URINE EXAMINATION- Urine analysis (Urinalysis) is one of the oldest laboratory

procedures in the practice of medicine. It is done for general evaluation of health, diagnosis
of disease of the kidneys or urinary tract, diagnosis of other systemic disease that affect
kidney function, monitoring of patients with diabetes, and screening for drug abuse.

Sample Collection-The patient should be explained the correct method of sample collection:

 Ask the female patients to clean the local area with wet cotton swab, separate the labia
with fingers and urinate.
 In males, withdraw the foreskin, clean urethral meatus and glans with wet cotton
swab.
 Discard initial 10-20 mL of urine. Then clean catch, midstream sample is collected in
wide mouthed, sterile plastic container.
 Tightly close the screw cap of the container.
 Label with patients name, age, sex, date, and time of collection.
 Urine sample should be examined within 2 hours of collection.

Types of Urine Samples- Types of urine samples are depicted in Table-

Types Description
Random This can be taken at any time of day, is most common
specimen
Morning sample First urine in the morning, which is most concentrated, is required for
pregnancy test, microscopic test, and culture.
24 Hours urine For culture and certain quantitative and qualitative analysis. All the urine
sample passed from morning 8:00 AM to next day same time is collected.
The total volume is measured and aliquot of sample is send to the
laboratory.
Suprapubic Needle aspiration to obtain sterile urine.
aspiration

Physical Examination of Urine-

Gross examination studies volume, color, odor, pH, and specific gravity.

Volume- In normal adults, daily urine collection is about 600-2,000 mL. In infants it is 300-
600 mL/day. Volume of urine is measured by collecting 24 hour urine samples.

Note-

 Polyuria: If daily volume output is more than 2,500 mL/day.

 Oliguria: Decreased daily volume of urine, less than 500 mL/day.
 Anuria: Extremely low daily urine output, volume is less than 150 mL/day.
 Nocturia: Urine volume in excess of 500 mL at night.

Color and Appearance-

  Normal urine is pale and transparent. Urine can turn turbid due to presence of any
solid content like cells, casts, crystals, solutes, bacteria, etc.
 Color variation of urine can be seen in many conditions-

Colour Cause
Yellow green Bile pigments(as an jaundice)
Colourless Reduced concentration (diabetes mellitus)
Whitish turbid pus Bacteria or epithelial cells
Red brown Hemoglobin ( hemolysis and hemoglobinuria)
Red Blood (hematurea) in kidney damage, kidney tumors, eating
beetroot
Pinkish brown Hemolytic anemia
Yellow foam Bile or medication
Orange Riboflavin, colouring agent in sweet
Black Parentral iron therapy

Odor-Normally urine has a faint aromatic odor. Urine may emit different smells depending
upon its biochemical constituent:

 Fruity: Ketoacidosis
 Ammonical: Old sample, bacterial decomposition
 Mousy: Phenylketonuria
 Putrid (like fecal): UTI

pH Reaction-Reflects ability of kidney to maintain normal hydrogen ion concentration in

plasma and ECF. Urine is normally acidic with pH varying from 5.5-6.8.

Urine pH is measured using:

 Litmus paper
 pH indicator paper strips
 pH meter

Specific Gravity (SG)-Measures the concentrating and diluting power of kidney.

Concentrating ability of kidney is one of the first functions to be lost as a result of damage
due to renal tubules.Normal SG is 1.008-1.030 in a 24-hour sample.

Methods of measuring:

 Urinometer
 Refractometer
 Dipstick method

Microscopic Examination of Urine-

 Red blood cells (RBCs): RBCs in urine appear as refractile disks. Presence of RBCs
in urine is called hematuria. RBCs appear in urine in urinary infections, tumors and
calculi, hemolytic anemia, patients on oral anticoagulant.
Note: May be a contaminant during menstruation in women.

 White blood cells: Also called pus cells. Pus cells are more seen in acute urinary tract
infection.
 Epithelial cells: Arise from any site in genitourinary tract, from kidney to the urethra
or from the vagina. Normally a few cells are found. Increased number of cells is
found in urinary tract infection, elderly female, prolapsed uterus.

Chemical Analysis of Urine-

Proteins-Normal range of urine protein is less than 150 mg/in 24 hour urine sample.
Increased excretion of protein in urine is proteinuria.

Heat Coagulation Test-

It is a cheap test which does not require technical expertise.

Principle: Proteins are coagulated on heating

Procedure:

 Fill 3/4th of the test tube with urine.

 Heat upper part of this tube.
 Coagulum can be formed due to proteins, phosphates, or urates.
 Add 3 to 4 drops of 3% Acetic acid.
 If the coagulum persists, then it is due to proteins and if it disappears it is due to
phosphates.

Interpretation of the heat coagulation test:

 No cloudiness-absence of proteins
 Haziness-traces of proteins present (up to 10 mg/ dL)

Sugar- Presence of sugar in urine is known as glucosuria. Most of the time its occurs as part
of a systemic disease process.

