Microscopic Examination of Urine

Prepared by: Kim J. Tagoctoc, RMT

 Learning Objectives:

List the physical and chemical parameters included in macroscopic urine screening and
state their signi cance
Describe the recommended methods for standardizing specimen preparation and
volume, centrifugation, sediment preparation, volume and examination, reporting of
results
Di erentiate between normal and abnormal sediment constituents
Discuss the signi cance of the cells, casts and crystals
Correlate physical and chemical urinalysis results with microscopic observations and
recognize discrepancies
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MICROSCOPIC EXAMINATION OF URINE

The third part of routine urinalysis is the

microscopic examination of urine.

It is the least standardized and most time-

consuming part of the routine urinalysis.

PREPARATION AND EXAMINATION OF ADDIS COUNT

THE URINE SEDIMENT
Normal Values:
The rst procedure to standardize the
quantitation of formed element in the urine • RBCS- 0- 500,000
microscopic analysis was the Addis count.
• WBC and Epithelial Cells- 0-1,800,000
The specimen of choice is a 12-hr urine.
• Hyaline Cast- 0-5000
Addis count was used primarily to monitor
the course of diagnosed causes of renal
disease.
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 SPECIMEN PREPARATION
• Specimen should be examined fresh or
adequately preserved.
• Sediments disintegrate in dilute alkaline
urine.
• Refrigeration may cause the precipitation
of amorphous urates and phosphates.
Warming the specimen to 37’C may
dissolve some of these crystals.
SPECIMEN VOLUME
Standard volume: 10-15 ml
Average volume: 12 ml
Centrifugation:
400 RCF for 5 minutes
Sediment volume: 0.5 - 1.0 mL
Volume of Sediment (Conventional
Glass Slide): 0.02 ml (20 uL)

 CORRELATION OF RESULTS

 EXAMINING THE SEDIMENT

Observation is done of a minimum of 10 elds both low (10x) and high (40x) power.
LPO: detect casts and ascertain the general composition of the sediment
HPO: identi cation of the elements

REPORTING THE MICROSCOPIC EXAMINATION

MANNER OF REPORTING
RBC, WBC Average number per 10 HPF
CASTS Average number per LPF
SQUAMOUS EPITHELIAL CELLS Rare, Few, Moderate or many per LPF
TRANSITIONAL EPITHELIAL CELLS Rare, Few, Moderate, or many per HPF
RENAL EPITHELIAL CELLS Average number per 10 HPF
OVAL FAT BODIES Average number per 10 HPF
BACTERIA, YEAST Rare, Few, Moderate, or many per HPF
TRICHOMONAS Rare, Few, Moderate, or many per HPF
SPERMATOZOA Present (based on laboratory protocol)
MUCUS Rare, Few, moderate or many per LPF
NORMAL CRYSTALS Rare, Few, Moderate, or many per LPF
ABNORMAL CRYSTALS Average number per LPF
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REPORTING MUCUS CRYSTALS EPITHELIAL CELLS BACTERIA

RARE 0-1 0-2 0-5 0-10
FEW 1-3 2-5 5-20 10-50
MODERATE 3-10 5-20 20-100 50-200
MANY >10 >20 >100 >200

TERM DESCRIPTION

RARE (1+) PRESENT, BUT HARD TO FIND

ONE ( OR MORE) PRESENT IN ALMOST EVERY FIELD OF

FEW (1+)
VIEW
EASY TO FIND; NUMBER PRESENT IN FOV VAIRS,
MODERATE (2+)
“ MORE THAN FEW, LESS THAN MANY”

MANY (3+) PROMINENT; LARGE NUMBER PRESENT IN ALL FOVS

FOV IS CROWDED OR OVERWHELMED WITH THE

PACKED (4+)
ELEMENTS

SEDIMENT EXAMINATION TECHNIQUES

URINE SEDIMENT CONSTITUENTS

The normal urine sediment may contain a variety of formed elements

Commonly reported normal values (Strasinger, 7th Edition):

