It gives basic things regarding urinalysis and will be very useful for medical students, house surgeons, laboratory technicians and postgraduates in medicine.

1. URINE EXAMINATION
Dr.S.Sethupathy,M.D.,Ph.D.,
Professor of Biochemistry,
Rajah Muthiah Medical College,
Annnamalai University

2. KIDNEY FUNCTIONS
 Excretion waste products such as urea,
Creatinine, uric acid
 Maintenance of acid base balance
 Maintenance of water and electrolyte
balance
 Hormone function – Erythropoietin
 Regulation of blood calcium level –
Formation of calcitriol by 1 α – hydroxylase

3. URINE EXAMINATION
A complete physical, chemical and
microscopic examination plays a an
important role in diagnosis of renal
and urinary tract diseases.

4. COLOR
 Normal urine - light yellow to amber
 Due to the presence of a yellow pigment, urochrome
 The more concentrated urine - the deeper the color.
 Deviations from normal color - certain drugs (B
comp), vegetables such as carrots, beets, and
rhubarb.
 Hematuria and hemoglobinuria- Red
 Milky white- Infection, Chyluria
 Yellowish green / orange – Bilirubin, bacterial
infection

5. ABNORMAL COLORS AND CAUSES

7. ODOR
Slightly aromatic, characteristic
of freshly voided urine.
Urine becomes more ammonia-
like upon standing due to
bacterial activity.

8. Odor Condition
Aromatic odor Normal
Fruity smell ( acetone) Diabeteic ketosis (Type 1)
Fishy odor UTI
Ammoniacal odor UTI caused by
pseudomonas & proteus
Mousy odor Phenyl ketonuria
Burnt sugar Maple syrup urine
disease

9. TURBIDITY
 Normal urine is transparent or clear
 Cloudy urine – causes
 RBCs, WBCs
 Epithelial cells
 Bacteria – Pyuria
 Casts
 Crystals
 Lymph – chyluria
 Semen

10. CASTS
 Urinary casts - microscopic cylindrical structures
produced by the kidney and present in the urine in
disease states.
 Casts first described by Henry Bence Jones
 Formed in the distal convoluted tubule and collecting
ducts of nephrons
 In urine, detected by microscopy, formed by Tamm–
Horsfall mucoprotein secreted by renal tubule cells, and
also by albumin in proteinuria.
 Generally 15-20 squamous epithelial cells/hpf or more
indicates urinary contamination.
 Hyaline casts may be seen in healthy subjects.
 Other types of casts are suggestive of renal disease.

11. URINARY CASTS

12. RBC CASTS

13. LEUCOCYTE (WBC) CASTS

14. HYALINE CASTS

15. GRANULAR CASTS

16. PIGMENT CASTS

17. CRYSTALS

18. CHYLE IN URINE
 Milky or hazy appearance of urine - high phosphate
or huge pus cells.
 Phosphates excluded by adding few drops of 5%
acetic acid.
 Pyuria -by centrifuging the sample that gives a clear
upper and a hazy lower zone of the fluid and then by
microscopy.
 In chluria, fat solvent (ether) almost completely clear
the opacity.
 Chylomicrons -visualized under microscope with dark
ground illumination or stained with Sudan III.
 Triglycerides estimation- controls no TGL.

19. SEMEN IN URINE
 In retrograde ejaculation semen goes
backward into the bladder.
 It is not a harmful condition.
 The semen mixes with urine and
passes out of the body the next time the
man urinates.

20. PH
 Ranges from 4.5 - 8.0.
 Average is 6.0, slightly acidic.
 Under 5.0 is acidic, higher than 8.0 is
alkaline
 Vegetarian diets increase alkalinity.
 Bacterial infections also increase alkalinity.

