Microscopic Examination of Urine

The microscopic examination of urine is of vital importance in determining the correctness of diagnosis of a renal system infection and disease. Specimen must be fresh and concentrated for more accurate results. First morning specimen is preferable. Proper urine collection is also necessary as well as proper techniques for microscopic examination of urinary sediments for accurate results. Urinary sediments should be examined with subdued light, using the LPO before HPO. Centrifugation for 3-5 minutes at 1500-3000 rpm is advisable. Urinary sediments consist of all solid particles and formed elements in the urine Two Types of Urinary Sediments: A. Unorganized due to a change in reaction or concentration (chemical part); examples are crystals and amorphous materials B. Organized most important (biological part); include casts, RBC, pus cells, epithelial cells, microorganisms, animal parasites, spermatozoa, yeasts, and fungi Reporting: Casts specify kind per coverslip (total count in 10-20 lpf) RBC and pus cells range per hpf Epithelial cells, microorganism, crystals under HPO (specify kind and report in plus sign): rare, occasional (+/-), few (+), many (++), abundant (+++ or ++++) or TNTC (too numerous to count) Plus system for quantifying urinary sediment: + (1-10) +++ (21-30) ++ (11-20) ++++ (more than 30) ORGANIZED STRUCTURES 1. Casts: albuminous materials thought to have come from exudates from blood, pathologic secretions of renal tubules or products of degeneration. They are formed primarily within the lumen of the distal convoluted tubule and collecting duct, providing a microscopic view of conditions with the nephrons. They may be hyaline, waxy, granular, fatty, or containing organized structures (blood, pus, epithelial, or bacterial). They are cylindrical in structure because they assume the shape of the tubules as they pass through. The protein that make up the matrix of casts is called Tamm-Horsfall protein. The presence of casts in urine is referred to as cylindruria. 1.1 Hyaline: colorless, homogenous, semi-transparent cylindrical structures with parallel sides and usually rounded ends. It is the least significant of the casts. They result from the precipitation of the Tamm-Horsfall protein (a specific mucoprotein) within the lumen of the kidney. Its persistent presence is a significant sign of renal disease (nephrosclerosis). 1.2 Waxy: grayish or colorless, homogenous and more opaque and wider than hyaline casts with broken ends and fissures and cracks on their sides. They stain pale pink or dark purple with Sternheimer Malbin stain. Their presence imply renal stasis and are associated with severe renal chronic disease and renal amyloidosis 1.3 Granular: hyaline casts with numerous fine or coarse granules. If found in considerable numbers, may denote glomerulo nephritis. They are due to epithelial degeneration. 1.4 Fatty: contain numerous globules of fat or the fat may be in fine refractile granules. If found in considerable number, many denote glomerulonephritis. Granules and fat droplets within the cast are due to epithelial segmentation. 1.5 Epithelial: true hyaline casts which contain many renal epithelial cells. Its presence implies desquamation of the epithelium, which is seen in parenchymatous inflammation. When the casts are well-preserved, they indicate active acute nephritis.

or crystals: accidentally take a cylindrical appearance and to distinguish them from casts.2 Transitional: caudate and pear-shaped with a central nucleus lining the renal pelvis and bladder. Their granules are partly neutrophilic and partly products of degeneration. Pus cells (leukocytes): these are granular spherical cells similar blood WBC.6 Blood: contain a large number of erythrocytes. 1. there is usually an increase in the amount of albumin. 4. A positive blood result in the chemical analysis with the presence of intact RBC is due to hematuria. they do not have nuclei. Normally present in the urine of woman. also called tail cells 2. 5. Not normally 6. and renal.1 Squamous: large flat cells with a large central nucleus found in the urethra or vagina. When abundantly present in urine.1. gentle heating or addition of certain chemicals will help b. Its presence in urine is known as pyuria and indicates chronic cystitis (suppuration in some parts of the urinary tract such as bladder. which is common in acute nephritis.7 Pus: contain large number in the kidney. implies destruction of renal tubules (tubular necrosis). Mucus threads: long. 2. slightly thinner in the center than around the edge.8 Bacterial: they are rare and their presence indicate a septic condition in the kidney Structures mistaken for casts: Mucus threads Cylindroids Masses of urates. usually pyclonephritis 1. urethra or renal pelvis) Erythrocytes: are refractile (shiny) biconcave disks resembling tiny buttons. Some of the lyse (rupture) realeasing hemoglobin and appear as faint colorless circles known as shadow or ghost cells. seen in glomerulonephritis. 2. Large amounts of blood from the kidneys give it a brown smoky appearance. abundant if calcium oxalate crystals are present Cylindroids: resemble hyaline casts in appearance except that they taper off to a fine filament. the cells swell losing their biconcave appearance. in cases of circulatory disturbances and irritation of the kidneys Masses of urates. They indicate hemorrhage in the renal tubules. frequently present in urine of male patients after nocturnal emissions and in both sexes after coitus Bacteria: very small organisms appearing to vibrate due to this type of motility called Brownian movement caused by the bombardment of water molecules against the organism. usually found together with hyaline casts esp. narrow. mononucleated cells larger than pus cells.3 Renal: small. Any abnormal increase in red blood cells in urine is called hematuria. round. Spermatozoa/ Sperm cells: have spherical heads and long thin tails. transitional. 2. or minute crystals a. the absence of erythrocytes with a positive blood result in the chemical analysis may be due to hemoglobin or myoglobin. which are degenerated. waxy strands or ribbon-like from the mucus surfaces. they are the scavengers of the body frequently leaving blood vessels in search of bacteria and cellular debris. Least significant of the epithelial cells. . hemolytic anemias and hemochromatosis 3. Epithelial cells: microscopic examination of urine can reveal three epithelia cell types squamous. often appear with split ends and curved but never rounded. red cells appear collapsed (crenated) having lost some of their intracellular fluid. phosphates. In very dilute urines. c. phosphates. nephrosis. Urine containing blood is always albuminous. In concentrated urine. most significant of the epithelial cells.

