Interpretation of Urine

DR
D R N AV E E D A N S A R I
RESIDENT MEDICINE UNIT 1
CMCH LARKANA
OUTLINES
Urine
What is Urine DR?
Why Urine DR?
Precautions For Urine Collection
Types of urine sample
Urinalysis using a dipstick test
Physical, Chemical & Microscopic testing of urine specimen
URINE
Urine is a liquid by-product of metabolism in humans and in many other animals

It is an ultrafiltrate of plasma from which glucose, amino acids, water and other
substances essential to body metabolism have to be reabsorbed.

It carries waste products and excess water out of the body.

Physiology
In normal adults, 25% of cardiac output or more than a liter of blood, profuse
the two kidneys each minute.

An ultrafiltrate of the plasma passes through each glomerular capillary tuft into
bowman’s capsule.

The filtrate has

◦ pH of 7.4 & Osmolality of 285 mosm/kg water (same as plasma)

Modification of this filtrate to produce excreted urine occurs in the tubules &
collecting duct of each nephron.
What is Urine DR?
Also called Urinalysis, one of the oldest laboratory procedures in the practice of
medicine.

It is a commonly ordered panel of tests on a urine sample.

Lab testing of urine generally falls under 3 categories

◦ Physical
◦ Chemical
◦ Microscopic
Why Urinalysis?
General evaluation of health

Diagnosis of disease or disorders of the kidneys or urinary tract

Diagnosis of other systemic disease that affect kidney function

Screening for drug abuse

Precautions For Urine Collection
Urine should be analysed as rapidly as possible, ideally within 30 minutes

If not possible:
• Refrigerate immediately and stored for preferably no more than 6–12 hours
after collection.
• Refrigerated urine should be brought to room temperature and thoroughly
mixed before analysis.
• Urine should not be frozen if sediment analysis is to be performed
• Casts are particularly vulnerable to disintegration and will only be detected if
fresh urine is examined very soon after collection
Urinalysis using a dipstick test
A dipstick is a thin plastic stick with a strip covered with chemicals.

The dipstick is placed in the urine to check for any abnormalities.

If a certain substance is present in urine the color of the chemical strip change.

It is one of the commonly used methods of checking the chemical components of

urine.
Advantages
◦ It is convenient to use.

◦ Easy to interpret

◦ Cost-effective

◦ The analysis can be done in just a few minutes of collecting urine

Disadvantages
◦ It might not always yield to accurate result as urine test using a test strip is time-
sensitive.

◦ It only shows limited information about the composition of urine.

◦ A urine test strip is more of qualitative and not much on the quantitative information
Physical Testing of urine
specimen
Color
The colour of urine varies from almost colourless to black
Variations in colour may be due to normal metabolic functions, physical activity,
ingested materials, or pathologic conditions
Normal urine color can be pale yellow, yellow, dark yellow or amber
Normal color of urine is largely due to pigment Urochrome.
Urochrome excretion is thought to be proportional to metabolic rate & is
increased during fever, thyrotoxicosis & starvation.
Pale or colorless urine in a normal person follows high fluid intake.

Dark urine maybe seen when fluids are withheld, thus the color roughly
indicates the degree of hydration & urine concentration, which should correlate
with specific gravity.
Dark Yellow/Amber/Orange
Not always signify a normal concentrated urine but can be caused by the presence of the
abnormal pigment bilirubin.

Presence of bilirubin is suspected if a yellow foam appears when the specimen is shaken.

Yellow-orange specimen caused by the administration of phenazopyridine (Pyridium) or

azo-gantrisin compounds to persons with urinary tract infections
Red/Pink/Brown
Non pathological
◦ Menstrual contamination,
◦ Ingestion of highly pigmented foods
◦ Ingestion of blackberries can produce a red color in acidic urine.

