University of Nebraska Medical Center

Objectives: On completion of this

unit, participants will be able to:
Describe considerations on collection,
handling, and processing of urine specimens

Routine Urinalysis- Physical

and Chemical Examination
off Urine
Ui

Identify screening tests for physical and

chemical examination of urine
Describe major sources of error in routine
urinalysis procedures

CLS 500: Application and Interpretation

of Clinical Laboratory Data

Define common terms applied to urinalysis

2
and renal disease

Objectives (continued)

Objectives (continued)

Correlate physical & chemical tests of

urine in:

Explain the significance of the following:

Pos Clinitest and neg dipstick for glucose
Pos dipstick for glucose and neg Clinitest
False p
positive dipstick
p
for p
protein
False negative for ketones
False negative for bilirubin
Neg bilirubin dipstick and pos Ictotest
Pos bilirubin and neg urobilinogen
Neg bilirubin and pos urobilinogen

Cystitis
Pyelonephritis
Renal glycosuria
Diabetes mellitus
Diabetes insipidus
Hepatic, obstructive or hemolytic jaundice
Acute and chronic glomerulonephritis
Nephrotic syndrome
3

What is Urine?

Objectives (continued)

A fluid which is continuously formed

in and excreted from the body

Predict the potential changes that may

take place in a urine specimen that
remains at room temperature for longer
than 2 hours

Composed of water and

metabolic waste products
An actual fluid biopsy of the kidney
kidney is the only organ with such a noninvasive means
by which to evaluate its status

CLS 500 Application and Interpretation of Clinical Laboratory Data

Routine Urinalysis- Physical and Chemical Examination of Urine

The Purpose of Urinalysis?

Functions of the Kidney

To aid in the diagnosis of disease

To monitor wellness (screening for
asymptomatic, congenital, or hereditary
disease))
To monitor the progress of disease
To monitor therapy (effectiveness or
complications)

Produces urine
Maintains electrolyte balance
Maintains blood pH
Produces hormones
Excretes waste

A Complete Urinalysis Provides

a Fountain of Information
acid base equilibrium
pancreas

liver

muscle
blood

intoxication

drug abuse

kidney

water status

Types of Urine Specimens

inborn errors of metabolism

cardiovascular system
carbohydrate metabolism
electrolytes

nutrition

bone

protein metabolism

respiratory system

gastrointestinal tract

hormones

fat metabolism

infection
pregnancy

urinary tract

2-hour postprandial
24-hour, 12-hour, 6-hour

central nervous system

9

General Considerations

Random
First morning
Midstream clean catch
Fasting
Catheterized
Suprapubic aspiration
Pediatric specimen
Timed collections (for quantitative testing)
10

Changes at Room Temperature

Use clean, dry, disposable, sterile

container
Label properly
ANALYZE WITHIN ONE HOUR
Preserve urine constituents
Refrigeration (2-8C)
Advantages vs disadvantages

Increased pH
Decreased glucose
Decreased ketones
Decreased bilirubin
Decreased urobilinogen
Increased bacteria
Increased turbidity
Disintegration of red blood cells and casts
Changes color

11

CLS 500 Application and Interpretation of Clinical Laboratory Data

Routine Urinalysis- Physical and Chemical Examination of Urine

12

Collection Errors

Historical Perspective: Urinalysis

Physical examination
of urine

Labeling (label the container, not lid)

Patient name
Patient identification number (MRN, DOB)
Date of collection
Time of collection
Test ordered
Name of ordering physician/clinician

Odor
Taste
Color
Clarity
Volume

Delay in testing
Testing after one hour
Lack of refrigeration

13

14

Historical Perspective

Reagent Strip Testing

Chemical examination of urine

Limited reactions/large volumes required

Time consuming/cumbersome
Clinical usefulness was not realized
Not routinely ordered

Microscopic exam of urine

Clinical usefulness not
realized until invention of
the microscope

Technology and necessity

Chemical reactions miniaturized
Required less urine
U i easy tto collect
Urine
ll t
Test results within minutes
Easy to perform
Increased test utilization
Brunzel, 2nd Ed, page 124 16

15

Reagent Strip Testing

Complete Urinalysis
Physical Examination

Ideal qualitative screening tool

Color, Clarity, Concentration

Odor, Volume

Sensitive: Low concentration of substances

Negative result = normal

Chemical
C
Examination

Specific: Reacts with only one substance

False negative and false positive

10 chemical reactions

Microscopic Examination

Cost effective: Relatively inexpensive tool

that provides information about the health
status of the patient
17

CLS 500 Application and Interpretation of Clinical Laboratory Data

Routine Urinalysis- Physical and Chemical Examination of Urine

18

Physical Properties
Volume
Average: 1200 to 1500 ml/24 hours
Extremes: 600-2,000 ml/24 hrs