It may also indicate presence of sugar in urine Fungi/ Mold: rarely found in urine but when present is identified by refractile. aeruginosa. tissue paper 10. it is usually a contaminant from the vagina or a result of urethral infection in males. S. sometimes called magnesium phosphates 2.4 Fibers from clothing.2 Air bubbles: look like fat globules or some of the crystals 10. Cocci Staphylococci and Streptococci 7. vaginalis (protozoa). to confirm. jointed. add iodine and a blue color will develop if it is starch 10.5 Talc 10. S. typhosa. small and round frequently found as a urine contaminant of women with Candida albicans infection of the vagina. vulgaris. and T. P. hematobium. Animal parasites: T. TB.present in urine but may be a contaminant in passing out through the urethra. 9. appear in urine after ingestion of large amounts of substances rich in oxalic acid like tomatoes. Its clinical significance lies in its tendency to produce calculi. thin irregular usually granular colorless plates. coli.3 Starch granules: spherical with concentric striations. They produce a uniform cloudiness. Bacilli E. or branched rods (hyphae) 8. cotton. which will not clear on filtration. Amorphous urates/phosphates: brick-red dust granules or deposits dissolved by heat and NaOH or HAc. hematobium ovum may be seen in urine which is bloody in nature Yeast cells: characteristically show budding. dissolve when heated with NaOH Calcium oxalate/carbonate: colorless envelope-shaped or dumbbell shaped crystals. vaginalis (flagella). 10. S.6 Fecal materials UNORGANIZED STRUCTURES Normal crystals and amorphous material in acid urine: Uric acid Calcium sulfate Calcium oxalate Sodium urates Amorphous urates Normal crystals and amorphous materials in alkaline urine: Amorphous phosphates Ammonium biurates Triple phosphate Calcium carbonate Calcium phosphate Abnormal crystals (acid urine): indicates abnormal metabolism Cystine Cholesterol Tyrosine Hippuric acid Leucine Sulfa crystals 1. Calcium phosphates: large forms.1 Diatoms: unicellular microscopic algae from tap water and belonging to plant kingdom 10. P. 5. . 3. no clinical significance Sodium urates: peacock-tail-like looking crystals arranged in fan sheaf-like or leaf-like structures Uric acid: yellowish-brown whetstone-shaped or rhombic plates or rosettes or lemon-shaped crystals. berries and asparagus. motile and when present. 4. Extraneous structures/ artifacts: due to contamination 10.

Cholesterol: large flat hexagonal plates with one or more corners cut off or notched out. gives green color to Morner reagent 11. may occur in nephritis conditions 13. 10. 8. Leucine: yellow oily-looking crystal. occur together with leucine in acute yellow atrophy and destructive diseases of the liver. needle-like crystals or long prismatic tables. spherical with radial or concentric striations. associated with liver disease like tyrosine. 14. gives blue color to Salkowski s test 12. gives red color to Sullivan test 7. Ammonium biurates: yellow spherical bodies with radial or concentric striations and long prismatic spicules. Tyrosine: fine needles in cluster or sheaves which may appear black in the center. Sulfa crystals: Sulfanilamide Sulfa pyridine Sulfachiazole Sulfadiazine (chestnut burr forms) Sulfa guanidine Sulfamethylthiazole . cigarette-butt looking crystals Cysteine: colorless refractile hexagonal plates or quadrilateral prisms soluble in HCl but not in HAc. known as thorn-apple looking elements Triple phosphates: ammonium-magnesium phosphate crystals with characteristic coffin-lid shape Calcium sulfate: long colorless. Hippuric acid: brown needles or prisms conglomerated into masses.6. soluble in HAc. 9.

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