Ultimate Guide to the Dipstick

Clay Walker PA-C

On the Medgeeks Facebook page, we had a post recently with questions on how to
appropriately interpret in office urinalysis results. I always thought that if one
person has a question about a topic, then there are likely multiple others that could
benefit from the information as well.

Regardless if you’re a practicing clinician or a current student, this review on the

commonly ordered urinalysis will hopefully allow you to brush up on things, or
perhaps glean some new information.

The urinalysis is an important test that can provide a litany of information and can
aid in the diagnosis of many conditions including a UTI, or could point you
towards others, such as a kidney stone or malignancy.

Collecting the Sample

The initial thing to do is collect the urine for testing. The external genitalia should
be cleansed, and then a midstream, clean-catch sample is collected. There is some
debate on whether cleansing of the genitalia is needed, and recent studies have
found that contamination rates have been similar between both approaches.1

Urine Color and Odor

Once the specimen is collected, the first thing that should be assessed is the odor
and color of the urine sample. Multiple things can alter the color of the urine, such
as medications, infection, foods, or metabolic by-products.1

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A common medication that will alter the color of a urine sample is Azo, which is
an over the counter medication often used to offset the dysuria symptoms that can
be caused by a UTI. Another common appearance seen in a urine sample is cloudy
urine. This is often present if there is pyuria or if there are phosphate crystals
present in alkaline urine.1

The odor of a urine sample can be altered with several medical conditions. If the
sample smells fruity or sweet, this can be indicative of diabetic ketoacidosis. An
ammonia smelling sample can be present if the urine sample has been held in the
bladder for an extensive period of time.

Urinary tract infections will often have a pungent odor, an intestinal-urologic

fistula would have a fecal odor, and cysteine decomposition would present with a
sulfur smell.

False Positives and False Negatives

A point of care urinalysis often can have several things that may lead to a false
positive or false negative result. These vary from medications, exercise,
dehydration, and even if the UA test strip is excessively exposed to air. A full list
of things to keep in mind is listed below.

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Specific Gravity
Specific gravity on dipstick tells us about the patient's hydration.

This can range from 1.003 to 1.030. If the value is less than 1.010 the patient is
well hydrated, if the value is over 1.020 the patient is relatively dehydrated. Other
than increased or decreased fluid intake, what else could affect specific gravity?

If the specific gravity is increased, this could also be related to excess sugar or
glucose in the urine related to uncontrolled diabetes, or diabetic ketoacidosis, or
SIADH where there is too much anti-diuretic hormone being released causing
concentrated urine.

Causes of decreased urinary specific gravity could be related to diabetes insipidus,

where there is a reduction or lack of antidiuretic hormone being produced, causing
dilute urine, along with adrenal insufficiency, or hyperaldosteronism.1

Dipstick PH
The pH on a urinalysis can span from 4.5 to 8, but often will be slightly acidic
around 5.5 to 6.5. Dietary habits such as eating cranberries can even affect the pH
of the urine, causing an acidic pH, whereas diets that have high levels of citrate
will lead to a higher urine pH.

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More times than not, the urine pH will mirror the serum pH. However, this is not
the case in renal tubular acidosis. In distal renal tubular acidosis, the serum pH
will be acidic, however the urinary pH will be alkaline. This is due to the kidneys
being unable to secrete protons into the urine.1

In proximal renal tubular acidosis, the kidney is unable to reabsorb bicarbonate

ions, leading to alkaline urine in the beginning, but then subsequently leads to an
acidic pH of the urine.

Urine that has an alkaline pH along with findings consistent with a UTI can be
indicative of a urea-splitting organism that can lead to the formation of magnesium
ammonium phosphate crystal, subsequently cause staghorn calculi. An acidic pH
can be more likely associated with uric acid calculi.1

Hematuria on Dipstick
The next result, on a urinalysis I look at, is hematuria or lack thereof. Blood can
be from things such as menses in females, but can also be due to more serious
causes, such as renal calculi or malignancy. Hematuria etiologies are broken down
into glomerular, renal, or urologic causes.

For a full workup and evaluation of hematuria, see the article Asymptomatic
Hematuria on the Medgeeks blog.

Always remember, if there is blood present on an in-office UA, this needs to be

confirmed by microscopy and entirely worked up!

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Proteinuria on Dipstick
Proteinuria is diagnosed when there is more than 150 mg of protein present in the
urine per day.

The presence of this much protein in the urine is a classic finding in renal disease.
However, the presence of small amounts of protein in the urine, 30 to 150 mg per
day, is an earlier sign of renal disease, microalbuminuria, which can be seen in
diabetic patients.1

Normal urinary protein that can be present in smaller amounts include albumin and
serum globulins. However, your routine in-office UA looks for albumin in the
urine and may not find other types of proteinuria.