Medications.
◦ Rifampin
◦ Phenolphthalein
◦ phenindione
◦ phenothiazines
Pathological causes
◦ RBCs
◦ Hemoglobin
◦ Myoglobin
◦ Porphyrins
Red is the usual color that blood (RBCs) produces in urine, but the color may
range from pink to brown, depending on the amount of blood, pH of the urine,
and the length of contact.
Hemoglobin and myoglobin, produce a red urine and result in a positive
chemical test result for blood.
A fresh brown urine containing blood may also indicate glomerular
bleeding.
Myoglobin exhibits a more reddish-brown color than hemoglobin.
Brown/Black
Melanin (melanoma).
Homogentisic acid (alkaptonuria).
Drugs
◦ Levodopa
◦ Methyldopa,
◦ Phenol derivatives
◦ Metronidazole
Blue/Green
Bacterial infections
◦ Pseudomonas species

Ingestion of breath Deodorizers

Medications
◦ Methocarbamol
◦ methylene blue
◦ amitriptyline
 Drugs Urine color
Alcohol, ethyl Pale
Deferoxamine Red
Levodopa Red than brown
Methyldopa Red to brown
Metronidazole Reddish-brown
Rifampin Orange-red
Riboflavin Bright yellow
Tetracyclines Yellow
Irone sorbitol Brown
 Odor
Odor Cause
Aromatic Normal
Foul, ammonia-like Bacterial decomposition,
urinary tract infection
Fruity, sweet Ketones
Maple syrup Maple syrup urine disease
Mousy Phenylketonuria
Cabbage Methionine malabsorption
Bleach Contamination
Turbidity
Turbidity is a term that refers to the transparency of a urine specimen.

Common terminology used to report turbidity includes clear, hazy, cloudy,

turbid, and milky
Turbidity Term
Clear No visible particulates, Freshly voided
transparent.
Hazy Few particulates, print Dehydration
easily seen through urine.
Cloudy Many particulates, print Bacteria growth
blurred through urine.
Turbid Print cannot be seen RBC , WBC
through urine.
Milky May precipitate or be Pyuria, Fat, Chyluria
clotted.
Clear hazy Cloudy Turbid Milky
Nonpathological Causes of Urine Turbidity

◦ Squamous epithelial cells

◦ Mucus
◦ Amorphous phosphates, carbonates, urates
◦ Semen, spermatozoa
◦ Radiographic contrast media
◦ Talcum powder
◦ Vaginal creams
Pathologic Causes of Urine Turbidity

◦ RBCs
◦ WBCs
◦ Bacteria
◦ Yeast
◦ Non-squamous epithelial cells
◦ Abnormal crystals
◦ Lymph fluid
◦ Lipids
Volume
Normally its 700ml to 2000ml per day (0.5ml to 1.5ml/kg/hour).
A diurnal rhythm of excretion also cooperates, so that excess water is excreted
more readily by the day than night.
Under physiologic conditions, the chief determent of urine volume is the intake
of water.
In normal pregnancy, the usual diurnal variation is reversed, causing nocturia &
excretion of dilute urine.
There are different terms which are used:

◦ Polyuria >2500 ml/day.

◦ Oliguria <500 ml/day.
◦ Anuria <100 ml/day
Specific Gravity (SG)
Specific gravity is defined as the density of a urine compared with the density of
a similar volume of distilled water at a similar temperature.
Urinary specific gravity is a measure of the concentration of solutes in the urine.
It provides information on the kidney’s ability to concentrate urine.
Urine always has SG greater than that of distilled water, which has an SG of
1.000.
Normal random urine specimens may range from 1.005 to 1.025, depending on
the patient’s amount of hydration.
Reabsorption of essential chemicals and water from the glomerular filtrate is
one most important function of kidney

It is often the first renal function to become impaired; therefore, an assessment

of the kidney’s ability to reabsorb is a necessary component of the routine
urinalysis.

This evaluation can be performed by measuring the specific gravity of urine.

Other than dipstick method, Specific gravity of urine can also be measured by

◦ Refractometer (total solids meter): It measures the ratio of the velocity of light in air
to the velocity of light in urine.

