ANALYSIS OF URINE AND OTHER BODY FLUIDS MIDTERM REVIEWER

Microscopic Examination of Urine

MICROSCOPIC EXAMINATION OF URINE  pH is a key variable in determining the

 Examines formed element found in the urine
sediments, thus, this procedure confirms what is
found in the physical and chemical phase of urine
examination.
 Urine sediments is a vital specimen used in the
microscopic examination wherein this can confirm the
disease based on the markers found in the physical
and chemical examination of urine.
crystal present in a urine specimen.
o Micro-organisms – Bacteria is common in
patients with UTI; Parasites: T. vaginalis, D.
renale, T. trichiuria (contaminant), Trichomoniasis
(urine is a common sample used of both genders
for the evaluation of such parasite)
o Miscellaneous materials – sperm (usually seen
in males and reporting of such depends on the
SOP of the hospital; appearance of such in
females should not be reported for it is not related
to any pathologic conditions)

URINE ANALYSIS REPORTING

MICROSCOPIC QUANTITATIONS

Urine Sample – 45-50 mL

 Evaluation for feasibility and validity for urinalysis:
a. Label should be checked and should match the
requisition form;
b. Recorded in the laboratory logbook; and
c. Examination for physical characteristics will
follow.
 PHYSICAL EXAMINATION (10-15 mL)
 Examination of color and clarity
 CHEMICAL EXAMIANTION
 Presence of dissolved substances
 Centrifugation process for 400 rcf for 5 minutes
where sediments is obtained for Microscopic NOTES:
examination Epithelial cells are reported by either semi-quantitative
 Sediment is about 0.5-1.0 mL in volume and around (None, Rare, Few, Moderate and many) or quantitative
20 μL is taken from that of the volume for microscopic
examination.
when accounted into figures. Certain hospitals have a
 MICROSCOPIC EXAMINATION (20 μL) protocol of using semi-quantitative reporting when using
the Low Power Field (LPF).

 Formed element to be seen in urine: Cast – High Power Objective is used when identifying it
o Cells – RBC, WBC, Epithelial Cells while Low Power Objectives is used when reporting it.
o Cast – has relation to pathologic conditions (RBC
Cast seen in glomerulonephritis; WBC Cast seen I. CELLULAR STRUCTURES
in pyelonephritis; Broad cast in renal failure) and
physiologic conditions (Hyaline Cast: increased in
stress and extraneous exercises)
o Crystals – Calcium oxalate crystal in seen in
normal urine; Uric acid crystals and Bilirubin
crystals are signs of pathologic condition.
 Crystals may form in an acidic or alkaline
urine:
a. Calcium oxalate crystals in
normally seen in an acidic or
nearly neutral urine. NOTE:
b. Ammonium Biurate is seen in Never report that there is no RBC seen in urine
alkaline urine. specimen. Normal reporting is 0-2/HPO.

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Unpreserved Urine Sample
 RBC appear to be swollen (hypotonic) – hgb content
of the cell is dissolved out referred to as SHADOW
CELL where RBC’s biconcave appearance is not
anymore seen.

2 Morphological appearance of RBC that is pathologic

 Dysmorphic – irregular borders
 G1 Cells is a RBC that has a biconcave appearance
with irregular borders which is related to renal
problems; more specific than dysmorphic red blood
cells. NOTE:
Macroscopic Hematuria – it is being observed even just
Dilute Urine in the conduct of Gross examination of urine. The
 RBC appear to be swollen (hypotonic) – hgb content examination of physical attributes of urine is an example of
of the cell is dissolved out referred to as GHOST CELL macroscopic hematuria.
where RBC’s biconcave appearance is not anymore
seen. Hematuria is possible even the urine’s color is not red.

Microscopic Hematuria – excessive amount of RBC in

RBC without biconcave the urine is only seen by the conduct of microscopic exam.
Normal

Crenate RBC

NOTE:
oil Appearance of infarctions, trauma or tumor can cause
lacerations within nearby tissues causing bleeding, as a
result, RBC is seen in the urine.
Miscellaneous
bubbles

NOTE:
To determine RBC well and differentiate it with other
structures or artifacts, you just need to adjust the rheostat
of the microscope. Also, the size of the RBC is smaller than
that of bubbles and oil.