One question I had when I first started practicing was, what does 1+, 2+, 3+
protein on a UA even mean? And how much should be there before I get worried?

If the UA in office shows trace protein, this is equal to 5-10 mg/dL, which is below
the significant threshold for proteinuria. If 1+ protein is seen, it is equal to 30 mg/
dL, and is considered positive or significant.

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A result of 2+ is equal to 100 mg/dL of protein, 3+ is equal to 300 mg/dL, and 4+
is equal to 1000 mg/dL of protein in the urine.

Proteinuria can be transient or persistent. Transient causes of proteinuria are

typically related to intermittent changes in glomerular filtration or perfusion which
leads to the seen protein excess.

The most commonly observed transient cause of proteinuria is orthostatic

proteinuria, which is a benign etiology. This can be diagnosed with negative UA
results for protein, after having the patient lay down for eight hours, and then
having the patient provide a urine sample.

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Persistent proteinuria can be split into glomerular, tubular, or overflow etiologies.

Glomerular proteinuria is the most common type, in which excess urinary albumin
is often the cause.

Tubular proteinuria often occurs when the renal system is not breaking down or
absorbing the regularly filtered protein from the glomerulus. In tubular
proteinuria, the amount of proteinuria is not routinely over 2 grams daily.1

Lastly, overflow proteinuria is seen when the renal system cannot overcome and
absorb the amount of protein that is present in the filtrate. In any of these cases of
persistent proteinuria, further evaluation is indicated with a 24-hour urinary protein

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evaluation or a urinary protein to creatinine ratio, microscopic urinalysis, urine
protein electrophoresis, and BMP.1

Glucose and Ketones on Dipstick

Glucose is regularly filtered by the kidneys and is all customarily reabsorbed.
However, when the amount of glucose is too much for the kidney to reabsorb,
glycosuria occurs. This typically happens when the serum glucose is over 180 mg/
dL, and is often seen in uncontrolled diabetes, liver disease, pancreatic disease,
Fanconi syndrome, and Cushing syndrome.1

Ketones are present when the body is breaking down fat for energy; they are
generally not seen in the urine. It is commonly seen in uncontrolled diabetics, but
can also be seen in patients that may be doing a ketogenic diet (carbohydrate
reduced or free), in pregnancy, or starvation.1

Nitrites and Leukocyte Esterase on Dipstick

Nitrites are seen in the urine when bacteria are present that convert nitrates to
nitrites. Gram-negative and gram-positive bacteria, both are capable of this
conversion, and if positive, is an indication that there are bacteria present in the
urinary tract of the patient.

Nitrites in the urine is specific, but not very sensitive, meaning that if positive,
there is a good chance a UTI is present, but if negative, it does not mean that a UTI
is not present.

The UA dipstick is very sensitive to air, so the container should be closed ASAP. If
not, this could lead to false positive nitrite results.

Leukocyte esterase is present if neutrophils are present in the urinary tract, and can
be present if pyuria is present with a UTI.

Bilirubin on Dipstick
Lastly, bilirubin is not generally seen on a urinalysis. Indirect bilirubin is not water
soluble and cannot be filtered by the kidneys. However, direct bilirubin is water

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soluble, and if present in the urine, a further workup for liver abnormalities or
biliary obstruction is needed.1

Urine can have a small amount of urobilinogen present, which occurs due to the
process of direct bilirubin being broken down in the intestine, reabsorbed into the
portal circulation, and then filtered through the kidneys.1

If there is an increased amount of urobilinogen noted on UA, this can be due to

liver disease or hemolysis, and decreased amounts can be due to biliary obstruction
or antibiotic use.1

I hope this overview has answered some questions for those practicing as well as
current students in their didactic studies, or in their rotations. If anyone has any
questions, feel free to contact us, and I am more than happy to help!

Resources
1. Am Fam Physician. Urinalysis: A Comprehensive Review. 2005;71:1153-62.
2. Am Fam Physician. Urinalysis: Case Presentations for The Primary Care
Physician. 2014;90(8):542-547.
3. UpToDate. Sampling and evaluation of voided urine in the diagnosis of
urinary tract infection in adults. Accessed: February 7, 2018.
4. LabCorp. Urinalysis. https://www.labcorp.com/results. Accessed: February 7,
2018.

This article, blog, or podcast should not be used in any legal capacity whatsoever,
including but not limited to establishing standard of care in a legal sense or as a
basis of expert witness testimony. No guarantee is given regarding the accuracy of
any statements or opinions made on the podcast or blog.

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