This document summarizes the key components of a urine physical examination, including urine volume, color, appearance, specific gravity, osmolality, pH, and microscopic examination. Normal ranges are provided for each component, along with potential causes of abnormalities. The microscopic examination may reveal elements like white blood cells, red blood cells, epithelial cells, crystals, casts, bacteria, yeast, and other non-bacterial organisms that can indicate underlying renal, genitourinary, or systemic health issues. A urine physical examination provides important physical and microscopic findings to evaluate fluid, electrolyte, and acid-base balance and detect various diseases and disorders.

1. URINE PHYSICAL EXAMINATION
Dr Abdul Hafeez Kandhro
Senior Lecturer
B.Sc, M.Sc; Medical Technology,
M.Phil Biochemistry
Ph.D. Medical Technology
(Mahidol University, Bangkok , Thailand)

2. • Urine Volume
• Urine Color
• Urine Appearance
• Urine Specific Gravity
• Urine Osmolality (Optional)
• Urine PH
URINE PHYSICAL EXAMINATION

3. URINE VOLUME
Normal volume is 750 –2000ml/24H
• Under 750 ml (oligouria) dehydration, infection,
obstruction, renal
stones, kidney, failure, etc).
• Over 2000ml (polyuria) diabetes insipidus, hypertension,
Nephrotic syndrome, ingestion of alcohol or drugs, endocrinal
disorders.
• Absent of urine (anuria) obstruction, kidney failure,
stenosis.

4. • Urine volume refers to the quantity of urine
produced per unit of time.
• Typically, this volume is expressed per day or
some fraction of a day (e.g., 8 h, 12 h) or,
particularly in the ICU, hourly.
• Urine volume is therefore used a vital sign and
recorded along with other parameters such as
body temperature, heart rate, and blood
pressure.
URINE VOLUME
Kannan N., Kellum J.A. (2012) Physiology of Urine Volume. In: Vincent JL., Hall J.B. (eds) Encyclopedia of Intensive Care
Medicine. Springer, Berlin, Heidelberg

5. • Urine volume is determined by the need to
maintain homeostasis in terms of fluid balance,
solute clearance, and plasma osmolarity.
• When there is an increase in blood volume, a
counteractive fluid loss is induced by the atria in
two ways.
• First, the increase in atrial stretch elicits reflex
dilation of kidney arterioles leading to an increase in
glomular filtration. Simultaneously, the atria send
signals to the hypothalamus, resulting in a decrease
in
URINE VOLUME
Kannan N., Kellum J.A. (2012) Physiology of Urine Volume. In: Vincent JL., Hall J.B. (eds) Encyclopedia of Intensive Care
Medicine. Springer, Berlin, Heidelberg

6. URINE COLOR

7. https://www.medicalnewstoday.com/articles/313779.php#colors

8. RED
• Blood. Factors that can
cause urinary blood
(hematuria) include urinary
tract infections, an enlarged
prostate, cancerous and
noncancerous tumors,
kidney cysts, long-distance
running, and kidney or
bladder stones.
• Foods. Beets, blackberries
and rhubarb can turn urine
red or pink.
• Medications. Rifampin
(Rifadin, Rimactane), an
antibiotic often used to treat
tuberculosis, can turn urine
reddish orange — as can
phenazopyridine (Pyridium),
a drug that numbs urinary
tract discomfort, and
laxatives containing senna.
ORANGE
Orange urine can result from:
Medications. Medications that
can turn urine orange include the
anti-inflammatory drug
sulfasalazine (Azulfidine);
phenazopyridine (Pyridium); some
laxatives; and certain
chemotherapy drugs.
Medical conditions. In some
cases, orange urine can indicate a
problem with your liver or bile
duct, especially if you also have
light-colored stools. Dehydration,
which can concentrate your urine
and make it much deeper in color,
can also make your urine appear
orange.

9. Cloudy or murky urine
• Urinary tract infections and kidney stones can cause urine to appear
cloudy or murky.
• Risk factors
• Discolored urine that isn't the result of foods or medications could
be caused by a medical condition that affects urine color. Factors
that put you at risk of medical conditions that can affect urine color
include:
• Age. Tumors of the bladder and kidney, which can cause blood in
the urine, are more common in older people. Men older than 50
occasionally have urinary blood due to an enlarged prostate gland.
• Family history. A family history of kidney disease or kidney stones
makes it more likely that you'll develop these problems. Both can
cause blood in the urine.
• Strenuous exercise. Distance runners are most at risk, but anyone
who exercises vigorously can have urinary bleeding.

