AUB

CLSI definition of urinalysis

“the testing of urine with procedures
commonly performed in an expeditious,

HISTORY
reliable, safe, and cost-effective
manner”
Analyzing urine = the beginning of laboratory medicine
Importance
• Cavemen drawings and Egyptian hieroglyphics
1. Readily available, easily collected specimen
– Observations: Color, clarity, odor, viscosity, sweetness
2. Contains information, which can be obtained
• 5th century BC: Hippocrates wrote uroscopy book by inexpensive laboratory tests, to assess
many metabolic functions
• AD 1140: Color charts; 20 colors
• 1694: Frederik Dekkers: Albumin (albuminuria) determination by “boiling” • Reasons to perform:
- Aids disease diagnosis
• Charlatans – aka “pisse prophets” - Screens for asymptomatic diseases
– 1627: Thomas Bryant published a book - Monitors disease progress & therapy
effectiveness
→ Inspired the First medical licensure laws
• 17th century: Microscope
– Evaluation of sediment
– Thomas Addis: methods for quantitating the microscopic sediment
• 1827: Richard Bright: urinalysis as part of a routine physical exam

URINE
URINE FORMATION URINE FORMATION
collecting ducts --> renal pelvis --> ureters -->
• Kidneys form urine as an ultrafiltrate of plasma
urinary bladder --> urethral voiding (micturition)
• Reabsorption of water and filtered substances converts approximately 170,000 mL of filtered
plasma to the average daily urine output of 1200 mL. (Refer to next lesson).

URINE COMPOSITION PRIMARY COMPONENTS OF NORMAL URINE

• Normal: 95% water, 5% solutes Urea - from protein & amino acid breakdown
• Solute variations: diet, activity, metabolism, endocrine, body position Creatinine - from creatine metabolism (muscles)
• Organic substances: Urea, Creatinine, Uric acid Uric acid - from nucleic acid breakdown
Chloride - found in combination with sodium
– Primary organic component: Urea and other inorganic substances
• Inorganic solids: Chloride, Sodium, and Potassium Sodium - varies by intake
– Primary inorganic component: Chloride Potassium - combined w/ chloride & other salts
Phosphate - combined w/ sodium; blood buffer
• Indicative of disease: presence of cells, casts, crystals, mucus, bacteria
Ammonium - regulates blood & tissue fluid acidity
Calcium - combined w/ chloride, sulfate, and
Phosphate
URINE VOLUME

• Determined by body’s state of hydration

• Influenced by fluid intake, nonrenal fluid loss, antidiuretic hormone (ADH) variations, Technical tip
excretion of large amounts of dissolved solids (e.g., glucose) If needed to verify whether a fluid is urine or
not, test for urea and creatinine content.
• Usual daily volume = 1200 – 1500 mL
• Normal range = 600 – 2000 mL Reason:
Both of these substances are present in higher
concentrations in urine than in other body fluids

TER DEFINITI
MS ONS
• Oliguria – decrease in urine output
* Infants: less than 1 mL/kg/hr Polyuria of DI vs Polyuria of DM

* Children: less than 0.5 mL/kg/hr → meaning:

* Adults: less than 400 mL/day in increased water
intake
- Causes: dehydration (from vomiting, diarrhea, perspiration, or severe burns)

• Anuria – cessation of urine flow

- Causes: 1. serious kidney damages
2. decreased renal bloodflow

• Nocturia – increased urine excretion at night * Normally, kidneys excrete 2x or 3x more urine → both: diluted ←
during the day than during the night
• Polyuria – increased daily urine volume
* Adults: more than 2.5 L/day
* Children: 2.5 to 3 mL/kg/day
- Causes: 1. diabetes insipidus (DI) and diabetes mellitus (DM)
2. artificially induced (by diuretics, caffeine, or alcohol)
→ suppress the secretion of antidiuretic hormone

