Ch apter Basic Examination of Urine John Bernard Henry, M.D, Teginalda B. Lauzon, M. ).. MT(ASCP) G. Berry Schumann, M.D. URINE FORMATION, 412 hnmical Sereoning. EXAMINATION G1 URip SEDIMENT, 437 Foruace Fleenenty af Leia BASIC (ROUTINE) =eiminusion iE ‘Motiids for MGceascopie Untinlyaie Aulamatid Vianadyais URINARY CALCULI, 449 ‘Muniteiag Patients Analisis ef Caleb, URIMANY SURZENING BOR INHERITED METABOLIC DISEASES. 452 Aminoutial Microieupic Compunnnt Ls tra! Settiese The exarhination of uri Inedieal information regarding’ the diseases invohing: ihe ‘Sepey an Tower urinary eric. Buh functimal pliystolnste) prvies 2 wide variety of useful and Sructal (anatomic) divorces of the kidney anc Iosece Sagi tact tye: elucidated, und vinsoste, monitoring, And peognastis information may he gathered as well, Wheg lexions ebttined Without pain, danecr. and with analy minredl We Believe latorsnory urine tests will ‘emnaim.an essestial part of clicical medicine, Mamy clinical laboraiocy disciplines are iawolved fa ke Seleation Of trne. These include. chemin, miceebiology, ‘ule wet urinalysis, cylalgy. and othcr specialty sects New technologies, inhiding imimunceviochemstry. woleos te piel eee biology, DNA ploidy, and cell cycle analy fal continue to cxptod potentia| diagnostic and proquce: {Rlcewetion, iis impietant thit usc of wine labersony Atsts distinguish the clinical witty of individaal text. Table 18" lists ibe bemetis G.c; for wrsening. dingninis, mage ‘oring. or Pmgnosis} of compton urine laboratory ies The purpose of thik chapler is to diccuse information ‘Sect from urinalysis. At presen, dee types of urinalysis ore ‘they inciode (1) ‘Teagent stip (dipstioky uri ‘physician offices, and pa ‘wet urinalysis. conumonly lyse and (3.9 urinalysis -1pprech tthe uri agin Ak ‘The dipstick urinalysis remaint a valeable: front-line tt for the extly detection an! monitoring of paticnts foe chionleal abnormalitits and isu part of every urine aveeseinegt Reagent strip urinalysis sncompanscx che physiochemical 2 (1) macrescopsc ring As ur physicochemical determinsiions fappearanes, specific fravity, and multiparameter reagent {Sverel cheinieal constituents). and (2) a heighuield or pace Sohlrest microscopic examination of urine sediment for ev, dance of Wematuria. pyotia, cytindroria (casts) -and cyst. una. Cytodiignostic urinalysis has gained rasdical lane 25 a more sensitive pathologie tt sediment in several renal and lower utinary tact disorders, system conditions, We beliosw’ that this spectrum of urinals moors the necds ‘a maltimensional heohh ere system. Each laborstory i stcoursged to ideutify their own enigue requieaene based on the patient population nerve and ta then sclert the Most Gost-lfective tise oF urine wars, 411— 2 Parts ¢ URINE: AND omuin Hany Hts om Thble 18-1, BENEFITS OF COMMON UNINE LAsioRATORY. Tests ee chem Gems (Resse sit Prene = Henman Leakcoparin iene = War icneba Deer be ' . . ae Ftenaa Fence Leesan Iiectoe Gintnes Screar Uaerierstisner ea + - + ¥ Uliwereiagy Cine i 2 i (esvetond) eterna Viel needing etapa ‘Slomertaean 3 “eH is sina ‘evalu Siento Lire echt Tefen the igs Ora ae) BNa ws COMPONENTS OF BASIC (ROUTINE) URINALYSIS sal nobles inte rng af calesin af wine petincs A Bai ute) unas i competed of fear pans: mine Ct ee Reemse le geiner ciel Povsphysicel examination, chemical Feedcns Sng SUPE Tithe (12, aio) mean cok Sug. aed yen ee Hections ane therefore. preferred 1 teadom specimens for squxoticative wit. Specimen Evaluation Ba aoemal ddl, 25% of