URINALYSIS

Basic Examination of Urine

 Physical Examination

 Chemical Examination

 Microscopic Examination
Physical Examination
 Color
 Pigment
 urochrome (yellow)
 urobilin ( yellow)
 uroerythrin (pink)
 Normal random urine specimens
 pale yellow
 straw
 light yellow
 yellow
 dark yellow
 amber
 Yellow-brown, yellow orange, yellow green
 urobilin in excess, bilirubin, biliverdin
 Red and cloudy
 red blood cells (hematuria), menstrual contamination,
beets
 Red and clear, pink red or red-brown
 hemoglobin or myoglobin is present (hemoglobinuria)

 Dark brown, black urine

 methemoglobin, rhabdomyolysis, homogentisic acid,
melanin
 Appearance (Clarity)
 Normal random urine specimen
 clear
 hazy
 slightly cloudy
 cloudy
 Turbidity
 white blood cells
 red blood cells
 epithelial cells
 bacteria
 White cloudiness
 Alkaline urine
 precipitated amorphous phosphates
 carbonates

 Acidic urine
 precipitated amorphous urates
 calcium oxalate
 uric acid crystals
 Specific Gravity
 A measure of the density of the dissolved
chemicals in the urine
 urea
 sodium
 chloride
 Isosthenuric – urine with SG of 1.010
 hyposthenuric
 hypersthenuric
 Normal random urine specimen
 SG range from 1.015 to 1.025
Chemical Examination
 Urine composition
 Major organic substances
 Urea
 Creatinine
 Uric acid

 Major inorganic substance

 Chloride
 Sodium
 Potassium
 Reagent Strip

 Primary method for chemical exam. of urine

 The result of this testing is regarded as semi-
quantitative.
 The test strips test for:
- pH - Blood
- Glucose - Protein
- Bilirubin - Urobilinogen
- Ketone - Nitrite
- Specific Gravity - Leukocyte Esterase.
 pH
 Normal random specimen
 pH range is 4.5 to 8.0

 Ability of the kidneys to maintain normal hydrogen

ion concentration in plasma and extracellular fluid
 Aid in determining the existence of systemic acid-
base disorders or metabolic or respiratory origin

 Aid in the management of urinary conditions that

require the urine to be maintained at a specific pH
 Acid urine
 High protein diet, cranberries
 Pharmacologic agents like ammonium chloride,
methionine, methenamine mandelate
 Metabolic/respiratory acidosis, diuretics, prolonged
vomiting, diabetic ketoacidosis
 Alkaline urine
 diet high in fruits and vegetables
 sodium bicarbonate, potassium citrate, acetazolamides
 metabolic/respiratory alkalosis
 Clinical Significance of Urine pH

 Respiratory or metabolic acidosis

 Respiratory or metabolic alkalosis
 Defects in renal tubular secretions and re-
absorption of acids and bases
 Precipitation of crystals and calculi formation
 Treatment of urinary tract infection
 Determination of unsatisfactory specimen
 The test is based on the double indicator
(methyl red/bromthymol blue) principle that
gives a broad range of colors covering the
entire urinary pH range.

 Confirmatory test is by
 pH meter with a glass electrode
 Protein
 Most indicative of renal disease
 Albumin
 low molecular weight protein and the major
serum protein found in normal urine
 Normal urine protein content
 mostly Tamm-Horsfall protein
 less than 10mg/dL or 100mg/24hours

 Proteinuria
 more than 150 mg/24 hours
Clinical Significance of Urine Protein

 Glomerular membrane damage

 Immune complex disorders
 Amyloidosis
 Toxic agents
 Impaired renal tubular re-absorption
 Multiple myeloma
 Diabetic nephropathy
 Pre-eclampsia
 Orthostatic or postural proteinuria
 This test is based on the protein-error-of-pH
indicators (tetrabromphenol blue) principle.

 The strip test is more sensitive for albumin

 Confirmatory method:
 Precipitation method (sulfosalicylic acid and
trichloroacetic acid) also test for globulin,
glycoproteins, Bence-Jones proteins
 Glucose

 presence of glucose in urine indicates that

the filtered load of glucose exceeds the
maximal tubular reabsorptive capacity
 occurs when the blood level is more than
100 to 200 mg/dL
 Less than 0.1% of glucose normally filtered
by the glomerulus appears in urine (< 130
mg/24 hr)..
Clinical Significance of Urine Glucose

 Diabetes mellitus
 Impaired tubular re-absorption
 Central nervous system damage
 Thyroid disorders
 Pregnancy with possible latent diabetes
mellitus
 This test is based on a double sequential
enzyme reaction (specific glucose oxidase
and peroxidase)
 Copper reduction test
 To detect reducing sugars in urine like fructose,
lactose, galactose, maltose and pentose
 Most newborn and infant urines are routinely
screened for reducing sugars
 Clinitest
 Benedict’s test – more sensitive
 Ketones
 Formation of urine ketones occurs when
carbohydrate metabolism is compromised
and fat becomes the major source of energy.

