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Urine Dipstick Testing PDF
Urine Dipstick Testing PDF
E
mergency physicians routinely clinical parameters.
order urinalysis (UA) many times Urine Specific Gravity: Urine spe-
each shift. Its usually a straight- The eyeball is no longer adequate or proper JCAHO or lab procedure to read and cific gravity (USG) generally correlates
forward issue, and most physicians record results of the dipstick. A machine is used to read the dipstick and print out with the urine osmolality. The most use-
the results. Quality assurance is very problematic unless this routine is used.
think they are well versed in the inter- ful information derived from the USG is
pretation of the results: You give it a insight into the patients hydration status
glance, and make a decision. The dip- and the concentrating ability of kidneys.
stick analysis, the microscopic exam, Specimen Collection: For most urine is a sign of infection, it can simply The latter function is disrupted in a vari-
and other information gleaned from a men and women and in most ED situa- represent a concentrated specimen or ety of diseases.
UA make their way into decision-making tions, a midstream clean-catch tech- reflect diet. Urine that has prolonged The normal USG ranges from 1.003 to
for a variety of diagnostic, therapeutic, nique is usually adequate. According to bladder retention time can develop an 1.030. USG less than 1.010 is suggestive
and disposition issues. Like most things these authors (but many would
learned in detail many years ago, the disagree), the time-honored
interpretation of the UA should be revis- ritual of cleaning the external Accuracy of Urinalysis
ited on a regular basis. genitalia in women has little or
I find myself thinking I know every- no proven benefit, although it for Disease Detection
thing about a certain test only to find is commonly emphasized. In
that the guidelines have changed, tech- some reviews, contamination Condition Test Results Sensitivity (%) Specificity (%)
nology has advanced, and previously rates are similar in specimens Microscopic Dipstick >1+ blood 91-100 65-99
held dogma is now relegated to the sta- obtained with or without prior hematuria
tus of misconception. With that in mind, cleaning. (Arch Intern Med
Ill review the ins and outs of the urinal- 2000;160:2537.) Urine should Significant1 Dipstick >3+ protein 96 87
ysis in emergency medicine. When one be refrigerated if it cannot be proteinuria
considers the complexity of the UA, it is examined for more than two Culture- Dipstick Abnormal 72-97 41-86
obvious that this is not a simple test. The hours because delayed analy- confirmed UTI leukocyte
intricacies and subtleties are actually sis can produce unreliable esterase
quite amazing. This months column results. Abnormal 19-48 92-100
focuses on dipstick testing, and next Physical Properties: A nitrites
months will review urine microscopy. variety of foods, medications,
metabolic products, and infec-
Urinalysis: A Comprehensive tions can cause abnormal Microscopy >5 WBC/HPF 90-96 47-50
Review urine colors and odors. Nor- >5 RBC/HPF 18-44 88-89
Simerville J, et al mal urine is clear and light yel- Bacteria (any 46-58 89-94
Am Fam Physician low in color. Concentrated amount)
2005;71(6):153 urine produces a darker color,
a common finding in the morn- 1. Defined as 3 plus or greater on dipstick.
The authors of this nifty review dis- ing after overnight water Source: Adapted from Am Fam Physician 2005;71:1153.
cuss the value of the standard UA for the restriction. Cloudy urine can
diagnosis of many urinary tract condi- be normal, usually caused by
tions, including malignancy and meta- precipitated phosphate crys-
June 2007 EMN 25
InFocus
of three urine samples. The urine dip- a variety of drugs, including the obvious,
stick is used to test for the peroxidase heparin and warfarin.
activity of erythrocytes, not for the actu- RBC casts are classic for acute
al presence of the physical RBC. Of glomerulonephritis. Hematuria also can
course, myoglobin and hemoglobin pro- be associated with TTP, renal vein
duce a positive dipstick for hematuria thrombosis, sickle cell trait, or merely
because these substances also will cat- running a marathon. Contrary to popular
alyze this reaction; these are the end- belief, significant hematuria will not ele-
products of hemolyzed RBCs or muscle vate the protein concentration to the
breakdown. High doses of vitamin C will required cut-off deemed positive, 3 plus
inhibit this process, and can invalidate or more on the dipstick. The authors
the dipstick for this test. This also holds note that up to 20 percent of patients
true for stool guaiac testing; vitamin C with a gross hematuria have a urinary
can produce a false-negative occult tract malignancy, so this condition
blood in stool. It has always been stan- requires a full work-up. Hematuria, in
dard that a positive dipstick for blood in the absence of proteinuria or RBC casts,
the absence of RBCs by microscopy is suggests a pure urologic cause
indicative myoglobinuria or hemoglobin- (stones/malignancy) for hematuria.