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AUB

SPECIMEN HANDLING
SPECIMEN COLLECTION

• Clean, dry, leak-proof containers

- flat-bottomed = avoid overturning
– Recommended: Disposable, wide-mouthed, and flat-bottom w/ screw caps
- screw caps = less likely to leak than snap tops
• Clear containers/at least 50 mL capacity - wide-mouthed = to facilitate women
– Facilitates automated analysis - clear = to see specimen’s color and clarity
– 12 mL minimum for analysis
• Individually-packaged sterile containers for microbiologic studies and if
more than 2 hours elapse between collection and analysis
• Adhesive bags for pediatrics
• Large plastic containers for 24-hour specimens

SPECIMEN LABELING

• Information on label: Patient’s name, ID number, date, time

• Additional information: age, location, health-care provider’s name
• Placed on container, NOT on the lid
• Requisition form (manual or computerized)
– Must accompany specimen
– Information must match label
– Time of receipt is stamped on requisition
– Other information: method of collection, type of specimen, interfering medications

SPECIMEN REJECTION
• Unlabeled
• Nonmatching labels and requisition forms
• Contaminated with feces or toilet paper
• Contaminated exteriors
• Insufficient specimen quantity
• Improperly transported
• Labs must have written policies for rejection of specimens

SPECIMEN INTEGRITY
Changes in urine composition take place not only in vivo but also in vitro
• Test within 2 hours
• Refrigerate or chemically preserve if testing is delayed
• Most problems are caused by bacterial multiplication
• Increased: color, turbidity, pH, nitrite, bacteria, odor
• Decreased: glucose, ketones, bilirubin, urobilinogen, RBCs, WBCs, casts

Changes in unpreserved urine:

Analyte: Change: Causes:
Darkened/
Color Oxidation or reduction of metabolites
Modified
Bacterial multiplication causing breakdown of
Odor Increased
urea to ammonia
Breakdown of urea to ammonia by urease
pH Increased
producing bacteria/loss of CO2
Bacterial growth and precipitation of
Clarity Decreased
amorphous material

Glucose Decreased Glycolysis and bacterial use

Ketones Decreased Volatilization and bacterial metabolism
Bilirubin Decreased Exposure to light (photooxidation to biliverdin)
Urobilinogen Decreased Oxidation to urobilin
RBCs, WBCs,
Decreased Disintegration in dilute alkaline urine
and casts
Trichomonas Decreased Loss of motility, death
Nitrite Increased Multiplication of nitrate-reducing bacteria
Bacteria Increased Multiplication

SPECIMEN PRESERVATION

• Routine: Refrigeration at 2°C to 8°C Technical tip

– Decreases bacterial growth and metabolism Must return to room temp because the enzyme
– Must return to room temperature for chemical testing reactions on the strips perform best at room
temp
• Culture: refrigerated during transit and kept refrigerated until cultured up to 24 hours
• Chemical preservative
– Ideal: bactericidal, inhibits urease, preserves formed elements
– Should not interfere with chemical tests
• Commercial transport tubes are available, but they must be compatible with tests

Prepared by: Angel Cris A. Aguirre

AUB

Preservatives Advantages Disadvantages Additional Information

Refrigeration - Does not interfere w/ chemical tests - Precipitates amorphous phosphates and - Prevents bacterial growth for 24
urates hours
Boric Acid Prevents bacterial growth and - Interferes with drug and hormone - Keeps pH at about 6.0
metabolism analyses - Can be used for urine culture
transport
Formalin - Excellent sediment preservative - Reducing agent - Rinse specimen container with
(formaldehyde) (interfering with chemical tests for formalin to preserve cells and casts
glucose, blood, leukocyte esterase, and
copper reduction)
Sodium Fluoride - For drug analyses - Inhibits reagent strip tests for glucose,
blood, and leukocytes
Commercial - When refrigeration is not possible - Check tablet composition to know
preservative tablets - Have controlled concentration to possible effects on desired tests
minimize interference
Urine Collection Kits - Contains collection cup, transfer
(Becton Dickinson, straw, culture& sensitivity (C&S)
Rutherford, NJ) preservative tube, or UA tube
Light gray and gray - Sample stable at room temp (RT) for - Do not use if urine is below minimum - Preservative: boric acid, sodium
C&S tube 48 hours; prevents bacterial growth fill line borate and sodium formate.
and metabolism - Keeps pH at about 6.0
Yellow UA Plus tube - Automated instruments - Must refrigerate within 2 hours - Round or conical bottom
- No preservative
Cherry red/yellow - Stable for 72 hours at RT - Must be filled to minimum fill line - Round or conical bottom
Preservative Plus - Instrument-compatible - Bilirubin and urobilinogen may be - Preservative: sodium propionate,
tube decreased if specimen is exposed to light ethyl paraben, and chlorhexidine
and left at RT

