Unit 5: Urine Analysis

• Urinalysis gives a semi quantitative estimate of the renal function

and clues to the etiology of renal dysfunction.
• Urine is a fluid extracted by the kidneys, pass through the ureters,
stored in the bladder and discharged through the urethra
• Freshly voided urine from healthy individuals is clear and pale
yellow in color
• Having aromatic odor from volatile organic acids, and specific
gravity about 1.024
• It normal pH is slightly acidic (pH 5.0 to 6.0) and contains 95 %
water 1
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• In the presence of disease conditions, depending on the
abnormality, the urine will have abnormal constituents.
• The standard urinalysis panel includes:
 Physical examination of urine

- e.g. Color, odor, SG, pH, foam, volume----

 Chemical examination of urine

- e.g. Glucose, protein-----

 Microscopic examination of urine

- e.g. Cells ( WBC, RBC, .parasites, yeast-----) and

crystals 3
 Specimen collection
• The type of the urine specimen depends on type of the test to be made.
Single random specimen- - a specemen obtained at any time during examination.
Preferable for:-
 Chemical Screen
 Microscopic examination

 Morning specimen- concentrated and preferred for most of urine tests

 Mid stream of clean catch specimen- avoid bacterial contamiation of urine during
sample collection. used for microbial culture and routine urinalysis.
 24- Hour specimen - obtained within 24 hours.
Necessary for quantitative tests, especially for quantitative determination of
protein.
 Catheterized specimen- used for microbiological examination. Needs sterile glass
container
 Suprapubic aspiration (urine from bladder)- to get sterile urine from infants 4
 Physical Examination of Urine
• It is the assessment of the physical properties of the urine

• Usually it gives hint for the subsequent urinalysis

• It includes:
 Volume
Color

Odor

Foam

 Transparency

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 Volume

• In adults normally 750-2000ml/day in which the volume

depends on fluid intake and excretion of fluid in extra renal
system (faeces, breathing and sweating)

1) Increased urine volume

Polyuria: > 2000 ml/day

Physiologic causes are:- excess water intake

- drugs with diuretic effect

- high protein diet

- high salt diet 6

Pathologic polyuria:

a) Defective hormonal regulation in diabetic insipidus-central or

renal unresponsiveness to anti diuretic hormone (ADH)

b) Defective renal salt/water absorption can be due to diuretic

agents and/or tubular defect resulting salt wasting

c) Osmotic diuresis in Diabetes Mellitus with hyperglycemia there

is excessive glucose loss with water
 Diabetes insipidus - a rare disorder of the pituitary gland causing an
inadequate amount of the hormone vasopressin which controls urine
production, to be produced, leading to excessive passing of urine and
extreme thirst 7
2) Decreased urine volume

- Oliguria:- if urine volume is less than 500ml/day

- Anuria:- complete absence of urine formation (0-100ml/day)

Causes are: - water deprivation

- Acute or chronic progressive renal failure

- Acute renal failure can be due to:

• Post renal: bilateral hydronephrosis due to long standing
obstruction of urinary tract
• Renal disease: acute glomerulonephritis, interstitial nephritis,
acute tubular necrosis, and chronic renal failure 8
 Color

-Normal urine is amber yellow to straw colored due to

urochrome and partly due to urobilin and uroerythrin

- It roughly indicates the degree of concentration of the urine

-The color of normal urine varies throughout the day depending

on the concentration of the urine, where the early morning
urine is intensely colored than late afternoon urine

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Abnormal urine colors:
a) A nearly colorless urine:- is may be due to
- Large fluid intake
- Untreated DM, diabetes insipidus, alcohol ingestion, diuretic
therapy
b) Red urine or reddish dark brown
- Hematuria
- Hemoglobinuria
- Myoglobinuria

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c) Yellow-brown or green-brown urine

- Mostly associated with bile pigment chiefly bilirubin

- On shaking the urine, large yellow foam may be seen

d) Orange red or orange brown urine

- Presence of urobilinogen

- and low pH urine urobilin which is dark yellow to orange

on shaking the foam is colorless.

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e) Dark brown or black urine

- drugs like methyl dopa

- hemoglobin in acidic urine, melanin

- alkaptonuria a disease of tyrosine metabolism

f) Blue green urine

– Intestinal putrification ,pseudomonas infection

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 Odor

-Due to the volatile acid has aromatic odor

-Sweet (fruity) smell is due to acetone in diabetes ketosis

-Unpleasant smell is due to infection

 pH

-It indicates the ability of renal tubules to maintain the H+

concentration

−pH measures degree of acidity or alkalinity of

urine
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• Normal urine is slightly acidic ~ 5.5
 Acidic urine
 Uncontrolled DM
 ƒƒ Malabsorption syndromes
 ƒ Diabetic ketoacidosis
 ƒ Dehydration, Diarrhea
 ƒ Starvation
 Alkaline urine >7

