This document provides information and instructions for collecting urine samples and performing a urinalysis. It discusses obtaining first morning voids, clean-catch samples, and timed urine collections. The types of urinalysis covered are macroscopic examination, chemical analysis using urine dipsticks, microscopic examination, and culture. Specific tests on the dipstick like glucose, bilirubin, ketones, specific gravity, blood, pH, protein, urobilinogen, nitrite, and leukocyte esterase are explained.
REVISION NOTES ON URINE ANALYSIS BASED ON LECTURE NOTES WITH EMPHASIS ON IMAGE BASED QUESTIONS
SAMPLE
COLOUR OF URINE
PH OF URINE
HEMATURIA
SPECIFIC GRAVITY OF URINE
PROTEINURIA
CASTS IN URINE
REVISION NOTES ON URINE ANALYSIS BASED ON LECTURE NOTES WITH EMPHASIS ON IMAGE BASED QUESTIONS
SAMPLE
COLOUR OF URINE
PH OF URINE
HEMATURIA
SPECIFIC GRAVITY OF URINE
PROTEINURIA
CASTS IN URINE
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WHAT IS URINE ANALYSIS?
Urine analysis, also called Urinalysis – one of the oldest laboratory procedures in the practice of medicine.
Also knows as Urine- R&M (routine & microscopy)
Is an array of tests performed on urine
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
Monitoring of patients with diabetes
Screening for drug abuse (eg. Sulfonamide or aminoglycosides)
COLLECTION OF URINE SPECIMENS
Improper collection---- may invalidate the results
Containers for collection of urine should be wide mouthed, clean and dry.
Analyzed within 2 hours of collection else requires refrigeration.
URINE CULTURE
Culture within 1 hour after collection or stored in a refrigerator at 4oC for no more than 18 hours.
Culture is performed when Polynephritis or Cystitis is suspected.
UTI is most frequent caused by E.Coli.
Other common agents are Enterobacter, Proteus, and Enterococcus faecalis.
URINALYSIS; WHAT TO LOOK FOR?
• Urinalysis consists of the following measurements:
Macroscopic or physical examination
Chemical examination
Microscopic examination of the sediment
Urine culture
PHYSICAL EXAMINATION OF URINE
Examination of physical characteristics:
Volume
Color
Odor
pH
Specific gravity
The refractometer or a reagent strip is used to measure specific gravity
PHYSICAL EXAMINATION
Normal- 1-2.5 L/day
Oliguria- Urine Output < 400ml/day
Dehydration
Shock
Acute glomerulonephritis
Renal Failure
Polyuria- Urine Output > 2.5 L/day
Increased water ingestion
Diabetes mellitus and insipidus.
Anuria- Urine output < 100ml/day
Seen in renal shut down Volume
PHYSICAL EXAMINATION
Normal
pale yellow in color due to pigments urochrome (different colour pigments in urine), urobilin (When urobilinogen- degraded product of bilirubin, is exposed to air, it is oxidized to urobilin, giving urine its yellow color) and uroerythrin (red pigment in urine).
Cloudiness
may be caused by excessive cellular material or protein, crystallization or precipitation of non pathological salts upon standing at room temperature or in the refrigerator.
Color
Colour of urine depending upon it’s constituents.
PHYSICAL EXAMINATION
Abnormal Colors:
Colorless – diabetes, diuretics.
Deep Yellow – concentrated urine, excess bile pigments, jaundice Color
Blue-Green – Methylene Blue, Pseudomonas (Bactrium), Riboflavin (Vitamin B2, in FAD give Yellow Orange Color)
Pink-Orange-Red – Hemoglobin, Myoglobin, Phenolphthalein, Porphyrins, Rifampicin (antibiotic against TB give orange color to urine)
Red-Brown-Black - Hemoglobin, Myoglobin, Red Blood Cells, Homogentisic acid (Homogentisic acid present in Blood and its oxidized form alkapton are excreted in the urine, giving it an unusually dark color), L-DOPA (Levodopa, is the most effective drug for Parkinson’s disease), Melanin (brown Pigment)
The test measures the amount of sugar in a urine sample. Normal urine does not contain glucose. Microscopic Examination. A variety of normal and abnormal.
