ANALYSIS OF URINE AND OTHER BODY FLUIDS • Urea: metabolic waste product produced in the liver from
Lesson: Introduction to Urinalysis the breakdown of protein and amino acids (nearly half of the
1 History and Importance
2 Urine
3 Specimen
HISTORY AND IMPORTANCE
• Edwin Smith Surgical Papyrus: Egyptian hieroglyphics
from which study of urine can be found
• Early urinalysis: examining a bladder-shaped flask of urine
seeing only the urine but not the patient
o Basis: Color, turbidity, odor, volume, viscosity, sweetness
(attracted ants or tasted sweet)
• 5th century BCE: Hippocrates wrote book on “uroscopy”
• Middle Ages: physicians concentrated received instruction
in urine examination as part of training
• 1140 CE: color charts had been developed that described
the significance of 20 different colors
• Chemical Testing:
o Early Method: “ant testing” and “taste testing” for glucose
o 1694: Frederik Dekkers: discovered albuminuria by
boiling urine
• Pisse Prophets: charlatans without medical credentials
offering predictions to the public for a healthy fee,
compromised credibility of urinalysis
o Thomas Bryant (1627): wrote a book about pisse
prophets, which inspired the passing of the first medical
licensure laws in England
• 17th century:
o Examination of urinary sediment
o Thomas Addis: development of methods for quantitating
the microscopic sediment
• 1827: Richard Bright: introduced the concept of urinalysis
as part of a doctor’s routine patient examination
• 1930s: number/complexity of urinalysis test reached a point
of impracticality, disappearing from routine examinations
• Two unique characteristics of a urine specimen for
continued popularity:
o A urine specimen is readily available and easily collected.
o Urine contains information, which can be obtained by
inexpensive laboratory tests, about many of the body’s
major metabolic functions.
• Clinical and Laboratory Standards Institute (CLSI):
o Urinalysis: “testing of urine with procedures commonly
performed in an expeditious, reliable, accurate, safe, and
cost-effective manner”
o Purpose:
▪ aid in diagnosis of disease
▪ screen asymptomatic pop. for undetected disorders
▪ monitor progress of disease and therapy effectiveness
URINE
URINE FORMATION
• Site of production: Kidney
o Urine: ultrafiltrate of plasma
o Reabsorption of water and filtered substances
o Filtered plasma: 170,000 mL
o Average daily urine output: 1200 mL
URINE COMPOSITION
• General composition: urea and other organic and
inorganic chemicals in water (95% water, 5% solute)
• Factors affecting solute concentration:
o Dietary intake
o Physical activity
o Body metabolism
o Endocrine functions
total dissolved solids in urine)
• Organic substances: creatinine and uric acid
• Inorganic substances: chloride, sodium, and potassium
o Dietary intake greatly influences inorganic conc.
• Other substances: hormones, vitamins, and medications
• Other formed elements: cells, casts, crystals, mucus, and
bacteria (not part of original filtrate, indicative of disease)
• Urine vs. Other Body Fluids: test for urea and creatinine
o Higher in urine: creatinine, urea, sodium, chloride
o Absent in urine: protein and glucose
Primary Components in Normal Urine
Component Comment
Urea Primary organic component.
Product of metabolism of protein and amino
acids.
Creatinine Product of metabolism of creatine by
muscles
Uric acid Product of breakdown of nucleic acid in
food and cells
Chloride Primary inorganic component.