he edie exit, de mers than Cheer Biss the two kidneys ath cite alte lee ane Proceeds with any testing. the urine spmcinen ullmufirate of the plasma passes through each glomerular must be evalusted in terms of its acceptability: Considers. Thales is fttate to produce excreted urine occigs in the Sansportation dclays in moving the specimen th the labo’ Tons aad collecting doc af each nephron, Final coms iy Each laboratory should have writen. and enforced fins depend on the sate: of byuration. Entering tho collec Siidelines for the aseeptance or rejection af epecimugy a 3 duets the nL ic usualy about 6 with a Ipicel Wenney properly labeled spécimen must have the petionts fall nase eh and the osmolality my he increased 0 SD rene sod the date and time of collection. Additonal infoemetes Per ace, Melbleted person, tk: ommola may be ean ‘these three esscntials constituce inini hag Stomerila trate volume of aboot 48 Lin M4 hang Wofily one specimen iy submited for muhipe testing. (or an BU mae) lise Reem rediced 9 abeyt 1 or 2 Tuand bacteriologic examination should be jeelored et provided that shearing as teen propely ceed Wah pa sisi patie: and penons im acute-renal flue. it may be Access 1D process 2 volime of rine fxs than the stan dandized volume. In such cases. 2 notation should be made and tests mast pertinent ta the diagnosis should be performed: first. Gross/Physical Examination Appearance COLOR The yellow color of urine is due: Ingely te the pigment ursehrome and so amall amounts of urobiling and urbety- thin. Urochiome exéretio ix thought to be: proportional 1o the metsbolic rate and is increaced during fever, hyrotoxico- sis, and stacvation, The pink pigment (uroeryteia) may be deposited in uric acid or urste crystals (brick dust depisit), snd these should not be confnsed with blood. Pale or color- less urine in a normal person follows high Maid intcke, Dicker urine niay be seen when fluids ure with. Thos, the Chapter tn | Baie Pacinicien tire = 113 ‘color foughly indiestes the dees ef tpdiation and urine concentration, which should comelate wath arine specific gravity, Note that pale urine of high specie sxovary many be ‘Found in diabetes. melinss and after the ae of cadioograpihic media Normal concentrited serine say show « wedimemary: de- pokit if allowed 19 étand after cooting Grom body tempers tre. Precipitation due 1a plonphates or eramew many then ce cut, Mucus’ from the urinary and geminal maces ia scm as small eloudy patebes (iubceulac) i= normal ere Certain food and candy dyes ober the arinc (Linea. 96S, as dodrigs used for investipstion and therapy Am SRoCuES cred urine associated with ingestion of Bests Ls sam i pest sally susceptible pervems Some of the more important changes ia the grow appear ance of urine are described in this section. For-coler changes tn urine in pediatric patients, sce Come (19683, A compretien> sive fist i prided in Table 18-2 RED URINE, The most comme anormal colar is rod ox ralcbrown, When it is-seen ix feriles. comtarsination with menstrual flow shauld he esasidered. The urine in hematarsa Table 18-2, APPEARANCE AND COLOR GF WieiNt Crue Klar Choay ‘ery de wee Phnepinies, earhonsies aes i acl Lookers: Ret cele (memicy") Bactta. vests ‘Spermatoend Premio asd Min. rncons aids Cale“ Chap pes ese fecal eoarxmisaton Radiographic ye Meera enn Lipid passin Cipla, ety Eulaifed pratin Acne Concer urine ban excose ilrabin iiephietvlwesen Dilirubis bilvesin Hesrghenit Explivcyles Myginnen Pomtyin Fiscin. aniline dye oss ‘ensinal