Urinalysis

By Us: AlaEldin S.O.Ashmaik

BSc.Higher Diploma.MSc
Chemical Pathology
Microscopic examination of urine
 Microscopic examination of urine
• The microscopic examination is a valuable
diagnostic tool for the detection and
evaluation of renal and urinary tract
disorders and other systemic diseases.
• The microscopic elements present in urine
are collected in the form of deposit by
centrifugation. A small drop of the sediment
is examined by making a cover slip
preparation under microscope.
 (1) Red blood cells in urine

These are red blood cells found in urinary sediment

under bright field microscopy (160x magnification).
 Red Blood Cells (RBCs):
-
• Erythrocytes
greater than 0 –
2/hpf are
considered
abnormal.
• Trauma, vascular
injury,
renal/urinary
calculi obstruction.
 Hematouria
• The presence of RBCs in urine due to trauma or
damage of the urinary systems.
• Causes:
Prerenal:Bleeding ,hemoglobinopathies ,malignant
hypertension.
Renal : Renal calculi, renal TB, glomerularnephritis,
diseases, renal tumors, pyelonephritis
Postrenal : trauma, exposure to toxic chemicals,
anticoagulant therapy , severe UTI, calculi and
tumors of urinary tract.
 (2)White Blood Cells (WBCs):
• Leukocytes greater in
number than 2 –
3/hpf are considered
abnormal.
• - These cells are
usually
polymorphnuclear
phagocytes(segmente
d neutrophils).
• - Acute
glomerulonephritis,
urinary tract infection.
 White blood cells/red blood cells in urine

This is a photograph of urinary sediment under brightfield microscopy (250X

magnification). The sediment contains two red blood cells (right) and one
white blood cell (left). The white blood cell appears to have a lobulated
nucleus.
 (3)Epithelial cells:
• Normally few cells 3 - 5/hpf are frequently
encountered in normal urine because they are
continuously sloughed off the lining of the
nephrons and urinary tract.
• 1.Tubular epithelial cells:
Indicate clinically significant active tubular injury.
• 2.Transitional epithelial cells (bladder):
Large numbers will be seen only in cases of
urinary catheterization, bladder inflammation or
neoplasm.
• 3.Squamous epithelial cells:
Often seen in urine specimens from females.
 1.Tubular epithelial cells:

• Indicate clinically significant active tubular

injury.
 Tubular Epithelial Cells

A group of attached renal tubular epithelial cells are seen in the

center of this slide. The background contains white blood cells
and red blood cells (bright field microscopy, 250X
magnification)
 2.Transitional epithelial cells (bladder):

• Large numbers will be seen only in cases of

urinary catheterization, bladder
inflammation or neoplasm.
 3.Squamous epithelial cells:

• Often seen in urine specimens from females.

 Squamous epithelial cell in urine

This is a squamous epithelial cell under brightfield microscopy

(250X magnification).Squamous epithelial cells are
characterized by a small, round, central nucleus with a large
amount of granular or wrinkled cytoplasm (a "fried egg"
appearance).
 Squamous epithelial cells

Shown here is a group of squamous epithelial cells in urine

sediment. Interference-contrast microscopy was used to
enhance surface characteristics of the cells (200X
magnification). A few white blood cells and bacteria are visible
in the periphery Often seen in urine specimens from females.
.
 Urine Microscopy
• Cells Casts Crystals.
• Casts are formed within nephron.
• Casts Suggest Kidney pathology.
• Casts can be made up of Protein, lipid, cells or
mixed.
• Crystals suggest high concentration or altered
solubility.
Casts
 Casts:
• Urinary casts are formed in the tubules of the
kidney.
• The renal tubules secrete a mucoprotein called
Tamm-Horsfall protein which is the basic matrix
of all casts.
• (1)Granular casts:
• Always indicate significant renal disease.
• (2)Hyaline casts:
• Not considered pathologic (may present in
normal urine).
 Casts:
• (3)Cellular cast:
A. Red Blood Cell cast: glomerular inflammation
result in hematuria.
B. White Blood Cells cast: pyelonephritis, nephrotic
syndrome.
C. Epithelial cells cast: heavy metal poisoning, renal
toxicity.
D. Waxy cast: tubular inflammation and always
pathologic.
E. Fatty casts: nephrotic syndrome (fatty
degeneration of tubular epithelium).
 (1)Granular casts:

• Always indicate significant renal disease.