Found in combination with sodium (table salt)
and other inorganic substances
Sodium Primarily from salt, varies by intake
Potassium Combined with chloride and other salts
Phosphate Combines with sodium to buffer the
blood
Ammonium Regulates blood and tissue fluid acidity
Calcium Combines with chloride, sulfate, and
phosphate
URINE VOLUME
• Urine volume depends on amount of water that kidneys
excrete (usually determined by body’s state of hydration)
• Factors that influence urine volume:
o Fluid intake
o Fluid loss from nonrenal sources
o Variations in antidiuretic hormone (ADH) secretion
o Need to excrete increased amounts of dissolved solids
(e.g., glucose or salts)
• Normal daily urine output: 1200-1500 mL
o Still considered normal: 600-2000 mL
• Oliguria: a decrease in urine output in adults commonly
when the body enters a state of dehydration due to
excessive water loss from vomiting, diarrhea, perspiration,
or severe burns
o Infants: <1 mL/kg/hr
o Children: <0.5 mL/kg/hr
o Adults: <400 mL/day
• Anuria: cessation of urine flow due to oliguria as a result
from any serious damage to the kidneys or from a decrease
in the flow of blood to the kidneys
• Nocturia: An increase in the nocturnal excretion of urine
o Normal: kidneys excrete two to three times more urine
during the day than during the night
• Polyuria: an increase in daily urine volume often
associated with diabetes mellitus and diabetes insipidus
o Adults: >2.5 L/day
o Children: 2.5-3 mL/kg/day
o Other cause: diuretics, caffeine, or alcohol (all suppress
ADH secretion)
• Diabetes mellitus: caused by a defect either in pancreatic
production of insulin or in insulin function, resulting in
increased conc. of body glucose
o Kidneys: do not reabsorb excess glucose, necessitating
excretion of increased amounts of water to remove the
dissolved glucose from the body
o Urine specimen: high specific gravity (glucose) not dilute
• Diabetes insipidus: results from a decrease in the
production or function of ADH
o Kidney: water necessary for adequate body hydration is
not reabsorbed from the plasma filtrate
o Urine specimen: truly dilute, has a low specific gravity
• Polydipsia: increased ingestion of water as compensation
for fluid loss, producing an even greater volume of urine
• First symptom of diabetes: Polyuria with polydipsia
REQUISITION FORM
• Must accompany specimens delivered to the laboratory
• Must match the information on the specimen label
• Must contain time the specimen is received in the laboratory
• Additional information:
o method of collection or type of specimen
o possible interfering medications
o patient’s clinical information

SPECIMEN REJECTION
• Specimens in containers that are unlabeled or improperly
labeled
• Labels and requisition forms that do not match
• Specimens contaminated with feces or toilet paper
• Containers with contaminated exteriors
• Specimens of insufficient quantity
• Specimens that have been transported improperly
• Specimens that have not been preserved correctly during a
time delay
• Specimens for urine culture collected in a nonsterile
container
• Inappropriate collection for the type of testing needed (e.g.,
midstream clean-catch specimen for bacterial culture)

SPECIMEN HANDLING
SPECIMEN INTEGRITY
SPECIMEN • After collection, specimens should be delivered to the
SPECIMEN COLLECTION laboratory promptly and tested within 2 hours
CONTAINERS o Otherwise: refrigerate or add appropriate chemical
• Standard Precautions (SP): must be observed when preservative
handling urine due to biohazards (wear gloves at all times) o Most changes in unpreserved sample are related to
• Characteristic of Container: clean, dry, leakproof presence and growth of bacteria
o Disposable: eliminate chance of contamination due to Changes in Unpreserved Urine
improper washing Analytes Change Cause
▪ Bags with adhesive for pediatric specimens Color Modified/Darkened Oxidation or reduction of
▪ Large containers for 24-hour specimens metabolites
o Screw-top lids: less likely to leak than are snap-on lids Odor Increased Bacterial multiplication
ammonia smell causing breakdown of urea
o Wide mouth: facilitate collections from female patients
to ammonia
o Wide, flat bottom: prevent overturning
pH Increased Breakdown of urea to
o Clear: allow for determination of color and clarity ammonia by urease-
• Recommended capacity: 50 mL alowing for producing bacteria/loss
o 12 mL of specimen needed for microscopic analysis of CO2
o Additional specimen for repeat analysis Nitrite Increased Multiplication of nitrate-
o Enough room for mixing specimen by swirling container reducing bacteria