• 0-2 or 3 RBCs per hpf
• 0-5 to 8 WBCs per hpf
• 0-2 hyaline casts per lpf

URINE SEDIMENT CONSTITUENTS

1. Desquamated/spontaneously exfoliated epithelial lining cells of the kidney and lower

urinary tract
2. Cells of hematogenous origin (leukocytes and erythrocytes)

RED BLOOD CELLS

Microcytic and Crenated

RBCs

Dysmorphic RBCs
WHITE BLOOD CELLS
WHITE BLOOD CELLS

Hansel-stained eosinophils

RBCs and one WBC

WBCs with acetic acid
SQUAMOUS EPITHELIAL CELLS

Clump of Squamous Epithelial Cells with Folded Forms

KOVA-stained Squamous Epithelial Cells
TRANSITIONAL/UROTHELIAL EPITHELIAL
CELLS

Syncytia of Transitional Epithelial Cells Caudate transitional epithelial cells

RENAL TUBULAR EPITHELIAL CELLS

RTE Cells (Oval Distal Convoluted Tubule Cells)

Oval Fat Bodies

RTE Cells (Cuboidal from Collecting Duct)

EPITHELIAL CELLS
BACTERIA

KOVA-stained Bacteria
Rod-shaped Bacteria

YEAST

Budding Yeast
PARASITE

Trichomonas vaginalis

Schistosoma haematobium ova

Enterobius vermicularis ova

 Mucus threads

Spermatozoa
MISCELLANEOUS STRUCTURES
 FREQUENTLY CONFUSED URINARY SEDIMENTS

DIFFERENTIATING
SEDIMENT SOURCES OF ERROR REMEDY
CHARACTERISTICS

YEAST RBCS DO NOT EXHIBIT

RED BLOOD CELL OIL DROPLETS BUDDING, NOT REFRACTILE ADD ACETIC ACID
AIR BUBBLES AND APPEARS ONLY IN THE * LYSE RBCS
SEDIMENT PLANE * YEAST, OIL DROPLETS AND
RBCS ARE SMALLER THAN WBCS ARE INTACT
CRENATED RBCS GRANULES OF WBC
WBCS

RTE CELLS ARE LARGER WITH

RENAL TUBULAR EPITHELIAL SUPRAVITAL STAINING OR
WHITE BLOOD CELL AN ECCENTRIC NUCLEUS
CELLS ACETIC ACID
WBCS IN AMEBOID MOTION
HAVEFOR
LOOK AN IRREGULAR SHAPE
THE PRESENCE OF
FOLDED SQUAMOUS
CAST NUCLEUS OR CAST MATRIX IN
EPITHELIAL CELLS
ORDER TO DIFFERENTIATE THE
TWOEPITHELIAL
TRANSITIONAL
SPHERICAL TRANSITIONAL RENAL TUBULAR EPITHELIAL
CELLS HAVE CENTRALLY SUPRAVITAL STAIN
EPITHELIAL CELLS CELLS
LOCATED NUCLEUS
BOTH CAN POLARIZE LIGHT.
STARCH AND CRYSTAL
FREE-FAT DROPLETTS THE MANNER OF COLLECTION
DROPLETS
SHOULD BE NOTED.

 FREQUENTLY CONFUSED URINARY SEDIMENTS

DIFFERENTIATING
SEDIMENT SOURCES OF ERROR REMEDY
CHARACTERISTICS

AMORPHOUS PHOSPHATES OBSERVE FOR BACTERIAL USE OF PHASE CONTRAST

BACTERIA
AND URATES MOTILITY MICROSCOPY

YEAST EXHIBIT BUDDING ADD ACETIC AICID TO LYSE THE

YEAST RBCS
WHILE RBCS DO NOT RBCS

OBSERVE FOR MOTILITY AND

USE OF PHASE CONTRAST
TRICHOMONAS WBCS, RTE CELLS THE PRESENCE OF FLAGELLA
MICROSCOPY
AND UNDULATING MEMBRANE

CLUMPS OF MUCUS USUALLY

MUCUS HYALINE CAST HAVE AN IRREGULAR
APPEARANCE
 CAST
-unique to the kidney
-cylindruria- refers to the presence of casts
-examination is done in low-power
magnification, subdued light and at the edges
of cover slip
-use high power to identify the composition
-reported as average number per 10 lpfs
-cylindroids- have the same significance as
hyaline cast