TYPES OF SPECIMEN
Type of specimen
Random
First morning
Fasting
24-hour (or timed)
Catheterized
Midstream clean-catch
Suprapubic aspiration
Three-glass collection
Purpose Special conditions
- Routine screening time, length, method of collection, and
patient’s dietary and medicinal intake
- Routine screening
- Pregnancy tests important: instruct patients when
- Orthostatic protein confirmation they must follow special collection
procedure
- Glucose monitoring
- Quantitative chemical tests
- Bacterial culture
- Routine screening
- Bacterial culture
Historical note
- Bladder urine for bacterial culture
- Cytology
- Prostatic infection

RANDOM SPECIMEN
• Most common type received
• Routine for obvious abnormalities
• Any time; Collection time must be recorded
• Dietary intake and physical activity may alter results
– Patient has to collect an additional specimen under controlled conditions

FIRST MORNING SPECIMEN

• Ideal screening specimen
– Patient is in a basal state
• More concentrated than a random specimen
• Patient collects immediately on arising, delivers to lab within 2 hours
– Refrigeration is an alternative

FASTING SPECIMEN
• Second specimen voided, collected after the first morning specimen
• Does NOT contain metabolites from evening meal

24-HOUR OR TIMED SPECIMEN

• Carefully timed = accurate quantitative results
• Good for diurnal variation solutes (catecholamines, electrolytes)
• Patient must remain adequately hydrated during short collection period
• Patient must be instructed on the collecting procedure
• Concentration of a substance in a particular period must be calculated from the urine volume
produced during that time

Prepared by: Angel Cris A. Aguirre

AUB
• Must be thoroughly mixed; volume must be accurately measured and recorded
• Multiple containers of the same collection must be combined and mixed thoroughly
• Additives should NOT interfere with the tests to be performed
• For measuring substances with diurnal variation (results differ in a.m. and p.m.) and substances that vary
with meals, activity, and body metabolism
• Shorter timed specimens can be used for substances with consistent levels
• Accurate timing is critical for accurate results

2-HOUR POSTPRANDIAL SPECIMEN

1. Patient voids before eating routine meal
2. Eats meal
3. Collects next specimen 2 hours after finishing meal
4. Monitors insulin therapy
5. Results can be compared with fasting urine specimen and blood test results

GLUCOSE TOLERANCE SPECIMEN

• Institutional option for collection with blood glucose tolerance test
• NOT frequently done
• Specimens are collected at the same intervals as the blood samples
• To correlate renal threshold with patient’s ability to metabolize glucose

GLUCOSE TOLERANCE SPECIMEN

• Sterile specimen collected from bladder with a hollow tube (catheter)
• Most common test is bacterial culture

MIDSTREAM CLEAN-CATCH SPECIMEN

• Alternative to catheterized specimen; Less traumatic method
• Less contaminated than routine collection
• Provide patient with mild cleansing material and container and instructions
• Do not touch or contaminate inside of container

SUPRAPUBIC ASPIRATION
• Completely free of contamination for culture and cytology
• External introduction of needle; aspiration from the bladder
• Possible pediatric specimen