Microscopic examination of urine Casts • Urinary casts are cylindrical aggregations of particles that form in the distal nephron, dislodge
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1. Urinalysis
Course: IDPT 5005
School of Medicine, UCDHSC
Francisco G. La Rosa, MD
Francisco.LaRosa@uchsc.edu
Assistant Professor, Department of Pathology
University of Colorado at Denver Health Science Center, Denver, Colorado
2. Specimen
Collection
– First morning voiding (most concentrated)
– Record collection time
– Type of specimen (e.g. “clean catch”)
– Analyzed within 2 hours of collection
– Free of debris or vaginal secretions
3. Urine Specimens
Collected for a number of tests:
– Clean voided specimens
For routine urinalysis
– Clean-catch or midstream urine
specimens
For urine culture
– Timed urine specimens
For a variety of tests that depend of the
client’s specific health problem
4. Obtaining Samples
Clients need varying degrees of instruction
and assistance to provide clean voided
specimens.
About 120 ml (4 oz) of urine is generally
required.
Clients who are seriously ill, physically
incapacitated, or disoriented may need to use
a bedpan or urinal in bed. Others may
require supervision and/or assistance in the
bathroom.
5. Directions for Collection
The nurse should explain that all
specimens must be free of fecal
contamination, so voiding needs to
occur at a different time from
defection.
Instruct female clients to discard toilet
tissue in the toilet or in a waste bag
rather than in the bedpan or hat, since
tissue in the specimen makes
laboratory analysis more difficult.
6. Obtaining Specimen
When the specimen is obtained, put
the lid tightly on the container to
prevent spillage and contamination.
Label the specimen.
7. Obtaining Timed
Specimens
All timed urine specimens should be
refrigerated to prevent bacterial growth
and decomposition of the urine
components.
Each voiding of urine is collected in a
clean container and then emptied
immediately into the large refrigerated
bottle.
8. Obtaining Timed
Samples
Alert signs are placed in the client’s
room to remind staff of the test in
progress.
Specimen identification labels need to
indicate the date and time of each
voiding in addition to the usual
identification information.
9. Obtaining Timed
Samples
Clients need to be told why the test is being
done and how they can assist.
Instructions should include the following:
– All urine must be saved and placed in the specimen
containers once the test starts.
– The urine must be free of fecal contamination and
toilet tissue.
– Each specimen must be given to the nursing staff
immediately so that it can be placed in the
appropriate specimen bottle.
10. Obtaining Timed
Samples
The collection period is started by
having the client void in the toilet,
bedpan, or urinal.
– This urine is usually discarded, but check
facility procedure.
All subsequent urine specimens are
collected.
13. Types of Analysis
− Macroscopic Examination
− Chemical Analysis (Urine
Dipstick)
− Microscopic Examination
− Culture (not covered in this lecture)
− Cytological Examination
14.
15. Macroscopic Examination
Odor:
− Ammonia-like: (Urea-splitting bacteria)
− Foul, offensive: Old specimen, pus or inflammation
− Sweet: Glucose
− Fruity: Ketones
− Maple syrup-like: Maple Syrup Urine Disease
Color:
− Colorless Diluted urine
− Deep Yellow Concentrated Urine, Riboflavin
− Yellow-Green Bilirubin / Biliverdin
− Red Blood / Hemoglobin
− Brownish-red Acidified Blood (Actute GN)
− Brownish-black Homogentisic acid (Melanin)
16. Macroscopic Examination
Turbidity:
− Typically cells or crystals.
− Cellular elements and bacteria will clear by
centrifugation.
− Crystals dissolved by a variety of methods (acid or
base).
− Microscopic examination will determine which is
present.