Physical Examination of Urine

Terms
Anuria -no urine output
Polyuria -increased urine output
Oliguria -decreased urine output
Nocturia -excessive output at night
Dysuria -painful urination

Color, Clarity, Foam,

Concentration, Odor, Volume

20

Colorless

Clarity / Appearance

Yellow

Color

Dilute Urine

Normal

Blue
Brown

Cloudy

Pseudomonas infection

Lines are barely

visible; cannot
read newsprint

Clear

Hemoglobin

Like water;
easily read
newsprint

Red

Green

Blood

Medication

Turbid
Cannot see
through it;
often have
particulates

Bright Yellow
Vitamins

Orange

Amber

Pyridium

Bilirubin

Dark Green

Hazy

Biliverdin

Blurry but
lines are still
visible

21

22

Foam

What Can Cause Urine to be

Hazy, Cloudy, or Turbid?

White foam
Epithelial
Cells

White
Blood
Cells

Amorphous
Material

Fat

Red
Blood
Cells
Mucus

Sperm
Bacteria

Powder

Casts

Crystals

protein is
present

Yellow foam

Yeast

bilirubin is
present
23

CLS 500 Application and Interpretation of Clinical Laboratory Data

Routine Urinalysis- Physical and Chemical Examination of Urine

Odor

Concentration

Faintly aromatic
Normal

Concentration is determined by the

specific gravity test
2 ways specific gravity can be determined

Ammonia
Old urine

Pungent
UTI
U

Refractometer
R f t
t
Reagent Strip

Fruity, Sweet
Ketones

Most labs use this method

Increased glucose and protein levels do not
interfere

Mousy, Barny
PKU disease

Maple syrup
Maple syrup urine
disease

25

26

Taste thank goodness we

dont do this anymore!!
Chemical Examination of Urine

This doesnt
taste like
lemonade!!!

Reagent Strip Testing

Reagent Strip Testing

Chemically impregnated absorbent
pads attached to an inert plastic strip
Each pad is a specific chemical reaction that
takes place upon contact with urine
Chemical reaction causes the color of the pad to
change: reaction is timed
Color compared to a color chart for interpretation
29

Reagent Strip Proper Storage

Tightly closed container

Cool dry place
Avoid volatile fumes
Expiration date
Do not use if pads are discolored
Do not touch pads

Run positive and negative controls once/day

CLS 500 Application and Interpretation of Clinical Laboratory Data

Routine Urinalysis- Physical and Chemical Examination of Urine

30

Quality Control

The Dipstick Procedure

Ensures reliability of results

Evaluates reagent strip
Run 2 controls once a day
Positive control
Negative
N
ti control
t l
BOTH controls MUST
be ok else patient
testing cannot be
performed

Wear gown & gloves

Mix the urine
Insert reagent
g
strip
p
Remove excess urine
Time the reactions
Compare test areas to color chart
Record results

31

32

The Urine Dipstick

Glucose

10 Reactions on 1 Plastic Strip

Glucose
Bilirubin
Ketones
Specific gravity
Blood
pH
Protein
Urobilinogen
Nitrites
Leukocytes

Purpose of the test

What is normal
What is abnormal
Causes of
abnormal results
Causes of false
pos/neg results

All glucose is normally reabsorbed in the tubules

unless the blood level is higher than the renal
threshold (160 to 180 mg/dl)
Normal = Negative
Abnormal = Diabetes mellitus
Impaired tubular reabsorption
Inborn errors of metabolism
34

33

Glucose
Glucosuria
Glycosuria

Glucose
Sensitivity: ~ 100 mg/dl
Specificity:

Terms used
interchangeably

Reacts only with glucose

False positive:

Caused by renal and non

non-renal
renal disease

Strong oxidizing agents (bleach)

Peroxides

Pre-renal glycosuria: plasma glucose level

exceeds renal threshold (diabetes mellitus)

False negative:

Renal glycosuria: plasma glucose level

below renal threshold, but tubules cannot
reabsorb glucose back into bloodstream

Ascorbic acid (reducing agent)

High ketone levels
Improperly stored urine: glycolysis
35

CLS 500 Application and Interpretation of Clinical Laboratory Data

Routine Urinalysis- Physical and Chemical Examination of Urine

36

Clinitest (tablet test)

