AUBF

ROGUEL, CLAIRE ANN M. | 1ST SEM

PHYSICAL EXAMINATION OF URINE
INTRODUCTION Green Pseudomonas Positive urine culture
The physical examination of urine includes the infection
determination of: Asparagus None
1. Urine color Blue- Amitriptyline Antidepressant
2. Clarity green
3. specific gravity - aids in the evaluation of Methocarbamo Muscle relaxant, may
renal tubular function l (Robaxin) be green-brown
Early physicians based many medical the color and Clorets None
clarity of urine Indican Bacterial infections,
• Today, it provides preliminary information intestinal disorders
concerning disorders, such as glomerular
Methylene Fistulas
bleeding, liver disease, inborn errors of
blue
metabolism, and uri`nary tract infection
Phenol When oxidized
The results of the physical portion of the
urinalysis -> useful in used explaining findings in Propofol Anesthetic
the chemical and microscopic areas of urinalysis. Familial "Blue diaper
hypercalcemia syndrome
COLOR Indomethacin Nonsteroidal anti-
varies from almost colorless to black (Indocin, inflammatory drug
• variations may be due to normal metabolic Tivorbex)
functions, physical activity, ingested materials, Pink RBCs Cloudy urine with
or pathological conditions Red positive chemical test
• change in urine color is often the reason results for blood and
that a patient seeks medical advice RBCs visible
o determine whether this color change is microscopically
normal or pathological Hemoglobin Clear urine with
positive chemical
CLINICAL/ test results for blood;
COLOR CAUSE LABORATORY intravascular hemolysis
CORRELATIONS Myoglobin Clear urine with
Colorle Recent fluid Commonly observed positive chemical
ss consumption with random specimens test results for blood;
PALE Polyuria or Increased 24-hour muscle damage
YELLO diabetes volume and low Beets Alkaline urine of people
W insipidus specific gravity who are genetically
Diabetes Elevated specific susceptible
mellitus gravity and positive Rifampin Tuberculosis
glucose test result medication
Dilute random Recent fluid Menstrual Cloudy specimen with
specimen consumption contamination RBCs, mucus, and clots
DARK Concentrated May be normal after Port Porphyrins Negative test for
YELLO specimen strenuous exercise or wine blood, may require
W in first morning additional testing
specimen Red- RBCs oxidized Seen in acidic urine
B complex brown to after standing; positive
vitamins methemoglobi chemical test result for
Dehydration Fever or burns n blood
Bilirubin Yellow foam when Myoglobin
shaken and positive Brown Homogentisic Seen in alkaline urine
chemical test results Black acid after standing; specific
for bilirubin (alkaptonuria) tests are
Acriflavine Negative bile test available
results and possible Malignant Urine darkens on
green fluorescence melanoma standing and reacts
Melanin or with nitroprusside
Nitrofurantoin Antibiotic administered melanogen and ferric chloride
for urinary tract Phenol Interfere with copper
infections derivatives reduction tests
Orange Phenazopyridi Drug commonly Argyrol Color disappears with
-yellow ne (Pyridium) administered for (antiseptic) ferric chloride
urinary tract infections Methyldopa or Antihypertensive
Phenindione Anticoagulant, orange levodopa
in alkaline urine, Metronidazole Darkens on standing,
colorless in acid urine (Flagyl) intestinal and vaginal
Sulfasalazine Anti-inflammatory drug infections
(Azulfidine) Chloroquine Antimalarial drugs
Yellow- Bilirubin Colored foam in acidic and
green oxidized to urine and false- primaquine
biliverdin negative chemical test Methocarbamo Muscle relaxant
results for bilirubin l
 Fava beans, None • bilirubin is present - it will be detected during
rhubarb, or the chemical examination
aloe o yellow foam appears when the
specimen is shaken
NORMAL URINE COLOR o bilirubin also may contain hepatitis
Common descriptions include: virus, reinforcing the need to follow
• pale yellow standard precautions
• yellow
• dark yellow ↑ increased concentration of protein -> large
under a good light source, against a white amount of white foam
background.
photo-oxidation of large amounts of excreted
Urochrome (1864) - presence of a pigment, causing urobilinogen to urobilin -> also produces a yellow-
the yellow color of urine orange urine
• named by: Thudichum • yellow foam does not appear when the
• a product of endogenous metabolism specimen is shaken.
• under normal conditions, the body produces it
at a constant rate Photo-oxidation of bilirubin -> imparts a yellow-
• dependent on the body’s metabolic state, green color to the urine
with increased amounts produced in patients • caused by the presence of biliverdin
with thyroid conditions and/or those in
fasting states. The yellow-orange specimen caused by the
• Urochrome also increases in urine that stands administration of phenazopyridine (brand name
at room temperature Pyridium) or azo-gantrisin
o ↑Urochrome = room temperature compounds to people who have urinary tract
• the intensity of the yellow color in a fresh urine infections
specimen -> can give a rough estimate of • this thick, orange pigment not only obscures
urine concentration. the natural color of the specimen, but also
o dilute urine = pale yellow interferes with chemical tests that are based
o concentrated specimen = dark on color reactions
yellow • important to recognize the presence of
phenazopyridine -> so labs can use
Two additional pigments (smaller quantities, contribute alternative testing procedures
little to the color of normal, fresh urine) • produce a yellow foam when shaken, which
1. uroerythrin (pink pigment) - most evident in could be mistaken for bilirubin.
refrigerated specimens, resulting in the
precipitation of amorphous urates in an acid Other medications that can cause an orange-colored
urine. urine:
• Uroerythrin attaches to the urates, 1. anti-inflammatory drug sulfasalazine
giving a pink color to the sediment (Azulfidine)
2. Urobilin - oxidation product of the normal 2. some laxatives
urinary constituent urobilinogen, imparts an 3. certain chemotherapy drugs.
orange-brown color to urine that is not
fresh. Red/Pink/Brown
One of the most common causes of abnormal urine
color is
the presence of blood.
• Red is the usual color that blood produces in
urine, but the color may range from pink to
brown, depending on the amount of:
1. Blood
2. pH of the urine
3. length of contact