17. Appearance
Including color and clarity
Color : normally , pale to dark yellow
(urochrome)
Abnormal color :
some drugs cause color changes
1. red urine : causes: hematuria
hemoglobinuria
myoglobinuria
2. yellow-brown or green-brown urine :
bilirubin
cause : obstructive jaundice
18. Red Urine
Causes of Asymptomatic Gross Hematuria by
Incidence
Acute Cystitis (23%)
Bladder Cancer (17%)
Benign Prostatic Hyperplasia (12%)
Nephrolithiasis (10%)
Benign essential hematuria (10%)
Prostatitis (9%)
Renal cancer (6%)
Pyelonephritis (4%)
Prostate Cancer (3%)
Urethral stricture (2%)
19. Appearance
Clarity : normally, clear
Abnormal color : cloudy urine
Causes: 1. crystals or nonpathologic salts
phosphate, carbonate in alkaline urine
(dissolve---add acetic acid)
uric acid in acid urine
(dissolve---warming to 60℃)
2. various cellular elements: leukocytes,
RBCs, epithelial cells
20.
21. Urine volume
The average adult : 1000ml to 2000ml/24h
Increase
polyuria ---more than 2000ml of urine in
24
hours
1. physiological states: water intake, some
drugs, intravenous solutions
2. pathologic states: diabetes mellitus,
diabetes insipidus
22. Urine volume
Decrease
Oliguria ---less than 400ml of urine in 24 hours
Anuria ---less than 100ml of urine in 24 hours
1. prerenal: hemorrhage, dehydration,
congestive heart failure
2. postrenal: obstruction of the urinary tract
(may be stones, carcinoma)
3. renal parenchymal disease:
acute tubular necrosis, chronic renal failure
24. Chemical Analysis
Urine Dipstick
Glucose
Bilirubin
Ketones
Specific Gravity
Blood
pH
Protein
Urobilinogen
Nitrite
Leukocyte Esterase
25. Typical Test Strip
Test Sensitivity_
Glucose – 4 to 7 mmol/L
Bilirubin – 7 to 14 µmol/L
Ketone – 0.5 to 1.0 mmol/L (Acetoacetic acid)
Blood – 150 to 620 µg/L (Hemoglobin)
Protein – 0.15 to 0.3 g/L (Albumin)
Nitrite – 13 to 22 µmol/L
Leukocytes – 5 to 15 cells/ µL
pH – pH 5.0 to 8.5
Specific Gravity – 1.000 to1.030
Urobilinogen – 0.2 to 8 µmol/L
BioMedica Diagnostics Inc. / D. Jette / March 25
2003
27. Uses and Limitations of Urine Glucose
Detection
Significance
– Diabetes mellitus.
– Renal glycosuria.
Limitations
– Interference: reducing agents, ketones.
– Only measures glucose and not other sugars.
– Renal threshold must be passed in order for glucose to spill
into the urine.
Other Tests
– CuSO4 test for reducing sugars.
28. Detection of Reducing Sugars* by
CuSO 4
Sugar Disease(s)
- Galactose Galactosemias
- Fructose Fructosuria, Fructose
Intolerance, etc.
- Lactose Lactase Deficiency
- Pentoses Essential Pentosuria
- Maltose Non-pathogenic
* NOT Sucrose because it is not a reducing sugar
29. Urine versus Blood Glucose
Urinalysis Glucose Result
++
+
trace
Negative
200 400 600 800 1000
Blood Glucose (mg/dL)
30. The Urine
Dipstick: Bilirrubin
Negative Chemical Principle
+ (weak)
Bilirubin + Diazo salt Acidic Azobilirubin
--------->
++ (moderate)
Read at 30 seconds
+++ (strong) RR: Negative
31. Uses and Limitations of Urine Bilirrubin
Detection
Significance
- Increased direct bilirubin (correlates with urobilinogen and serum
bilirubin)
Limitations
- Interference: prolonged exposure of sample to light
- Only measures direct bilirubin--will not pick up indirect bilirubin
Other Tests
- Ictotest (more sensitive tablet version of same assay)
- Serum test for total and direct bilirubin is more informative
33. Uses and Limitations of Urine Ketone Detection
Significance
- Diabetic ketoacidosis
- Prolonged fasting
Limitations
- Interference: expired reagents (degradation with exposure to
moisture in air)
- Only measures acetoacetate not other ketone bodies (such as in
rebound ketosis).
