Examination of Urine

Urinary System 
3
Introduction

 Urine is formed in the kidneys, is a product of 

ultrafiltration of plasma by the renal glomeruli 
which is a network of arteriolar capillaries, 
each glomeruli is surrounded by Bowmans capsule 
(a double epithelial sac) like a rounded funnel 
which leads to the tube.

4
Purpose

 Urine contains important metabolic information

 Urine is cheap, simple, readily available
 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)

5
Collection of urine specimens

 The first voided morning urine (most 

concentrated) - qualitative
 Random urine (routine)
 24hrs sample- quantitative
 Mid-stream clean catch (MSCC) (for urine 
culture)- UTI
 Post prandial sample-D.M
 Attention
 Need to be examined within 1 hour
6
Clean Catch 
7

8
24 hour urine sample

1. For quantitative estimation of proteins

2. For estimation of vanillyl mandelic acid, 
5-hydroxyindole acetic acid, metanephrines
3. For detection of AFB in urine
4. For detection of microalbuminuria

9
Types of Analysis

 1- Macroscopic Examination
 Physical characteristics color, odor, 
turbidity, volume, specific gravity
 Chemical Analysis (Urine Dipstick) pH, glucose, 
protein, ketones, pus (WBCs bacteria), RBCs, 
hemoglobin, bile
 2- Microscopic Examination of urine sediment 
crystals, cells, etc.

10
Physical examination

 Volume
 Color
 Odour
 Reaction or urinary pH
 Specific gravity
11
Urinary volume

 The average daily urine output 1200 - 1500 mL 

(1.2 - 1.5 L)
 The normal daily range of urine output 600 - 
2000 mL (0.6 - 2.0 L)
 Polyuria- gt2000ml
 Oliguria- lt400ml
 Anuria-complete cessation of urine(lt200ml)
 Nocturia-excretion of urine by an adult of gt500ml 
with a specific gravity of lt1.018 at night 
(characteristic of chronic glomerulonephritis)

12
Causes of polyuria gt 2000ml

 Diabetes mellitus
 Diabetes insipidus
 Polycystic kidney
 Chronic renal failure
 Diuretics
 Intravenous saline/glucose

13
Oliguria lt400ml

 Dehydration-vomiting, diarrhea, excessive 

sweating
 Renal ischemia
 Acute tubular necrosis
 Obstruction to the urinary tract
 Acute renal failure

14
Urine Color and Clarity
  Urine color and clarity can indicate what 
substances may be present in urine.
 Confirmation of suspected substances is obtained 
during the chemical and microsopic examination.

15
Urine Color

 Normal urine color ranges from pale yellow to 

deep amber the result of a pigment called 
urochrome
 Most changes in urine color are harmless and 
temporary and may be due to
 Certain foods beets may turn urine red
 Dyes in foods/drinks
 Supplements vitamins
 Prescription drugs

16
Abnormal colors of urine possible causes

 Unusual urine color can indicate an infection or 

serious illness .
 Colourless- dilution, diabetes mellitus, 
diabetes insipidus, diuretics
 Milky- genitourinary tract infection
 Orange-fever, excessive sweating, bilirubin
 Red-beetroot ingestion,haematuria
 Brown/ black- alkaptunuria, melanin
 Green - bile, Pseudomonas bacteria

17
Examples of Urine Color 
18
Urine Clarity

 Urine clarity refers to how clear the urine is.

  Terms used clear, transparent, slightly cloudy, 
cloudy, or turbid.
 Normal urine can be clear or cloudy.
 The clarity of the urine is not as important as 
the substance that is causing the urine to be 
cloudy.
 Turbidity - cloudiness due to
 particulate matter
 suspended in urine


19
Urine Clarity

 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).
 Other substances that can make urine cloudy (such 
as red blood cells, white blood cells, or 
bacteria) indicate a condition that requires 
attention.

20
Examples of Urine Clarity 
21
Odour

 Normal aromatic due to the volatile fatty acids

 Standing (old) urine takes on an ammonia odor 
due to urea-splitting bacterial
 Foul, offensive Old specimen, pus or 
inflammation
 Sweet Glucose
 Fruity Ketones
22
Chemical Analysis 
23
Urine dipsticks (Reagent Strips)

 Urine dipstick are plastic strips on which are 

attached to a series of chemically impregnated 
absorbent pads, each pad contain certain 
chemicals that react with substance in the urine 
producing a color change in pad, this color 
change is compared with a series of known 
standards.

24
Chemical Analysis
Urine Dipstick 
25
Reagent Strips 
26
Procedure

 Reagent strips are used only once and discarded.

