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URINALYSIS

Faculty of Medicine
University of Tabuk
What is urinalysis?
■ It is one of most commonly used laboratory tests to
assess:
1. The state of the kidney and urinary tract.
2. Metabolic or systemic (non-kidney) disorders.
■ Normally urine is composed of 96% water and 4%
dissolved substances derived from waste products of
metabolism.
■ The actual composition of urine varies, depending on
diet, metabolism, general health of the body, and
health of the kidney.
Methods of urine collection
■ Random collection:
 Taken at any time of day with no precautions regarding
contamination.
 Sample may be dilute, isotonic, or hypertonic and may contain
white cells, bacteria, and squamous epithelium as
contaminants.
 In females, the specimen may contain vaginal contaminants
such as trichomonas, yeast and red cells during menstruation.
■ Early morning sample:
 Before ingestion of any fluid.
 Usually hypertonic and reflects the ability of the kidney to
concentrate urine during dehydration which occurs overnight.
■ Clean-catch, midstream urine specimen:
 Collected after cleansing the external urethral meatus.
 The first half of the stream serves to flush contaminating cells and
microbes from the outer urethra prior to collection.
 Used when urine is tested for infection
■ Catherization of the bladder through the urethra:
 Used in a comatose or confused patient.
 Procedure risks are introducing infection and traumatizing the
urethra and bladder.
■ Suprapubic transabdominal needle aspiration of the
bladder:
 Provides the purest sampling of bladder urine.
 A good method for infants and small children.
■ 24-hour urine collection
 Used for quantitative and qualitative analysis of substances
Urinalysis

■ Urinalysis consists of the following measurements:


1. Macroscopic examination (physical)
2. Chemical examination (dipstick test)
3. Microscopic examination of urine sediment
Macroscopic urinalysis
1. Color
■ Normal fresh urine is amber yellow in color (may be pale in
diluted to dark yellow in concentrated urine)
■ Abnormal urine colors can be a result of disease, medications
or certain foods.
Colour Pathological causes

Brown Bile pigments, myoglobin,


haemoglobinuria,
Green or blue Pseudomonal urinary tract
infection (UTI)
Red Hematuria

