Urinalysis

University of Tabuk
Faculty of Medicine
Laboratory medicine module
 Types of Urine Collection Methods
Urine specimens may be collected in a variety of ways according
to the type of specimen required, the collection site and patient
type.
1-Randomly Collected Specimens are not regarded as
specimens of choice because of the potential for dilution of the
specimen when collection occurs soon after the patient has
consumed fluids.
2-First Morning Specimen is the specimen of choice for
urinalysis and microscopic analysis, since the urine is generally
more concentrated.
3-Midstream Clean Catch Specimens are strongly
recommended for microbiological culture and antibiotic
susceptibility testing because of the reduced incidence of cellular
and microbial contamination.
Timed Collection Specimens may be required for quantitative
measurement of certain analytes, including those subject to
diurnal variation. Analytes commonly tested using timed
collection include creatinine, urea, potassium, sodium, uric acid,
cortisol, calcium, citrate, amino acids, catecholamines.

Collection from Catheters (e.g. Foley catheter)using a syringe,

followed by transfer to a specimen tube or cup. Alternatively,
urine can be drawn directly from the catheter to an evacuated
tube using an appropriate adaptor.
Supra-pubic Aspiration may be necessary when a non-
ambulatory patient cannot be catheterized or where there are
concerns about obtaining a sterile specimen by conventional
means.

Pediatric Specimens present many challenges. For infants and

small children, a special urine collection bag can be adhered to
the skin surrounding the urethral area .
 Preservatives for 24 Hour Specimens
Urine should be analysed as rapidly as possible
• ideally within 30 minutes.
• If not possible:
– it should be refrigerated immediately and stored for
preferably no more than 6–12 hours after collection.
– Refrigerated urine should be brought to room
temperature and thoroughly mixed before analysis
– Urine should not be frozen if sediment analysis is to be
performed.
• When a preservative is required, it should be
added to the collection container before the urine
collection begins. Commonly used preservatives
for 24 hour specimens are hydrochloric acid,
boric acid, acetic acid, thymol and toluene.
Urine Specimen Reception in the Laboratory

• In addition to routine checks and precautions

taken for all specimens received in the clinical
laboratory, the following additional ‘check
items’ apply to urine specimens.
• Labels
• Volume
• Collection Date and Time
• Collection Method
• Specimen Preservation
• Light Protection
 Why urinalysis?
• General evaluation of health
• Diagnosis of disease or disorders of the kidneys
or urinary tract
• Diagnosis of other systemic disease that
affect kidney function

• Monitoring of patients with diabetes

 What is urinalysis?
• urinalysis is a group of manual and/or automated
qualitative and semi-quantitative tests performed on
a urine sample.

• A routine urinalysis usually includes the following :

• physical examination.
• Chemical examination.
• Microscopic examination.
• urinalysis (UA), also known as Routine and
Microscopy (R&M), is an array of tests performed
on urine, and one of the most common methods of
medical diagnosis.
  Normal- 1-2.5 L/day
Volume  Oliguria- Urine Output < 400ml/day
Seen in:
– Dehydration
– Shock
– Acute glomerulonephritis
– Renal Failure

 Polyuria- Urine Output > 2.5 L/day

Seen in:
– Increased water ingestion
– Diabetes mellitus and insipidus.

 Anuria- Urine output < 100ml/day

Seen in: renal shut down Volume
  Normal- pale yellow in color due to
Color pigments urochrome, urobilin and
uroerythrin.

 Color of urine depending upon it’s

constituents

1-Colorless………..Very dilute urine

Polyuria,diabetes

2.Yellow orange(high colored)--

Concentrated urine
Excess urobilin ,Bile pigments ,Intake of
carrots
 3-Red
Hemoglobin, RBC ,Menstrual
contamination
4.Cloudy
Pus cells bacteria,yeast,spermatozoa

5. Brown black
- Methemoglobin ,alkaptonuria ,Melanin

6-Milky…………Fat

yellowish green :
Due to excretion of bile in urine ,
e.g : Jaundice
 Turbidity  normal urine……clear.