21. ACIDIC URINE
 High protein diets increase acidity.
 Dehydration
 Diabetic ketoacidosis
 Diarrhea
 starvation

22. ALKALINE URINE
 gastric suctioning , pyloric obstruction,
vomiting - that takes away stomach acids
 kidney failure
 kidney tubular acidosis
 respiratory alkalosis
 urinary tract infection

23. SPECIFIC GRAVITY
 Specific gravity measures the ability of the kidneys to
concentrate or dilute urine depending on fluid intake.
 Normal range 1.005 - 1.030 , average range 1.010 -
1.025.
 Low specific gravity is associated with conditions
like diabetes insipidus, excessive water intake,
diuretic use or chronic renal failure.
 High specific gravity levels are associated with
diabetes mellitus, adrenal abnormalities or excessive
water loss due to vomiting, diarrhea or kidney
inflammation. A specific gravity that never varies is
indicative of severe renal failure.

24. VOLUME

25. HIGH S.G
 Volume loss (dehydration, vomiting, diarrhea,
fever)
 Heart failure
 Renal artery stenosis
 Shock
 Syndrome of inappropriate antidiuretic
hormone
 Diabetes mellitus-glucosuria

26. LOW S.G
 Diabetes insipidus
 Excessive water intake
 Diuretic use
 Chronic renal failure (fixed S.G- 1.010).
 Renal failure , Pyelonephritis ,
 Glomerulonephritis
 Psychogenic polydipsia
 Malignant hypertension

27. ABNORMAL CONSTITUENTS
 Glucose – Glycosuria
 Normally the filtered glucose is reabsorbed by the
renal tubules
 Renal threshold for glucose- Blood glucose level
160-180 mg/dl
 If blood glucose levels exceeds renal threshold level,
glucose spills over into the urine.
 Main cause: diabetes mellitus
 Renal glucosuria- reduced renal threshold level
 Blood glucose level-normal but urine glucose
positive

28. PROTEIN (ALBUMIN)
 Albumin do not pass through glomerulus.
 Presence indicates abnormal increased
permeability of the glomerulus membrane.
 Non-pathological causes are: pregnancy,
physical exertion, increased protein
consumption.
 Pathological causes are: glomerulonephritis ,
bacterial toxins, chemical poisons.

29. URINARY PROTEIN -ALBUMINURIA
 Less than 30 mg /24 hrs or 30 mg/gm
Creatinine or 30 µg/mg creatinie is normal.
 30 – 300 mg /24 hrs or 30 -300 mg/gm
creatinine or 30-300 µg/mg Creatinine
is microalbuminuria
 More than 300 mg / day – frank albuminuria
 Healthy albumin to Creatinine ratio:
 less than or equal to 3.5 mg/mmol ( 30mg / gm
Creatinine) - Creatinine mol.wt: 113

30. URINARY KETONES
 Ketone bodies -acetoacetic acid, beta-
hydroxybutyric acid,
 Causes: diabetes mellitus, starvation, ketogenic
diet
 drinking excess alcohol
 excessive vomiting , pregnancy
 illness or infection
 heart attack , emotional or physical trauma
 medications, such as corticosteroids and
diuretics

31. URINARY KETONES RANGE
 Under 0.6 millimoles per liter or 6mg/dl -
Normal
 ketone level 0.6 to 1.5 millimoles per liter
or 6-15 mg/dl higher than normal; test again
in 2 to 4 hours
 1.6 to 3.0 millimoles per liter or 16- 30 mg/dl
–Moderate
 Above 3.0 millimoles per liter or > 30mg/dl -
high

32. BILIRUBIN
 Fouchet’s test: This is a simple and sensitive test.
Five ml of fresh urine in a test tube is mxed with 2.5 ml of
10% of barium chloride .A precipitate - barium sulphate-
bilirubin complex forms
 Filter and spread the precipitate on a filter paper.
 one drop of Fouchet’s reagent is added to the precipitate.
(Fouchet’s reagent consists of 25 grams of trichloroacetic
acid, 10 ml of 10% ferric chloride, and distilled water 100
ml).
 Immediate development of blue-green color around the
drop indicates presence of bilirubin .
 Causes: liver disorders, cirrhosis, hepatitis, obstruction of
bile duct

33. FOUCHET’S TEST - POSITIVE
Reagent strips or tablets impregnated with diazo
reagent: :Based on reaction of bilirubin with diazo reagent;
Color change is proportional to the concentration of bilirubin.
Tablets (Ictotest) detect 0.05-0.1 mg of bilirubin/dl of urine;
Reagent strip tests are less sensitive (0.5 mg/dl).