◦ Urinometer: is a weighted float marked with a scale for specific gravities from 1.000
to 1.060. The urinometer is simple and quick to use
HYPOSTHENURIA (< 1.010): Indicates dilute urine, which may be caused by

◦ Diabetes insipidus
◦ Drinking excessive amounts of liquid.
◦ Pyelonephritis, glomerulonephritis.
◦ Malignant hypertension
◦ Use of diuretics
HYPERSTHENURIA (>1.010): Indicates very concentrated urine, which may be
caused by:

◦ Volume loss (dehydration, vomiting, diarrhoea, fever)

◦ Hepatorenal syndrome
◦ Diabetes mellitus.
◦ Adrenal insufficiency.
◦ Shock
◦ CCF
◦ Mannitol
If SG is markedly increased (1.040-1.050), can be caused by

◦ Artifact

◦ Excretion of radiographic contrast

ISOSTHENURIC:

◦ There is little or no variability between several specimens from a patient , and SG is

fixed at about 1.010.

◦ It indicates: severe renal damage in which there is disruption of both concentrating

and diluting abilities.
Chemical Testing of urine
specimen
PH
The importance of urinary pH is primarily as an aid in determining the existence
of systemic acid-base disorders of metabolic or respiratory origin and in the
management of urinary conditions that require the urine to be maintained at
a specific pH.

The urine pH is highly dependent upon diet & cannot be used to infer anything
about the acid-base status of a patient in the absence of an ABG & metabolic
panel.
Normal pH for urine ranges from 4.5 – 8.0.

A pH < 7 indicates acidic urine and a pH > 7 alkaline urine.

Foods (such as citrus fruits and dairy products) and medications (such as antacids)
can affect urine pH.

In a diet high in protein the urine is more acidic, while a diet high in vegetable
material yields a urine that is more alkaline
The pH of freshly excreted urine does not reach 9 in normal or abnormal
conditions.

A pH of 9 is associated with an improperly preserved specimen and indicates

that a fresh specimen should be obtained to ensure the validity of the analysis.
CAUSES OF ACIDIC URINE
◦ Acidosis (DKA)
◦ Uncontrolled diabetes
◦ Diarrhoea
◦ Starvation and dehydration
◦ Respiratory Acidosis
◦ High protein diet
CAUSES OF ALKALINE URINE
◦ UTI with urease producing organisms
◦ Salicylate intoxication
◦ Urinary retention due to obstruction
◦ Chronic renal failure
◦ Metabolic alkalosis
◦ Renal tubular acidosis
◦ High vegetable diet, milk
Glucosuria
The glucose test is the most frequent chemical analysis performed on urine it is
valuable in the detection of diabetes mellitus.

Under normal circumstances, almost all the glucose filtered by the glomerulus is
reabsorbed in the proximal convoluted tubule; therefore, urine contains only
minute amounts of glucose.

Glucosuria occurs when blood glucose exceeds this renal threshold.

Renal threshold for glucose is approximately 160 to 180 mg/dL.

Blood glucose levels fluctuate, and a normal person may have glucosuria
following a meal with a high glucose content.

Glucosuria in the absence of hyperglycemia reflects, a tubular resorption defect

eg: Fanconi syndrome
Causes of glucosuria
Non-renal causes:
◦ Diabetes mellitus
◦ Pancreatic cancer
◦ Acromegaly
◦ Cushing syndrome
◦ Hyperthyroidism
◦ Pheochromocytoma
◦ Stress
◦ Gestational diabetes
Renal causes

◦ Fanconi syndrome

◦ Advanced renal disease

◦ Osteomalacia
Ketonuria
Ketones represents three intermediate products of fat metabolism namely,
acetone, acetoacetic acid and beta hydroxybutyric acid.

Ketone blood level are normally very low (2-4 mg/dl).

◦ 20% acetoacetic acid
◦ 2% acetone
◦ 78% B-hydroxybutyric acid.

Urine dipsticks detect acetoacetate and to a lesser extent, acetone but do not
detect beta hydroxybutyrate (BHB).
Normally, measurable amounts of ketones do not appear in the urine, because
all the metabolized fat is completely broken down into carbon dioxide and
water.

However, when the use of available carbohydrate as the major source of energy
becomes compromised, body stores of fat must be metabolized to supply
energy.