 UTI, Renal failure

 Salisylate intoxication

 Lung disease involving hyperventilation and loss of CO2 with

alkalosis

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 Specific gravity

• Specific gravity reflects kidney's ability to concentrate urine

• Indicates the relative proportion of dissolved components to
the total volume of specimen
• The range of urine SG depends on the state of hydration and
varies with urine volume and the load of solids to be excreted
• SG varies inversely with urine excretion (decrease in volume
increase in SG in normal condition)

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 Hypersthenuria- increased SG

- Seen in water depletion and loss

 Hyposthenuria- decreased SG

- Seen in chronic glomerulonephritis

- Diabetic insipidus low SG with large urine volume

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 Appearance of urine
• Normal fresh urine is clear and transparent
• Cloudy urine may be due to:
a) Precipitation of crystals or non pathologic salts referred as
amorphous
b) Presence of different cellular elements
- WBC – form cloudy appearance similar to phosphates
- Bacteria, RBC, epithelial cells, mucus, pus
c) Lipiduria, fat globules, appear in the urine
- In nephrotic syndrome (triglycerides & cholesterol)

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 Foam

- Freshly voided urine will produce small, whitish foam

- Large yellow foam- bilirubin

- Large whitish foam- protein

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Chemical Examination of Urine
• Chemical analysis of urine is the valuable means in the detection
of many diseases
• Urine contains many normal chemical composition, but during
abnormal condition the constituent changes in kind and quantity
• Normal constituents: urea, creatinine, uric acid, ammonium
salts, chlorides, sulfates, phosphates of sodium, potassium,
calcium and magnesium.
• Abnormal constituents: glucose, proteins, ketone bodies,
bilirubin, bile salts, etc.
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 Chemical Exam
• The presence of normal and abnormal
chemical elements in the urine are
detected using dry reagent strips.
• These plastic strips contain absorbent
pads with various chemical reagents for
determining a specific substance.
• When the test strip is dipped in urine
the reagents are activated and a
chemical reaction occurs.
• The chemical reaction results in a
specific color change.
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 Chemical Exam
• After a specific
amount of time
has elapse, this
color change is
compared against
a reference color
chart provided by
the manufacturer
of the strips.

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 Chemical Exam
• The intensity of the color formed is
generally proportional to the amount
of substance present.

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Chemical Analysis
Urine Dipstick
Glucose
Bilirubin
Ketones
Specific Gravity
Blood
pH
Protein
Urobilinogen
Nitrite
Leukocyte Esterase23
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The Urine Dipstick
Glucose

Chemical Principle
Negative
Glucose Oxidase
Trace (100 mg/dL)
Glucose + 2 H2O + O2 --->
+ (250 mg/dL) Gluconic Acid + 2 H2O2

++ (500 mg/dL) Horseradish Peroxidase

3 H2O2 + KI ---> KIO3 + 3 H2O
+++ (1000 mg/dL)
Read at 30 seconds
++++ (2000+ mg/dL)
RR: Negative

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  Protein

• Normally trace amount is found which is not detectable

• Protein in urine (proteinuria) is usually albumin, but

less commonly globulin and indicates kidney disease
• The amount is usually high in diseases of lower urinary
tract infection

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  Glucose

• It is not the normal constituent of urine

• Rise in diabetes patient also in ingestion of large

amount of carbohydrate and impairment of renal tubules
reabsorption
• Urine glucose tests are used to:
Screen and confirming diagnosis of diabetes

Monitoring the effectiveness of diabetes control

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  Ketone bodies

• Ketone bodies are produced from metabolism of fatty acid

• It includes mainly acetone, beta hydroxybutyric acid and

acetoacetic acid
• In normal person ketone bodies are formed and completely
metabolized and negligible in urine
• Ketones are excreted when the body metabolizes fats
incompletely (ketonuria), such as in diabetes

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  Bilirubin
• It is formed from break down of hemoglobin

• It is present in urine when any disease that increase the amount

of direct bilirubin in blood stream
• Not detected in urine but appear secondary to biliary obstruction
(extra hepatic or intrahepatic)
 Urobilinogen (UBG)

• In the intestine most of the bilirubin is converted to UBG

(stercobilinogen)
• It is used in detecting and differentiating liver disease, hemolytic
disease and biliary obstruction 28
  Hemoglobin

 Hemoglobinuria – presence of Hgb in urine

• Usually related to conditions outside the urinary tract

• Occur when there is excessive destruction of RBC

 Hematuria – presence of RBC in urine

• Indicates bleeding some where in the urinary tract

• Both indicate disorder

• It can be distinguished by microscopic examination of the

urinary sediment

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  Leukocyte
• Presence indicates inflammation at some point in the urogenital tract

• It is determined by the activity of enzyme leukocyte esterase in

multiple reagent strip test but is less sensitive than microscopic exam

 Nitrite

• Nitrite indicates urinary tract infection (UTI)

• Because certain bacteria can convert nitrate to nitrite

• The urine should present in the bladder for at least 4hrs preferably
overnight
• The first morning urine for adequate conversion of nitrate to nitrite