 Testing
 Perform within 1 hour after collection
 Allow refrigerated specimens to return to room 
temperature.
 Dip strip briefly, but completely into well 
mixed, room temperature urine sample.
 Withdraw strip.
 Blot briefly on its side.
 Keep the strip flat, read results at the 
appropriate times by comparing the color to the 
appropriate color on the chart provided.

27
Procedure

 Instruments are available which detect color 

changes electronically and prints out results
28
Handling and Storage of Strips

 Handling and Storage

 Keep strips in original container
 Do not touch reagent pad areas
 Reagents and strips must be stored properly to 
retain activity
 Protect from moisture and volatile fumes
 Stored at room temperature
 Use before expiration date

29
Sources of Error

 Timing - Failure to observe color changes at 

appropriate time intervals may cause inaccurate 
results.
 Lighting - Observe color changes and color charts 
under good lighting.
 QC - Reagent strips should be tested with 
positive controls on each day of use to ensure 
proper reactivity.
 Sample - Proper collection and storage of urine 
is necessary to insure preservation of chemical.

30
Sources of Error

 Testing cold specimens - would result in a 

slowing down of reactions test specimens when 
fresh or bring them to RT before testing
 Inadequate mixing of specimen - could result in 
false reduced or negative reactions to blood and 
leukocyte tests mix specimens well before 
dipping
  Over-dipping of reagent strip - will result in 
leaching of reagents out of pads briefly, but 
completely dip the reagent strip into the urine

31
The Urine Dipstick
Glucose
Chemical Principle
Glucose Oxidase
Glucose 2 H2O O2 ---gt Gluconic Acid 2 H2O2
Horseradish Peroxidase
3 H2O2 KI ---gt KIO3 3 H2O
Read at 30 seconds RR Negative 
32
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.

33
Urine versus Blood Glucose

Urinalysis Glucose Result

trace
Negative
400
600
800
1000
200
Blood Glucose (mg/dL) 
34
The Urine Dipstick
Bilirrubin
Chemical Principle
Acidic
Bilirubin Diazo salt ---------gt Azobilirubin
Read at 30 seconds RR Negative 
35
Bilirubin

 Bilirubin is a byproduct of the breakdown of 

hemoglobin.
 Normally contains no bilirubin.
 Presence may be an indication of liver disease, 
bile duct obstruction or hepatitis.
 Since the bilirubin in samples is sensitive to 
light, exposure of the urine samples to light for 
a long period of time may result in a false 
negative test result.

36
Ketones

 Ketones are excreted when the body metabolizes 

fats incompletely (ketonuria)

37
The Urine Dipstick
Ketones
Chemical Principle
Acetoacetic Acid Nitroprusside ------gt Colored 
Complex
Read at 40 seconds RR Negative 
38
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

39
Specific gravity

 Depends on the concentration of various solutes 

in the urine.
 Measured by-urinometer
 - refractometer
 - dipsticks

 Specific gravity reflects kidney's ability to 

concentrate.
 Want concentrated urine for accurate testing, 
best is first morning sample.
 Low specimen not concentrated, kidney disease.
 High first morning, certain drugs

40
Urinometer

 Take 2/3 of urinometer container with urine

 Allow the urinometer to float into the urine
 Read the graduation at the lowest level of 
urinary meniscus
 Correction of temperature albumin is a must.
 Urinometer is calibrated at 15or 200c
 So for every 3oc increase/decrease add/subtract 
0.001
 For 1gm/dl of albumin add0.001
41

42
The Urine Dipstick
Specific Gravity
Chemical Principle
X Polymethyl vinyl ether / maleic 
anhydride ---------------gt X-Polymethyl vinyl 
ether / maleic anhydride H
H interacts with a Bromthymol Blue indicator 
to form a colored complex.
Read up to 2 minutes RR 1.003-1.035 
43
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)

44
High specific gravity(hyperosthenuria)

 Normal-1.016-1.022
 Causes
 All causes of oliguria
 Glycosuria
45
Low specific gravity(hyposthenuria)

 All causes of polyuria except glycosuria

 Fixed specific gravity (isosthenuria)1.010
 Seen in chronic renal disease when kidney has 
lost the ability to concentrate or dilute

46
Blood

 Presence of blood may indicate infection, trauma 

to the urinary tract or bleeding in the kidneys.
 False positive readings most often due to 
contamination with menstrual blood.