 Ketones (acetone, aceotacetic acid, beta-

hydroxybutyric acid) results from either
diabetic ketoacidosis or some other form of
calorie deprivation (starvation)
Clinical Significance of Urine Ketones

 Diabetic acidosis
 Insulin dosage monitoring
 Starvation
 Excessive carbohydrate loss
 This method is based on a nitroprusside
(sodium ferricyanide) reaction for ketones.

 The test strip detect about 5 to 10 mg/dl of

acetoacetic acid

 Confirmatory test:
 Nitroprusside tablet test (Acetest)
 Blood
 > 5 red blood cells/microliter of urine – is
clinically significant
 Chemical tests for hemoglobin – accurate
means of detecting presence of blood
 Microscopic examination – can differentiate
between hematuria and hemoglobinuria
Clinical Significance of Urine Blood

 Hematuria
 Renal calculi
 Glomerulonephritis/pyelonephritis
 Tumors
 Trauma
 Exposure to toxic chemicals or drugs
 Strenuous exercise
 Hemoglobinuria
 Transfusion reactions
 Hemolytic anemia
 Severe burns
 Infections
 Strenuous exercise/RBC trauma
 This test is based on the liberation of oxygen from
peroxide in the reagent strip by the peroxidase-like
activity of heme in free hemoglobin, lysed red blood
cells or myoglobin.

 Test strip detects 0.05 to 0.3 hemoglobin/dl urine

 Bilirubin
 Bilirubin in urine can provide early indication
of liver disease

 Conjugated bilirubin appear in the urine

when there is obstruction of the bile duct and
or when the integrity of the liver is damaged.
Clinical Significance of Urine Bilirubin

 Hepatitis
 Cirrhosis
 Other liver disorders
 Biliary obstruction
 This test is based on the coupling of bilirubin
with diazotized dichloroanaline in a strongly
acid medium (Diazo reaction).

 The test detects 0.5 to 0.8 mg/dl urine.

 Confirmatory test:
 Diazo tablet test
 Urobilinogen

 Normal – 0.5 to 2.5 mg or units/24 hrs.

 Urine urobilinogen is increased in any

condition that causes an increase in
production (hemolytic disorders) or retention
of bilirubin (liver disease).
 Clinical Significance of Urine
Urobilinogen
 Early detection of liver diseases
 Hemolytic disorders
 This test is based on the modified Ehrlich reaction,
in which para-diethylaminobenzaldehyde in
conjunction with a color enhancer reacts with
urobilinogen in a strongly acid medium
 Nitrite
 A positive nitrite test indicates that bacteria
may be present in significant numbers in
urine.
 Gram negative rods such as E. coli are more
likely to give a positive test.
 If nitrite test is positive, a culture should be
considered provided that the specimen was
properly collected and stored prior to testing.
 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
 This test depends upon the conversion of
nitrate (derived from the diet) to nitrite by the
action of Gram negative bacteria in the urine

 The test detects 0.05 to 0.075 mg of nitrite/dl

urine
 Leucocyte Esterase
 A positive test results from the presence of
white blood cells either as whole cells or as
lysed cells.

 A negative test means that an infection is

unlikely and that, without additional evidence
of urinary tract infection, microscopic exam
and/or urine culture need not be done to rule
out significant bacteriuria.
 Clinical Significance of Urine
Leukocytes
 Urinary tract infections
 Screening of urine culture specimens
 Granulocytic leukocytes contain esterases
releases pyrrole then reacts with the
diazonium salt to form a purple product

 The intensity of the color produced is

proportional to the amount of enzyme
present which is related to the number of
leucocytes present.
 Specific Gravity
 a convenient index of urine concentration

 measures density and is only an approximate guide

to true concentration.
 Reagent strips are available that also measure
specific gravity in approximations. Most laboratories
measure specific gravity with a refractometer.
 Specific gravity between 1.002 and 1.035 on a
random sample should be considered normal if
kidney function is normal.
 Clinical Significance of Urine
Specific Gravity
 Patient hydration and dehydration
 Loss or renal tubular concentrating ability
 Diabetes insipidus
 Determination of unsatisfactory specimens
due to low concentration
 This test is based on the apparent pKa
change of certain pretreated polyelectrolytes,
in relation to ionic concentration of urine
 Refractometer
 Measure refractive index of a solution (dissolved
solids present) and the scale is valid only for
urine
 The SG gravity reading is generally slightly lower
than a urinometer reading by about 0.002
 Urinometer
 Directly measures SG of urine at room
temperature
 Summary of Chemical Testing by
Reagent Strip
Test Principle
pH Double-indicator system
Protein Protein error of indicators
Glucose Double sequential system
reaction; Glucose oxidase and
peroxidase
Ketones Sodium nitroprusside reaction
Blood Pseudoperoxidase activity of
hemoglobin
Bilirubin Diazo reaction
 Summary of Chemical Testing by
Reagent Strip
Test Principle
Urobilinogen Ehrlich’s reaction
Nitrite Nitrate reduction
Leukocytes Granulocytic esterases reaction
Specific gravity pK change of polyelectrolyte
Microscopic Examination
 Microscopy
 Brightfield microscopy
 Unstained
 Crystal-violet safranin stain
 Phase-contrast microscopy
 To detect more translucent formed elements
notably the casts.
 Polarized microscopy
 To distinguish crystals from fibers
 Lipid droplet with cholesterol esters form Maltese
crosses with crossed polars
 Urinary Sediments

