ANALYSIS OF URINE AND BODY FLUIDS
URINALYSIS I
LEC 2 BY ILUMINADA R. CINCO, RMT, MPH(c)
AUGUST 31, 2022
LEARNING OBJECTIVES
● State the reasons for performing urinalysis
● Differentiate the types of urine specimens, the correct procedure
of collection & the diagnostic use of each.
● List the different urine specimen containers & their usage.
● Briefly discuss methods of preserving urine specimens
● List the changes that happen when urine is allowed to stand at
room temperature for more than 2 hours
● Describe the methods for identifying an unknown fluid as urine.
● State possible reasons for rejecting a urine sample
● List the components of Routine Analysis
● Discuss the relationship of urochrome to normal urine colour.
● Discuss the abnormal urine colours & their significance.
● List the pathologic & non-pathologic causes of urine turbidity.
● State possible cause of abnormal urine odour.
● Describe the principle of pH determination & significance
● Describe the principle of Specific Gravity determination & the
significance of the test.
● Recognize normal & abnormal daily urine volume
BRIEF HISTORY AND IMPORTANCE
● Urine analysis was actually the beginning of Laboratory Medicine
● It began 6000 years ago with the analysis of human urine which
was called Uroscopy until the 17th century and today is termed
as URINALYSIS
● Examination of urine back then was based only on the physical
examination of urine samples. They only base it on the color, the
turbidity, the odor, the volume, the viscosity.
Figure 1. Drawings from Egyptian Hieroglyhics
● This was based on the drawings they saw from Egyptian
hieroglyphics and from the drawings of cavemen. This shows a
physician examining a bloody-shaped glass of urine.
● Now later on, it progressed to “ant testing”. If the urine attracts
ants it means it's sweet so it contains a lot of glucose. Then It
even progresses from ant testing to taste testing, so taste if the
urine is sweet or not. (note: inaudible si miss on this part so not
sure)
● And after that, it progresses to “chemical testing” to the
examination of protein: the determination of albuminuria wherein
if the urine is boiled, the protein will coagulate. If it coagulates,
there is an increased amount of protein in the sample.
● Then after that, the microscope was invented in the 17th century
which led to the examination of the urine sediments wherein they
developed methods to quantitate these sediments.
● Now we have what we called Addis Count wherein a 12 hour
urine sample is collected and the cells are counted.
URINE SPECIMEN
➢ Referred to as a liquid tissue biopsy of the urinary tract -
painlessly obtained
➢ urine is considered as a liquid biopsy. So it is painlessly
obtained.
➢ It yields a great deal of information quickly & economically.
But like any other laboratory procedure it should be carefully
performed & properly controlled.
REASONS FOR PERFORMING URINALYSIS
1. Diagnosis & management of renal or urinary tract diseases
■ So you examine the urine. The physician will want to know if
there is any Urinary Tract Infection UTI
2. Detection of metabolic or systemic disease not directly related to
the kidney
■ So during examination it can be used to detect other
diseases. For example, some liver disorders can be
diagnosed by the presence of a certain crystal. Then
pregnancy testing can also be detected by using urine
samples for the presence of the hormone hCG.
3. Monitoring the progress of disease & check effectiveness of
therapy
■ Like this certain patient has a urinary tract infection then the
physician is giving him antibiotics. So there is an initial urine
analysis prior to the medication and after treatment. There is
a follow up urinalysis to check whether the drug is effective
or if the patient is improving
URINE COLLECTION
● is very important since if the urine sample is not collected properly
then it is useless to proceed to the analysis. The patient will pay
for the laboratory fee but the results are inaccurate.
● Urine samples must be collected in a clean, dry container and
should be examined when freshly voided, within 2 hours of
voiding. If analysis is to be delayed (later than the 2 hours), urine
samples should be refrigerated or preserved.
There are several types of collection for urine samples. The first one
here is collection of samples for a Routine Urinalysis. This is the most
common examination being done in Clinical Microscopy Laboratory.
A. COLLECTION OF URINE FOR URINALYSIS
Method of Collection: Collect the sample midstream (midstream
specimen). Midstream means collecting the middle portion of urination.
Instruct the patient to urinate and let the first part of the urination flow
into the toilet bowl then collect now the middle portion of urination and
then discard the third portion - the last part of urination is not collected.
TWO TYPES OF SAMPLE FOR ROUTINE URINALYSIS:
1. Random Specimen
Advantageous for the patient because it can be collected at any
time of the day and it’s still suitable for routine
examination or for most examinations.
Disadvantage: the concentration of the formed elements in the urine
sample which include the urinary cast, red blood cell,
and white blood cell. These formed elements in the
urine will be affected by the degree of hydration of
the patient. If the patient takes in lots of fluid on that
day then the urine is diluted. If the patient takes in
less water or the water is withheld the patient will
also have concentrated urine sample. It
varies/depends on the degree of hydration.
2. First Morning Specimen
● Considered as the specimen of choice.
Why? —--Because the urine sample is more concentrated and
stable.
Why stable? —--Because the urine specimen is acidic or has an