Bubbles and oil seen in urine specimen are contaminants.

Calcium oxalate crystal is commonly mistaken as RBC. NOTE:

To differentiate such, the use of acetic acid is needed. (2%) This can cause damages to the adjacent tissues causing
Acetic acid has the capacity to lyse RBC while is only allow bleeding in the urinary tract resulting to hematuria.
Calcium oxalate to remain.

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NOTE:
Salpingitis – inflammation of the fallopian tube
Diverticulitis – inflammation of the diverticulum
Malaria – much related to hemoglobinuria
NOTE:
Pyuria – WBC appearance in the urine.
Neutrophil/Polymorphonuclear cells – most common
WBC seen in urine. Its presence in the specimen suggest
infection and other diseases.
WBC is mistaken to be epithelial cells and v.v.
The positivity of Leukocyte esterase suggests the
appearance of WBC but Nitrite doesn’t always suggest
such. The positivity of Nitrite depends on the
microorganism that causes the UTI.
The negativity of Nitrite doesn’t always rule out UTI.
WBC is seen to be:
 Granulated.
 Glitter cells during hypotonic because of the
Brownian movement of the granules.
 Renal tubular epithelial cells are bigger than
WBCs, no granulation, nucleus is not
lobulated
Purplish in appearance – stained WBC
NOTE:
Gross pyuria – rupture of renal or urinary tract abscess.
It is the excessive appearance of WBC in the urine
sediment but not used as a sole indication of UTI.
Stains used for Eosinophils
 Wright’s
 Diff-quik
 Papanicolaou stain
 Hansel stain (most common stain for eosinophil)
Mononuclear cells – seen in early transplant rejection
and may require cytodiagnostic testing.
 RTE cell – related to renal problem/failure that
needs transplantation; it is a significant epithelial
cell that has not to be mistaken as WBC.
 WBC – it is treated with antibiotics
EPITHELIAL CELLS
 Squamous EC – has largest size, most commonly
seen, least clinical significance, contaminant.
 Urothelial EC – linings of urinary tract.
 RTE – most significant related to renal failure.
Squamous epithelial cell – stained using violet
safranin, Purple nuclei, pink to violet cytoplasm. *SEC
become clinically significant by the presence of
Gardnerella vaginalis that may be embedded on the
surface of squamous epithelial cell termed as clue cell
– seen not in the urine but in the vaginal wet
preparation.
Transitional epithelial cells – spherical when they
absorbed water in the bladder, caudate (teardrop
appearance if they are seen to have a tail, polyhedral
if it has multiple sides. These morphological
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 appearance is seen when the bladder is filled or
emptied with urine.
Point of Differentiation from RTE Cells
1. TEC has a nucleus that is centrally located
compared to RTE cells.
2. Smaller than SEC (40-200 μm).
3. Round or pear shaped with a round centrally
located nucleus (occasionally binucleated
forms may be seen.)
4. When stained, TEC appear to be:
 Dark blue nuclei
 Pale blue cytoplasm
RTE cell – has a great clinical significance
 Columnar: PCT – largest RTE Cells, has a
columnar or rectangular appearance, has
granules in the cytoplasm, nuclei are present.
 Round or oval: DCT – spherical appearance,
eccentric nucleus compared to RTE Cell.
Comparison of RTE and WBC
 Size: RTE Cell is larger than WBC
 Granulation: WBC has granulations
 Globulation: WBC Nuclei is globulated
 Cuboidal: Collecting Duct – eccentric nucleus,
cuboidal appearance, maybe seen individually or
in clump (no shape).
OVAL FAT BODIES
Renal Tubular Epithelial cells that absorbed lipoproteins,
determine using Sudan III or Oil Red O stain (stains used
in lipids)
OFB is observed when a person has nephrotic
syndrome. Patient’s urine is turbid and lipiduria.
CASTS – may vary depending on its classification formed
in kidney.
 Matrix cast – only matrix is being observed. Waxy
cast also known as broad cast associated with
renal damage.
 Inclusions cast – granules, fat globules, etc.
 Pigments
 Cells – Telescope sediment or nobecula; RBC,
WBC and RTE cells are seen at the same time in
the sediment.
Known to have a rounded appearance or edges.