• Microbiological studies: individually packaged sterile Bacteria Increased Multiplication
containers with secure closures (also used if more than two Clarity Decreased Bacterial growth and
hours elapse between collection and analysis) precipitation of amorphous
• BD Vacutainer Urine Transfer Straw: nonsterile, plastic material
holder device containing a needle with a straw attachment Glucose Decreased Glycolysis and bacterial use
used with the collection container to fill evacuation tubes Ketones Decreased Volatilization and bacterial
o Purpose: sterile transfer of urine to tubes metabolism
▪ with preservatives for microbiology testing Bilirubin Decreased Exposure to light/photo
▪ with conical bottoms for sediment analysis oxidation to biliverdin
▪ with round bottoms for automated reagent strip test Urobilinogen Decreased Oxidation to urobilin
RBC, WBC, Decreased Disintegration/lyse in dilute
Casts alkaline urine
LABELS Trichomonas Decreased Loss of motility, death
• Labeled immediately after collection:
o patient’s last and first name
SPECIMEN PRESERVATION
o identification number
o date and time of collection • Temperature:
o Routine refrigeration: 2-8°C (decreases bacterial growth
• Additional information:
and metabolism)
o patient’s age and location
o Urine culture: refrigerated during transit and kept
o health-care provider’s name
refrigerated until cultured, up to 24 hours
o preservative used, if any
o Reagent strips: return to room temperature before test
• Must be attached to the container not to the lid
o Drawbacks: precipitation of amorphous urate and
• Should not become detached if refrigerated or frozen phosphate crystals
• Chemical preservatives: added if transported over a long
distance without refrigeration
o Commercially prepared transport tubes with a lyophilized
preservative: allow for the transport, testing, and storage
o Characteristics:
▪ Bactericidal
▪ Inhibit urease
▪ Preserve formed elements in the sediment
▪ Do not interfere with chemical test
TYPES OF SPECIMENS
RANDOM SPECIMEN
• Random Specimen: received most commonly due to its
ease of collection and convenience for patient at any time
o Actual time of voiding should be recorded on the container
o Useful for routine screening tests to detect obvious
abnormalities
o Source of error: dietary intake or physical activity just
before collection
FIRST MORNING SAMPLE
• First Morning Sample: ideal screening specimen;
concentrated specimen, assuring detection of chemicals/
formed elements not present in dilute random specimen
• Uses:
o (1) Prevent false-negative pregnancy tests
o (2) Evaluate orthostatic proteinuria
• Remind patient to:
o (1) collect the specimen immediately on arising
o (2) deliver within 2 hours or refrigerate
24-HOUR SPECIMEN
• 24-Hour (or Timed) Specimen: measuring the exact
amount of a urine chemical (instead of presence/absence)
• Diurnal variation (low in morning, high in afternoon):
catecholamines, 17-hydroxysteroids, electrolytes
• If conc. remain constant, collect over a shorter period
• Instruction: begin and end the collection period with an
empty bladder
• Conc. of substance in a particular period must be calculated
from urine volume produced during that time
• Handling: mixed thoroughly and the volume accurately
measured and recorded upon arrival in the laboratory
o Two containers: contents of the containers should be
combined and thoroughly mixed before aliquoting
o Aliquot: amount saved must be adequate to permit
repeat or additional testing
• Preservation: refrigerated or kept on ice during collection
• Common Error (Timed Urine Collection):
o Loss of urine specimen
o Inclusion of two first morning specimens
o Inaccurate measurement of total urine volume
o Inadequate urine preservation
o Transcription error
• Other error:
o False elevated: adding urine formed before the start of
the collection period
o False decreased: failure to include the urine produced at
the end of the collection period
• Procedure:
o Provide the patient with written instructions, and explain
the collection procedure.
o Provide the patient with the collection container and
preservative, if required.
o Day 1: 7 a.m.: Patient voids and discards specimen;
collects all urine for the next 24 hours.
o Day 2: 7 a.m.: Patient voids and adds this urine to the
previously collected urine.
o Specimen is transported to the laboratory, where the
entire 24-hour specimen is thoroughly mixed and the
volume is measured and recorded.
o The required amount of urine (~50 mL) is aliquoted.
o The remaining specimen is discarded.