uria, not true hematuria. Proteinuria: Healthy kidneys limit
The authors present a table listing 45 the protein permeability of the glomeru-
causes of hematuria. Although some lar capillaries, but diseased kidneys
The proper way to use a dipstick is to totally immerse it in urine, turn it on its side
rare ones, such as Fabrys disease, will allow more protein to be filtered so pro-
on filter paper to absorb runoff and keep chemicals from running onto the adjacent
patch, and wait two minutes before reading. Dont forget to put the lid back on the likely escape the detection and knowl- teinuria is a hallmark of a variety of
container. edge of the emergency physician, it is renal diseases. Blood proteins are nor-
important to know that hematuria can mally filtered and then reabsorbed by
of relative hydration, and values greater Hematuria: The strict definition of be associated with malignant hyperten- the proximal tubule cells. Urinary pro-
than 1.020 indicate relative dehydration. hematuria by the American Urological sion, numerous urinary tract cancers, teins include primarily albumin, but
Pathologic conditions that increase the Association is the presence of 3 or more infections, nephrolithiasis, nephritis some serum globulins are detected. The
USG without regard to hydration includ- red cells per high-powered field in two (lupus) and vasculitis, tuberculosis, and Continued on next page
ed glycosuria and Syndrome of Inappro-
priate Antidiuretic Hormone Secretion
(SIADH). In such cases, osmolality is the
more important parameter to measure.
Urine Dipstick Testing:
A decreased USG, also known as dilute Causes of False-Positive and
urine, is associated with diuretic use, False-Negative Results
diabetes insipidus, adrenal insufficiency,
aldosteronism, or a plethora of condi- Dipstick test False-positive test False-negative test
tions causing impaired renal function.
It should be noted that the purpose of Bilirubin Phenazopyridine (Pyridium) Chlorpromazine (Thorazine), selenium
the kidney is to concentrate urine when Blood1 Dehydration, exercise, hemo-globinuria, Captopril (Capoten), elevated specific gravity,
needed. Many renal diseases alter this menstrual blood, myoglobinuria, semen pH < 5.1, proteinuria, vitamin C,
concentrating function and result in a in urine, highly alkaline urine, oxidizing dipstick exposed to air
fixed specific gravity about 1.010, the agents use to clean perineum
specific gravity of the glomerular fil-
trate. This is known as isosthenuria, a Glucose Ketones, levodopa (Larodopa), Elevated specific gravity, uric
condition seen, for example, in patients dipstick exposed to air acid, vitamin C
with renal dysfunction due to sickle cell Ketones Acidic urine, elevated specific Delay in examination of urine
disease. gravity, some drug metabolites,
Urinary pH: In general the urine pH (e.g., levodopa)
reflects the serum pH, but the primary
and normal function of the kidney is to Leukocyte3 Contamination,2 Elevated specific gravity, glycosuria, ketonuria,
acidify the urine. Normal serum pH is Esterase nephrolithiasis proteinuria, cephalexin (Keflex), nitrofurantoin
7.4, but the normal urinary pH ranges (Furadantin), tetracycline, gentamicin,
from 4.5 to 8. Because of normal meta- vitamin C
bolic activity, the generally accepted Nitrites Contamination, exposure of dipstick Elevated specific gravity, elevated urobilinogen
normal pH of urine is about 5.5 to 6.5. In to air levels, nitrate reductase-negative
renal tubular acidosis (RTA), the kidney bacteria, pH<6.0, vitamin C
cannot acidify the urine, so the urine can
be alkaline while the patients serum Protein4 Alkaline or concentrated urine, Acidic or dilute urine, primary protein
demonstrates a metabolic acidosis. quaternary ammonia compounds, is not albumin, such as Bence-Jones
The urine pH can be related to diet. iodinated radiocontrast agents protein
Acid urine can be the result of ingestion Specific5 gravity Dextran solutions, IV radi-opaque dues, Alkaline urine
of fruits (hence the use of cranberry proteinuria
juice) that acidify the urine. Diets high in
citrate and in citrus fruits, legumes, and Urobilinogen Elevated nitrate levels, Phenazopyridine
vegetables can cause alkaline urine.