Urine tests for sugar:

Procedure of Benedict's Test-

 Pipette 5 mL of Benedict's reagent in a test tube.

 Add 8 drops of urine to the Benedict's reagent.
 Heat carefully on a flame of a gas burner.
 Cool and observe the color change and precipitate formation and analyze the test
result.

Test tube colour Finding

Blue No reducing sugar
Green Traceable (0.5-1g)
Yellow Low (1-1.5g)
Orange-red Moderate (1.5-2g)
Black-red High>2g

Causes of glucosuria:

 Diabetes mellitus
 Hyperthyroidism, hyperadrenalism hyperpituitarism

Ketones (Ketonuria)-

Presence of ketone bodies which are intermediate products of fat metabolism, in urine is
considered abnormal.

Test-Rothera's Test-

Procedure-

 Take 5 mL of urine in a test tube and saturate it with ammonium sulfate.

 Add 1 crystal of sodium nitroprusside.
 Mix. Run liquid ammonia carefully at the side of the tube so as to form a layer on top
of the urine.
 Formation of purple ring at junction of two fluids indicates positive test.

Causes of Ketonuria: Diabetic Ketoacidosis, fever, starvation, severe vomiting.

Occult Blood-

Presence of blood in urine is an abnormal finding and is called hematuria.

Benzidine Test-

 Add 2 mL of urine in test tube.

 Add 2 mL of 1% Benzidine solution in acetic acid.Shake well.
 Add 2 mL of hydrogen peroxide.
 Mix and observe for a change in color.
 Positive result: Green or blue color indicates hematu

Urine Pregnancy Test (UPT)-

This is a rapid and easy pregnancy testing method. Commercial UPT kits are available, which
detect ẞ-hCG excreted in the urine of pregnant females.

STOOL EXAMINATION-

Human feces is called as stool. It is the waste residue of indigestible materials expelled
through the anus during defecation. Stool examination is done in cases of diarrhea, dysentery,
malabsorption syndromes, and colorectal malignancies
Sample Collection-

 Stool should be collected in a dry, sterilized, wide mouthed glass, or plastic container.
 Avoid contamination with disinfectants in bed pan, urine, any other body secretions or
water.
 Tightly screw the container. Name and label immediately.
 Examination of stool should be done within 1 hour of sample collection. So transport
the sample immediately to laboratory.
 Avoid heat exposure.
 If the sample delivery is delayed, then use stool preservatives.
 5%-10% formalin
 Polyvinyl alcohol
 Three random samples should be tested before giving negative test results

Physical Examination of Stool-

 Quantity: Adequate sample 2-3 gm in weight or 4-5 mL in volume

Color and appearance:

 Normal: Light to dark brown, soft, well formed

Abnormal color and appearance of stool-

Abnormal colour Causes

Black Bleeding from stomach, taking iron tablets,
Bright red Fresh blood in colorectal cancer,piles
Clay Obstructive jaundice, barium x-ray
Mucus Excessive straining and constipation
Frothy and bulky Malabsorption, lipids in stool
Pus Dysentry,anorectal fistula

Abnormal consistency:

 Watery, thin stool mixed with mucous and blood is suggestive of Typhoid and
Amoebiasis.
 Liquid stool mixed with mucous and pus is suggestive of Ulcerative Colitis, Regional
Enteritis, Shigella, and Intestinal TB. Infection, Acute diverticulitis
 Rice water stool which is colorless and without odor is suggestive of Cholera.

Microscopic Examination of Stool-It is done on wet-mount slides

Direct Mount Slide Procedure-

 Apply the patient's sample to a small area on a clean microscope slide. Remove any
gross fibers and particles.
 Immediately before the specimen dries, add 1 or 2 drops of normal saline with a
pipette. Mix with pipette tip.
  Lugol's iodine and Eosin 1% is used in a similar way to prepare the slides. Iodine
stain helps to examine the nuclei of cysts, eosin helps to see motile organisms.

Chemical Examination of Stool-

Occult Blood Test-

This is the most important screening test for intestinal cancers. It may also be positive in
parasitic infestations like hookworm, E. histolytica etc. Method- Benzidene test. Place small
quantity of stool specimen on a clean glass slide, add 1 or 2 drops of benzidene solution
Observe change in color.

Observations: Color changes to Green to Blue: Occult blood present.

Microbiological Examination-

Stool Culture-Human feces contain more than thousand organisms per gram wet weight.
These include:

 Gram negative: Escherichia coli, Enterobacter, Proteus, and Pseudomonas aeruginosa.

 Gram positive: Clostridia, Lactobacilli, and Enterococci.

While most of the normal bacteria are anaerobes, most of the bacterial stool pathogens grow
on aerobic culture plates. Therefore, aerobic culture media are used for culture. Any
suspicious organisms that grow on the media are identified using microscopic and
biochemical tests.

Hanging Drop Test-Place a drop of stool in the center of a coverslip. Place a drop of
vaseline at each corner of the coverslip. Invert a slide and examine microscopically for motile
organisms like Vibrio cholerae.