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acidic pH. Usually when people wake up in the morning, they will
have an acidic urine sample. In acidic pH the formed elements are
better preserved.
● Aside from using the first morning specimen for routine urinalysis,
this is also recommended for pregnancy testing to prevent a
false negative pregnancy test. The hormone HCG being tested is
more concentrated in the first morning sample.
● Another use for the first morning specimen is for evaluating
Orthostatic Proteinuria.
B. COLLECTION FOR QUANTITATIVE ANALYSIS
Figure 2. 24-hour urine collection container.
Another way to collect urine is for quantitative analysis. Quantitative
Analysis is the use of timed specimens. These are the:
1. 2 to 12 hours timed collections
2. 24 hours specimen
● 2 hour sample - usually used for urobilinogen determination
because it is the time of peak excretion of
urobilinogen
★ urine sample is taken between 2-4
PM (afternoon specimen)
● 12 hour sample - used for quantitative cell count, one
example is Addis counting (the cells, WBCs
and RBCs are counted)
● 24 hour sample - a clearance testing (for glucose, protein, or
creatinine)
For timed specimens, collection instructions are very important (on how
to collect their timed specimens). For example, we have a patient for a
24 hour specimen. When he goes to the laboratory and asks for a
container, a big brown plastic container (3000 ml urine sample) is
needed. Depending on the type of examination needed, a urine
preservative is also added.
You have to instruct the patient that the urine is voided but discard the
first urine sample at the beginning of the collection period, then collect
the succeeding samples. The last sample will be collected at 7am on
the following day.
After the collection, the specimen is brought to the laboratory for
examination. The MT will check the label and measure the volume of
the urine. Hence, the first examination done is the determination of
urine volume. After that, aliquots are taken. You get several small
samples of the 24-hr collection and store it in the freezer if it cannot be
examined right away. You can’t keep the whole container in the freezer
for a long period (takes up lots of space and can be mistaken for juice
bottles since we use recycled bottles for their volume capacity).
NOTE: During the 24-hour collection, the sample should be refrigerated
(the big brown container is being placed in a refrigerator for a 24 hour
period). Each time a patient voids, the sample is added to the container
in a refrigerator.
Errors in the results are often related to collection problems like:
So that’s why instruction should be clear and should be understood by
the patient because errors are related to collection problems
1 Loss of voided specimen
- So if ever the patient forgets that he is having a 24-hr
collection and urinates in the CR and fails to collect it, so you
miss 1 sample. So do not accept your specimen. So you
should discontinue and start all over again.
2 Failure to discard the first specimen/ sample
- So if at the start of the collection period, always remind the
patient to discard the first sample
3 Poor preservation
- As we’ve mentioned earlier, aside from refrigerating the
sample, you also need to add in a preservative. So 1 example
is addition of acid or conc HCl for example is added to prevent
growth of bacteria because you will be storing it for 24 hrs.
4 Inadequate refrigeration
- You should also remind the patient that each time he collects a
sample, it should be added to the big container which is being
placed in the refrigerator and should not stay at room
temperature without refrigeration
C. COLLECTION FOR BACTERIOLOGIC EXAMINATION
● A clean-catch midstream specimen is desirable but sometimes
catheterization or suprapubic aspiration of the bladder is
necessary.
Another collection of urine for examination is for bacteriologic
examination or microbiologic examination. So what is the type of
specimen being used? It is the clean-catch sample. So if we say
“clean-catch specimen,” that is understood that it is collected clean
catch and it is midstream. So if the patient is unable to void, another
alternative is to use a catheterized sample, or if not, suprapubic
aspiration of the bladder is done by the physician/doctor, not the
MedTech. And, one very important consideration if you receive
requests for bacteriologic examination is that the specimen container
should be sterile because if you have a collection for routine urinalysis,
you can use a clean and dry container, chemically free. But, for
microbiologic examination, the specimen container should be sterile.
● Bacterial culture should be done immediately but if not possible,
urine should be refrigerated at 4 degrees Celsius/Centigrade
until cultured.
● Strong bacterial agents such as hexachlorophene or povidone
iodine should not be used. Mild antiseptic towelettes are
recommended.
SPECIAL COLLECTION TECHNIQUE
Aside from the usual or the routinely-done collection, we have one
example, urethral catheterization.
1. Ureteral Catheterization
● introduce a catheter into the urethra & bladder. Necessary for
patients who are unable to void.
2. Subrapubic Aspiration
● urine is aspirated with a syringe & needle above the symphysis
pubis through the abdominal wall into the full bladder.
● Now, this is usually used for anaerobic cultures, for problem
cultures, and also for infants, wherein when you say problem
cultures, contamination cannot be ruled out; also for infants,
when it is very difficult to collect a sample and if ever a sample
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is collected, usually it is contaminated, so they will resort to this