 CAST COMPOSITION AND FORMATION

1. Aggregation of uromodulin protein into
individual protein fibrils attached to RTE cells
2. Interweaving of protein fibrils to form a loose
fibrillar network
3. Further protein fibril interweaving to form a
solid structure
4. Possible attachment of urinary constituent to
the solid matrix
5. Detachment of protein fibrils from epithelial
cells
6. Excretion of cast

HYALINE CAST

HYALINE CAST (A) HYALINE CAST (B) AMORPHOUS URATES

RBC CAST

KOVA-stained RBC cast

WBC CAST

WBC CAST WBC CLUMP

BACTERIAL CAST
EPITHELIAL CELL CASTS

RTE Cell Cast RTE Cast with bilirubin-stained cells

FATTY CASTS
MIXED CELLULAR CASTS
GRANULAR CASTS

Finely Granular Cast Granular Cast

WAXY CASTS

Granular cast degenerating into waxy cast Waxy cast

BROAD CASTS
 These structures are rarely of clinical signi cance. The primary reason for the
identi cation of urinary crystals is to detect the presence of few abnormal types.

FORMATION:

• Formed from the precipitation of urine solutes such as inorganic salts,

organic compounds, and medications (iatrogenic compounds)
URINARY • Temperature, solute concentration and pH a ects the precipitation of these
CRYSTALS crystals.

GENERAL IDENTIFICATION TECHNIQUES

• The most valuable initial aid for identifying crystals in a urine specimen is the
pH.

• Crystals are routinely classi ed as normal or abnormal, also their

appearance in acidic or alkaline urine. Another aid for classi cation is the
polarization characteristics of crystals under polarized light.

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NORMAL CRYSTALS IN
ACIDIC URINE
NORMAL CRYSTALS SEEN IN ACIDIC URINE

AMORPHOUS URATES
• Appear yellow-brown granules
• Occurs in clumps that resemble granular
casts
• Frequently encountered in refrigerated
specimens but disappear when the urine
is warmed
• Uroerythrin- pink pigment that causes a
pink color on the surface of the granules
• Found in acidic urine with pH greater
than 5.5

NORMAL CRYSTALS SEEN IN ACIDIC URINE

URIC ACID CRYSTALS

• Seen in variety of shapes: rhombic, four-
sided flat plates (whetstones), wedges
and rosettes
• Appears yellow-brown but may be
colorless
• Similar to cystine but highly birefringent
• Associated with increased levels of
purine metabolism and nucleic acids
• Appears in the urine with pH less than 5.5

URIC ACID CRYSTALS UNDER POLARIZED LIGHT

NORMAL CRYSTALS SEEN IN ACIDIC URINE

ACID URATES AND SODIUM

URATES
• Seen in less acidic urine
• Acid urates appear as larger
granules
• Sodium urate have needle shaped
and can be found both synovial
fluid and urine

SODIUM URATE CRYSTALS

NORMAL CRYSTALS SEEN IN ACIDIC URINE

CALCIUM OXALATE
• Seen frequently in acidic urine, found also
in neutral and even alkaline urine
• Dihydrate- most common form
• Colorless, octahedral envelope or as two
pyramids joined at their base
• Monohydrate- oval or dumbbell shaped,
birefringent
• Presence in ethylene glycol poisoning
(antifreeze)
• May be associated with renal calculi;
foods high in oxalic acid , such as
tomatoes , asparagus; ascorbic acid
SODIUM URATE CRYSTALS

NORMAL CRYSTALS IN
ALKALINE URINE
NORMAL CRYSTALS SEEN IN ALKALINE URINE

AMORPHOUS PHOSPHATES
• granular
• causes white precipitation on
refrigerated samples that is NOT
dissolve on warming