Red blood cells (RBCs) - remaining in an acidic urine

for several hours cause the urine to turn brown due
to the oxidation of hemoglobin to methemoglobin

A fresh urine containing blood that is brown -> may

indicate glomerular bleeding, resulting from the
conversion of hemoglobin to methemoglobin.

POSITIVE CHEMICAL TEST FOR BLOOD (produce a

red urine)
1. Hemoglobin
2. Myoglobin

urine is red and cloudy -> when intact RBCs

(hematuria) are present
specimen is red and clear -> hemoglobin or
Abnormal Urine Color myoglobin is present
Dark Yellow/Amber/Orange
examining the patient’s plasma -> helps
• may not always signify a normal concentrated
distinguish between hemoglobinuria and
urine
myoglobinuria
• can be caused by the presence of the
• Chemical tests is also available
bilirubin (abnormal pigment)
 Blue/Green
Hemoglobinuria -> resulting from the in vivo limited to bacterial infections, including urinary
breakdown of RBCs is accompanied by red plasma. tract infection by Pseudomonas species, and
• The possibility of hemoglobinuria being intestinal tract infections, resulting in increased
produced from the in vitro lysis of RBCs also urinary indican
must be considered.
familial benign hypercalcemia -> rare inherited
Breakdown of skeletal muscle-> produces disorder
myoglobin • called “blue diaper syndrome”
• children with the disorder will have blue urine
Myoglobin -> is cleared more rapidly from the
plasma than is hemoglobin Ingestion of breath deodorizers (Clorets) -> result
• therefore does not affect the color of the in a
plasma. green urine
• frequently exhibits a more reddish-brown
color than does urine containing hemoglobin. Brightly colored food dyes that cause green urine
1. B vitamins
Porphyrin in specimens -> may appear red 2. Asparagus
• resulting from the oxidation of
porphobilinogen to porphyrins Medications that may cause blue urine
• referred to as having the color of port wine. 1. methocarbamol (Robaxin)
2. methylene blue
Nonpathogenic causes of red urine: 3. indomethacin (Indocin,Tivorbex)
1. menstrual contamination 4. amitriptyline (Elavil)
2. ingestion of highly pigmented foods 5. propofol (Diprivan)
3. medications.
patients who are hospitalized -> reveals urine that is
genetically susceptible people abnormally colored
• eating fresh beets -> causes a red color in • may signify either a pathological condition
alkaline urine that requires the urine to stand for a period of
• eating blackberries -> can produce a red time before color development or the presence
color in acidic urine of medications.
• Phenol derivatives - found in certain IV
medications produce green urine on
oxidation

purple staining - occur in catheter bags

and is caused by indican in the urine or a
bacterial infection, frequently caused by
Klebsiella or Providencia species