Must use reduced light to appreciate the appearance of
cast.
Cylindruria – appearance of cast in the urine.
Formed when there is urinestasis, matrix of the casts are
being secreted by the cells in the nephrons and will
interwebbed with each other to form the mold for the cast.
Some elements in the filtrate may be attached to the matrix
because of urinestasis – Tamm Horsefall Protein
(Uromodulin - comprise primarily the matrix for cast) – for
WBC cast.
Hyaline cast – youngest cast, no embedded materials.
Once it is embedded with RBCs and the like, it becomes
cellular cast and must be identified.
Cellular cast may be disintegrated to granular cast leading
into a waxy cast wherein waxy cast appearance indicates
that there is an extreme hypostasis. Waxy cast – oldest
cast.
 Hyaline cast – low refractive index (examined in
reduced light), colorless, related to strenuous
activities and stress (contribute to its increase),
renal problems.
 RBC cast – check the surrounding of the cast,
nearest cell determines the type cast. Orange red
and related to glomerulonephritis.
 WBC cast – related to pyelonephritis, marker on
differentiating upper (pyelonephritis) and lower
(cystitis) UTI – WBC is seen in pyelonephritis and
not in cystitis. Cast is formed in the kidney and the
occurrence of UTI in the kidney will build up the
tendency of the WBC to embed in the cast, leading
to Cylindruria, which indicates that the presence of
it in the urine suggests that there is
pyelonephritis (inflammation of the renal
tubules).
Composed of neutrophil (primarily). If stained, it
can appear into purplish appearance. WBC cast
(has matrix) is different form WBC clump (no
definite shape).
 Bacterial cast – suggestive of UUTI (Upper UTI).
Hardly identified with the granular cast. Perform a
gram staining to determine if it is a bacterial cast.
Gram positive: purplish; Gram negative:
pinkish or reddish.
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  RTE Cell cast – stained: purplish, related to renal
problems.
 Granular cast – (formerly cellular cast)
disintegrated cellular cast. Seen in strenuous
exercise and metabolic processes:
o Coarse granular cast
o Finely granular cast
 Waxy cast – better visualize when staining
procedure is performed. Related to extreme
urinestasis (hypostasis) and renal failure. Oldest
cast. Granular cast disintegrated into waxy cast
because of reduce urine flow.
 Broad cast – large cast that are suggestive of
renal damage and destruction of DCT may occur.
Granular and waxy cast are the most common
to become a broad wax. All types may become
broad depending on the stasis condition.
MISCELLANEOUS STRUCTURES
 Bacteria – rod shaped are commonly seen in the
urine (bacilli), cocci – both can cause UTI. Nitrite
is used to confirm the presence of bacilli as the
causative agent of UTI. Cocci is not capable
enough to reduce nitrate to nitrite.
WHAT IS THE NEXT THING TO BE DONE
WHEN THERE IS A PRESENCE OF BACTERIA
IN THE URINE SEDIMENT?
 Yeast – observed in person with DM,
immunocompromised, vaginal moniliasis.
There are instances that in DM, the presence of
fungal element is seen (Candida albicans).
2 conditions that hasten the growth of fungi in the
genitalia
1. Acidic pH – ketoacidosis improves the
acidity of the area.
2. Increased glucose level
In chemical examination, yeast may cause a
positive result of the leukocyte esterase because
WBC need to respond to this type of infection
while nitrite will be tested negative because yeast
doesn’t have the capacity to reduce nitrite to
nitrate.
Yeast maybe mistaken as RBC, for differentiation,
observed for the appearance of budding.
WBC is present but nitrite is negative.
 Parasites – Schistosomes, Trichomonas (most
commonly observed and can be mistaken as
WBC, RTE cells if not moving), Dioctophyma
renale. Enterobious vermicularis is a contaminant
when seen in the urine of a person.
 Spermatozoa/sperm cells – tapered heads and
long tail. In the chemical examination, sperm can
cause positive protein result in the chemical
examination. Reporting of such depends on the
SOP of the hospital. Head is mistaken as blood
cells.