CATHETERIZED SPECIMEN
• Catheterized Specimen: collected under sterile conditions
by passing a hollow tube (catheter) through the urethra into
the bladder/to urine bag, used for bacterial culture
MIDSTREAM CLEAN-CATCH SPECIMEN
• Midstream Clean-Catch Specimen: provides a safer, less
traumatic method for obtaining urine for bacterial culture
and routine urinalysis as an alternative to cathetirized
specimen
• More representative than random specimen: less
contaminated by epithelial cells and bacteria
• Do not use strong bacterial agents (hexachlorophene or
povidone-iodine) as cleansing agents
o Recommended: Mild antiseptic towelettes/ Castile Soap
Towelettes
• Female Cleansing Procedure:
o Wash hands.
o Remove the lid from the sterile container without touching
the inside of the container or lid.
o Separate the skin folds (labia).
o Cleanse from front to back on either side of the urinary
opening with an antiseptic towelette, using a clean one for
each side.
o Hold the skin folds apart and begin to void into the toilet.
o Bring the urine container into the middle stream of urine,
and collect an adequate amount of urine.
▪ Do not touch the inside of the container or allow the
container to touch the genital area.
o Finish voiding into the toilet.
o Cover the specimen with the lid.
▪ Touch only the outside of the lid and container.
o Confirm the container is labeled correctly with the
patient’s first and last name and time of collection, and
place it in the specified area, or follow facility policy.
• Male Cleansing Procedure:
o Wash hands.
o Remove the lid from the sterile container without touching
the inside of the container or lid.
o Cleanse the tip of the penis with antiseptic towelette and
let it dry. Retract the foreskin if uncircumcised.
o Void into the toilet. Hold back the foreskin if necessary.
o Bring the sterile urine container into the middle stream of
urine, and collect an adequate amount of urine.
▪ Do not touch the inside of the container or allow the
container to touch the genital area.
o Finish voiding into the toilet.
o Cover the specimen with the lid.
▪ Touch only the outside of the lid and container.
o Confirm the container is labeled correctly with the
patient’s first and last name and time of collection, and
place it in the specified area, or follow facility policy.
PROSTATITIS SPECIMEN
THREE-GLASS COLLECTION
• Before collection, cleanse area using male midstream
clean-catch procedure
• Procedure:
o (1) Collect first urine passed in a sterile container
o (2) Collect midstream portion in another sterile container
o (3) Massage prostate so that prostate fluid will be passed
with the remaining urine into a third sterile container.
• Perform (1) quantitative culture on all specimen, (2)
microscopic examination on first and third specimen
o Prostatic infection (third specimen): white blood
cell/high-power field count and bacterial count 10x that of
the first specimen, with macrophages containing lipids
o Second specimen: used as a control for bladder and
kidney infection
▪ Positive result: indicates invalid third specimen due
to contamination by infected urine
• Note: When both a routine urinalysis and a culture are
requested on a catheterized or midstream collection, the
culture should be performed first to prevent contamination
of the specimen. A collection transfer kit also can be used.
PRE- AND POSTMASSAGE TEST
• Procedure:
o (1) Collect clean-catch midstream urine specimen
o (2) Massage prostate
o (3) Collect second urine sample
• Positive result: significant bacteriuria in postmassage
specimen of greater than 10 times the premassage count
STAMEY-MEARES TEST FOR PROSTATITIS
• Traditional four-glass urine collection technique:
o Voided Bladder (VB1): first urine specimen; first 10 mL
of urine and represents the urethral specimen.
o Then the patient voids another 100 to 150 mL of urine.
o Voided Bladder 2 (VB2): second specimen collected;
another 10 mL of urine and represents bladder specimen
o Expressed prostatic specimen (EPS): third specimen;
the fluid collected during prostatic massage
o Voided Bladder 3 (VB3): fourth specimen consisting of
the first 10 mL of urine collected after EPS, containing any
EPS trapped in the prostatic urethra
• Handling: send four specimens for culture
o Centrifuge three urine specimens
o Examine sediment for white blood cells/aggregates,
macrophages, oval fat bodies, bacteria, and fungal hypha
• Use of VB1: test for urethral infection or inflammation
• Use of VB2: test for urinary bladder infection
• Use of prostatic secretions: cultured and examined for
white blood cells
o Abnormal: >10-20 WBC/HPO
PEDIATRIC SPECIMEN
• Collection material: soft, clear plastic bags with
hypoallergenic skin adhesive to attach to the cleaned
genital area of both boys and girls
• Sterile samples: catheterization or suprapubic aspiration
• Procedure (routine specimen analysis):
o Ensure the area is free of contamination.