 Turbidity in urine may be due to:

a. amorphous phosphate and
carbonates
b. crystals, cellular exudates,
bacteria and fungus
c. fat
d. pus
Odor
Normal - aromatic due to the volatile fatty
acids

• On long standing – ammonical

(decomposition of urea forming ammonia
which gives a strong ammonical smell)

• Foul, offensive ….. pus or inflammation

• Sweet …. Diabetes
• Fruity ….. Ketonuria
• Maple syrup-like ….. Maple Syrup Urine
Disease
• Rancid - Tyrosinaemia Odour
 • Reflects ability of kidney to maintain normal
pH hydrogen ion concentration in plasma & ECF

• Urine pH ranges from 4.5 to 8

• Normally it is slightly acidic lying between… (6 –
6.5)

PROCEDURE : Dip the litmus paper strips in the

urine, remove and read the color
change immediately.

Blue litmus turns red – acid

Red litmus turns blue – alkaline
 Decrease in pH Increase in pH
Respiratory acidosis Respiratory alkalosis

Metabolic acidosis Metabolic alkalosis

Severe diarrhoea Vomiting

Starvation UTI caused by Proteus

and Pseudomonas
UTI caused by E.coli
 SPECIFIC GRAVITY
It is measurement of urine density which reflects the ability of the
kidney to concentrate or dilute the urine relative to the plasma
from which it is filtered.
• Measured by:
– urinometer
– refractometer
– dipsticks
Range of 24 hour sample( 1.015- 1.025)
Hyposthenuria
- Consistently low specific gravity <1.007.
-Due to concentration problem.

Hypersthenuria
- Consistently high specific gravity
- Due to deprivation of water.

Isosthenuria
- Fixed specific gravity of 1.010
- Indicates poor tubular reabsorption
 Increased specific Decreased specific
gravity gravity

- Diabetes mellitus -Pyelonephritis

- Dehydration - Hypertension
- Proteinuria - Polydipsia
- Glycosuria - Diabetes insipidus
- Lipoid nephrosis - Diuretics
 2-Chemical examination of urine
A urine test strip can quantify
parameters such as:
Leukocytes – with presence in urine
known as leukocyturia
Nitrite – with presence in urine known
as Nitrituria
Protein – with presence in urine known
as Proteinuria also see Albuminuria and
Microalbuminuria
Blood – with presence in urine known
as Hematuria
specific gravity
pH.
Glucose.
Proteins: sulfosalicylic acid detects total proteins ,some
radio-opaque dyes ,κ and λ light chains.
Dip stick :detect albumin only .
Bence Jones proteins (acid/heat precipitation at 56 ċ .
Immunofixation detect κ and λ light chains.
• Glucose
1. Clinitest tablets :detects reducing substances such as
glucose, galactose, fructose, lactose, pentose, ascorbic
acid, salicylates, homogentisic acid.
(NOTE: sucrose is not a reducing sugar)

2. Dipsticks :specifically detect glucose with glucose

oxidase reaction; (NOTE: Reducing agents such as
ascorbic acid can quench reaction giving a false
negative result)
Ketone bodies
1. Dipsticks or reagent tablets (acetone, acetoacetate, NOT β-
hydroxybutyrate)

Heme proteins (Hemoglobin, occult blood; Myoglobin)

1. Guaiac test, modified
2. Dipsticks (NOTE: Reducing agents such as ascorbic acid can
quench reaction giving a false negative result. Also, at urine pH
below 6.0, red cells are not lysed, and a false negative test may
result.)

Bilirubin (Direct or conjugated bilirubin)

1. Dipsticks or reagent tablets

Urobilinogen
1. Dipsticks
 3-Microscopic examination of urine

• A microscopic examination may or may not be

performed as part of a routine urinalysis.
• When there are abnormal findings on the
physical or chemical examination.
• It is performed on urine sediment – urine that
has been centrifuged to concentrate the
substances in it at the bottom of a tube.
 3-Microscopic examination of urine
• Urine Sediment
• Casts. ―Imprints of renal tubules; examine and count
under LPF
• Cells (erythrocytes; leukocytes; squamous epithelial
cells – urethra, vagina; transitional epithelial cells –
bladder; renal tubular cells, etc.). Examine and count
under HPF.
• Crystals
• Bacteria ,Yeast
• Artifacts (e.g., glass, dust, pollen, starch granules, hair,
oil, plant fibers)
• Urine Casts
formed in two ways,
A. by precipitation and gelling of proteins in
tubular fluid.
B.by clumping of cells in tubules.
The matrix of all casts is a specific mucoprotein
common to all casts, namely Tamm-Horsfall
protein.
• The classification of casts is based on
appearance.
• physical properties.
• type of cellular components.
 Casts
Stained Granular casts