10. BLUE
Dyes. Some brightly colored food
dyes can cause green urine. Dyes
used for some tests of kidney and
bladder function can turn urine
blue.
Medications. A number of
medications produce blue or green
urine, including amitriptyline,
indomethacin (Indocin, Tivorbex)
and propofol (Diprivan).
Medical conditions. Familial benign
hypercalcemia, a rare inherited
disorder, is sometimes called blue
diaper syndrome because children
with the disorder have blue urine.
Green urine sometimes occurs
during urinary tract infections
caused by pseudomonas bacteria.
Dark brown or cola-colored
Food. Eating large amounts of fava
beans, rhubarb or aloe can cause dark
brown urine.
Medications. A number of drugs can
darken urine, including the antimalarial
drugs chloroquine and primaquine, the
antibiotics metronidazole and
nitrofurantoin (Furadantin), laxatives
containing cascara or senna, and
methocarbamol — a muscle relaxant.
Medical conditions. Some liver and
kidney disorders and some urinary tract
infections can turn urine dark brown.
Extreme exercise. Muscle injury from
extreme exercise can result in pink or
cola-colored urine and kidney damage.

11. • Substances that cause cloudiness but that are not considered
unhealthy include: mucous, sperm and prostatic fluid, cells from the
skin, normal urine crystals, and contaminants (like body lotions and
powders).
• RBCs, WBCs, Bacteria) indicate a condition that requires attention
URINE APPEARANCE

12. Increased SG:
• Loss of body fluids
(dehydration)
• Diarrhea that causes
dehydration
• Heart failure
• Sugar (glucose) in the urine
• Syndrome of inappropriate
antidiuretic hormone
secretion (SIADH)
Decreased SG:
• Damage to kidney tubule
cells (renal tubular
necrosis)
• Diabetes insipidus
• Drinking too much fluid
• Kidney failure
URINE SPECIFIC GRAVITY

13. • Determination of urinary osmolality is more important
than specific gravity because it gives more accurate
reflection of the concentration of dissolved substances.
• It is the measure of the moles of dissolved particles (un
dissociated molecules and ions) contained in a kilogram
(Kg) of a solvent.
• The normal osmolality of random urine specimen varies
from 40 - 1350 m.osmol/kg.
• • The normal osmolality of 24 hours urine specimen
varies from 500 - 800 m.osmol/kg.
Osmolality of urine

14. • Urine pH is used to classify urine as either a
dilute acid or base solution.
• Lower pH = Greater the acidity
• Higher pH = Greater the alkalinity
• Depending on the person's acid-base status, the
pH of urine may range from 4.5 to 8.
• The kidneys maintain normal acid-base balance
primarily through the reabsorption of sodium
and the tubular secretion of hydrogen and
ammonium ions.
URINE pH

15. • Urine becomes increasingly acidic as the amount
of sodium and excess acid retained by the body
increases.
• Alkaline urine, usually containing bicarbonate-
carbonic acid buffer, is normally excreted when
there is an excess of base or alkali in the body.
• Secretion of an acid or alkaline urine by the
kidneys is one of the most important
mechanisms the body uses to maintain a
constant body pH
URINE pH

16. A highly acidic urine pH occurs in:
• Acidosis
• Uncontrolled diabetes
• Diarrhea
• Starvation and dehydration
• Respiratory diseases in which carbon dioxide retention occurs and
acidosis develops
A highly alkaline urine occurs in:
• Urinary tract obstruction
• Pyloric obstruction
• Salicylate intoxication
• Renal tubular acidosis
• Chronic renal failure
• Respiratory diseases that involve hyperventilation (blowing off carbon
dioxide and the development of alkalosis)
URINE pH

29. WHITE BLOOD CELLS
• White blood cells
• Pyuria refers to the presence of elevated number
of leukocytes (granulocytes) :
• – Upper or lower UT infection
• – Glomerulonephrotis
• – Vaginal & cervical infections
• – External urethral meatus (men & women)
• Normal range:
• 02/HPF (5+ indicates an infection and 10+
indicates more severe conditions).