 Mucus – produced by RTE, glands and squamous
cells. They appear like threadlike in the urine, has
low refractive index and it is longer than casts.
 Urinary sediment artifacts – fibers must be in the
stool and if seen in the urine, it is known as a
contaminant; starch (gloves); oil droplets (oil
immersion); bubbles (cover slip); pollen grain
(seasonal contaminant).
CRYSTALS – not clinically significant but reported. Its
formation depends on the (pH) acidity, electrolytes or
presence of salts and urinestasis.
o Normal crystals – maybe seen in an acidic or
alkaline urine
o Abnormal crystals – seen only in an acidic urine.
pH affects crystal formation
 Ammonium biurate – cannot be seen in an
acidic urine, formed only in an alkaline urine.
 Uric acid crystals – must be acidic urine
Crystal formation – precipitation of urine solutes, some
are formed during refrigeration (amorphous urates).
Polarized microscope can be used in identifying crystals.
Normal crystals in acidic urine
o Amorphous urates – yellow brown (it appears to
be in brick dust appearance when refrigerated),
pH usually greater than 5.5. Upon the addition
of hydrochloric acid, it can turn into a uric acid.
o Uric acid – rosette shape or flower like formation.
May resemble cysteine crystals but always
polarize. Yellow-brown color. Can be formed
when amorphous urate is added with acid as a
reagent. Seen in pH of less than 5.5.
TECHNICALLY, it is commonly seen in the normal
urine of a person.
o Calcium oxalate – seen in an acidic or neutral pH
urine. May have a two morphological appearance:
pyramid or enveloped appearance known as
johnisaacreyesvalle
 dihydrate calcium oxalate. Monohydrate if it is o Cholesterol crystals – related to Lipiduria.
oval or dumbbell shaped and misidentified as rbc. Known to have a notched corners and broken
Wedelyte (dehydrate); wewelyte glass appearance, staircase pattern, highly
(monohydrate). Increased if a person has taken birefringent in polarizing microscopy
lots of Vitamin C (normal).  Nephrotic syndrome – breakdown of the
glomerular filtration barrier.
Normal crystals in alkaline urine  Nephritic syndrome – is related to an
o Amorphous phosphate – yellow brown and allergic induced inflammation of tubules.
white precipitate if refrigerated. Formed in an
alkaline urine of a patient. Nephrotic syndrome Nephritic syndrome
o Triple phosphate – coffin-lead appearance. Also Breakdown of GFB Allergic induced
known as Manila City Hall Crystal and inflammation of tubules
scientifically known as Strovite. It is related to UTI Lipiduria occurs Appearance of increased
eosinophil
and seen in an alkaline urine of a person. Can be Albuminuria (Albumin Not related to edema
observed using polarizing microscopy. wasting) resulting to edema
o Calcium Phosphate – flat rectangle, no clinical (accumulation of water in
significance the tissues)
o Calcium Carbonate – small, dumbbell, and
spherical shaped. No clinical significance. Liver Disease Crystals
Capacity to produce lots of gases when acetic acid o Tyrosine crystals – needle or rosette shaped
is added to the urine sample. appearance, related to aminoacidopathy
o Ammonium biurate – the only urate crystal that (emanating from your liver damage).
is seen in alkaline urine of a patient. Yellow brown o Leucine crystals – spherical shaped with radial
spicule covered spheres, old specimens and with striations, yellow brown
urea spitting bacteria. Thorny apple appearance o Bilirubin crystals – clumped needles or granules,
yellow color
Major Characteristics of Normal Urinary Crystals
o URINARY TRACT INFECTION
o *These crystals are formed when the patient is taking
o drugs to treat UTI
o Sulfonamide crystals – sheaves of wheat
appearance.
o Ampicillin crystals – needle formation when
urine is refrigerated.

Major Characteristics of Abnormal Urinary Crystals

o
o

Abnormal crystals
o Cysteine crystals – (6) hexagonal appearance,
seen in cases of cystinuria (appearance of cystine
amino acid in the urine, technically an
aminoacidopathy – problem in the metabolism of
cystine proteins secreted in the filtrate), mimics
uric acid crystals.

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