o Attach the bag firmly over the cleaned genital area,
avoiding the anus.
o A diaper is placed over the collection bag.
o When enough specimen has been collected, remove the
bag and label it, or pour the specimen into a container and
label the container following facility policy
• Procedure (microbiology specimen):
o Clean the area with soap and water and sterilely dry the
area, removing any residual soap residue.
o Firmly apply a sterile bag.
o Sterilely transfer the collected specimen into a sterile
container and label the container.
o Note: Check the applied bags ~every 15 minutes until the
needed amount of sample has been collected
DRUG SPECIMEN COLLECTION
• Most vulnerable drug-testing program part: urine collection
• Chain of custody (COC): provides this documentation of
proper specimen identification from the time of collection to
the receipt of laboratory results
o Standardized form that must document and accompany
every step of drug testing, from collector to courier to
laboratory to medical review officer to employer
• To withstand legal scrutiny: prove that no tampering of the
specimen occurred (substitution, adulteration, or dilution)
o May be “witnessed” or “unwitnessed.”
• Witnessed collection: suspected that the donor may alter
or substitute the specimen or when it is the policy of the
client ordering the test
o Same-gender collector will observe the collection of 30-
45 mL of urine
• Protocol:
o Taken within 4 minutes from the time of collection to
confirm the specimen has not been adulterated
o Temperature: within 32.5°C to 37.7°C
▪ Outside temp. range: record temperature, contact
supervisor/ employer immediately (may indicate
specimen contamination); recollect second specimen
o Check color, pH, specific gravity
▪ pH > 9: suggests adulteration of the urine specimen
▪ sg < 1.005: indicate dilution of the urine specimen
o Labeled, packaged, and transported
• Procedure:
o The collector sanitizes his or her hands and wears gloves.
o The collector adds bluing agent (dye) to the toilet water
reservoir to prevent an adulterated specimen.
o The collector eliminates any source of water other than
toilet by taping the toilet lid and faucet handles.
o The donor provides photo identification or positive
identification from the employer’s representative.
o The collector completes step 1 of the COC form and has
the donor sign it.
o The donor leaves his or her coat, briefcase, and/or purse
outside the collection area to avoid the possibility of
concealed substances contaminating the urine.
o The donor sanitizes his or her hands and receives a
specimen cup.
o The collector remains in the restroom but outside the stall,
listening for unauthorized water use, unless a witnessed
collection is requested.
o The donor hands the specimen cup to the collector. The
transfer is documented.
o The collector checks the urine for abnormal color and for
the required amount (30 to 45 mL).
o The collector checks that the temperature strip on the
specimen cup reads 32.5°C to 37.7°C.
▪ The collector records the in-range temperature on the
COC form (COC step 2).
▪ If the specimen temperature is out of range or the
specimen is suspected of having been diluted or
adulterated, a new specimen must be collected and a
supervisor notified.
o The specimen must remain in the sight of the donor and
collector at all times.
o With the donor watching, the collector peels off the
specimen identification strips from the COC form (COC
step 3) and puts them on the capped bottle, covering both
sides of the cap.
o The donor initials the specimen bottle seals.
o The collector writes the date and time on the bottle seals.
o The donor completes step 4 on the COC form.
o The collector completes step 5 on the COC form.
o Each time the specimen is handled, transferred, or placed
in storage, every individual must be identified and the date
and purpose of the change recorded.
o The collector follows laboratory-specific instructions for
packaging the specimen bottles and laboratory copies of
the COC form.
o The collector distributes the COC copies to appropriate
personnel.

Types of Urine Specimens

Type of Specimen Purpose
Random Routine screening
First morning Routine screening
Pregnancy tests
Orthostatic protein
24-hour (or timed) Quantitative chemical tests
Catheterized Bacterial culture
Midstream clean-catch Routine screening
Bacterial culture
Suprapubic aspiration Bladder urine for bacterial
culture
Cytology
Three-glass collection Prostatic infection
Four-glass collection Prostatic infection