Ketones are excreted when the body metabolizes fats incompletely (ketonuria)
Clinical significance of Ketonuria:
◦ Diabetic acidosis
◦ Insulin dosage monitoring
◦ Starvation
◦ Malabsorption
◦ Strenuous exercise
◦ Vomiting
◦ Diarrhea
◦ Exposure to cold
Haemoglobinuria
It is the presence of blood pigments in the urine without the presence of red
blood cells.

Haemoglobinuria appears as a clear red specimen.

It results from the lysis of red blood cells produced in the urinary tract,
particularly in dilute, alkaline urine.
It also may result from intravascular haemolysis and the subsequent filtering of
haemoglobin through the glomerulus.

Lysis of red blood cells in the urine usually shows a mixture of hemoglobinuria
and hematuria, whereas no red blood cells are seen in cases of intravascular
hemolysis.
Causes
◦ Transfusion reactions
◦ Haemolytic anemias
◦ Severe burns
◦ Infections/malaria
◦ Strenuous exercise/red
◦ blood cell trauma
◦ Brown recluse spider bites
Hematuria
It is the presence of red blood cells in urine.

Greater than five cells per microliter of urine is considered clinically significant

Hematuria produces a cloudy red urine

It is most closely related to disorders of renal or genitourinary origin in which

bleeding is the result of trauma or damage to the organs of these Systems.
Causes
◦ Renal calculi
◦ Glomerulonephritis
◦ Pyelonephritis
◦ Tumours
◦ Trauma
◦ Exposure to toxic Chemicals
◦ Anticoagulants
Myoglobinuria
Myoglobin, a heme-containing protein found in muscle tissue, not only reacts
positively with the reagent strip test for blood but also produces a clear red-
brown urine.

The diagnosis of myoglobinuria is usually based on the patient’s history and

elevated serum levels of the enzymes creatinine kinase and lactic
dehydrogenase.

The concentration of myoglobin in the urine must be atleast 25 mg/dL before

the red pigmentation can be visualized.
Causes
◦ Muscular trauma/crush
◦ Prolonged coma
◦ Convulsions
◦ Muscle-wasting diseases
◦ Alcoholism/overdose
◦ Drug abuse
◦ Extensive exertion
◦ Cholesterol-lowering statin medications
Urinary Bilirubin
Normally, no detectable amounts of bilirubin are present in urine.

Conjugated bilirubin appears in the urine when the normal degradation cycle is
disrupted by obstruction of the bile duct (e.g., gallstones or cancer) or when the
integrity of the liver is damaged, allowing leakage of conjugated bilirubin into
the circulation
Causes
◦ Biliary tract disease
◦ Cirrhosis
◦ Gallstones in biliary tract
◦ Hepatitis
◦ Tumors of gallbladder
Urine Urobilinogen
Bilirubin excreted into the intestine is metabolized by bacteria and forms
urobilinogen.

Urobilinogen is reabsorbed via the portal circulation and a small amount is

excreted in the urine.
Normally present in low amounts (0.5-1 mg/dL)

Elevated in
◦ Liver disease
◦ Intestinal obstruction
◦ Hemolytic anemia
◦ Hemolysis
Nitrites
The reagent strip test for nitrite provides a rapid screening test for the presence
of urinary tract infection (UTI).
Nitrite testing is sensitive, but not specific, in detecting UTIs. Normally no
nitrites are detected in the urine.
Urinary nitrates are converted to nitrites by bacteria in the urine.
A positive nitrite result signifies that bacteria capable of this conversion
(eg, Escherichia coli, Klebsiella, Proteus, Enterobacter, Citrobacter,
Pseudomonas) are present in the urinary tract.
However, some bacteria are not capable of converting nitrates to nitrites
(eg, Staphylococcus, Streptococcus, Haemophilus), and these bacteria may still
be present in the urinary tract despite a negative test result.