PROSTATITIS SPECIMEN
• Collection similar to midstream clean-catch • Prostatic infection if…
• Three-glass collection • WBC/hpf count:
- Container 1: first urine passed *Quantitative cultures on all 3 specimens specimen 3 > specimen 1
- Container 2: midstream urine *Examine 1 and 3 microscopically for WBCs • Bacterial count:
- Massage prostate to obtain prostatic fluid specimen 3 > specimen 1 (10x)
- Container 3: remaining urine and fluid • Specimen 2 is a control for bladder or
kidney infection
• Pre- and postmassage test
• (+) culture in specimen 2 invalidates
- Specimen 1: midstream clean-catch specimen (+) culture in specimen 3 (can NOT
- Specimen 2: postmassage specimen differentiate UTI vs prostate
infection)
• Prostatitis is indicated by a quantitative culture result in the second glass that is 10 times higher
than specimen 1

PEDIATRIC SPECIMEN
• Soft, clear, plastic bags, with hypoallergenic tape applied to genital area
• Monitor bag frequently
• Clean-catch method with sterile bag – Cleaning for microbiology specimens
• Bags with tubes to a larger container – For timed specimens

DRUG SPECIMEN COLLECTION

• Proper collection, labeling, and handling must be documented • Points to consider:
• Chain of custody: documentation from the time of collection until the time of receipt of lab results – Photo ID of urine donor;
– Free of substitution, adulteration, or dilution or ID by employer
• Standardized form always accompanies specimen – No unauthorized access to specimen
• Specimen must withstand legal scrutiny
• Witnessed versus unwitnessed collection
– Determined by test orderer
– Both specimens must be handed immediately to collector
• Adulteration tests
– Temperature taken within 4 minutes must be 32.5°C to 37.7°C
– Report temperatures outside of range immediately
– Collect another specimen ASAP
– Inspect urine color for anything unusual

Prepared by: Angel Cris A. Aguirre

 AUBF | Physical Examination of Urine
Compiled by: Vienna Cari-cari
Red/ Pink/ Brown
• Common cause: Blood
• Pink = small amount of blood
• Brown = Oxidation of hemoglobin to methemoglobin
 Color = (fresh spx) Glomerular bleeding
 Odor
 Clarity/ transparency • Port wine-colored = Oxidation of porphobilinogen to
 Specific Gravity Porphyrias
 Volume
• Red = (cloudy) RBCs
IMPORTANCE = (clear) Hgb / Myoglobin
– Correlation with other chemical & microscopic results □ Hemoglobin
– Preliminary information of disorders like – in vivo lysis of RBCs
• Glomerular bleeding – px’s plasma = red
• Liver disease – for spx handling: consider in vitro lysis
• Inborn error of metabolism (IEM) □ Myoglobin
• UTI – breakdown of skeletal muscle
• Renal tubular function – (fresh spx) more reddish/brown
– px’s plasma = clear
COlOR
NORMAL: Light / Pale yellow, Yellow, Dark yellow Brown / Black
Substances responsible: • Additional testing for specimens that
• Urochrome – yellow pigment – Turn black after standing at room temperature
– Increased in: – Test negative for blood
□ thyroid disorders
□ fasting • Melanin
□ spx sits at room temp – Excess in malignant melanoma
• Uorerythrin – pink pigment – Oxidation of melanogen to melanin
– Attaches to amorphous urates formed in • Homogentisic acid
refrigerated spx – Black color in alkaline urine
• Urobilin – Alkaptonuria
– Oxidation of urobilinogen (normal constituent) • Medications, levodopa, phenol derivatives, flagyl
– Orange-brown in older spx