Meat eaters tend to have more acidic 1. Test depends on peroxidase activity of RBC. Tests will be positive with intact or lysed cells. This test is very sensitive and may be positive in
urine, and vegetarians tend to have alka- normal urine (1-2 RBC/HPF).
line urine. In the presence of a docu- 2. Especially vaginal contamination.
mented UTI, alkaline urine may suggest 3. Sterile pyuria seen with interstitial nephritis, TB, nephrolithiasis.
infection with a urea-splitting organism 4. Not clinically significant unless 3 plus or greater. Detects mainly albumin and requires protein excretions of 300-500 mg/day.
(such as proteus). In alkaline urine, 5. Accurate analysis for osmolality requires osmometer.
triple phosphate crystals (magnesium
ammonium phosphate crystals) can Source: Adapted from Am Fam Physician 2005;71:1153.
form a staghorn calculus. Uric acid
stones form in an acidic urine.
26 EMN June 2007
InFocus
Laws in two states requiring disclosure of gift certificates, meals, textbooks, or con- District of Columbia mandated state dis- The study also found that pharmaceuti-
pharmaceutical company payments to ference fees. In contrast to many other closure of payments made to physicians by cal companies made substantial numbers
physicians do not provide the public with professions, medicine allows payments pharmaceutical companies. In two of of payments of $100 or more to physi-
easy access to payment information and from a company to an individual who these states, Vermont and Minnesota, pay- cians. In Vermont, among 12,227 pay-
are of limited quality when accessed, decides whether and how often to use ment disclosures are publicly available. ments totaling $2.18 million publicly dis-
according to a study in the March 21 products produced by the company. The The authors of the study found that closed, there were 2,416 payments of
issue of the Journal of the American Med- American Medical Association recom- the laws enacted by Vermont and Min- $100 or more to physicians. In Minneso-
ical Association. mends that gifts but not other payments nesota fail to provide the public with easy ta, among 6,946 payments totaling
Interactions between the pharmaceuti- to physicians should benefit patients and access to information about payments $30.96 million publicly disclosed, there
cal industry and health care professionals should not exceed $100 in value. from pharmaceutical companies to physi- were 6,238 payments of $100 or more to
often involve payments, including cash, Recent legislation in five states and the cians and other health care professionals. physicians.
June 2007 EMN 27
InFocus
dehydrated is that they cannot concen- and I could not determine the exact with quality control with dipstick testing ward as one would like. It is clearly not
trate their urine. Finding an USG of specifics. Importantly, if your dipsticks in the ED. We all now use machines to foolproof nor a gold standard for many
1.010 in a patient with advanced sickle are scattered around the ED lab in an read the dipstick rather than relying on a things. A plethora of conditions pro-
cell disease does not mean they are well open container for more than two nurses eyeball, and a printout has duce false-positive or false-negative
hydrated. They may be quite dehydrated weeks, about three-quarters of them will replaced the pen. Nonetheless, our hos- results. It can serve as a useful guide to
and unable to concentrate their urine. give a false-positive result for nitrites. pital lab often disagrees with the ED the emergency physician as a screening
While USG usually corresponds to Perhaps the lab is better at protecting reading for leukocyte esterase and the test or as a diagnostic test, but there are
osmolality, large molecules in the urine, dipsticks than the ED, but I rarely see degree of hematuria. times when the dipstick must be corre-
such as glucose or IV dye, can produce the top put back on the container in my Like most things in medicine, the lated with other testing and clinical
large changes in USG with relatively EDs stat lab. Everyone has difficulty dipstick urinalysis is not as straightfor- information.
minimal changes in osmolality. It has
been shown that there is no clear or
consistent relationship between USG
and osmolality (Arch Dis Child CME Participation Instructions
2001;85:155) so when osmolality deter-
minations are important, an osmometer
should be used.