(suprapubic aspiration) procedure.
3. 3 Glass Collection
● used to determine prostatic infection
● Instead of discarding the 1st urine passed, so, if you remember
in routine urinalysis, you collect only the middle portion of
urination. But in this type of collection, you prepare 3 specimen
containers so that in the 1st glass, collect the first portion of
urination. Then, the middle (midstream) portion is collected in
the 2nd container, and prior to collecting the last part of
urination, the prostate is massaged so that what comes out is
prostatic fluid together with the urine in the 3rd bottle/container.
Take note that these 3 containers should be sterile.
● After you have your samples, you perform quantitative cultures
on each of the three specimens. 1st & 3rd are examined
microscopically (NOTE: in the PPT, 1st & 3rd; in the audio,
Ma’am said “each of these”). In prostatic infection, the 3rd
specimen will have a WBC/hpf & bacterial count 10x that of the
1st specimen. The 2nd is used as control for bladder or kidney
infection.
CHAIN OF CUSTODY
● Chain of Custody (COC) is the process that provides this
documentation of proper sample ID from time of collection to
the receipt of lab results.
● The COC is a standardized form that must document and
accompany every step of drug testing, from collector, to
courier, to lab, to medical review officer, to employer.
SPECIMEN COLLECTION
● Urine specimen collections may be “witnessed” or
“unwitnessed”
● Collect sample about 30 to 45 ml. urine.
● Urine temperature must be taken within 4 min. of collection
to confirm that the specimen has not been adulterated.
● Temperature should read between 32.5 °C to 37.7 °C
● Urine color is inspected to identify any sign of contaminants.
(Toilet lid + faucet handles are taped to eliminate source of
H2O. Toilet water reservoir is added with bluing agent (dye) to
prevent adulterated specimen.