VARIATIONS Summary
Normal variations caused by: Abnormal variations caused by: Colorless - Common in random
- Normal metabolic functions - Bleeding
- Physical activity - Liver disease - Polyuria (DM and DI)
Pale yellow - Diluted random
- Ingested materials - Infection
- Pathologic conditions Dark yellow - normal: Concentrated
- abnormal: Bilirubin (indicates Hepa virus)
Amber
- Medications (ex: Acriflavine, Pyridium,
Dark Yellow/ Amber/ Orange Nitrofurantoin, Phenindione)
Orange
• Normal = Concentrated Yellow green /
- Bilirubin oxidized to biliverdin
• Abnormal = Bilirubin Yellow brown
→ Bilirubin indicates possible hepa virus Green - Pseudomonas aeruginosa infx
• Foam - Amitriptyline
– Bilirubin produces yellow foam when shaken - Methocarbamol (Robaxin)
– Normal urine =small amount of foam caused by protein - Clorets
Blue green - Indican
• Photooxidation of large amounts of urobilinogen - Methylene blue
→ no yellow foam when shaken - Phenol
• Photooxidation of bilirubin to biliverdin = Yellow-green - (cloudy) RBCs
- (clear) Hgb, Myoglobin
• Phenazopyridine (pyridium) or Azo-Gantrisin for UTI
Pink / Red - Porphyrins, Rifampin
produces thick orange pigment and yellow foam - Beets, Black raspberries nonpathogenic
→ no bilirubin - Menstruation
→ thick pigment is noticeable, obscures natural color,
and interferes with reagent strips - RBCs oxidized to methemoglobin,
Methemoglobin, Homogentesic acid
- Melanin or Melanogen
Brown /
Blue/ Green - Alkaptonuria
Black - Phenol derivatives, Argyrol (antiseptic)
• Pathogenic causes: Bacterial infections - Methyldopa (Levodopa)
– Urinary: Pseudomonas infection - Metronidazole
– Intestinal: causes increased urinary indican oxidizing to
indigo blue
Color and clarity procedure:
• Catheter bags: purple color from Klebsiella, Providencia, • Well-mixed specimen
and indican • Clear container
• IV phenol medications • View against a white background
– Clorets (green) medications: Robaxin, methylene blue, • Adequate room lighting
Elavil (blue) • Consistent volume of specimen

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 AUBF | Physical Examination of Urine
Compiled by: Vienna Cari-cari

CLARITY/TRANSPARENCY VOLUME
→ Refers to transparency or turbidity
NORMAL: ADULT: 600 – 2000 mL
NORMAL: Clear (freshly voided) CHILDREN: 600 – 800 mL
→ no visible particulates
→ print easily seen VARIATIONS: VARIATIONS:
•Oliguria
• Polyuria
- Few particulates • Anuria
Hazy
- Print easily seen
- Many particulates
Cloudy
- Print blurred SPECIFIC GRAVITY
Turbid - Print can NOT be seen Specific gravity
Milky - Many precipitates; clotted – density of a solution compared with the density of a
Nonpathogenic turbidity Pathogenic turbidity similar volume of distilled water at similar temp.
- Hazy female specimens with - Most common: – (In urine) measure of density o dissolved chemicals in
squamous epithelial RBCs, WBCs, bacteria the specimen
cells and mucus
- Nonsquamous epithelial Importance:
- Bacterial growth in • Evaluate the ability of the kidney to reabsorb
nonpreserved specimens cells, yeast, abnormal
crystals, lymph fluid, lipids • Detects possible dehydration or abnormalities in
- Refrigerated specimens antidiuretic hormones
with precipitated - Extent of turbidity should
amorphous phosphates correspond to the amount • Determines if specimen is concentrated enough to
(white) and urates (pink) of material observed in provide reliable screening results
- Contamination: fecal, microscopic examination
NORMAL: 1.003 to 1.035
talc, semen, vaginal → most common 1.015 to 1.025
creams, IV contrast → below 1.003 may not be urine
media → consistent low readings = further testing

• Visual examination Isosthenuric = 1.010 (SG of plasma ultrafiltrate)

– Gently swirl specimen in a clear container in front of a good
Hyposthenuric < 1.010
light source
• Automated turbidity readings are available Hypersthenuric > 1.010 higher than 1.1010
• Clarity is one of the criteria considered in determining the
necessity of performing a microscopic examination
METHODS USED

