Chapter Three

•Physical Examination of Urine

•Introduction
 Physical examination of urine is the first part of routine
urinalysis
 It usually gives hint for the subsequent urinalysis. For
example, white turbid urine sample may suggest to the
technician the presence of leukocytes (pus cells) and/or
Epithelial cells in microscopic examination
 Steps in basic urine analysis
First: physical characteristics of urine are noted and recorded.
Second: series of chemical tests is run.
Third: urine sediment is examined under microscope to identify
the components of sediments.
 Physical Characteristics
• direct visual observation.
• Normal fresh urine: pale or dark yellow clear.
• Vol:750 - 2000 ml/24hr.
• Physical examination involves:
[Link]
[Link]
[Link]
[Link]
[Link]
[Link] gravity
Urine Color
•Volume
 For urine volume measurement, the patient should
collect 24 hr urine specimen.
 Measurement of urine volume is done by using
graduated cylinder and is recorded in terms of
ml/24 hr
•
 AGE VOLUME (ML/24 HR)
New born 20 -- 350
One year 300 – 600
Ten years 750 -- 1500
Adult 750 -- 2000
 Definition of some terms related with urine volume
 Polyuria: Is excess production of urine ( > 2000 mL/24hrs)

 It may result physiologically after consumption of

o intravenous glucose or saline
o coffee, alcohol, tea, caffeine
o pharmacological agent, such as thiazides and other diuretics
 Oliguria: Is insufficient production of urine (< 400mL/24 hrs)
 It may occur due to
o dehydration or poor blood supply to kidney that may be due to
prolonged vomiting, diarrhea,etc
o obstruction of some area of the urinary tract/system
(mechanical)
o cardiac insufficiency
o various renal diseases such as glomerulonephritis, etc
o during fasting
o Excessive salt intake etc.
 Anuria : Complete absence of urine production
 It may occur due to
o complete urinary tract obstruction
o acute renal failure
o acute glomerulonephritis
o hemolytic transfusion reaction, etc
 Odor

• Normal , recently voided urine has a

characteristic aromatic odor
• Changes in urine odor may be due to disease,
diet, or the presence of microorganisms
• Although urine odor is not usually reported on
the urinalysis form, it is a noticeable property
that can alert the technician to possible
abnormalities or improper handling of the urine
specimen
• Old urine specimen, i.e. after collection, left on
the bench without preservative for more than 2
hr, it will have ammonical (pungent) odor. The
ammonical odor is due to bacterial conversion
of urea in the urine into ammonia
  A freshly voided sample of urine with a foul, pungent
odor suggests urinary tract infection (UTI)
 The presence of ketone bodies in the urine, that may be
due to diabetes mellitus, vomiting, starvation, strenuous
exercise, is characterized by “sweet fruity” odor
 Foods such as garlic and asparagus can also produce an
abnormal urine odor

• Although urine odor may be striking in certain

instances, it is not a reliable enough characteristic to
use alone in diagnosing disease
• Foam
 Normal urine produce small amount of white foam.
 But during certain abnormal physiological and metabolic
conditions (such as jaundice) amount of foam increases and
the color becomes yellowish. This is due to the presence of
bilirubin in urine but should not be taken as a confirmatory
test
 It is performed by shaking urine in a container
•. Color
 Normally color of urine may vary with in a day; in the morning it has dark yellow
color, while in the afternoon or evening, the color ranges from light yellow to colorless.
Normal urine color varies from straw (light yellow color) to dark amber (dark yellow)
 Light yellow indicate the urine is more diluted and has low specific gravity.
 Here the exceptional condition is that of diabetic mellitus. In this condition the color of
urine is mostly light yellow, because of high glucose content its specific gravity is
high.
 Dark amber (dark yellow) color mostly indicate that the urine is concentrated and has
high specific gravity
 Normal urine color results from a combination of three pigments:
 Urochrome- responsible for yellow color formation. This pigment found in
high proportion than the other two
 Uroerythrin – responsible for red color formation
 Urobilin – responsible for the orange-yellow color formation.
 Depending up on the constituent of urine, the abnormal color of urine varies as
follows:
o Pale to colorless urine may indicate
 Large fluid intake
 Diabetes mellitus
 Alcohol consumption
 Nervousness

•
 o Dark yellow or Amber urine may indicate
 Concentrated urine
 Decrease fluid consumption
 Dehydration
 Fever
 Certain urinary tract medication (eg. phenazophyridine)
o Orange color may indicate the presence of bilirubin.
o Yellow-green/Yellow-brown

 Bilirubin oxidized to biliverdin

 Colored foam in acidic urine and false-negative chemical
test results for bilirubin
 Pink Red
 RBC (Hematuria) : Cloudy or smoky red urine
 Indicate presence of red blood cell in the urine.
 Positive chemical test results for blood and RBCs visible
microscopically
 Hemoglobin (Hemoglobinuria) : Clear urine with positive chemical test results for

blood; may result from Incompatible blood transfusion

o Increase red blood cell destruction (intravascular
hemolysis) due to different hemo parasites E.g. Malaria,
Glucose – 6 phosphate dehydrogenase deficiency, Certain
infectious diseases
 Myoglobin(Myoglobinuria): Clear urine with positive chemical test results for blood;

urine have low specific gravity than in Hemoglobinuria. Shows muscle damage.
 Brown Black

 RBCs oxidized to methemoglobin: Seen in acidic urine

after standing; positive chemical test result for blood
 Methemoglobin: Denatured hemoglobin
 Melanin or melanogen: Urine darkens on standing
o Milky urine may contain fat, cystine crystals, and
many WBC or amorphous phosphates
•
 Interfering Factors

 An abnormal colour does not necessarily indicate disease.