30. • Normal RBCs 0 – 2 /HPF
• The causes of glomerular-based hematuria include the following:
• Thin basement membrane nephropathy (benign familial hematuria)
• Alport syndrome, IgA nephropathy
• Nonglomerular causes of hematuria are associated with the following:
• Proteinuria - >500 mg/d
• No RBC casts
• No dysmorphic RBCs
• 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, “nutcracker syndrome”)
RED BLOOD CELLS

31. • 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 trauma
• Anticoagulants
• Chemotherapeutic agents (mitotane, ifosfamide,
cyclophosphamide)
RED BLOOD CELLS

32. • Normal urine – not present/unquantified
• Renal tubular epithelial cells, usually larger than
granulocytes, contain a large round or oval
nucleus are normally slough into the urine in
small amounts.
• Positive – nephrotic syndrome, condition leading
to tubular degeneration.
EPITHELIAL CELLS

33. • Urinary crystals
• • Normal urine – present but unquantified.
Type of crystals:
• – Calcium oxalate
• – Triple phosphate
• – Amorphous phosphates
• – Uric acids
• Uric acid crystals (hyoeruricemia)
• – Cyctine
• – Tyrosine
• – Leusine
• Elevated numbers of crystal may indicates:
• – Hipercalcemia
• – Cystine crystal –cystinuria
• May due to renal failure or other renal disease.
URINARY CRYSTALS

34. • Calcium oxalate crystals ("envelope-shaped") and
acute kidney injury is seen with ethylene glycol
ingestion.
• Uric acid crystals ("diamond" or "barrel" shaped)
and acute kidney injury is seen in tumor lysis
syndrome, hyperuricosuria (Gout).
• Cystine crystals ("hexagonal")are seen with
cystinuria.
• Magnesium ammonium phosphate and triple
phosphate crystals (struvite) are "coffin-lid" shaped
and seen with UTIs caused by urea-splitting
organisms (ie, Proteus, Klebsiella).
URINARY CRYSTALS

37. • Formed at the distal convoluted tubule or the collecting duct
(distal nephron).
• Protein based cylindrical molds of the renal tubule
• Result of damage to the renal tubule
• Can contain cells and other material
• Dehydration and acidic urine especially predisposes to cast
formation.
• Types of casts
• • Protein
• • RBC
• • WBC
• • Other
CASTS

38. • Hyaline casts are found in healthy individuals and are
relatively nonspecific. Increased after strenuous exercise,
and in concentrated urine or with diuretic therapy.
• Red cell casts are nearly diagnostic of glomerulonephritis
or vasculitis.
• White cell casts and pyuria are most commonly seen with
tubulointerstitial nephritis and acute pyelonephritis, Renal
tuberculosis and vaginal infections.
• "Muddy-brown" granular casts are diagnostic of acute
tubular necrosis.
• Waxy and broad casts are consistent with advanced renal
failure. Fatty casts and lipiduria, with the typical "maltese-
cross" appearance on polarized microscopy, are commonly
seen with nephrotic syndrome.
CASTS

41. • Abundant normal microbial flora of the vagina
or external urethral meatus.
• Ability to rapidly multiply in urine standing
room temperature.
• However, it should be interpret in view of
clinical symptoms.
• Bacterial culture must be done in case of
bacteriuria
URINARY BACTERIA

42. • Yeast cells may be contaminants or represent
a true yeast infection.
• Often difficult to distinguish from red cells and
amorphous crystals but can be distinguished
by their tendency to bud.
• Most often they are Candida, which may
colonize bladder, urethra or vagina.
URINARY YEASTS

43. • Yeast cells are not normally found in the urine
specimen. They can be distinguished from red
cells and amorphous crystals by their tendency
to bud.
• 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).
URINARY YEASTS

44. • Non bacterial organisms
• General "crud" or unidentifiable objects may find
their way into a specimen, particularly those that
patients bring from home.
• Spermatozoa can sometimes be seen.
• Rarely, pinworm ova may contaminate the urine.
• ova from bladder infestations with
schistosomiasis may be seen.
NON BACTERIAL ORGANISMS