1. Urinometer method
ODOR – Contains weighted float attached to a scale that has
• Not routinely reported been calibrated
• Fresh urine: faintly aromatic – Less accurate than other methods
• Older urine: ammonia
• Metabolic disorders:
- maple syrup urine disease
- ketosis (fruity)
- infection (ammonia/unpleasant)
• Food
- garlic, onions, asparagus (genetic: only certain people can
smell asparagus, but all produce odor)

NORMAL: Faintly Aromatic / Nutty

Substance responsible:
• Urinod

VARIATIONS:
Bacterial decomposition due to prolonged
Ammoniacal
standing of urine, UTI
Maple syrup Maple syrup urine disease (MSUD)
Fruity / Sweet Ketones (DM, starvation,vomiting)
Sweaty feet Isovaleric acidemia / glutric acidemia
Mousy odor Phenylketonuria
Rotting fish Trimetygl aminuria
2. Harmonic Oscillation Densitometry
Cabbage Methionine malabsorption – Principle: the frequency of a sound wave entering a sol’n
Rancid / Sour Tyrosinemia changes in proportion to the density of a solution
Fecaloid Recto Vesical Fistula
Foul / Putrid UTI
Bleach Contamination

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 AUBF | Physical Examination of Urine
Compiled by: Vienna Cari-cari
3. Refractometer method Osmolality
– Determines the concentration of dissolved particles in a
specimen • More representative measure of renal concentrating ability
– Measures the refractive index • SG depends on the number of particles present in a
– Refractometer solution and the density of these particles
- measures velocity of light in air versus velocity of • Affected only by the number of particles present
light in solution – Substances of interest are small molecules
- prism in the refractometer determines the angle that - Sodium
light is passing through the urine and converts angle - Chloride
to calibrated viewing scale - Urea

– Advantages: • Measuring (in UA) requires an osmometer

• Temperature compensation not needed
- light passes through temp compensating liquid
- compensated between 15°C and 38°C
• Small specimen size: one or two drops
– Additional step in the routine UA procedure
• Automated osmometer utilizes freezing point depression
Osmolarity

Glucose and Protein Correlations • Osmolality of a solution can be determined by measuring a

property that is mathematically related to the number of
• Subtract 0.003 for each gram of protein present particles in the solution
• Subtract 0.004 for each gram of glucose present – Colligative property
• Conc. can be determined from chemical reagent strip tests
• Changes in colligative properties
• Example: – Lower freezing point
A spx containing 1 g/dL protein and 1 g/dL glucose has a SG – Higher boiling point
reading of 1.030. Calculate the corrected reading. – Increased osmotic pressure
– Lower vapor pressure
1.030 – 0.003 (protein) = 1.027
1.027 – 0.004 (glucose) = 1.023 → corrected SG
Reagent Strip SG

• Reaction is based on change in pKa (dissociation constant) of a

Methodology
polyelectrolyte in an alkaline medium
– Releasing H ions in direct proportion to the number of
ions in the solution
– More H ions released = Lower pH
– Indicator: bromothymol-LS blue
- on the reagent pad
- measures the change in pH
- changes from blue (1.000 [alkaline]), through
- shades of green, to yellow (1.030 [acid])
– Not affected by nonionizing substances

SG Dipstick

1. Drop of urine placed on prism

2. Focus on light source, and read scale
3. Wipe off prism between specimens
4. Calibration
– Distilled water = 1.000; adjust set screw if necessary
– 5% NaCl = 1.022 ± 0.001
– 9% sucrose = 1.034 ± 0.001

Clinical Correlations

• Abnormally high results: > 1.040

– Radiographic contrast media (IVP)
– Dextran, other IV plasma expanders
– Check patient’s clinical course/history
• Reagent strip readings and osmometry not affected by high-
molecular-weight substances
→ Should be used as an alternative if possible

Osmole

• 1 g molecular weight of a substance divided by the no. of

particles into which it dissociates = to MW of substance
– Glu = 180 g/osm (C + H + O)
– NaCl = 58.5 g/osm (Na + Cl)
• Milliosmole (mOsm)
→ unit of measure used in the clinical lab
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