Orange Bile pigments

Dark yellow Dehydration


Macroscopic urinalysis
2. Turbidity or cloudiness
Cloud or turbid urine may be due to:
 Contamination with vaginal mucus, prostatic fluid or
epithelial cells.
 Excess phosphate or oxalate crystals
 Pyuria secondary to infection
 Chyluria (presence of chyle/lymph in the urine - usually
secondary to lymphatic obstruction)
 Bacteruria
Macroscopic urinalysis
3. Odour
■ Normal urine odour is described as urinoid.
 Infection, causes pungent smell (foul).
 Alkaline fermentation causes an ammoniacal smell
 Diabetic ketoacidosis produces a sweet or fruity odour.
 Gastrointestinal-bladder fistulae produces a faecal smell
Urine dipstick chemical analysis
■ Dipstick is a paper strip with patches impregnated with
chemicals that undergo a color change when certain
constituents of the urine are present.
■ The strip is dipped into the urine sample, and after the
appropriate number of seconds, the color change is compared
to a standard chart to determine the findings.
■ The most frequently performed chemical tests using reagent
test strips are:
1. Specific gravity 2. pH 3. protein
4. Glucose 5. ketones
6. Hemoglobin and myoglobin 7. bilirubin 8. urobilinogen
9. Nitrites
Specific gravity
■ Specific gravity is a measure of urine concentration of solutes.
■ This tests the ability of the kidneys to concentrate or dilute the
urine.
■ Normal specific gravity is between 1.002-1.025.
■ Is measured by urinometer, refractometer or dipstick
■ Increased SG in: dehydration, glycosuria, renal artery stenosis,
heart failure (secondary to decreased blood flow to the kidneys),
inappropriate antidiuretic hormone secretion and proteinuria.
■ Decreased SG is seen in: excessive fluid intake, renal failure, and
diabetes insipidus.
pH
■ Urine is commonly acidic (5.5-6.5) due to metabolic activity.
■ The range is 4.5 to 8.
■ Some of the dissolved substances in urine will precipitate to
form crystals when the urine is acidic and others will form
crystals when the urine is basic.
■ Crystals formation may lead to kidney stones or "calculus”.
■ By modifying urine pH through diet or medications, the
formation of these crystals can be reduced or eliminated.
■ Alkaline urine (high pH) is seen in tubular acidosis and in
infection with urease-splitting organisms. Acidic urine (low pH)
may be caused by diet (eg, acidic fruits such) and uric acid
increase.
Protein
■ Normal protein which can be found in urine is protein secreted by
the kidney tubules (Tamm-Horsfall protein).
■ When urine protein is elevated is called proteinuria(>150
mg/day).
■ Causes of proteinuria: stress, exercise, fever, nephrotic
syndrome, chronic renal diseases, pregnancy, multiple myeloma.
■ Most dipstick tests detect albumin but may not detect Bence
Jones' protein or globulins.
■ Sulfosalicylic acid is used to detect Bence Jones' protein.
■ Persistent significant proteinuria detected by dipstick requires
further assessment with 24-hour urinary protein excretion.
Glucose
■ Glucose is normally not present in urine. When glucose is
present, the condition is called glucosuria
■ Causes of glucosuria: diabetes mellitus, hormonal disorders, liver
disease, medications and pregnancy.
■ Dipsticks uses the glucose oxidase reaction for screening
(specific for glucose).
■ dipsticks miss other reducing sugars such as galactose and
fructose. For this reason, most newborn and infant urines are
routinely screened for reducing sugars by methods other than
glucose oxidase (such as the Clinitest).
Ketones
■ Ketones are not normally found in the urine.
■ Ketones are not normally found in the urine.
■ They are produced when glucose is not available to the body's
cells as a source of energy.
■ Causes: starvation, DM (type I), high protein diet
■ Dipstick tests for the presence of acetoacetic acid at 5-10
mg/dL but not acetone or beta-hydroxybutyric acid.
■ Test tablets containing sodium nitroprusside can detect acetone
and beta-hydroxybutyric acid.
Blood (Hemoglobin) and Myoglobin
■ A positive test indicates either hematuria, hemoglobinuria or
myoglobinuria.
■ Free hemoglobin or myoglobin causes field change, whereas
intact RBCs are broken down on contact with the reagent pad
and release local hemoglobin, producing a dot.
■ Haematuria is defined as >3 RBC/high power field (HPF).
■ The test depends on the perioxidase activity of RBCs.
Bilirubin
■ Bilirubin is not present in the urine of normal healthy
individuals.
■ It is a waste product that is produced by the liver from the
hemoglobin of RBCs that are broken down.
■ It becomes a component of bile, a fluid that is released into
the intestines to aid in food digestion.
■ Unconjugated bilirubin is water-insoluble and not normally
present in the urine even when its level is increased in the
blood.
■ Conjugated bilirubin only appears in urine in the presence of
liver disease or obstruction of the bile ducts.
Urobilinogen
■ Urobilinogen is normally present in urine in low concentrations.
It is formed in the intestine from bilirubin, and a portion of it is
absorbed back into the blood.
■ Positive test results may indicate liver diseases such as:
1. Viral hepatitis, cirrhosis, liver damage due to drugs or toxic
substances,
2. Conditions associated with increased RBC destruction
(hemolytic anemia).
■ When urine urobilinogen is low or absent in a person with
urine bilirubin and/or signs of liver dysfunction, it can indicate
the presence of hepatic or biliary obstruction.
Ascorbic Acid (Vitamin C)