Other Tests
- Ketostix (more sensitive tablet version of same assay)
- Serum glucose measurement to confirm DKA
34. The Urine
Dipstick: Specific
Gravity
1.000
Chemical Principle
1.005
X+ + Polymethyl vinyl ether / maleic anhydride
1.010 --------------->
X+-Polymethyl vinyl ether / maleic anhydride + H+
1.015
H+ interacts with a Bromthymol Blue indicator to
1.020 form a colored complex.
1.025 Read up to 2 minutes
RR: 1.003-1.035
1.030
35. Uses and Limitations of Urine Specific Gravity
Significance
- Diabetes insipidus
Limitations
- Interference: alkaline urine
- Does not measure non-ionized solutes (e.g. glucose)
Other Tests
- Refractometry
- Hydrometer
- Osmolality measurement (typically used with water deprivation test)
36. The Urine
Dipstick: Blood
Negative
Chemical Principle
Trace (non-hemolyzed)
Lysing agent to lyse red blood cells
Moderate (non-hemolyzed)
Diisopropylbenzene dihydroperoxide +
Tetramethylbenzidine
Trace (hemolyzed)
Heme
------------> Colored Complex
+ (weak)
++ (moderate) Read at 60 seconds
RR: Negative
Analytic Sensitivity: 10 RBCs
+++ (strong)
37. Uses and Limitations of Urine Blood Detection
Significance
- Hematuria (nephritis, trauma, etc)
- Hemoglobinuria (hemolysis, etc)
- Myoglobinuria (rhabdomyolysis, etc)
Limitations
- Interference: reducing agents, microbial peroxidases
- Cannot distinguish between the above disease processes
Other Tests
- Urine microscopic examination
- Urine cytology
38. The Urine
Dipstick: pH
5.0
6.0 Chemical Principle
H+ interacts with:
6.5
Methyl Red (at high concentration; low pH) and
Bromthymol Blue (at low concentration; high
7.0
pH), to form a colored complexes
(dual indicator system)
7.5
8.0 Read up to 2 minutes
R.R.: 4.5-8.0
8.5
39. Uses and Limitations of Urine pH Detection
Significance
- Acidic (less than 4.5): metabolic acidosis, high-protein diet
- Alkaline (greater than 8.0): renal tubular acidosis (>5.5)
Limitations
- Interference: bacterial overgrowth (alkaline or acidic),
“run over effect” effect of protein pad on pH indicator pad
Other Tests
- Titrable acidity
- Blood gases to determine acid-base status
40. pH Run Over Effect
Glucose
Bilirubin
Ketones
Specific Gravity Buffers from the protein area of
the strip (pH 3.0) spill over to the
Blood pH area of the strip and make the
pH pH of the sample appear more
acidic than it really is.
Protein
Urobilinogen
Nitrite
Leukocyte Esterase
41. The Urine
Dipstick: Protein
Chemical Principle
“Protein Error of Indicators Method”
Negative Pr
H Pr
H Pr
Trace H
Pr Pr
+ (30 mg/dL) H H
H Pr
++ (100 mg/dL) Tetrabromphenol Blue
H+ H H
+ +
(buffered to pH 3.0)
H+ H H
+ +
+++ (300 mg/dL) Pr Pr
Pr
Pr Pr
++++ (2000 mg/dL) Pr
Read at 60 seconds
RR: Negative
42. Causes of
Proteinuria
Functional Renal
- Severe muscular exertion - Glomerulonephritis
- Pregnancy - Nephrotic syndrome
- Orthostatic proteinuria - Renal tumor or infection
Pre-Renal Post-Renal
- Fever - Cystitis
- Renal hypoxia - Urethritis or prostatitis
- Hypertension - Contamination with vaginal
secretions
44. Uses and Limitations of Urine Protein
Detection
Significance
- Proteinuria and the nephrotic syndrome.