Glucose Dipstick vs Clinitest

Is a copper reduction test (cupric to cuprous)

Detects all reducing sugars
Reacts with glucose, galactose, lactose,
fructose,, ascorbic acid,, homogentisic
g
acid;;
not sucrose
All children <2 years: screened for metabolic
disorder (galactosemia)

Clinitest is non-specific
Reacts with all reducing substances

Clinitest not as sensitive

Will detect
d t t glucose
l
att 250 mg/dl
/dl

Dipstick is specific for glucose (enzyme rxn)

Dipstick more sensitive
Will detect glucose at 100 mg/dl

37

38

Bilirubin

Bilirubin is formed from the breakdown of

g
in the reticuloendothelial ((RE))
hemoglobin
system
Only conjugated bilirubin is found in urine
Normal = Negative
Abnormal = Liver disease-hepatic jaundice
Obstruction-obstructive jaundice39

Bilirubin

40

Bilirubin Dipstick vs Ictotest

False Negative
Ascorbic acid inhibits
High urine nitrites inhibit
Low bilirubin concentration
Improper
I
specimen
i
handling:
h dli
protect
t t ffrom lilight
ht

False Positive
Urine color interference
Drug induced color changes: phenazyridine,
indican-indoxyl sulfate
Perform Ictotest to confirm presence of bilirubin
41

Specificity is the same: both react with

conjugated bilirubin
S
Sensitivity
iti it diff
differs
Reagent strip: ~0.5 mg/dl
Ictotest:
0.05 0.1 mg/dl

CLS 500 Application and Interpretation of Clinical Laboratory Data

Routine Urinalysis- Physical and Chemical Examination of Urine

42

Ketones

Ketones
Fruity odor =
acetone

Ketones are products of incomplete fat metabolism

Normally fats are completely metabolized to CO2
and
d water
t
Normal = Negative
Abnormal = Inability to utilize carbohydrates
Diabetes mellitus (DKA)
Inadequate intake of carbohydrates
Excessive loss of carbohydrates

43

44

Specific Gravity

Ketones
False Negatives
Improper storage
Volatilization
Bacterial breakdown

Specific gravity measures the concentrating and

diluting abilities of the kidney; results are dependent
on hydration status

False Positives
Compounds containing free-sulfhydryl groups
Highly pigmented urines (color interference)

Normal = 1.002 to 1.035

Majority of urines are 1.010-1.025
Abnormal = Increased SG means the urine is concentrated
= Decreased SG means the urine is dilute

45

Specific Gravity

46

Specific Gravity: Terms

Isosthenuria

Physiologically impossible
>1.040 (suspect interfering substance)
1.000 (suspect water)

Fixed at 1.010
Renal tubules lost absorption and secreting capability

Hypersthenuria
Increased specific gravity
Concentrated urine
Hypertonic

Sensitivity: 1.000
Specificity: detects only ionic substances
Radiographic dye
Mannitol
Glucose

Hyposthenuria

Does not interfere

with this method
47

Decreased specific gravity

Dilute urine
Hypotonic

CLS 500 Application and Interpretation of Clinical Laboratory Data

Routine Urinalysis- Physical and Chemical Examination of Urine

Sensitivity issues:
Pregnancy testing
Urinary tract infection
Protein
48

Blood

Blood
Blood in urine indicates pathology

The presence of blood in the urine may indicate

g to the kidney
y or urinary
y tract
damage
Normal = Negative
Abnormal = Kidney stones (renal calculi)
Glomerulonephritis
Strenuous exercise
Hemolytic anemia
Transfusion reactions

Two forms found in urine

Intact RBC
Hemolyzed RBC

49

Blood

50

Blood: Terms

Positive with hemoglobin or myoglobin

False Positive

Hematuria
(intact RBC)

Menstrual contamination
Microbial peroxides
Oxidizing agents (bleach)

All will give a

positive
iti bl
blood
d
reaction

H
Hemoglobinuria
l bi i
(hemolyzed RBC)

False Negative
Ascorbic acid
High levels of protein
High nitrite reduces strip reactivity

Myoglobinuria
(muscle protein)
51

52

pH

pH

Normal: ranges from 4.5 8.0

Kidneys help regulate the acid-base balance of the
body.
body Detects systemic acid-base
acid base disorders
Normal = 4.5 to 8.0
Acidic = acidosis, high protein diet, starvation,
dehydration, or diarrhea
Alkaline = alkalosis, UTI, vegetarian diet, vomiting
or chronic renal failure

First morning void: acidic

Physiologically impossible: <4.5
>8.0
1. Urine not handled properly
2. Old urine
3. Treatment induced