cmtaton Poephiyrioe Emthmeytes Hemogiobia oo sentiox ‘Meters ein asp lohin ‘Balun (dipyintcd Matheraagichin Honmgeatise kd Melanin adic ‘Peeaonsanae infecrons hops iy ‘Yellow weunge Yellow-ereen ‘Yellow bree, Rad Rei porle Brow ack Bhveween iso GOP nae Ivlsble in Slate cee acid pee mtu ape so nucle in done aces acd Tasoiabe in line ote acd ‘May he Boecalenr Pup ones Reswreveal thule Isacid une Imolunic ts cise seems aia idan ofa injury — soluble kn eter ‘Lymplauie oberon lube m ster Wginal creams Goon dunvesceuce ‘Dehydration, fever No yeu foam "Yellow foam + sacle birohi= ‘Yow toma “Dee ron, yellow fou Dasicve } reams sep for Bacd Paine May be cores Foods cna Yellow saline, went Clots eases Mig be eile Acidgit ose injury Reval of wrsle heraoeb lod; sic tl (Oe vung, alkaline wep re sanding. rte Seal inestin infections Moutideoderinacid rine om standing. Blood and biocd pigments axe aaily distecied by meant of & reagent stip. A positive jest maa -disstes the presence of iemogiohin or myagloban (ace Blot, Hemoglobin, and Myogiobin in Urine) Tn the porphyrins, the trinc msy be normal. red oe pur~ ple. Tris usually red in congenital eryiropoieae and the eutanea Limin form of porphyria. [a acute inci tent hépatic porphyria, i is normal but darkens oa standing 4 lead porphysinuria, the urine color ic normal. Red cine alto may be associated with the use of drugs snd dyes in di Sgnostic Wests— for cxample, phenolsulfonphthalein (PSP), Which is sometimes used tn testing real function, causes + ‘red colot im alkaline urine. In the presence of unstable he moglobin, such as hemoalobin Kiln, the urine i red-beow a and does not give a positive tes: result for hemogiobia or for bilimbia. The pigment is prohubly a dipyrrole or bilities. cin. YELLOW-BROWN: OR GREEN-BROWN URINE. Yee low-brown or green brown urine fs most afien aswociaicd With bile pigments. chiefly bilieubia. On shaking the urine specie. a yellow foam may be seen. which dainguishes bilitbin from 2 normal, dart. concentrated urine, which hes ‘white foam, tn severe obsimctive jauodice the urine may bo dhark: green, ORANGE-RED OR O®ANGE-SROWN URINE. Urine Sonttining large amoures-of urabilin may rosemble » dark concentrated normal urine, Exereted urobilinogen is col less Ini is couveried io the presence of light and sei pH > seobilin which is-dark yellow or arange. Uabilin dacs nor ‘sole thc foam on shaking a urine sarmple.Uinary analgesics (phenazopyridiaes) cause an oringe eilor and culo? any foam, present DARK BROWN OR BLACK URINE. AGid uring comain- ‘ng Nemnoglobin darkens on stundinig becauxe of the forms Koa of methemoglobin, Othes. mixer causes af dark heowa uriae-are homogeditisic acid (ilkspremuria) and melanin, Col. ‘orless melanggens are converie! in acid urine to miclanie, Urine: containing bumogentisic acid darkens more rapily ‘when alkaline. Dark Wrown oe cole-cotored urine #6 seen In sow patienis aking levodopa: See Table 18—| for cates of colored wines and Table 18-3 for » ist of common dimes causing eulorod rine. Character (Clarity) "Normal urine is essemtintly clear. and tbe presence of par ‘eulate tater in unspan urine needs o be explained mice seopically. Cluudy urine is my necessarily guthalagie. ‘The be duc to the precipitation of crystals oF non Patholugic salts feed to ani amorphous. Phosphete (ara Secasionally cashemate) precipitaics in alkaline urine: the Phosphates and carbonates redissolve when acetic’ acid is auld. Ure acid and wates-camye a white, pink. or ormge ‘loud in nid urine and