Limitations
- Interference: highly alkaline urine.
- Much more sensitive to albumin than other proteins
(e.g., immunoglobulin light chains).
Other Tests
- Sulfosalicylic acid (SSA) turbidity test.
- Urine protein electrophoresis (UPEP)
- Bence Jones protein
45. Proteins in “Normal” Urine
Protein % of Total
Daily Maximum
Albumin 40%
60 mg
Tamm-Horsfall 40%
60 mg
Immunoglobulins 12%
24 mg
Secretory IgA 3%
6 mg
Other 5%
47. Uses and Limitations of Urobilinogen
Detection
Significance
- High: increased hepatic processing of bilirubin
- Low: bile obstruction
Limitations
- Interference: prolonged exposure of specimen to oxygen
(urobilinogen ---> urobilin)
- Cannot detect low levels of urobilinogen
Other Tests
- Serum total and direct bilirubin
48. The Urine
Dipstick: Nitrite
Chemical Principle
Acidic
Negative Nitrite + p-arsenilic acid -------> Diazo compound
Diazo compound + Tetrahydrobenzoquinolinol
Positive
----------> Colored Complex
Read at 60 seconds
RR: Negative
49. Uses and Limitations of Nitrite Detection
Significance
- Gram negative bacteriuria
Limitations
- Interference: bacterial overgrowth
- Only able to detect bacteria that reduce nitrate to nitrite
Other Tests
- Correlate with leukocyte esterase and
- Urine microscopic examination (bacteria)
- Urine culture
51. Uses and Limitations of Leukocyte Esterase Detection
Significance
- Pyuria
- Acute inflammation
- Renal calculus
Limitations
- Interference: oxidizing agents, menstrual contamination
Other Tests
- Urine microscopic examination (WBCs and bacteria)
- Urine culture
52. Microscopic Examination
General Aspects
Preservation
- Cells and casts begin to disintegrate in 1 - 3 hrs. at room temp.
- Refrigeration for up to 48 hours (little loss of cells).
Specimen concentration
- Ten to twenty-fold concentration by centrifugation.
Types of microscopy
- Phase contrast microscopy
- Polarized microscopy
- Bright field microscopy with special staining
(e.g., Sternheimer-Malbin stain)
53. Microscopic Examination
Abnormal Findings
Per High Power Field (HPF) (400x)
– > 3 erythrocytes
– > 5 leukocytes
– > 2 renal tubular cells
– > 10 bacteria
Per Low Power Field (LPF) (200x)
– > 3 hyaline casts or > 1 granular cast
– > 10 squamous cells (indicative of contaminated specimen)
– Any other cast (RBCs, WBCs)
Presence of:
– Fungal hyphae or yeast, parasite, viral inclusions
– Pathological crystals (cystine, leucine, tyrosine)
– Large number of uric acid or calcium oxalate crystals
54. Microscopic Examination
Cells
Erythrocytes
- “Dysmorphic” vs. “normal” (> 10 per HPF)
Leukocytes
- Neutrophils (glitter cells) More than 1 per 3 HPF
- Eosinophils Hansel test (special stain)
Epithelial Cells
- Squamous cells Indicate level of contamination
- Renal tubular epithelial cells Few are normal
- Transitional epithelial cells Few are normal
- Oval fat bodies Abnormal, indicate Nephrosis
64. Microscopic Examination
Bacteria & Yeasts
Bacteria
- Bacteriuria More than 10 per HPF
Yeasts
- Candidiasis Most likely a contaminant
but should correlate with
clinical picture.
Viruses
- CMV inclusions Probable viral cystitis.