34. UROBILINOGEN
 Normal – 0.2 mg/dl - 1mg/dl
 Less than 0.2 mg/dl - low
 More than 1 mg /dl – high
 High urobilinogen level
 Hemolytic anemias, malaria
 False Positive Results - Elevated nitrate in the
urine
 High carbohydrate intake
 Timing (test is done later in the afternoon)
 Drugs that make the urine red, such as
phenazopyridine (Pyridium)

35.  Low urobilinogen-- cholestasis - causes
include :
 Bile duct blockage (gallstones, cysts, and
tumors)
 Liver disease/damage
 Pregnancy
 Severe infection
 Pancreatic cancer
 Broad-spectrum antibiotics
 False Negative Results
 Exposure of urine sample to direct sunlight–
urobilinogen breaks down

36. HEMATURIA- CAUSES
 Kidney infections (pyelonephritis).
 A bladder or kidney stone.
 Enlarged prostate.
 Kidney disease. .
 Cancer.
 Inherited disorders. Sickle cell anemia
 Alport syndrome, which affects the filtering membranes in the
glomeruli of the kidneys.
 Kidney injury. A blow or other injury to your kidneys from an
accident or contact sports can cause
 Medications. drug cyclophosphamide and penicillin , aspirin,
heparin can cause urinary bleeding.
 Strenuous exercise. It's rare for strenuous exercise to lead to
gross hematuria,

37. HEMOGLOBINURIA -CAUSES
 Acute glomerulonephritis
 Burns , Renal cancer , Malaria
 Microangiopathies,
 Transfusion reactions
 IgM autoimmune hemolytic anemia
 Glucose-6-phosphate dehydrogenase deficiency
 Pyelonephritis
 Sickle cell anemia
 Tuberculosis of the urinary tract
 March hemoglobinuria secondary to repetitive impacts on the
body, usually the feet
 Athletic nephritis secondary to strenuous exercise
 Acute lead poisoning

38. DIP-STICK TEST –HEMATURIA
 A nondiagnostic screening test.
 A positive result is due to oxidation of a test-strip
reagent; it does not confirm that blood cells are
present.
 Factors that can cause a positive result on a dipstick
test include hemoglobinuria, myoglobinuria,
concentrated urine, menstrual blood in the urine
sample, and rigorous exercise
 False-positive results can occur (certain dyes or
drugs, beets, oxalates).
 The strip is read in a min. (sensitivity of 100% and a
specificity of 99% in detecting 1-5 RBCs per high-
power field (hpf).

39. DIP-STICK TEST FOR HEMATURIA
 Confirm presence of RBCs microscopically.
 If the specific gravity of the urine is very low
(< 1.007), microscopy can fail to detect owing
to cell lysis.
 Repeat the test after restricting the patient’s
fluid intake
 Other investigations should be avoided, and
the dipstick and microscopic urinalysis
should be repeated twice within 2 weeks.

40. LEUKOCYTES AND NITRITES
 Normal - 0-5 WBCs per high power field
(wbc/hpf)
 High number of leukocytes
may indicate the presence of urinary tract
infection
 If the test for leukocyte esterase is positive
but finds no nitrite, an infection may still be
present.
 E. coli bacteria are most commonly
associated with nitrites in the urine.

41. Test Report format Results
Physical- color and odor
Turbidity
Specific gravity
pH
Chemical - protein
Glucose
ketones
urobilinogen
bilirubin
blood
leukocytes
nitrites
Microscopic - RBCs
Leukocytes
Crystals
Casts
Bacteria /yeast

42. Thank you