53

CLS 500 Application and Interpretation of Clinical Laboratory Data

Routine Urinalysis- Physical and Chemical Examination of Urine

54

Protein

pH
Invalid test results due to:
Improper handling of urine sample

Normal kidneys excrete little protein (<10 mg/dl)

Proteinuria associated with early renal disease

Contamination of urine vessel prior to

collection

Normal = Negative (Albumin reacts)

Run-over phenomenon (dipstick technique)

Transient: occurs with fever, exposure to heat or

cold, emotional stress or pregnancy, exercise

55

Pathological: membrane damage, disorders

affecting tubular reabsorption

56

Renal Causes of Proteinuria

Protein

Glomerular damage:

The protein that is found in urine comes from

Bloodstream
Urinary tract

Proteinuria is an indicator of early renal disease

Proteinuria also caused by non-renal disease

Most serious cause of proteinuria

Most common cause of proteinuria
Glomerulonephritis
Nephrotic
N h ti S
Syndrome
d
(hi
(highest
h t llevels
l off protein)
t i )

Tubular dysfunction:

Multiple myeloma

Reabsorption capability decreased

Toxin exposure, inherited disorder
Fanconis syndrome: heavy metal poisoning
57

58

Protein

Protein
False Negative

Sensitivity: ~ 10-25 mg/dl

Specificity: reacts primarily with albumin

Dilute urine
Presence of other proteins

False Positive
Highly buffered or alkaline urine >8.0
Alkaline drugs
Improper storage and handling
Contamination of detergents

Uromodulin (Tamm-Horsfall protein matrix in casts)

Globulins
M
Myoglobin
l bi
Free light chains (Bence-Jones protein)
Hemoglobin

Exercise/transitory conditions

59

CLS 500 Application and Interpretation of Clinical Laboratory Data

Routine Urinalysis- Physical and Chemical Examination of Urine

60

10

Urobilinogen

Urobilinogen is formed in the intestine from

bilirubin
bili bi by
b bacteria
b t i (most
(
t is
i excreted
t d in
i the
th feces)
f
)
but some is reabsorbed back into the bloodstream
where small amounts are excreted in the urine
Normal = 0.2 to 1.0 mg/dl
Abnormal = Hemolytic disease
Liver disease
61
Cannot determine absence of UBG

62

Nitrites

Nitrite
False Positive

Some gram negative bacteria reduce dietary nitrates

to nitrites. The bacteria that cause urinary tract
infections (UTI) are often nitrite producers

False
F l N
Negative
ti

Normal = Negative
Abnormal = UTI
Cystitis (bladder infection)
Pyelonephritis (kidney infection)
Rapid screening test for UTI

Substances that mask reaction color

Foods (beets); Drugs
Improper specimen storage/handling

Ascorbic acid
Bacteria cannot reduce nitrates
Bladder time not sufficient: need 4 hours
Low nitrate levels (lacks dietary nitrates)
Antibiotic inhibition of bacteria
Further reduction of nitrites to nitrogen

63

64

Leukocytes

Leukocytes
False Positive
Substances that induce color mask
Vaginal contamination

The presence of leukocytes in the urine indicate a

possible urinary tract infection.
infection Can detect intact
WBC and lysed WBC (granulocytes)
Normal = Negative
Abnormal = Urinary tract infection (UTI): cystitis,
pyelonephritis, urethritis

False Negative

Not waiting the two minutes

Lymphocytes present; are not detected
Increased glucose & protein
Strong oxidizing agents
Drugs

65

CLS 500 Application and Interpretation of Clinical Laboratory Data

Routine Urinalysis- Physical and Chemical Examination of Urine

66

11

Leukocytes

Leukocytes

Abnormal:

Sensitivity: 5-15 WBC/hpf

Bacterial infection:
Cystitis (bladder infection)
Pyelonephritis (kidney infection)
Urethritis (infection/inflammation of urethra)

False positive
Vaginal contamination
Color masking

Non-bacterial infection:
Yeast
Trichomonas

False negative
67

Oxidizing agents (bleach)

Lymphocytes (no granules)

68

University of Nebraska Medical Center

Ascorbic Acid (Vitamin C)

Interferes with Reagent Strip reaction
Causes false negative reactions for
Blood
Nitrite
Bilirubin
Glucose

BBNG: Bad Boys No Good

BGNB: Bad Girls No Better
70

CLS 500 Application and Interpretation of Clinical Laboratory Data

Routine Urinalysis- Physical and Chemical Examination of Urine

12