 Red blood cells

 White blood cells
 Epithelial cells
 squamous, transitional, renal tubular
 Casts
 hyaline, rbc, wbc, cellular, granular, fatty, waxy, broad
 Crystals
 Bacteria, fungi, parasites
 Spermatozoa
 Mucus
 Fibers, starch granules, pollen
 Red Blood Cells

 Normal = 0 to 2 rbc/hpf

 Increased RBC - hemorrhage, inflammation,

necrosis, trauma or neoplasia somewhere
along the urinary tract (or urogenital tract in
voided specimens).
 White Blood Cells

 Normal = >5 wbc/hpf

 In hypotonic urine, they are called “glitter cells”

because of the brownian movement of the
granules produces a sparkling appearance

 Greater numbers (pyuria) generally indicate the

presence of an inflammatory process somewhere
along the course of the urinary tract (or urogenital
tract in voided specimens).
 Squamous Epithelial Cells

 The largest cells seen in normal urine

specimens. Abundant irregular cytoplasm
and a central small round nucleus.

 Reported in terms of rare, few, many and

packed

 Main significance is as an indicator of

contamination from genital tract
 Transitional Epithelial Cells

 Originate from the renal pelvis, ureters,

bladder and/or urethra.
 Most often they are round or polygonal; less
commonly pear-shaped, caudate or spindle-
shaped. They are generally somewhat
smaller and smoother in outline than
squamous cells, but larger than WBC
 Seldom pathologically important unless with
unusual morphology
 Renal Tubular Cells

 Most significant – increased number indicate

tubular necrosis and renal graft rejection
 Round and slightly larger than leukocytes
(10-14 um) with lightly granular cytoplasm
and round, well defined and eccentric
nucleus. The cytoplasm often shows a
perinuclear halo when stained.
 Reported in numbers/hpf
 Oval Fat Bodies

 Renal tubular cells that absorb lipids and

become highly refractile
 Under polarized light, Maltese cross
formation in droplets containing cholesterol
are seen.
 Reported in numbers per hpf
Casts
 Hyaline Cast

 Tubular secretions consists entirely of Tamm-

Horsfall protein
 Normal = 0-2/lpf
 Physiologic - strenuous exercise, heat
exposure, dehydration, emotional stress
 Pathologic – acute GN, acute pyelonephritis

chronic renal disease, congestive heart

disease
 RBC Cast

 Red blood cells are enmeshed in or attached

to the protein matrix
 Maybe found in healthy individual after
strenuous exercise
 Pathologically, it is assoc. with GN or any
condition that damages glomerulus, tubules,
or renal capillaries
 WBC Casts

 White blood cells enmeshed or attached to

the protein matrix
 Signifies infection or inflammation within the
nephron
 Most frequently seen in pyelonephritis and
acute interstitial nephritis.
 Refractile, exhibit granules, visible multilobed
nuclei
 Renal Tubular Cast

 Tubular cells usually seen in cast are from

collecting tubules
 Among the disorders associated with the
presence of increase of this cast are:
 acute interstitial nephritis
 acute transplant rejection
 tubular necrosis.
 Granular Cast

 The hyaline matrix casts filled with granules

similar to cytoplasmic degeneration granules
 The cytoplasm granulation could then be
integrated in a cast as free granules, as
cytoplasmic fragments, or as complete cells.
 Rare finding is physiologically due to stress
and exercise
 Pathologically due to GN and pyelonephritis,
 Fatty Cast

 Attachment of free lipid droplets, lipids from

disintegrating oval fat bodies and oval fat
bodies to the cast matrix produces a fatty
cast
 Highly refractile and contain yellow-brown fat
droplets
 Mostly seen in patient with nephrotic
syndrome
 Waxy Cast

 Waxy casts have a smooth consistency but

are more refractile and therefore easier to
see compared to hyaline casts.
 They commonly have squared off ends, as if
brittle and easily broken.
 Found especially in chronic renal diseases,
and are associated with chronic renal failure;
they occur in diabetic nephropathy,
malignant hypertension and
glomerulonephritis.
 Normal Urine Crystals
 Acid ph
 Uric acid
 Amorphous urates
 Calcium oxalate