■ Occasionally, people taking vitamin C or multivitamins may have
large amounts of ascorbic acid in their urine.
■ When this is suspected, a laboratorian may test the sample for
ascorbic acid (vitamin C) because it has been known to interfere
with the accuracy of some of the results of the chemical test strip,
causing them to be falsely low or falsely negative.
■ Examples of tests that may be affected include the urine dipstick
tests for glucose, blood, bilirubin, and nitrite.
Nitrite
■ This test relies on the breakdown of urinary nitrates to
nitrites, which are not found in normal urine.
■ Many Gram-negative and some Gram-positive bacteria
are capable of producing this reaction.
■ A positive nitrite test indicates that bacteria is present in
significant numbers in urine.
Microscopic urinalysis
■ Methodology
■ A sample of urine (usually 10-15 ml) is centrifuged in a test tube
at relatively low speed (about 2-3,000 rpm) for 5-10 minutes until
a sediment is produced at the bottom of the tube. A drop of
sediment is poured onto a glass slide and then covered.
■ Examination
■ The sediment is first examined under low power to identify most
crystals, casts, squamous cells, and other large objects
■ The numbers of casts seen are usually reported as number of
each type found per low power field (LPF).
■ Next, examination is carried out at high power to identify fine
crystals, cells, and bacteria.
Cells
1. Red Blood Cells
■ Hematuria is the presence of abnormal numbers of red cells in
urine due to: glomerular damage, tumors which erode the urinary
tract anywhere along its length, kidney trauma, urinary tract
stones, renal infarcts, acute tubular necrosis, upper and lower
urinary tract infections, nephrotoxins and physical stress.
■ Red cells may also contaminate the urine from the vagina in
menstruating women or from trauma produced by bladder
catheterization.
■ in fact, only cell ghosts and free hemoglobin (intact RBCs are
difficult to be seen) can be seen.
2. White Blood Cells
■ Pyuria refers to the presence of abnormal large numbers of
leukocytes in urine
■ Appear with infection in either the upper or lower urinary tract or
with acute glomerulonephritis.
■ White cells from the vagina, especially in the presence of vaginal
and cervical infections, or the external urethral meatus in men
and women may contaminate the urine.
3. Epithelial Cells
■ Renal tubular epithelial cells, normally slough into the urine in
small numbers.
■ However, with nephrotic syndrome and in conditions leading to
tubular degeneration, the number sloughed is increased.
■ When lipiduria occurs, these cells contain endogenous fats, such
cells are called oval fat bodies
■ Transitional epithelial cells from the renal pelvis, ureter, or
bladder may be seen with increased number in transitional cell
carcinoma.
■ Squamous epithelial cells from the skin surface or from the outer
urethra can appear in urine
Casts
■ Urinary casts are formed only in the distal convoluted tubule
(DCT) or the collecting duct (distal nephron). The proximal
convoluted tubule (PCT) and loop of Henle are not locations for
cast formation.
1. Hyaline casts are composed of a mucoprotein (Tamm-Horsfall
protein) secreted by tubule cells.
■ Tamm-Horsfall mucoprotein is the matrix or "glue" that cements
urinary casts or cells together.
■ Factors which favor protein cast formation are: low flow rate, high
salt concentration, and low pH, all of which favor protein
denaturation and precipitation.
2. Red blood cell casts may stick together and form red blood cell
casts.
■ These casts are indicative of glomerulonephritis, with leakage of
RBC's from glomeruli, or severe tubular damage.
3. White blood cell casts are most typical for acute pyelonephritis,
but they may also be present with glomerulonephritis.
■ Their presence indicates inflammation of the kidney, because
such casts will not form except in the kidney.
4. Granular casts
■ When cellular casts remain in the nephron for some time before they
are flushed into the bladder urine, the cells may degenerate to
become a granular cast a waxy cast.
■ Granular and waxy casts are derive from renal tubular cell casts.
Crystals
■ Urine contains many dissolved substances (solutes), these
solutes can form crystals (solid forms) in the urine if:
■ The urine pH is increasingly acidic or basic
■ The concentration of dissolved substances is increased.
■ Crystals are considered "normal" if they are from solutes that are
typically found in the urine.
■ Some examples of crystals that can be found in the urine of
healthy individuals include:
1. Sodium urates 2. Calcium oxalates
3. Amorphous phosphates 4. Crystalline uric acid
5. Triple phosphate
■ If the crystals are from substances that are not normally in
the urine, they are considered "abnormal."
■ Abnormal crystals may indicate an abnormal metabolic
process. Some of these include:
■ Calcium carbonate
■ Cystine in urine of neonates with congenital cystinuria or
severe liver disease
■ Tyrosine in congenital tyrosinosis or marked liver impairment
■ Note, all crystals are precipitated in acidic urine except
phosphate crystals in alkaline urine.
Crystals
■ Changes which occur with time after collection include:
1) decreased clarity due to crystallization of solutes,
2) Rising pH
3) Loss of ketone bodies
4) Loss of bilirubin
5) Dissolution of cells and casts
6) Overgrowth of contaminating microorganisms.
■ Urinalysis may not reflect the findings of fresh urine if the sample
is left for > 1 hour.