4. Ureteral catheterization
● Used to differentiate bladder infection from kidney infection.
● Ureteral catheters are inserted via a cystoscope into each
ureter.
● Bladder urine is 1st collected, then a bladder washout
specimen.
● Ureteral urine specimens are obtained separately from each
kidney pelvis and carefully labeled right ureter and left ureter
to differentiate bladder.
○ You would determine if there is kidney infection.

For DIABETIC Monitoring

Figure 3. Sample of a witnessed urine collection

1. Fasting specimen (2nd morning specimen)
● 2nd voided specimen after a period of fasting.
SPECIMEN CONTAINERS
● This specimen will not contain any metabolite from food taken
or ingested prior to the beginning of the fasting period.

2. 2-Hour Postprandial Specimen

● Patient is instructed to void shortly before consuming a
routine meal and to collect a specimen 2 hrs after eating.
● Specimen is tested for glucose and used primarily for
monitoring insulin therapy in person with Diabetes Mellitus
(DM).

3. Glucose Tolerance Test (GTT)

● Test used for monitoring diabetic patients.
● Specimens are collected to correspond with the blood
samples drawn during a GTT. Figure 4. Sample Specimen Container
● Most tests include fasting, ½ hr, 1 hr, 2 hrs, and 3 hrs.
○ Example: a 3-hr GGT, we need several samples. 1. Disposable plastic containers, 100 to 200 ml. with lids for
The patient is asked to fast and a fasting specimen routine screening.
is taken-a blood sample together with urine 2. 12 ml. capped plastic disposable tubes are also available.
specimen. After the blood is drawn, the patient is 3. Rigid brown plastic containers, 3000 mL with wide mouths &
asked to drink a glucose load usually 100g glucose screw caps for 24 hr collection.
load and 30 mins after, a blood sample is drawn and ● Why is it brown?
another urine sample is also collected. One hour a. In order to preserve the photosensitive that consists
after, 2 hrs after and 3 hrs after, glucose is examined each for to be detected.
in the blood and also in urine specimens.
● Tested for glucose and ketones
● Usually for pregnant women, to check for gestational
diabetes, they perform a 2-hr Glucose Tolerance Test wherein
a 75g glucose load is also given

DRUG SPECIMEN COLLECTION

● Urine collection is the most vulnerable part of a drug testing
program. Correct collection procedure and documentation are
necessary to ensure that drug testing results are those of the
specific individual submitting the specimen.
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quantitative chemical determinations (