108. Case Diluted urine, request a voided urine in the morning
If persisting low SG, possible diabetes insipida
1 A microscopic may give negative results
Glucose Negative
Bilirubin Negative
A 35-year old man undergoing routine pre
employment drug screening.
Ketones Negative
Physical characteristics: Clear.
S.G. 1.001 Microscopic: Not performed.
Drugs Identified: None.
Blood Negative
pH 5.5
Questions:
Protein Negative - What is your differential diagnosis?
- What would you do next to confirm your
Urobilinogen 0.2 mg/dL suspicion?
- Would you order a microscopic analysis
Nitrite Negative on this sample?
L.E. Negative
109. Case Possible gallbladder or hepatic disease.
No hemolytic anemia. Perform bilirubins in serum
2 Microscopic unlikely to provide additional info
Glucose Negative
Bilirubin +++
A 42-year old woman presents with “dark urine”
Ketones Negative
Physical characteristics: Red-brown.
S.G. 1.020 Microscopic: Not performed.
Blood Negative
Questions:
pH 5.5
- What is your differential diagnosis?
Protein Negative - Could this be a case of hemolytic anemia?
- How would you rule it out?
Urobilinogen 0.2 mg/dL - What tests would you order next? Why?
Nitrite - Would you order a microscopic analysis?
Negative
L.E. Negative
110. Case Possible UTI, request culture and antibiotic sensitivity
Negative Nitrite test: Gram positive bacteria
3 Lower SG may show less number of cells and bacteria
Un-common diagnosis in this type of patient
Glucose Negative
A 42-year old man presents painful urination
Bilirubin Negative
Ketones
Physical characteristics: dark red, turbid
Negative
Microscopic: leukocytes = 30 per HPF
S.G. 1.030 RBCs = >100 per HPF
Bacteria = >100 per HPF
Blood +++
Questions:
pH 6.5 - What is your suspected diagnosis?
- What would you do next?
Protein Trace
- What do you make of the nitrite test?
Urobilinogen 1.0 mg/dL - How would the microscopic exam differ if
the S.G. were 1.003?
Nitrite Negative - Is this a common diagnosis for this type of
patient?
L.E. +++
111. Case Diabetes
May be decompensated and with ketoacidosis
4 Ketones should become negative after treatment
Glucose ++
Bilirubin Negative
Ketones Trace A 27-year old woman presents with severe
abdominal pain.
S.G. 1.015
Physical characteristics: clear-yellow.
Blood Negative Microscopic: Not performed.
pH 6.0
Questions:
Protein Negative - What is the most likely diagnosis?
- What do you make of the ketone result?
Urobilinogen 1.0 mg/dL - What do you expect to happen to the ketone
measurement when treatment begins?
Nitrite Negative
L.E. Negative
112. Case Glomerulonephritis
RBC casts reveals renal cortex involvement
5 RBC cast are not always present in GN
Glucose Negative
8-year old boy presents with discolored urine
Bilirubin Negative
Ketones Physical characteristics: Red, turbid.
Negative
Microscopic: erythrocytes = >100 per HPF
S.G. 1.015 (almost all dysmorphic)
Red cell casts present.
Blood +++
Questions:
pH 6.5 - What is the most likely diagnosis in this
Protein case?
+
- Does the presence of red cell casts help you
Urobilinogen 1.0 mg/dL in any way?
- If the erythrocytes were not dysmorphic
Nitrite Negative would that change your diagnosis?
L.E. Negative
113. Case “Functional” proteinuria?
Microscopic may reveal a few leukocytes
6 Request protein concentration in 24 h urine
Glucose Negative
22-year old man presenting for a routine
Bilirubin Negative
physical required for admission to medical
Ketones Negative school
S.G. 1.010 Physical characteristics: Yellow
Microscopic: Not performed
Blood Negative
Questions:
pH 5.0
- What is your differential diagnosis?
Protein + - Would you order a microscopic analysis on
this sample?
Urobilinogen 0.2 mg/dL - What would you do next to confirm the
diagnosis?
Nitrite Negative
L.E. Negative