Therefore, a positive test suggests a UTI (typically due to Enterobacteriaceae),

but a negative test result does not rule out a UTI. 
Clinical Significance of Urine Nitrite
◦ Cystitis
◦ Pyelonephritis
◦ Evaluation of antibiotic therapy
◦ Monitoring of patients at high risk for urinary tract
◦ Infection
◦ Screening of urine culture specimens
False positive urine nitrite
◦ Improperly preserved specimens
◦ Highly pigmented urine
◦ Expired, contaminated or improperly stored strips, e.g. prolonged exposure to
the air (nitrous gases)
◦ Drugs that color the urine red e.g. phenazopyridine
◦ Bacterial contamination from sample collection
◦ Bacteria can multiply and convert nitrate to nitrite in specimens that are
more than 4 hours old
False negative urine nitrites
◦ Insufficient contact time between bacteria and urinary nitrite
◦ Large quantities of bacteria converting nitrite to nitrogen
◦ Presence of antibiotics
◦ High concentrations of ascorbic acid
◦ High specific gravity
Leukocyte esterase
WBCs contain an enzyme known as leukocyte esterase, which is released when
WBCs undergo lysis.
Prior to the development of the reagent strip leukocyte esterase (LE) test,
detection of increased urinary leukocytes required microscopic examination of
the urine sediment
Chemical test for leukocytes (leukocyte esterase) offers a more standardized
means for the detection of leukocytes because it detects the presence of
leukocytes that have been lysed particularly in dilute alkaline urine, and would
not appear in the microscopic examination
Significance of Urine leukocyte esterase
Bacterial and nonbacterial urinary tract infection
Inflammation of the urinary tract
Screening of urine culture specimens
A positive LE test result is most frequently accompanied by the presence of
bacteria, which may or may not produce a positive nitrite reaction
LE test contributes significantly more to the reliability of this practice than does
the nitrite test.
Proteinuria
Proteinuria
Normal urinary protein excretion is < 150 mg/24 hours and consists mostly of
secreted proteins such as Tamm-Horsfall proteins (mucoproteins secreted by the
distal tubule)
The normal mean albumin excretion rate (AER) is 5-10 mg/day, with an AER of >
30 mg/day considered abnormal.
Nephrotic-range proteinuria is the loss of 3 grams or more per day of protein
into the urine or, on a single spot urine collection, the presence of 2 g of protein
per gram of urine creatinine.
Most dipstick tests that are positive for protein are a result of benign
proteinuria, which has no associated morbidity or mortality.
Common Causes of Benign Proteinuria
Dehydration
Emotional stress
Fever
Heat injury
Inflammatory process
Intense activity
Most acute illnesses
The pathophysiologic mechanisms of proteinuria can be classified as tubular,
overflow or glomerular.
Tubular proteinuria
Tubular proteinuria is a result of tubulointerstitial disease affecting the proximal
renal tubules and interstitium.
This results in decreased proximal reabsorption of proteins—in particular, low
molecular weight proteins (generally below 25,000 Daltons) such as beta-2
microglobulin.
Under normal conditions these proteins are completely reabsorbed in the
proximal tubules.
The amount of proteinuria is usually < 2 g/day and dipstick results may be
negative.
Causes of tubular proteinuria include the following:

◦ Acute interstitial nephritis

◦ Immunosuppressive agents
◦ Analgesics
◦ Cryoglobulinemia
◦ Sjögren syndrome
Overflow proteinuria
Overflow proteinuria is most commonly associated with increased production of
abnormal low molecular weight proteins (eg, light chains in multiple myeloma,
myoglobin in rhabdomyolysis).
It exceeds the reabsorption capacity of the proximal tubule, leading to spilling
of the protein into the urine.
These low molecular proteins can be toxic to the tubules and can cause acute
kidney injury.
Glomerular Proteinuria
Glomerular disease is the most common cause of pathologic proteinuria.
Glomerular malfunction can cause large protein losses; urinary excretion of
more than 2 g per 24 hours is usually a result of glomerular disease.
The primary protein lost is albumin.
Glomerular Proteinuria that do not result from pathological damage to the
glomerulus include transient and orthostatic proteinuria.
Detecting and Quantifying Proteinuria
◦ Dipstick method
◦ Sulfosalicylic acid (SSA) turbidity test
◦ 24-hour urine specimen
◦ Albumin-to-creatinine ratio (ACR)
Dipstick method
Dipstick analysis is used in most outpatient settings to semi quantitatively
measure the urine protein concentration.