Medications that produce red urine CLARITY

1. rifampin refers to the transparency or turbidity of a urine
2. phenolphthalein specimen
3. phenindione
4. phenothiazines In routine urinalysis, clarity is determined by visually
examining the mixed specimen while holding it in front
Brown/Black of a light source.
Additional testing is recommended – urine that turn • Color and clarity are routinely determined at
brown or black on standing and have negative the same time
chemical test results for:
1. blood Common terminology used to report clarity:
2. inasmuch - as they may contain melanin CLARITY TERM
3. homogentisic acid - , a metabolite of Clear No visible particulates, transparent
phenylalanine, imparts a black color to Hazy Few particulates, print easily seen
alkaline urine from patients with the inborn through urine
error of metabolism, called alkaptonuria. Cloudy Many particulates, print blurred through
urine
Melanin - oxidation product of the colorless Turbid Print cannot be seen through urine
pigment melanogen, which is produced in excess Milky May precipitate or be clotted
when a malignant melanoma is present
Normal Clarity
Medications producing brown/black urines: Freshly voided, normal urine is usually clear,
1. antimalarial drugs (chloroquine and particularly if it
primaquine, levodopa, methyldopa, phenol is a clean-catch midstream specimen
derivatives, and the antibiotics metronidazole
[Flagyl] and nitrofurantoin [Furadantin]) Precipitation of amorphous phosphates and
2. laxatives containing cascara or senna
carbonates may cause a white cloudiness in an
3. methocarbamol - a muscle relaxant.
alkaline urine
Nonpathogenic causes of a dark-brown (cola-
Nonpathological Turbidity
colored):
hazy but normal urine with the presence of
1. eating of large amount of fava beans
• squamous epithelial cells
2. rhubarb
• mucus (particularly in specimens from women)
3. aloe.
stand or refrigerated specimens -> may develop
turbidity that is nonpathological abnormalities in clear urine will be detected
before the microscopic analysis
Refrigerated specimens -> develop a thick turbidity • Current criteria used to determine the
caused by the precipitation of: necessity of performing a microscopic
1. amorphous phosphates examination on all urine specimens include
2. carbonates both clarity and chemical tests for RBCs,
3. urates. WBCs, bacteria, and protein

Amorphous phosphates and carbonates -> SPECIFIC GRAVITY

produce a white precipitate in urine with an the kidney’s most important function – has the ability
alkaline pH to concentrate glomerular filtrate by selectively
reabsorbing essential chemicals and water from
Amorphous urates produce a precipitate in acidic the glomerular filtrate
urine that • The evaluation of urine concentration is
resembles pink brick dust due to the presence of included in the routine urinalysis
uroerythrin • specific gravity in the routine urinalysis -
> to determine whether specimen
Additional nonpathological causes of urine turbidity: concentration is adequate to ensure the
1. mucus accuracy of chemical tests.
2. normal urine crystals
3. semen specific gravity of the plasma filtrate entering the
4. fecal contamination glomerulus is 1.010
5. radiographic contrast media
6. talcum powder isosthenuric: specific gravity of 1.010
7. vaginal creams hyposthenuric - specimens below 1.010
hypersthenuric - above 1.010