(1) Granular cast

• Non-specific but
usually pathologic
• Usually the
‘granules’ are from
the degeneration of
cellular casts
(1) Granular casts:
(1) Granular Casts in Urine:
 (2) Hyaline casts:

• Not considered pathologic (may present in

normal urine).
 (2) Hyaline casts:

Hyaline casts are difficult to see due to their low refractive index. This one is
granular, which makes it easier to visualize. (Bright field microscopy, 200X
magnification.)
(3)Cellular cast:
 A.Red Blood Cell cast:

• glomerular inflammation result in hematuria.

A. Red cell Casts in Urine:
A. Red cell cast

• Almost always associated

with glomerulonephritis or
vasculitis
• Virtually exclude extra-renal
causes of bleeding
B.White blood cell cast
 B. White blood cell cast

This is a white blood cell cast with intact leukocytes. The

leukocytes have multilobed nuclei. (Bright field
microscopy)
 B.White blood cell cast

• Seen in interstitial disease most commonly

• Also seen in glomerulonephritis
pyelonephritis, nephrotic syndrome.,
 C.Epithelial cells cast:

• heavy metal poisoning, renal toxicity.

 D.Waxy cast

• tubular inflammation and always pathologic.

 D.Waxy cast

This is a waxy cast seen in urine with interference-contrast

microscopy at 160X magnification. The cast is surrounded
by red blood cells and segmented neutrophils.
 E.Fatty casts

• nephrotic syndrome (fatty degeneration of

tubular epithelium).
Urine Crystals
 Urine Crystals

• Many of the crystals that are found in the

urine have little clinical significance. Although,
they may be found in calculus formation,
metabolic disorders, and in the regulation of
medication.
Crystal in Acidic Urine
 Acid urine:
1. Uric acid: can be normal occurance, gout.
2. Calcium oxalate: D.M, calculi, liver disease
3. Amorphous urates: salts of sodium,
potassium, magnesium and calcium.
4. Cholesterol crystals: nephrotic syndrome.
5. Cystine: highly pathologic, congenital
cystinuria.
6. Tyrosine: pathologic, sever liver disease,
tyrosinosis.
7. Leucine crystals in urine
 1.Uric acid

• Uric acid : can be normal occurance, gout.

 1.Uric acid crystals in urine

Uric acid crystals exhibit extreme pleomorphism in

size and in shape. They appear readily in acid urine
allowed to stand at room temperature. (Bright field
microscopy, 160X magnification)
 2.Ca Oxalate Crystals:

• D.M, calculi, liver disease

 2.Calcium oxalate crystals in urine

Calcium oxalate crystals are usually found in acid urine.

They commonly appear octahedral.(Brightfield
microscopy, 100X magnification.)
 3. Amorphous urates:

• salts of sodium, potassium, magnesium and

calcium.
 Amorphous urates in urine

Amorphous urates appear as fine pink or brownish-

tan granules (brightfield microscopy, 200X
magnification). They are salts of uric acid and are
normally found in acid or neutral urine.
 4.Cholesterol crystals:

• Cholesterol crystals: nephrotic syndrome.