The urinary dipstick only detects the presence of albumin and no other proteins.
False-positive results occur with
◦ alkaline urine (pH more than 7.5);
◦ when the dipstick is immersed too long;
◦ with highly concentrated urine;
◦ with gross hematuria;
◦ in the presence of penicillin, sulfonamides or tolbutamide;
◦ with pus, semen or vaginal secretions.

False-negative results occur with dilute urine (specific gravity more than 1.015)
and when the urinary proteins are non albumin or low molecular weight.
Dipstick test results are as follows

◦ Trace proteinuria - Approximately 10-30 mg/dL

◦ 1+ Approximately 30 mg/dL
◦ 2+ Approximately 100 mg/dL
◦ 3+ Approximately 300 mg/dL
◦ 4+ 1000 mg/dL or more
Sulfosalicylic acid (SSA) turbidity test
Sulfosalicylic acid (SSA) turbidity test qualitatively screens for proteinuria.
The advantage of this easily performed test is for proteins such as Bence Jones,
globulins & Albumins.
The SSA method requires a few milliliters of freshly voided, centrifuged urine.
An equal amount of 3 percent SSA is added to that specimen.
Turbidity will result from protein concentrations as low as 4 mg per dL (0.04 g
per L).
False-positive results can occur when a patient is taking penicillin or
sulfonamides or radiographic dyes.

A false-negative result occurs with highly buffered alkaline urine or a dilute

specimen
Sulfosalicylic acid turbidity test results are as follows:

◦ 0 – No turbidity (proteinuria, 0 mg/dL)

◦ Trace – Slight turbidity (proteinuria, 20 mg/dL)
◦ 1+ - Print visible through specimen (proteinuria, 50 mg/dL)
◦ 2+ - Print invisible (proteinuria, 200 mg/dL)
◦ 3+ - Flocculation (proteinuria, 500 mg/dL)
◦ 4+ - Dense precipitate (proteinuria, ≥1000 mg/dL)
24-hour urine specimen
Patients with persistent proteinuria should undergo a quantitative measurement
of protein excretion, which can be done with a 24-hour urine specimen.
The patient should be instructed to discard the first morning void; a specimen of
all subsequent voiding should be collected, including the first morning void on
the second day.
The urinary creatinine concentration should be included in the 24-hour
measurement to determine the adequacy of the specimen.
It is the Gold standard test for quantification of proteinuria.
Albumin-to-Creatinine Ratio (ACR)
ACR is calculated by dividing albumin concentration in milligrams by creatinine
concentration in grams.
It measures both albumin and creatinine in a one-time sample, also known as a
spot urine sample.
This test can be used for diagnosis, screening, and monitoring of kidney disease.
Microscopic Testing of urine
specimen
Terms
HPF (high power field) 40×Objective
◦ RBCs, WBCs & Bacteria reported as HPF

LPF (Low Power Field) 10×Objective

◦ Casts are usually reported as LPF
WBCs
The number of WBCs considered normal is typically 2-5 WBCs/hpf or less.
A high number of WBCs indicates infection, inflammation, or contamination.
Typically, most of the WBCs found are neutrophils.
Most authorities suggest that more than 5 to 10 white blood cells per high-
powered field on catheter specimen in the presence of a suggestive clinical
picture should be presumed to represent a true urinary tract infection until
proven otherwise by a negative culture.
The more white cells seen, the greater is the risk of urinary tract infection.
Urinary eosinophils and lymphocytes may also be found.
If found, urinary eosinophils may help diagnose acute interstitial nephritis (AIN).
Eosinophiluria is seen with AIN, but the absence of eosinophiluria does not rule
out AIN.
Urinary lymphocytes are often associated with tubulointerstitial diseases
RBCs
Microscopic hematuria is defined as the presence of 3 RBCs/hpf or more in 2 of
3 urine samples.
Normally, less than 2 RBCs/hpf are observed.
Hematuria may be transient or persistent.
Transient hematuria in young patients is fairly common and is typically benign.
Persistent hematuria should always warrant a full evaluation.
The causes of hematuria are often categorized as renal versus extrarenal.
If the cause is thought to be renal, it is further categorized into glomerular
versus non-glomerular.
The hallmark findings of hematuria of glomerular origin include red cell casts,
proteinuria (>500 mg/d), and dysmorphic RBCs.
Hematuria of glomerular origin is also commonly described as "cola-colored."
The causes of glomerular-based hematuria include the following:

◦ Thin basement membrane nephropathy (benign familial hematuria)

◦ Alport syndrome
◦ IgA nephropathy
Causes of nonglomerular-based hematuria include the following:

◦ Tubulointerstitial nephritis
◦ Pyelonephritis
◦ Polycystic kidney disease
◦ Renal cell carcinoma
◦ Sickle cell disease or trait
◦ Renovascular disease (eg, atheroembolic renal disease, renal vein thrombosis,
arteriovenous malformations)
Extrarenal-based hematuria may be caused by the following:

◦ Tumors/malignancies (prostate, ureteral, bladder)

◦ Stones (kidney, bladder)
◦ Benign prostatic hyperplasia
◦ Infections (pyelonephritis, cystitis, prostatitis, urethritis)
◦ Schistosomiasis
◦ Foley’s trauma
◦ Anticoagulants
◦ Chemotherapeutic agents (mitotane, ifosfamide, cyclophosphamide)
Epithelial cells
Epithelial cells that may be found in the urinary sediment include squamous
epithelial cells (from the external urethra) and transitional epithelial cells (from
the bladder).

Generally 15-20 squamous epithelial cells/hpf or more indicates that the urinary
specimen is contaminated.
Casts
Casts are cylindrical particles that are formed from coagulated protein secreted
by tubular cells.

The organic matrix is mainly composed of Tamm-Horsfall mucoprotein (which

glues or cements casts together).

They are usually cylindrical with regular margins, as they are formed in the long,
thin, hollow renal tubules and typically take the shape of the tubule in which
they are formed.
They are only formed in the distal convoluted tubule or the collecting duct and
not in the proximal convoluted tubule or in the loop of Henle.

Low urine pH, low urine flow rate, and high urinary salt concentration promote
cast formation (by favoring protein denaturation and precipitation)
 Casts Clinical Significance
Hyaline casts Healthy individuals, after strenuous exercise, concentrated
urine or with diuretic therapy
Red cell casts Glomerulonephritis or vasculitis
White cell casts Tubulointerstitial nephritis and acute pyelonephritis
"Muddy-brown" granular Acute tubular necrosis
casts
Waxy and broad casts Advanced renal failure
Fatty casts Nephrotic syndrome
Crystals
Crystals are solid forms of a particular dissolved substance in the urine.

Identifying factors of crystals include shape, color, and urine pH.

Crystal formation is determined by the urine pH & the supersaturation of the

molecules.
Bacteriuria
Bacteria in the urine sediment are generally due to infection or contamination.

Normally no bacteria should be seen in the urinary sediment.

This is not an unusual finding, given the abundance of normal microbial flora in the
vagina and/or external urethral meatus.

A urinalysis with positive tests for nitrites, leukocyte esterase, and bacteria is
highly suggestive of a urinary tract infection.
However, if a significant amount of squamous epithelial cells (≥15-20/hpf) are
present as well, these findings may primarily indicate a contaminated specimen
and the urinalysis should be repeated.
If the patient does not have concomitant symptoms consistent with a UTI, then
it is termed asymptomatic bacteriuria.
100,000/mL or more of a single organism reflects significant bacteriuria.
The presence of multiple organisms, especially at less than 100,000/mL, typically
suggests polymicrobial contamination.
Yeast
Yeast cells are not normally found in the urine specimen.

Commonly the yeast cells are of the Candida species, which can colonize the
vagina, urethra, or bladder.

Yeast cells may signify true infection or contamination (often due to

contamination by vaginal secretions in women with a yeast infection).
Thank You