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Urinalysis Lab

Robert Beach, M.D.

The routine urinalysis consists of the urinary dipstick exam and urinary sediment exams.
We will begin by discussion of the dipstick exam. The dipstick is a series of colored pads
each of which measures a different parameter and are compared to a color chart on the
container, which holds the sticks. The dipstick is placed in a sample of freshly voided
urine, then, according to a time chart on the container, read in comparison to the standard
chart. Substances or parameters routinely measured are pH, blood, protein, glucose,
ketones, specific gravity, bilirubin, and nitrites.

Urinalysis
• Dipstick
– Blood, Protein, Glucose, Ketones, pH
– Bilirubin, Nitrate (Bacteria)

• Urinary Microscopy



Cells
Casts
Crystals
Artifacts

Urinary Microscopy
Technique:
• Mix specimen and place ~ 10-15 ml or urine
into a centrifuge tube
• Centrifuge at 2K-5K rpm for ~ 5 minutes
• Pour off supernatant fluid and resuspend
sediment in the urine that drains back from
the sides of the tube (0.5 ml).

Urinalysis
• Dipstick
– Blood, Protein, Glucose, Ketones, pH
– Bilirubin, Nitrate (Bacteria)

• Urinary Microscopy



Cells
Casts
Crystals
Artifacts

(Solid arrow) Demonstrated on this slide are eumorphic, normal size and shape, red
blood cells (rbcs) and (open arrow) polymorphonuclear leukocytes. A normal urine
should have <3 rbcs/high powered microscopic field.

To a trained observer the presence of dysmorphic (fragmented) rbcs on a freshly
voided urine is indicative of glomerular origin of the hematuria.

This can be better appreciated with phase-contrast microscopy where the red cell
membrane demonstrates “blebs”.

This slide contains a multitude of many cell types. The largest cell is a transitional
epithelial cell, likely bladder or ureter in origin; the two cells below this are renal
tubular cells (nephron in origin) and are similar to PMNs except for an eccentric
mononuclear nucleus and a less granular cytoplasm, & PMNs (arrow).

This again demonstrates the subtle differences between PMNs (solid arrow) and
renal tubular epithelial cells (open arrow).

Cellular staining aids in discriminating PMNs and RTE cells. The cells containing
the darker staining nucleus are PMNs.

Squamous epithelial cells, very large & cuboidal in shape, frequently are seen in a
poorly collected urine specimen and indicate contamination from the vagina or
foreskin.

Gram negative rods are the most common bacterial pathogens of the urinary tract
(arrow).

When lipids are present in the urine in large amounts, e.g. nephrotic syndrome, they
appear as either free oval fat bodies or intracellular in RTE cells or PMNs.
Under
polarized light they have a maltese cross appearance.

Urinalysis
• Dipstick
– Blood, Protein, Glucose, Ketones, pH
– Bilirubin, Leucocyte Esterase

• Urinary Microscopy



Cells
Casts
Crystals
Artifacts

Casts are composed of filtered substances, cells, and Tamm-Horsfall protein,
which is secreted by the thick ascending limb cells. The proteinaceous matrix
insipates as fluid is removed from the luminal environment leaving the
proteinaceous material to take the shape of the tubular lumen (casts).

Casts are composed of filtered substances, cells, and Tamm-Horsfall protein,
which is secreted by the thick ascending limb cells. The proteinaceous matrix
insipates as fluid is removed from the luminal environment leaving the
proteinaceous material to take the shape of the tubular lumen (casts).

This slide reviews the types of casts seen, their clinical significance, and their
schematic appearance.

The hyaline cast is very faint and is best observed on the right as the microscopic
focus is adjusted.

This slide illustrates a coarsely granular cast. The granules are likely
degenerated cellular debris and may be seen with acute tubular necrosis.

Seen on this slide is the pathognomonic finding on urinalysis of
glomerulonephritis, i.e., a RBC cast. Note also dysmorphic RBCs surrounding
the cast.

In comparison the cast in this field is a WBC cast. Note cellular size and the
presence of nuclei in some of the cells.

This cast can easily be confused with the RBC cast. Features that distinguish the
difference are the refractoriness of the components and the appearance under
polarized light.

The maltese cross verifies that this is a lipid-laden cast.

Urinalysis
• Dipstick
– Blood, Protein, Glucose, Ketones, pH
– Bilirubin, Leucocyte Esterase

• Urinary Microscopy



Cells
Casts
Crystals
Artifacts

Schematics of common crystals seen in the urine.

Schematics of common crystals seen in the urine.

The most common crystal (also renal stone disease or urolithiasis) is calcium
oxalate. The crystal appears as a pyramid as seen from above or, as some
describe it, an envelope.

Uric acid crystals appear as refractile, multifaceted (or rosettes) crystals. This
can be described as a multilayered appearance.

Depending on urine conditions and pH uric acid appears as amorphous urates.
The urine sediment just appears “dirty”.

Amorphous urate is indistinguishable from amorphous phosphates as seen in this
slide except the latter disappears by acidification of the urine.

Cystine crystals as seen in patients with hereditary cystinuria. The crystals are
identified by the hexagonal shape.

Triple phosphate crystals are identified by their coffin lid shape. They are
frequently seen in individuals with chronic pyelonephritis with urea-splitting
(urease) bacteria leading to an alkaline urine. The stones formed are known as
staghorn calculi or struvite stones.

Sulfonamide crystals – appear as bundles of hay tied in the middle.

Tyrosine crystals – javelin shaped spicules. Seen in severe liver disease or
tyrosinosis

The next three examples are of common artifacts. The first is talc crystals from
the talcum powder on many examining gloves. It may be confused with lipid or
oval fat bodies (but does not polarize) or uric acid crystals (the center does not
display rosettes but a typical Y shape).

Clothing fibers – longer and more refractile ( and frequently larger) than casts.

Hair follicle next to a granular cast. The hair follicle has a central stripe.