 Alkaline pH
 Amorphous phosphates
 Calcium phosphate
 Triple phosphate
 Ammonium biurate
 Calcium carbonate
 Uric Acid Crystals

 pH -- acidic
 Color -- colorless, yellow brown or reddish
brown; highly birefrigent
 Shape -- variety (rhombic plates, spears,

wedges, needles)

 May indicate increased nucleoprotein

metabolism when found in freshly voided
urine
 Calcium Oxalate Crystals

 pH -- acid, neutral

 Color -- colorless

 Shape -- octahedral, dumbbell, oval

“envelop”

High potential for forming renal stones

 Amorphous Urate Crystals

 pH -- acidic

 Color -- pink or brownish-tan granules or

brick red dust

 Shape – fine granular without defining

shape;
form clumps
 Amorphous Phosphate Crystals

 pH - alkaline, neutral

 Color -- fine, colorless or slightly brown

granules.

 Shape -- granular
 Triple Phosphate Crystals
(Magnesium Ammonium Phosphate)

 pH -- alkaline

 Color -- colorless; birefrigent

 Shape -- “coffin-lid” appearance;

rosette-shaped

 Associated with urea-splitting bacteria

 Calcium Phosphate Crystals

 ph -- alkaline

 Color -- colorless

 Shape -- rosette and “pointed finger” forms

 Ammonium Urate (Biurate)
Crystals
 pH -- alkaline

 Color -- yellow brown

 Shape -- spicule-covered spheres,

“thorny apples”

The only urate crystals that occur in alkaline

urine
 Calcium Carbonate Crystals

 pH - alkaline

 Color -- colorless

 Shape -- small dumbbells; spicules

 Abnormal Urine Crystals
 Cystine
 Cholesterol
 Leucine
 Tyrosine
 Bilirubin
 Sulfonamides
 Radiographic dyes
 Ampicillin
 Cystine Crystals

 pH -- acidic

 Color -- colorless (cannot polarize)

 Shape -- thin hexagonal plates

 Significance -- metabolic defect; cystinuria

 Leucine Crystals

 pH -- acid, neutral

 Color -- yellow brown bodies

 Shape -- spheroids with concentric striations and

radial structures; dense, highly refractive (Maltese-
cross pattern under polarize light)

Significance -- severe liver disease

 Tyrosine Crystals

 pH -- acid, neutral

 Color -- colorless, yellow brown

 Shape -- needle shaped, single or

arranged in sheaves or rosettes, with fine
silky appearance.

 Significance -- severe liver disease

 Bilirubin Crystals

 pH -- acid

 Color -- bright yellow

 Shape -- clumped needles or spheres

 Significance -- liver disease

 Cholesterol Crystals

 pH -- acid

 Color -- colorless, polarized

 Shape -- irregular transparent to rectangular

plate with notch or one or more curve (“stair step
crystals”).

 Significance -- always considered pathological and

can be found in various renal diseases.
 Sulfadiazine crystals

 pH -- acid, neutral

 Color -- variable

 Shape -- rosettes, fan

 Significance -- tend to form renal calculi that

may damage renal tubules.
 Sulfonamide Crystals

 pH -- acid

 Color -- yellow

 Shape -- resemble uric acid crystals

Other Urine Elements
 Fungal elements
 Trichomonas vaginalis
 Bacteria
 Spermatozoa
 Mucus
 Starch or Talc powder
 Fiber
 Fungal elements
 Yeasts in unstained urine sediments are
round to oval in shape, colorless, and may
have obvious budding.
 The presence of yeast in the urine sediment
may indicate an infection. A frequently seen
yeast in urine is Candida.
 Yeast containing casts have a very high
clinical value; these are pathognomonic of
pyelonephritis.
 Trichimonas vaginalis
 The parasite that is more frequently seen in
urine is Trichomonas. Usually, this cell
comes from genital secretions contaminating
the specimen.
 Identification of the living cell is quite easy
owing to its spectacular motility.
 Bacteria

 Bacteria associated with urinary tract

infection are mostly bacillus (E. Coli) but
other shapes cannot be ruled out.
 Bacteria-coated urothelial cells are frequent
in cystitis.
 Spermatozoa

 Urinary spermatozoa is a contamination

arising from sexual activity.
 With a male subject, these represent a
residual drainage while with a female, these
have a vaginal contamination source.
 Mucus

 Mucus is a frequent finding of the urinary

sediment
 Mucus forming cells are found scattered all
over the urinary tract from the ascending
section of the loop of Henle to the bladder.
Starch Granules
Talcum Powder
Cotton Fiber
Thank you.