cells & casts) preserve best when
refrigerated at an acid pH (about 6) w/out
preservation.
● If we cannot perform the test within 2 hrs,
we need to refrigerate the samples.
● useful for aliquots of urine to be used for
quantitative chemical testing
○ You don't need to rinse the whole
quantity/volume of your urine
collected. You only get aliquots of
the urine.
● It will help retard loss of labile subs. such
2. Freezing as urobilinogen, bilirubin, &
porphobilinogen but not completely.
Figure 5. A container for 24-hour urine collection may require the ○ Then, you also need to rinse them
addition of a preservative. in a round-colored bottle. This is
for urobilinogen, bilirubin, &
4. Pediatric urine collectors of clear polyethylene are available porphobilinogen testing.
for male & female infants **Light sensitive pigments are preserved in
● For babies, it is hard to collect the urine sample so we dark colored containers
need these pediatric urine collectors.
Commonly used are toluene, formalin, thymol.
● There is a separate urine collector for male & female
1. Toluene – for preservation of acetone,
diacetic acid, reducing substances &
protein.
2. Formalin(40%) – for preservation of
formed elements
a. An excess will cause pption
(precipitation) of urea.
b. Will cause a false (+) Clinitest &
Fehling’s test.
3. Thymol – good preservative for most
chemical test
a. Will cause a false (+) reaction for
Figure 6. Pediatric collection unit consists of a clear, sterile, plastic bag protein w/ heat and acetic acid test
with adhesive for attaching to the child. but does not affect the dipstick
method.
5. Sterile containers are used for bacterial cultures. 4. Boric Acid – delay the decomposition of
● You have to check that containers given to patients chemicals as well as formed elements but
are sterile does not stop the growth of yeast. It will
● Also, make sure that the patient is properly precipitate uric acid.
informed regarding the collection like for chemo 5. Sodium Fluoride – preserve glucose in
patients. 24 hr. collection to inhibit glycolysis by
● Prior to the collection of the urine sample, the genital cells & bacteria. It will inhibit the reagent
has to be cleansed with mild antiseptic. We have this strip for glucose. It is a good preservative
in PMLS 2, do you remember? for drug analyses.
● For females, we have to instruct them that the labile 3. Chemical
Preservatives 6. Cytologic preservative – 50% alcohol
pool needs to be operated so make sure that there is a. for evaluation of tumor cells.
no source of contamination. 7. SACCOMANNOS FIXATIVE
● For a male patient, especially for an uncircumcised a. preserve cellular elements
male, there is a problem with contamination, so the b. Used for cytology studies
foreskin should be retracted prior to collecting the 8. Urine C & S transport kit
sample. a. for U/A and C & S on the same
specimen, decreases pH –
preservative is boric A.
9. Preservative tablet
a. used for transportation of urine for
routine screening U/A
b. preserve glucose & other
constituents by releasing
formaldehyde
c. They also contain benzoate &
mercury & have an acid reaction
Figure 7. Bacterial culture d. 95 mg tablet is used with 20 ml.
urine. In this concentration,
formaldehyde will not react with the
HANDLING AND PRESERVING SPECIMENS
copper reduction tests (clinitest -
We have several ways of preserving the sample. test for sugar; glucose is to be
tested and contains preservative
● (2-8 °C) most routinely used – to tablet so another method of
1. Refrigeration decrease bacterial growth. –in general, determination should be used. If
many substances for qualitative or formalin is effective, reagent strip is
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used.) & the preservative properly cells/ casts urine, hypotonic urine or both
used does not interfere with ● E.g. if the urine is alkaline or not hypotonic,
common reagent strips. the formed elements will disintegrate
e. Sp.Gr. will be slightly
increased.(0.002/tablet). If the TEST TO IDENTIFY URINE
specimen contains a preservative
The presence of considerable amounts of urea nitrogen and creatinine
tablet, subtract 0.002 to the specific
is highly suggestive of urine, as most other body fluids contain only
gravity reading.
small amounts of these substances.
10. pH adjustment
● a very low pH (< 3) will prevent
bacterial growth & stabilize 1. Test for UREA – a value of 600 mg/ 100 ml
substances such as catecholamines, 2. Test for CREATININE – a value of 50 mg. / 100 ml
VMA (Vanillylmandelic acid) or 5
HIAA (Hydroxyindoleacetic acid) test Sometimes, the doctor will send to the laboratory an unknown fluid, and
which is done in the clinical section of he wants to have it tested to identify whether this fluid is urine or not.
the laboratory and the sample to be
examined is urine. So what will the MedTech do to identify this fluid as urine?
—- The best way is to check for the presence of urea and creatinine.
These are the waste products of metabolism. They are also present in
CHANGES IN URINE WITH DELAYED TESTING
the blood, but they are present in the urine sample in large amounts.
What will happen when urine is allowed to stand at room temperature?
Result Reason UREA
● Breakdown or alteration of chromogen or
Blood urea 20 mg /100 ml
other urine constituent (e.g.) hemoglobin ,
melanin, homogentisic acid, porphyrins) Urine urea 600 mg /100 ml
Change in color High urea concentration indicates that the unknown sample is urine.
● E.g. hemoglobin converted into
(will darken)
methemoglobin: brown color
● E.g. Homogentisic acid: urine turns black CREATININE
upon standing Blood creatinine 1-2 mg /100 ml
Changes in odor ● Bacterial growth, decomposition Urine creatinine 50 mg /100 ml
● Increased bacteria
Increased turbidity ● Crystal formation, Precipitation of amorphous COMPONENTS OF ROUTINE URINALYSIS:
material I. Specimen Evaluation
● Glucose converted to acids and alcohols by II. Physical Tests
bacteria producing ammonia = CO2 is lost III. Chemical Examination
● Commonly the pH of the sample increases IV. Sediment Examination
(the usual phenomenology of the sample
Falsely low pH
● However, in patients who have increased This lecture will cover the first two components-- specimen evaluation
glucose in the urine, the glucose is converted & physical tests.
to acids and alcohols (urine becomes acidic
instead) SPECIMEN EVALUATION
● Volatilization of acetone
Before doing any testing, the MedTech should evaluate its acceptability
False negative ● Breakdown of acetoacetate by bacteria
Before starting any test in the lab, you don't simply accept any sample
ketone
● Yields false negative result being sent to the laboratory. You should estimate and know how to
evaluate samples. You should know when to accept and reject a
● Destroyed by light sample.
False negative ● Oxidation to biliverdin
bilirubin CONSIDERATIONS:
● Yields false negative result ● Proper labeling
● Destroyed by light ○ Name of patient, birthdate of patient, date, time of
False negative ● To avoid, samples should be placed in collection
urobilinogen brown-colored bottles then wrap the ● Proper specimen for the requested test
container with foil ○ Ex. urine submitted for urine culture
● Nitrite produced by bacteria after specimen is ■ Was the sample properly collected?
voided. ■ Is the sample clean-catch?
● It will be be false positive because when the ■ Is the container sterile?
urine is allowed to stand after voided, the ● Proper preservative
False positive ○ Check for proper preservative especially for timed
bacteria will multiply, then nitrite, being
nitrite specimens wherein a preservative is being added
produced by bacteria, will turn the reagent
strip result positive. ● Visible signs of contamination
● Side note: Nitrite can be tested with a ○ (Very) turbid urine, foul-smelling odor
reagent strip ■ Ammoniacal (ammonia-like odor) – indicates that the
● Nitrite converts to nitrogen and evaporates sample has already stood for some time
● When the patient really has a bacterial ● Transportation delays
infection (when urine is freshly voided and is ○ Emphasizes the importance of the time of collection (to
False negative
allowed to stand, instead of the bacteria check for any delays)
nitrite
producing nitrite, the nitrite will convert into ○ Ex. If the sample is not refrigerated and processed within 2
nitrogen so by the time you will examine it, it hours, the patient is asked to provide for another sample.
is no longer there, it has evaporated) ● In specimens submitted for multiple testing, bacteriologic
● Bacteria multiply in specimen before analysis exam should be done first.
Increased
● “Uria” : present in the urine in an increased ○ If urine is submitted for multiple tests (e.g. routine urinalysis
bacteriuria
amount alongside culture and sensitivity testing), the ruling is to give
Disintegration of ● Unstable environment, especially in alkaline
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the sample to the microbiology section FIRST for culture Dark green – severe obstructive jaundice
and sensitivity testing prior to performing routine urinalysis. Orange red or – large amounts of urobilinogen
○ Bacteriologic examination should be done first to prevent orange brown
cross-contamination. Orange red or ○ Acid urine containing hemoglobin that will
orange brown Dark darken upon standing
After you have accepted your urine sample, you may now start with a brown or black urine ○ Darkening in color is due to the conversion of
physical test. hemoglobin into methemoglobin
○ Homogentisic acid & melanin may be also
PHYSICAL TEST responsible for dark urine