• The determination is by dipsticks

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Microscopic Examination of Urine
• In normal condition urine contains small number of cells and
other formed elements
• It provides information useful for both diagnosis and prognosis

• Taking 10 ml of first morning urine and centrifuge it at 1500

rpm for 5 minute
• The urinary sediment are grossly categorized into:
Organized

Non-organized sediments based on the substance they

composed of
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• Organized elements: are those composed of biological origin
and includes:
Cells ( WBC, RBC, epithelia’s, spermatozoa)

Microorganisms (bacteria, yeast, protozoa, fungi)

Casts and that of biological origin

• Non-organized elements: are those with chemical origin

Crystal

Amorphous materials

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 Reference/normal values for urine sediment

 Red blood cells 0-2/HPF

 White blood cells 0-5 /HPF
 Renal epithelial cells few/HPF
 Transitional epithelial cells few/HPF
 Squamous epithelial cells few/HPF
 Hyaline cast 0-2 Casts/LPF
 Abnormal crystals Negative
 Bacteria Negative

Note: HPF(high power field)=40× objective, LPF(low PF)= 10×

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 Organized Elements

 RBCs
- Circular in shape

- In concentrated urine shrinked

and have different shape

- Normally 0-1/ HPF seen

- Result of bleeding at any point

along the urogenital tract

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 WBCs

- Greater than RBC in size

- Circular in shape

- In acidic urine nucleus and

granules are visible

- Normally 0-4/ HPF seen

- Pyuria indicates inflammation at

some point along the urinary

tract (bacterial or other causes)

• Pyuria - pus in the urine 35
 Squamous epithelial cells

- Large cell with small nucleus and

different shape

- Variable in number
- Normally few numbers are present

due to the normal wear and tear

- Reported only when present in large

number

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 Yeast cell
- Different in size,

- Oval in shape and refractive

- They do not dissolve in acetic

acid
- Easily differentiated by the

presence of their “bud”

- Seen in DM individuals

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 Bacteria

- Small in size

- 1-2 μm in diameter

- Can be motile

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 Parasites
• Commonly

– Trichomonas vaginalis

– Schistosomias hamatobium

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  Casts
• Few are seen and they are hyaline casts

• Formed by coagulation of protein and hyaline casts are formed

without cellular elements
• Cellular casts are formed by clumping of cells like RBC, WBC, .

• Granular cast are formed by degeneration of renal tubules,

degeneration of WBC and epithelial cell casts and later they
form waxy casts
• Seen in fever, postural proteinuria, nephrotic syndrome,
glomerulonephritis, etc
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Cast formation

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 Hyaline cast

• are colorless, homogeneous,

semitransparent, non-refractive
• Normally seen in very few

numbers

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 RBC cast
Seen in:

• Glomerulonephritis

• Renal necrosis

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 WBC cast
Seen in:
• Glomerulonephritis

• Pyelonephritis
 Pyelonephritis- inflammation

of the nephrons of kidney

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 Granular cast

• The result of cellular

degeneration in hyaline cast

• They could be

- Coarsely granular or

- Finely granular

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 Fatty cast

• Seen in:

– Glomerulonephritis

– Nephrotic syndrome

– Heavy proteinuria
• Glomerulonephritis- inflammation

of the kidneys, characterized by

albuminuria and high blood pressure

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 Waxy cast

• The final step in the

cellular degeneration
• Seen in advanced renal

failure and sever chronic

renal disease

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 Non-organized elements
 Crystals of acidic urine
– Amorphous urates
– Uric acid crystals
– Cystine, tyrosine, leucine crystals
– Cholesterol, bilirubin crystals
 Crystals of alkaline urine
– Amorphous phosphate
– Calcium carbonate
– Calcium phosphate
 Crystals found in both pH
– Calcium oxalate
– Triple phosphate
– Hemosiderine
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 Calcium oxalate

• It can be found in dihydrate or

monohydrate form.
• Occur in ethylene glycol
poisoning and severe chronic
renal/kidney disease
• It be associated with foods high
in oxalic acid, such as tomato
and asparagus and ascorbic acid

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 Triple phosphate

• They are commonly seen in

alkaline urine
• Colorless, prism shape that
resembles a “coffin lid”.
• They are often seen in highly
alkaline urine associated with urea-
splitting bacteria
• Often present in formation of
calculi & are associated with UTI
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 Uric acid crystal

• Yellow-brown in color but

may be colorless and have a
six-sided shape, similar to
cystine crystals.
• Increased amount of uric acid
crystals, are associated with
increased levels of purines
and nucleic acids, in patients
with leukemia and gout

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 Amorphous urate
• Yellow brown granules

• Found at acidic urine

• Encountered in refrigerated
specimens
• Pink sediment

• Dissolves when the sample

is heated

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 Amorphous phosphate

• Granular in appearance, similar

to amorphous urates, when
present in large quantities
• Following specimen
refrigeration, they cause a white
precipitate that does not dissolve
on warming.
• Differentiated from amorphous
urates by the color of the
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sediment and the urine PH