 4. Cholesterol crystals in urine

Cholesterol crystals are seen in the center of this field with squamous epithelial cells
on either side. Cholesterol crystals are found in acid or neutral urine. They appear as
regular or irregular transparent plates. They may occur singly or in large numbers.
Usually one or more corners are cut off or notched, justifying their description as
"stair step crystals". They are not commonly seen and are always considered
pathological. They can be found in various renal diseases. (Brightfield microscopy,
160X magnification.)
 5.Cystine:

• Cystine: highly pathologic, congenital

cystinuria.
 5. Cystine crystals in urine

Cystine, an amino acid, is an abnormal finding in

urine. Rarely seen, these crystals are found in acid
urine and are seen as thin, colorless, hexagonal plates.
(Brightfield microscopy, 160X magnification.)
 6. Tyrosine:

• Tyrosine: pathologic, sever liver disease,

tyrosinosis
 6.Tyrosine crystals in urine

Tyrosine crystals are not normally found in urine. They are products of protein
metabolism and appear in urine of people with tissue degeneration or necrosis
(acute liver disease, severe leukemia, typhoid fever, and smallpox). They are
present only when urine is acid. They are colorless to yellowish brown, needle
shaped crystals and have a fine silky appearance. The needles may be single or
arranged in sheaves or rosettes. Tyrosine crystals usually appear in urinary
sediment together with leucine crystals
 7. Leucine crystals in urine

Leucine crystals are not normally found in urine They appear in

urine in association with tyrosine and are manifestations of the
same clinical conditions. When found, leucine crystals are in acid
urine in the form of spheroids with concentric striations. They are
dense, highly refractive and appear as yellowish brown bodies.
(Brightfield, 160X magnification)
Crystal in Alkaline Urine
 Alkaline urine:
1. Triple phosphate
2. Amorphous phosphates
3. Calcium carbonate.
4. Calcium phosphate
5. Ammonium carbonate
1.Triple phosphate
 1.Triple phosphate crystals in urine

Triple phosphate crystals, viewed here with interference-

contrast microscopy (160X magnification), resemble
prisms or "coffin lids". They are found normally in
alkaline or neutral urine. They are colorless.
2.Amorphous phosphates in urine
 2.Amorphous phosphates in urine

Amorphous phosphates appear in neutral to alkaline

urine as fine, colorless or slightly brown granules. White
precipitate is observed on centrifugation. (Brightfield
microscopy, 160X magnification.)
3.Calcium carbonate
 3.Calcium carbonate crystals in urine

Calcium carbonate crystals are small and colorless and

appear in alkaline urine as granules or as small
dumbbells. Bacteria are also present in this field
(brightfield microscopy, 250X magnification).
 4.Calcium phosphate crystals in urine

Calcium phosphate crystals assume various forms

including the rosette and pointed finger forms shown
here with bright field microscopy (160X
magnification). They appear most often in alkaline
urine.
 Bacteria in urine:
• Normal urine is sterile and contains no
bacteria.
• Presence of large number of bacteria with
many pus cells indicates urinary tract
infection.
• Most pathogens seen in urine are gram
negative rods such as E.Coli and proteus
species.
Bacteria in urine
 Miscellaneous elements:
1. Yeast cells: Found in UTI, DM.
2. Trichomonas vaginalis (trophozoite).
3. Schistosoma haematobium (ovum).
4. Entrobius vermicularis (pin worm) fecal
contaminants in children.
5. Spermatozoa.
6. Mucus.
7. Starch.
8. Fiber .
9. Cotton fiber .
 yeast cells

yeast are visible on the left side of this slide with a squamous
epithelial cell on the right. There are no segmented neutrophils
seen. This suggests the yeast are a contaminant and not causing a
urinary tract infection (bright field microscopy, 200X).
Trichomonas vaginalis
Schistosoma haematobium
Spermatozoa
 Mucus

This slide shows mucus in urine with two entrapped white cells.
There are also two red cells present, one within the mucus and
one above it. Mucus fibers are fibrillar and delicate. They have a
very low refractive index. (Bright field microscopy, 160X
magnification.)
 Starch in urine

A derivative of cornstarch is used as a dusting powder for

surgical gloves. It can enter the urine during catheterization.
The starch granules are usually identifiable by their size,
shape and high refractive index. (Brightfield microscopy,
100X magnification.)
 Fiber in urine

This slide depicts a fiber artifact found in urine under brightfield

microscopy at 200X magnification.
 Cotton fiber in urine

A cotton fiber is easily identified by its size. A cotton fiber is

seen here with squamous epithelial cells and white blood
cells.(Brightfield microscopy, 51X magnification.)