear when freshly voided.
Clear-- No visible particulate matter present. Normal urine.
Slightly cloudy --Some visual particulate matter is present; newsprint is not obscured when
viewed through urine. Urates, phosphates, other crystals;
Cloudy--Visible particulate matter; newsprint can be viewed through urine but is obscured or
blurred. White blood cells,Red blood cells ("smoky"), Bacteria, yeast, Epithelial cells, Fat (lipids,
chyle)
Turbid Newsprint cannot be viewed through urine. Spermatozoa, Prostatic fluid, Mucus,
mucin, Calculi, Fecal contamination, Radiographic dye

pH
Method: All commercial reagent strips are based on a double-indicator system using
bromthymol blue and methyl red. This indicator combination produces distinctive colour changes
from orange (pH 5.0) to green (pH 7.0) to blue (pH 9.0).
pH Meter- Although the accuracy provided by a pH meter is not usually necessary, a pH meter is
an alternative method for determining the urine pH.

Clinical significance: The kidneys play a major role in regulating the acid-base balance of the
body. Normally, the urine pH varies from 4.5 to 8.0. The average individual excretes slightly
acidic urine of pH 5.0 to 6.0 because endogenous acid production predominates.

Acid Urine- Protein diet, diabetic ketoacidosis, severe diarrhoea, uraemia, respiratory acidosis,
acid-producing bacteria, such as Escherichia coli, chronic renal failure.

Alkaline Urine- Vegetarian diet, low-carbohydrate diet, citrus fruits, metabolic alkalosis
(vomiting), respiratory alkalosis (hyperventilation), urease-producing bacteria, such as Proteus,
Pseudomonas.

SPECIFIC GRAVITY
Specific gravity relates the density of urine to the density of an equal volume of water.
Because specific gravity is a ratio comparing the mass of the solutes present in urine to pure
water, the value for specific gravity always is greater than 1.000. Normal specific gravity values
for urine range from 1.002 to 1.035, reflecting the dilution or concentration of the final urine by
the kidneys. The specific gravity of the initial ultrafiltrate in Bowman's space is 1.010, the same
as that of protein-free plasma.
Therefore when an individual is healthy, the final urine specific gravity, like osmolality, depends
on the volume of water in which the solutes are eliminated, which depends directly on the
individual's fluid intake and state of hydration.
Severe methods are available to determinate the specific gravity in urine and they can be
devided into direct and indirect measurements.
The urinometer is a direct measure of density, whereas refractive index or reagent strip
determinations are indirect measurements. The reagent strip specific gravity method does not
measure the total solute content but only those solutes that are ionic.
-extremely high specific gravity value (i.e., greater than 1.050)-- excretion of a high-
molecular-weight substance, such as x-ray dye or mannitol;
hypersthenuria: the excretion of urine having a specific gravity greater than 1.010.
hyposthenuria: the excretion of urine having a specific gravity less than 1.010.
isosthenuria: the excretion of urine having the same specific gravity (and osmolality) as the plasma.
Because the specific gravity of protein-free plasma and the original ultrafiltrate is 1.010, the
inability to excrete urine with a higher or lower specific gravity indicates significantly impaired
renal tubular function.