NORMAL CRYSTALS SEEN IN ALKALINE URINE

TRIPLE PHOSPHATES
• ammonium magnesium
phosphates
• coffin lid/ prism shape
• Birefringent
• Seen in highly alkaline urine
associated with urea-splitting
bacteria

NORMAL CRYSTALS SEEN IN ALKALINE URINE

CALCIUM PHOSPHATES

• appear colorless, flat rectangular

plats or thin prisms in rosette
forms
• confuse with sulfonamides
• common constituent of renal
calculi

NORMAL CRYSTALS SEEN IN ALKALINE URINE

CALCIUM CARBONATE

• small, colorless with dumbbell or

spherical shapes
• Occur in clumps that resemble
amorphous material
• birefringent

NORMAL CRYSTALS SEEN IN ALKALINE URINE

AMMONIUM BIURATE

• yellow-brown
• “thorny apples” because of their
spicule-covered spheres
• Dissolved at 60’C and convert to
uric acid when treated with glacial
acetic acid
• Seen frequently in old specimens

ABNORMAL URINE CRYSTALS

CYSTINE CRYSTALS
• colorless, hexagonal plates, may be
thick or thin
• seen in cystinuria

ABNORMAL CRYSTALS
 ABNORMAL URINE CRYSTALS
CHOLESTEROL CRYSTALS
• usually seen in refrigerated specimens
because the lipid remains in droplet
form
• Appears rectangular plate with a notch
in one or more corners
• Highly birefringent and polarized light

ABNORMAL URINE CRYSTALS

RADIOGRAPHIC DYE CRYSTALS
• highly birefringent

ABNORMAL URINE CRYSTALS

SULFONAMIDE CRYSTALS
• seen in patients being treated with UTI

• inadequate patient hydration is the primary

cause of sulfonamide crystallization
• seen as needles, rhombics, whetstones,
sheaves of wheat, and rosettes with colors
ranging from colorless to yellow-brown

ABNORMAL URINE CRYSTALS

AMPICILLIN CRYSTALS
• present in large doses of penicillin
compound
• Colorless needles that tend to form
bundles

CRYSTALS ASSOCIATED WITH LIVER DISORDERS

TYROSINE CRYSTALS
• fine, colorless to yellow needles that forms
clumps or rosettes

CRYSTALS ASSOCIATED WITH LIVER DISORDERS

LEUCINE CRYSTALS

• Yellow-brown spheres with concentric

circles and radial striations

CRYSTALS ASSOCIATED WITH LIVER DISORDERS

BILIRUBIN CRYSTALS
• Clumpled needles or granules with the
characteristics yellow bilirubin

• sen in patients with hepatic disorders

ARTIFACTS
 URINARY SEDIMENT ARTIFACTS

Commonly encountered artifacts:

• Starch

• Oil droplets

• Air bubbles

• Pollen grains

• Fibers

• Fecal contamination

 STARCH GRANULES
• occurs from contamination by powder
used in gloves
• Appears highly refractile and has a
dimpled center
• Produce maltese cross formation

Starch Granules

 OIL DROPLETS AND AIR BUBBLES

• highly refractile and may resemble RBCs

• Oil droplets occur from immersion oil or

lotions and creams
• Air bubbles occur when specimen is
Oil droplets
placed under a cover slip

AIR BUBBLES

 POLLEN GRAINS
• seasonal contaminants that appears
spheres with cell wall and occasional
concentric circles

 HAIR AND FIBERS

• contaminants from clothing and diapers

• usually longer and more refractile

FIBER AND SQUAMOUS EPITHELIAL CELL

 FECAL ARTIFACTS
• indicates improper collection or the
presence of stula between intestinal and
urinary tracts
• appears as plant and meat bers

Vegetable ber
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REFERENCES:

• McPherson, Richard A., Pincus, Matthew R.. (2007). Henry's Clinical Diagnosis and
Management by Laboratory Methods 2 : Twenty-First Edition (21). : Saunders Elsevier.
• Strasinger, S.K. and Di-Lorenzo, M.S. (2008) Urinalysis and Body Fluids. 5th Edition, F. A.
Davis Company, Philadelphia.