Hyaline cast Granular casts

Stained waxy cast

waxy cast

Cellular cast
Stained Cellular cast
Types of urine casts
.
1. Hyaline casts. consist only of Tamm-Horsfall protein.
They are excreted by the normal kidney in small amounts.
Excretion of numerous casts is seen in all renal diseases.
2. WBCs casts: The number of WBCs in urine sediment is
normally low (1-4 WBCs/HPF)

The presence of >5 WBC/HPF = significant pyuria

When the number is high, it indicates an infection, damage

or inflammation somewhere in the urinary tract
.3. Red cell (erythrocyte) casts. Presence of these casts
indicates severe injury to the glomerular basement
membrane.
These casts are associated with
 acute glomerulonephritis (most common),
 lupus nephritis,
 Goodpasture’s Syndrome,
 subacute bacterial endocarditis.
• 4-Renal epithelial casts. Their presence points
to a pathological process affecting the tubular
portion of the nephron (tubular damage).
Epithelial casts are associated with exposure to
nephrotoxic agents and exposure to viruses.
• 5-. Granular casts. formed from breakdown
products of cellular casts and
immunoglobulins.
• 6. Waxy casts. they are associated with severe
chronic renal disease and amyloidosis.
• 7. Fatty casts. These casts are due to leakage of
lipoproteins through the glomerulus (seen in
nephrotic syndrome, diabetes mellitus, and with
damaged renal epithelial cells).
• 8. Mixed cell casts.
Crystal Appearance Urine pH

Calcium oxalates "Envelopes" acid

Sodium urates "Whetstones" acid

Triple phosphates(magnesium ammonium phosphate) "Coffin lids" alkaline

Ammoniumbiurates "Thorn apples" alkaline

Amorphous phosphates Amorphous debris alkaline

Tyrosine Needles in rosettes acid

Sulfonamides Sheaves acid

Cystine Hexagons acid

 Acidic Alkaline
Crystals Crystals

-Cystine Crystals -Amorphous Phosphates

-Bilirubin Crystals -Triple Phosphate Crystals

-Calcium Oxalate Crystals -Calcium Phosphate Crystals
- Uric Acid Crystals -Ammonium Biurate Crystals
- Amorphouse Urates -Calcium Carbonate
Tyrosine Crystals
• Microorganisms:
• Include: bacteria, trichomonads, yeast.
• -In health, the urinary tract is sterile: No microorganisms.

• -Presence indicates …..infection.

• -Microorganisms found may be from specimen contamination:

– From bacteria that normally live on the skin or in vaginal
secretions (most often women).

• -Yeast can also be present in urine and are more common in women
due to a vaginal yeast infection.
SPECIAL URINE CHEMISTRY: BIOCHEMISTRY OF
URINALYSIS
• Hemoglobin and Myoglobin
• Both are heme-containing proteins and have peroxidase
properties,they react with Hemastix and Labstix for
blood.‖
• The following methods are most common

• 1. Ammonium sulfate precipitation tests (not sensitive).

• 2. Spectrophotometric methods
• 3. Immunoassay methods
• 4. Ultrafiltration methods
• 5. Combinations of the above
• Myoglobinuria is seen in:
• 1. Crushing injuries
• 2. Electrocution
• 3. Clostridium welchii (C. perfringens) infections
• 4. Necrosis of muscle due to sustained pressure
(rhabdomyolysis)
• 5. Strenuous exercise
• 6. Certain genetic defects
Bilirubin
Urine is orange-green . Only water-soluble bilirubin,
conjugated with glucuronic acid is excreted into the
urine.
Bilirubin is found in the urine in:
1. Obstruction of biliary system
2. Hepatocellular damage

Urinary bilirubin is important in early detection of

jaundice and differential diagnosis of jaundice
Urobilinogen
It is formed by action of bacteria on conjugated bilirubin
in the gut. Subsequently it is partially reabsorbed and
excreted by the liver and kidney.
Increased in:
1. Hemolytic anemia
2. Early parenchymal liver disease

Decreased in:
Obstruction of extrahepatic bile ducts (particularly in
carcinoma of head of pancreas).
If the stool is chalky white, as in complete obstruction, no
urobilin (stercobilin) is present
• Hemosiderin
• Found as free granules or in epithelial cells,
macrophages and casts .
• Test: Prussian blue reaction on sediment
• Found in:
• Conditions of prolonged hemoglobinuria or
myoglobinuria
• Pernicious anemia, chronic hemolytic anemia,
multiple transfusions, paroxysmal nocturnal
hemoglobinuria, hemochromatosis.