47
The Urine Dipstick
Blood
Negative
Chemical Principle
Trace (non-hemolyzed)
Lysing agent to lyse red blood cells
Moderate (non-hemolyzed)
Diisopropylbenzene dihydroperoxide 
Tetramethylbenzidine ------------gt Colored 
Complex
Trace (hemolyzed)
Heme
(weak)
Read at 60 seconds RR Negative Analytic 
Sensitivity 10 RBCs
(moderate)
(strong) 
48
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

49
Urinary pH/ reaction

 Reaction reflects ability of kidney to maintain 

normal hydrogen ion concentration in plasma ECF
 Normal 4.6-8
 Tested by- 1.litmus paper
 2. pH paper
 3. dipsticks

50
The Urine Dipstick
pH
Chemical Principle
H interacts with Methyl Red (at high 
concentration low pH) and Bromthymol Blue (at 
low concentration high pH), to form a colored 
complexes(dual indicator system)
Read up to 2 minutes R.R. 4.5-8.0 
51
Acidic urine

 Ketosis-diabetes, starvation, fever

 Systemic acidosis
 UTI- E.coli
 Acidification therapy
52
Alkaline urine

 Strict vegetarian
 Systemic alkalosis
 UTI- Proteus
 Alkalization therapy

53
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 (gt5.5)
 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

54
pH Run Over Effect
Buffers from the protein area of the strip (pH 
3.0) spill over to the pH area of the strip and 
make the pH of the sample appear more acidic than 
it really is. 
55
Protein

 Presence of protein (proteinuria) is an important 

indicator of renal disease.
 False negatives can occur in alkaline or dilute 
urine or when primary protein is not albumin.
56
The Urine Dipstick
Protein
Chemical Principle
Protein Error of Indicators Method
Tetrabromphenol Blue (buffered to pH 3.0)
Pr
Pr
Pr
Pr
Pr
Pr
Read at 60 seconds RR Negative 
57
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

58
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

59
Urobilinogen

 Urobilinogen is a degradation product of 

bilirubin formed by intestinal bacteria.
 It may be increased in hepatic disease or 
hemolytic disease

60
The Urine Dipstick
Urobilinogen
Chemical Principle
Urobilinogen Diethylaminobenzaldehyde -------gt 
Colored Complex
(Ehrlichs Reagent)
Read at 60 seconds RR 0.02-1.0 mg/dL 
61
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 ---gt urobilin)
 - Cannot detect low levels of urobilinogen
 Other Tests
 - Serum total and direct bilirubin

62
Nitrite

 Nitrite formed by gram negative bacteria 

converting urinary nitrate to nitrite
63
The Urine Dipstick
Nitrite
Chemical Principle
Acidic
Nitrite p-arsenilic acid -------gt Diazo compound
Diazo compound Tetrahydrobenzoquinolinol -------
---gt Colored Complex
Read at 60 seconds RR Negative 
64
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

65
Leukocytes

 Leukocytes (white blood cells) usually indicate 

infection.
 Leucocyte esterase activity is due to presence of 
WBCs in urine while nitrites strongly suggest 
bacteriuria.

66
The Urine Dipstick
Leukocyte Esterase
Chemical Principle
Derivatized pyrrole amino acid ester 
------------gt 3-hydroxy-5-phenyl pyrrole
Esterases
3-hydroxy-5-phenyl pyrrole diazo 
salt -------------gt Colored Complex
Read at 2 minutes RR Negative Analytic 
Sensitivity 3-5 WBCs 
67
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

68
Normal Values

 Negative results for glucose, ketones, bilirubin, 

nitrites, leukocyte esterase and blood.
 Protein negative or trace.
 pH 5.5-8.0
 Urobilinogen 0.2-1.0 Ehrlich units

69
Microscopic examination

 Microscopic urinalysis is done simply pouring the 

urine sample into a test tube and centrifuging it 
(spinning it down in a machine) for a few 
minutes. The top liquid part (the supernatant) is 
discarded. The solid part left in the bottom of 
the test tube (the urine sediment) is mixed with 
 the remaining drop of urine in the test tube and 
one drop is analyzed under a microscope

70
Microscopic Examination
Abnormal Findings

 Per High Power Field (HPF) (400x)

 gt 3 erythrocytes
 gt 5 leukocytes
 gt 2 renal tubular cells
 gt 10 bacteria
 Per Low Power Field (LPF) (200x)
 gt 3 hyaline casts or gt 1 granular cast
 gt 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

71
Microscopic Examination
Cells

 Erythrocytes
 - Dysmorphic vs. normal (gt 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

72
Microscopic Examination
RBCs 
73
Microscopic Examination
RBCs 
74
Microscopic Examination
WBCs 
75
Microscopic Examination
Squamous Cells 
76
Microscopic Examination
Tubular Epithelial Cells 
77
Microscopic Examination
Transitional Cells 
78
Microscopic Examination
Transitional Cells 
79
Microscopic Examination
Oval Fat Body 
80
Microscopic Examination
LE Cell 
81
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.