Normal random specimens – approximately 1.002 to

1.035
NOT URINE - lower than 1.002
Most random specimens - between 1.015 and
1.030.

Specific gravity
density of a solution compared with the density of a
similar volume of distilled water (SG 1.000) at a
Nonpathological Causes Pathological Causes of similar temperature
of Urine Turbidity Urine Turbidity
Squamous epithelial RBCs urine -> is actually water that contains dissolved
cells WBCs chemicals
Mucus Bacteria specific gravity of urine -> is a measure of the
Amorphous phosphates, Yeast density of the dissolved chemicals in the specimen.
carbonates, urates Trichomonads • Influenced both by the number of particles
Semen, spermatozoa Nonsquamous epithelial present and their size
Fecal contamination cells o large molecules contribute
Radiographic contrast Abnormal crystals o more to the reading than do small
media Lymph fluid molecules
Talcum powder Lipids o This may require the need to correct
Vaginal creams for the presence of substances that are
not normally seen in urine such as
Pathological Turbidity glucose and protein
The pathological causes of turbidity in a fresh
specimen that are encountered most commonly are: Only method in use in routine urinalysis (requires
1. RBCs correcting)
2. white blood cells(WBCs) 1. Refractometer
3. bacteria - caused by infection or a systemic
organ disorder Other two methods
Other causes of pathological turbidity that are 1. chemical reagent strips
encountered less frequently include abnormal amounts 2. osmolality
of:
1. nonsquamous epithelial cells Method Principle
2. yeast, trichomonads Refractomet Refractive index
3. abnormal crystals ry
4. lymph fluid Osmolality Changes in colligative properties
5. lipids by particle number
Reagent pKa changes of a polyelectrolyte by
The clarity of a urine specimen certainly provides a strip ions
key to present
the microscopic examination results because the
amount of turbidity should correspond with the Refractometer
amount of material Refractometry determines the concentration of
observed under the microscope. dissolved particles in a specimen by measuring
refractive index.
Clear urine - is not always normal.
• However, with the increased sensitivity of Refractive index - a comparison of the velocity of
the routine chemical tests, most light in the air with the velocity of light in a solution.
 • The concentration of dissolved particles 1. reagent strip chemical test
present in the solution determines the 2. osmometry
velocity and angle at which light passes
through a solution.

Clinical refractometers
• make use of these principles of light by using a
prism to direct a specific (monochromatic)
wavelength of daylight against a
manufacturer-calibrated scale of specific
gravity.
• The concentration of the specimen determines
the angle at which the light beam enters the
prism.
• Therefore, the specific gravity scale is
calibrated in terms of the angles at which light
passes through the specimen
• distinct advantage: determining specific
gravity using a small volume of specimen
(one or two drops)
• Not necessary: Temperature corrections

Temperature is compensated between 15°C and

38°C.

Corrections for glucose and protein: calculated by

subtracting 0.003 for each gram of protein present
• 0.004 for each gram of glucose present.
• chemical reagent strip tests -> determines
the amount of protein or glucose present

PROCEDURE:
• a drop of urine is placed on the prism Osmolality
• the instrument is focused at a good light osmolality is affected only by the number of
source, particles present
• reading is taken directly from the specific
gravity scale. When evaluating renal concentration ability, the
• The prism and its cover should be cleaned substances of interest are small molecules, primarily:
after each specimen is tested • sodium (molecular weight 23)
• chloride (molecular weight 35.5)
CALIBRATION:
• calibrated using distilled water that However, urea (molecular weight 60) (no importance
• should give a reading of 1.000. to this evaluation), will contribute more to the
• If necessary, the instrument contains a zero specific gravity than will the sodium and chloride
setscrew to adjust the reading for distilled molecules
water
• further checked using 5% NaCl (reading: Because all three molecules contribute equally to the
1.022 ± 0.001) or osmolarity of the specimen, a more representative
• 9% sucrose (reading: 1.034 ± 0.001) measure of renal concentrating ability can be obtained
by measuring osmolarity
Urine control specimens representing low,
medium, and high concentrations also should be osmole -> is defined as 1 g molecular weight of a
run at the beginning of each shift. substance divided by the number of particles into
which
EXAMPLE: it dissociates.
A specimen containing 1 g/dL protein and 1 g/dL
glucose nonionizing substance, such as:
has a specific gravity reading of 1.030. Calculate the • glucose (molecular weight, 180)
corrected reading. o contains 180 g per osmole
• sodium chloride (NaCl) (molecular weight
1.030– 0.003 (protein) = 1.027– 0.004 (glucose) = 58.5),
1.023 corrected specific gravity o if completely dissociated, contains
29.25 g per osmole.
Results that are abnormally high—above 1.040
(patients undergone an IV pyelogram) OSMOLAL SOLUTION of glucose -> has 180 g of
• caused by the excretion of the injected glucose dissolved in 1 kg of solvent.
radiographic contrast media
• and caused by patients who are receiving OSMOLAR SOLUTION of glucose -> has 180 g of
dextran or other high molecular-weight IV glucose dissolved in 1 L of solvent
fluids (plasma expanders)
• Once the foreign substance has been cleared The unit of measure used in the clinical laboratory:
from the body, the specific gravity returns to milliosmole (mOsm)
normal. • It is not practical to use a measurement as
large as the osmole (23 g of sodium per
NOT AFFECTED BY THESE HIGH-MOLECULAR- kilogram)
WEIGHT SUBSTANCES, USE:
 POINT
Freezing 0°C Lowered 1.86°C
OSMOLARITY OF A SOLUTION Point
can be determined by measuring a property that is Boiling Point 100°C Raised 0.52°C
mathematically related to the number of particles in Vapor 2.38 mm Hg Lowered 0.3 mm
the solution (colligative property) and comparing Pressure at Hg at 25°C
this value with the value obtained from the pure 25°C
solvent Osmotic 0 mm Hg Increased 1.7 ×
Pressure 9
10 mm Hg
Solute dissolved in solvent causes the following
changes in colligative properties:
1. lower freezing point, HISTORICAL NOTE
2. higher boiling point Harmonic Oscillation Densitometry
3. increased osmotic pressure • based on the principle that the frequency of a
4. lower vapor pressure sound wave entering a solution changes in
proportion to the density of the solution.
Water is the solvent in urine, thus the number of • This technique was originally used in early
particles present in a sample can be determined by automated urinalysis instruments
comparing • The addition of reagent strip analysis for
a colligative property value of the sample with that specific gravity has replaced this technique in
of pure automated systems
water
Urinometry
To measure osmolality (urinalysis laboratory) The urinometer consists of a weighted float attached
• requires special equipment referred to as an to a
osmometer and, therefore, an additional step scale that has been calibrated in terms of urine
in the routine urinalysis procedure. specific
gravity.
A2O Advanced Automated Osmometer (Advanced • The weighted float displaces a volume of liquid
In equal to its weight and has been designed to
struments, Inc., Two Technology Way, Norwood, MA sink to a level of 1.000 in distilled water.
02062) • The additional mass provide by the dissolved
• uses freezing-point depression to measure substances in urine causes the float to displace
osmolality a volume of urine smaller than that of distilled
• providing a more automated method for water.
measuring both urine and serum osmolality • The level to which the urinometer sinks, as
• (The principles and uses of the freezing point shown in the figure, represents the specimen’s
and vapor pressure osmometers currently in mass or specific gravity
use in the) clinical laboratory)