rediesolve on watyning wy 60°C. Ath. Swoniwin urates wccur in neatll and alkaline wine and dis, solve in acetic ac. Leakicytes may forma white clon sire ilar to that Gaus by phosphates. bul in this case the cfowd Tewwaing after the addition of dilute axetic acid; the presence ‘Table 18-2. URINE COLOR CHANGES WITH COMMONLY USED DRUGS* Drug. Caer Abcubed cant Pile, Scie 2 Thuatines oemme Relic, asist;yllora-teouns, es eld (Circe (Parsten) imiscle Ra leu Dicimuamine Sraplie (Heer) ee Sette om ‘Onmgt eed Yelbow ence ine ‘tenon soaing eden brown: atatine Yebow (Green brown, ‘Dimkem if eaicing agen preset, radio fron Be, Blaesrees Dantcaing.sonsh bess Bawo-yelow ‘meena (yi) Oras ed (urinary analgesic, see ‘Shupcemded wich sttomamases (Aoe Gime, cc) (Hein) (aricowpulans) (pore diving hrs nematic) ccol pooseing Hern: cite no came (pea) ‘Phesptcalen (purgative) Ret murple, alkaline pH PhcastsoHowpiabales su Prokeced, saline pit sulfobeomopbstanicin) Retmapis ei Rimactane) Baga ranged hercules Eacapy ibaa inva? Drip yellow ‘Salfatladne (Azle) fa crates alti) Oise yeliog alkaline pt “ther seats mi sues ave eee wl pode er deer ence ‘secotily- ace (Eul- bie pare peeahtnones ate Sacee (epee Mot (ha Msescenes Said wine, At cause Ra eee Soma Youn siak ChaChem 9s 918, of leokucytes is confirmed hy alctascupic examination of the sediment. Bacterial growah canes a uniform opaiesconce that is mot femoved-by acidification or by flering through Paper. Turbidity. or smokiness may be due to fed lead cells ax Sen in gross hemutwia. This turbidity does noc clear on ‘warming, and the presence of erythrocytes may be euntirmed microscopically, The prescner of increased mumabrs of op- Ichelial cells may also account for turbidity. Spermnioroa sed Prostatic full may cause mubiaity tet cleared by acta Hon or beating. Prostatic fluid normally contains a few Ieuoeyes und ether formed elements. Mucus fom the urinary passages may cause-a fully, bully deposi, this is increased to inflammatory states. oF the lowce urinary teact or genital fact. Turbidity dac t9 blood cless. menstrual discharge. ind IMbeT nticular misterial such ay pieces of tixsoe, small cal ‘cali, clumps of pas, and fecal tater ix coraeeiines ceen. Fe ‘sal material in urine: may result from a fistuia-berween the ‘colon gr rectum ane bladder. Contamination with powde-entinl petosuria ip amounts of 1 16 4 g/day. At concentra ‘tons of 250 to 300 mid, L-xylulese reduces Benedict's ‘quilnarive veagent at SO°C (water bath) within 10 minutes ce {3 room tempersnur in several hoary, Hructine also seduces Benedict's reagent i low temperatures (seo: Henry, 1979). "The pentoses are identified by thin-layer chromatoeraphy. SUCROSE ‘Sucrose may appear in the wrine-after ingestion of very large amounts of sucrose. Sucrase deficiency ix wociatcd with intestinal diseases such ay spre in the same manner 3 luciase deficiency. Suctose intolerance is an inkestted disir- der assaciatod with sucrave and a-dlextrinas (ixomaliate) de- isteneies, Syeptoms ave simflor te these of lactuse defi ‘cieney and occur in the first few weeks of life when sweetened food is ingested. Tolerance may. develop. but st ‘erase may have to be avoided ‘permanently. Pnetitious swerosueia may ereste high-cpecilic-gravity ttine ‘with negative results of glucose oxidase ancl negative copper reduction tests. (Sucrose ix nota reducing sugar) Su- rose ferments yeast and can be scparaicd by chroroalogrs phy bur needs 19 be stained with a substance nat dependent ‘on reducing properties.