82
Microscopic Examination
Bacteria 
83
Microscopic Examination
Yeasts 
84
Microscopic Examination
Yeasts 
85
Microscopic Examination
Cytomegalovirus 
86
casts

 Urinary casts are cylindrical aggregations of 

particles that form in the distal nephron, 
dislodge, and pass into the urine. In urinalysis 
they indicate kidney disease. They form via 
precipitation of Tamm-Horsfall mucoprotein which 
is secreted by renal tubule cells.

87
Microscopic Examination
Casts 
88
Types of casts

 Acellular casts
 Hyaline casts
 Granular casts
 Waxy casts
 Fatty casts
 Pigment casts
 Crystal casts

 Cellular casts
  Red cell casts
 White cell casts
 Epithelial cell cast

89
Microscopic Examination
Casts

 Erythrocyte Casts Glomerular diseases

 Leukocyte Casts Pyuria, glomerular disease
 Degenerating Casts
 - Granular casts Nonspecific (Tamm-Horsfall 
protein)
 - Hyaline casts Nonspecific (Tamm-Horsfall 
protein)
 - Waxy casts Nonspecific
 - Fatty casts Nephrotic syndrome
 (oval fat body casts)

90

91
Red cell casts

 The presence of red blood cells within the cast 

is always pathologic, and is strongly indicative 
of glomerular damage.
 They are usually associated with nephritic 
syndromes.

92
Microscopic Examination
RBCs Cast - Histology 
93
Microscopic Examination
RBCs Cast 
94
Microscopic Examination
RBCs Cast - Histology 
95
White blood cell casts

 Indicative of inflammation or infection,

 pyelonephritis
 acute allergic interstitial nephritis,
 nephrotic syndrome, or
 post-streptococcal acute glomerulonephritis

96
(No Transcript) 
97
Microscopic Examination
WBCs Cast 
98
Epithelial casts

 This cast is formed by inclusion or adhesion of 

desquamated epithelial cells of the tubule 
lining.
 These can be seen in
 acute tubular necrosis and
 toxic ingestion, such as from mercury, diethylene 
glycol, or salicylate.

99
Microscopic Examination
Tubular Epith. Cast 
100
Microscopic Examination
Tubular Epith. Cast 
101
Granular casts

 Granular casts can result either from the 

breakdown of cellular casts or the inclusion of 
 aggregates of plasma proteins (e.g., albumin) or 
immunoglobulin light chains
 indicative of chronic renal disease

102
Microscopic Examination
Granular Cast 
103
Hyaline casts

 The most common type of cast, hyaline casts are 

solidified Tamm-Horsfall mucoprotein secreted 
from the tubular epithelial cells
 Seen in fever, strenuous exercise, damage to the 
glomerular capillary

104
Microscopic Examination
Hyaline Cast 
105
Waxy casts

 waxy casts suggest severe, longstanding kidney 

disease such as renal failure(end stage renal 
disease).

106
Waxy casts

107
Microscopic Examination
Waxy Cast 
108
Fatty casts
  Formed by the breakdown of lipid-rich epithelial 
cells, these are hyaline casts with fat globule 
inclusions
 They can be present in various disorders, 
including
 nephrotic syndrome,
 diabetic or lupus nephropathy,
 Acute tubular necrosis

109
Fatty casts

110
Microscopic Examination
Fatty Cast 
111
Crystal casts

 Though crystallized urinary solutes, such as 

oxalates, urates, or sulfonamides, may become 
enmeshed within a hyaline cast during its 
formation.
 The clinical significance of this occurrence is 
not felt to be great.

112
Contents of normal urine m/s

 Contains few epithelial cells, occasional RBCs, 

few crystals.

113
Crystals in urine

 Crystals in acidic urine

 Uric acid
  Calcium oxalate
 Cystine
 Leucine

 Crystals in alkaline urine

 Ammonium magnesium phosphates(triple phosphate 
crystals)
 Calcium carbonate

114
crystals

115
Microscopic Examination
Calcium Oxalate Crystals 
116
Microscopic Examination
Calcium Oxalate Crystals
Dumbbell Shape 
117
Microscopic Examination
Triple Phosphate Crystals 
118
Microscopic Examination
Urate Crystals 
119
Microscopic Examination
Cystine Crystals
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