With regard to urinary pH (normal
4.5-8.0), there are many causes of alka-
T o earn CME credit, you must read the article in Emer-
gency Medicine News, and complete the quiz, answer-
ing at least 80 percent of the questions correctly. Mail the
you within six to eight weeks of participation.
Lippincott Continuing Medical Education Institute, Inc.
is accredited by the Accreditation Council for Continuing
line urine, and not all patients with this completed quiz with your check for $10 payable to Lippin- Medical Education to provide continuing medical educa-
finding have urea-splitting organisms. cott Continuing Medical Education Institute, Inc., 770 tion for physicians. Lippincott Continuing Medical Educa-
The kidneys task is to acidify urine, and Township Line Road, Suite 300, Yardley, PA 19067. Only the tion Institute, Inc. designates this educational activity for a
normally a serum pH of 7.4 produces a first entry will be considered for credit and must be maximum of 1 AMA PRA Category 1 Credit. Physicians
urine pH of about 6.0. Interestingly, in received by Lippincott Continuing Medical Education Insti- should only claim credit commensurate with the extent of
the presence of urinary tract obstruc- tute, Inc. by June 30, 2008. Acknowledgment will be sent to their participation in the activity.
tion by a stone, the kidney loses its abil-
ity to secrete acid, and obstruction
alone can produce alkaline urine. (Pedi- June 2007
atr Nephro 1988;2:34.) Patients with a Questions:
significant metabolic acidosis would be
expected to produce an acidic urine, 1. The accuracy of urine dipsticks can deteriorate and give incorrect results if the dipsticks are old, exposed to air,
usually below 5.0. Higher pH would sug- or otherwise improperly stored.
gest RTA. True False
2. Dipsticks define the presence of intact RBCs in the urine specimen.
True False
Reader Feedback:
Readers are invited to 3. A dipstick test will be positive for blood will result if the patient has myoglobinuria.
ask specific questions True False
and offer personal
experiences, comments, or obser- 4. Leukocyte esterase positive dipsticks have a near 100% specificity for bacterial infection.
vations on InFocus topics. Literature True False
references are appreciated. Perti-
5. The most sensitive dipstick test for infection is the nitrite test.
nent responses will be published in
a future issue. Please send com- True False
ments to emn@lww.com. Dr.
Your evaluation of this CME activity will help guide future planning. Please respond to the following questions:
Roberts requests feedback on this
months column, especially person- 1. Did the content of this activity meet the stated learning objectives?
al experiences with successes, fail- Yes No
ures, and technique.
2. On a scale of 1 to 5, with 5 being the highest, how do you rank the overall quality of this educational activity?
5 4 3 2 1
3. As a result of meeting the learning objectives of this educational activity, will you be changing your practice behavior
In my experience, finding a trace or 1 in a manner that improves your patient care? If yes, please explain.
plus leukocyte esterase (LE) is com-
monly a falsely abnormal test. This is
Yes No
_____________________________________________________________________________________________________________________
likely mostly due to contamination.
Interestingly, nephrolithiasis alone, in 4. Did you perceive any evidence of bias for or against any commercial products? If yes, please explain.
the absence of infection, can produce a Yes No
dipstick positive for LE. This may lead __________________________________________________________________________________________________________________________________________________
the clinician to suspect infection in the 5. How long did it take you to complete this CME activity? _______ hour(s) _______ minutes
stone former when it is not present.
With regard to the ability of the dipstick 6. Please state one or two topics that you would like to see addressed in future issues.
to diagnose UTI (confirmed by culture), __________________________________________________________________________________________________________________________________________________
the specificity for a positive LE test can
__________________________________________________________________________________________________________________________________________________
be as low as 41%.
While many organisms are capable Please print.
of converting nitrates and nitrites, non- Name __________________________________________________________________________________________________________
nitrate-reducing organisms also can
cause false-negative nitrite results. Of Street Address ______________________________________________________________________________________________________________
course, patients who consume a low-
nitrate diet will not have the nitrate sub- ________________________________________________________________________________________________________________________________
strate for the bacteria to convert.
City, __________________________________________________________ State ______________ ZIP Code ______________________
The nitrite test is much more sensi-
tive for infection than the LE, although Telephone ______________________________________ E-mail __________________________________________________________
it takes a while for the bacteria to reduct
the nitrates to nitrites. The urine must
remain in the bladder for some time,