Variety of food and drugs can cause change in colour.
 Food staffs, such as beets will give white red color.
 Drugs such as Vitamin B12 and riboflavin (Vit B2) give bright yellow

color to urine.
 Rifampicin – gives red color to urine.
 Iron salt gives dark color to urine.
 Sulphonamides and nitrofurantoin will give bright yellow color.
 If urine is not examined within 30 minutes, urobilinogen will be oxidized to
urobilin and thus change urine color to dark yellow
 Appearance (Transparency)

 Fresh urine specimen is normally clear and transparent immediately after voiding

 As the urine reaches room temperature , or after refrigeration, it may become turbid, or cloudy

 Depending on the pH of the urine, this cloudiness may be due to amorphous urates ( acid) or

phosphates( alkaline)

 Turbidity or cloudiness in a freshly voided urine sample may be an indication of disease

 Four common causes of turbid urine are WBCs, RBCs, Epithelial Cells, and bacteria

 Fats or lipids cause urine to appear opalescent ( milky)

 Degree of cloudiness of the urine is described by using common terms, starting by clear to

turbid i.e. clear, hazy, cloudy, very cloudy and turbid

•
 Conditions Affecting the Appearance of
Normal and abnormal urine
Normal urine
Appearance Cause
Clear No visible particles
Hazy Mucous (female) squamous epithelial
cells
Cloudy Calcium oxalate uric acid, amorphous
phosphate and amorphous urate crystals
Abnormal urine
Appearance Cause
Cloudy red Red blood cells
Turbid or cloudy White blood cells, bacteria, renal
epithelial cells and lipids
Opalescent milk Fats and lipids
 . Specific Gravity of Urine

 measures the amount of substances dissolved in urine. also indicates

how well kidneys are able to adjust amount of water in urine. higher SG:
more solid material is dissolved in urine
 When you drink a lot of fluid, your kidneys make urine with a high amount
of water in it which has a low specific gravity. When you do not drink
fluids, your kidneys make urine with a small amount of water in it which
has a high specific gravity.
 The specific gravity of urine indicates the concentration of substances such
as urea, phosphates, chlorides, proteins, and sugars dissolved in the urine
 The specific gravity is an indicator of renal tubular function; it is used to assess the
ability of the kidneys to concentrate or reabsorb essential chemicals and water
 Darker urine samples are usually more concentrated than pale urine samples
 Patients who are dehydrated may have highly concentrated urine with a high
specific gravity
 Specific gravity may be measured with a urinometer, refractometer, or reagent
strip (dipstick method).
 The urinometer method requires 20-50 mL of urine, depending on the size of the
urinometer. The refractometer method requires only a drop of urine. Measuring
specific gravity with a reagent strip is performed with a chemical means
 Specimen should be the first urine passed at the beginning
of the day with the patient having taken no fluid for 10
hours. The testing of random urine specimen has little
clinical value.
 The specific gravity range of normal urine is 1.005-1.030,
with most samples falling between 1.010 and [Link]
gravity is highest in the first morning specimen, which is
usually greater than 1.020
 Calibration-To obtain correct specific gravity readings in urine,
the urinometer must be weighted to read exactly 1.000 in
distilled water. The reading on the urinometer scale should be
exactly 1.000. If it is not, a correction must be applied to all
values obtained for urine specimens with the urinometer. For
Example, Suppose the urinometer reads 1.002 in distilled water.
Therefore the urinometer correction factor 0.002 must be
subtracted from the subsequent relative specific gravity
measurements.
 . pH

 Is a test that determines acidity, neutrality or alkalinity of a solution.

 pH 7 indicate neutrality
 pH < 7 indicate acidity.
 pH > 7 indicate alkalinity.
 Normally, freshly voided urine pH range from 5-7 in healthy individuals, and average is
pH 6
 pH of urine can be measured by using different techniques, such as:
 litmus paper
 nitrazine paper
 Dipstick
 glass electrode
 These different pH measuring techniques are varying in their sensitivity and reading
techniques
  Litmus Paper

 In this technique, pH measurement takes place by using blue and red

litmus paper.
 After dipping the paper, look for a color change.
 If red litmus paper changes to blue, it indicates that the urine is alkaline
 If blue litmus paper changes to red, it indicates that the urine is acidic
 This technique is less sensitive method, because it indicates only the
alkalinity or acidity of urine, it does not tell the exact quantity or figure of
pH
 Nitrazine Paper
 This is also a paper that changes its color from yellow (for
acidic urine) to blue (for alkaline urine). Unlike litmus paper,
the color change is matched with reference color chart, and
based on the value of color change on the reference color
chart; the pH of the urine is recorded
 Reference color chart value range from 3 to 4 (for yellow
color) to pH 9 (that is for deep blue color). The result of urine
pH is usually reported by saying acidic or alkaline and by
indicating the figure.
 Urine dipstick method …To be discussed on chapter 4
 Glass Electrode
 This is very sensitive pH measurement technique. The measurement
is done by using small electronic instrument that has electronic pH
value indicator and glass electrode. This instrument operates on
battery or electricity.
 If urine specimen is left on bench for more than two hours,
bacteria will grow and convert urea into ammonia which makes
urine pH alkaline. Thus, pH should be measured in a fresh urine