“molality” -> is used most commonly because both

the solute and the solvent are expressed in the same
units of measure.

Reagent Strip Specific Gravity

convenient way to perform the routine urinalysis by
eliminating the need for an additional procedure.

reagent strip reaction

• based on the change in pKa (dissociation Odor
constant) of a polyelectrolyte in an alkaline • seldom of clinical significance
medium. • not a part of the routine urinalysis
• polyelectrolyte ionizes -> releasing • noticeable physical property
hydrogen ions in proportion to the number of
ions in the solution. faint aromatic odor - freshly voided urine
• The higher the concentration of urine, the As the specimen stands -> odor of ammonia becomes
more hydrogen ions are released, thereby more prominent.
lowering the pH 1. The breakdown of urea is responsible for the
• Indicator: bromothymol blue on the reagent characteristic ammonia odor.
pad measures the change in pH
↑ concentration of urine Causes of unusual odors:
↑ hydrogen ions 1. bacterial infections -> which cause a
↓ concentration of urine strong, unpleasant odor similar to ammonia
2. diabetic ketones -> which produce a sweet
• As the specific gravity increases, the indicator or fruity odor
changes from blue (1.000 [alkaline]) -> 3. maple syrup urine disease – a serious
through shades of green -> to yellow (1.030 metabolic defect results in urine with a strong
[acid]). odor of maple syrup

• Readings can be made in 0.005 intervals by Causes unusual or pungent odor in urine,
careful comparison with the color chart ingestion of:
1. onions
Particle Changes to Colligative Properties 2. garlic
PROPERTY NORMAL EFFECT OF 1 3. asparagus - everyone who eats asparagus
PURE MOLE OF produces an odor , but only certain people
WATER SOLUTE who are genetically predisposed can smell it.
Ions important in evaluating renal concentrating
ability
1. Na+,
2. Cl–
3. NH4

Thus, the reagent strip method provides additional

information and

These ions are not affected by nonionizing

substances, including:
1. Urea
2. Glucose
3. protein
4. radiographic dye (contaminating substances)

ODOR CAUSE
Aromatic Normal
Foul, Bacterial decomposition, urinary
ammonia tract infection
like
Fruity, Ketones (diabetes mellitus,
sweet starvation, vomiting)
Maple syrup Maple syrup urine disease
Mousy Phenylketonuria
Rancid Tyrosinemia
Sweaty feet Isovaleric acidemia
Cabbage Methionine malabsorption
Bleach Contamination