1. Color
Color - normally yellow, however variations in color may be caused by
diet, medication, and disease.

■ That's why if you look at the color, it will give you a clue on what
is happening in the patient.
■ Sometimes provide a clue for the diagnosis of certain diseases.
■ Yellow color is due to the pigment urochrome & to small
amounts of urobilin & urorythrin.
■ Urochrome excretion is increased during fever, thyrotoxicosis
and starvation.

Color also indicates the degree of hydration and urine concentration.

Pale urine - seen in a normal person with high fluid intake
○ Indicates that the patient is well-hydrated
Darker - seen when fluids are withheld
urine ○ Indicates that the patient is dehydrated
○ Although it is different from very dark yellow color due to
bilirubin
Pale urine - Is found in diabetes mellitus and also patients having or after
of high the use of radiographic media.
specific ○ When you look at the urine it is pale, usually it is an
gravity indication of urine having a very low specific gravity.
○ Patients having diabetes mellitus and patients after using
radiographic media will show pale urine but with high
specific gravity.

Color of urine can be due to certain food & candy dyes as well as
drugs. Example: Red urine - ingestion of beets
○ Red is the most abnormal color in the urine. If it is red, it usually
indicates the presence of blood but you have to double check
because it may be caused by ingesting certain food.
○ If the patient eats red beets, their urine may become red. Some
food dyes also cause urine to turn red.
○ This is why you have to ask the patient what food they have
eaten.
Red urine - most common abnormal color
a. Hematuria - may appear cloudy, smoky, pink, red, or brown
■ Commonly caused by infections
(glomerulonephritis), tumors, trauma (stones
& injury), poisoning Figure 8. See full table on page 11.
■ Presence of red blood cells (RBC) -
causes cloudiness or turbidity 2. Character (Clarity)
■ Most common description - smoky
Presence of particulate matter in unspun urine needs to be explained
b. Hemoglobinuria - clear red, clear red brown, or dark brown
microscopically. Cloudy urine may not be pathologic
■ Caused by severe burns, incompatible blood
transfusion, fever, snake venom
■ Congenital erythropoietic porphyria
■ Drugs (ex. Rifampin - treatment for TB) &
dyes used in diagnostic tests (ex.
Phenolsulfonphthalein) can cause red
colorization.
Yellow brown or – often associated with bile pigments chiefly
greenish brown bilirubin
urine ○ Shake test - simply put urine on a test tube
and shake it
■ Differentiates bilirubin-containing urine from
dehydrated urine
■ Yellow foam - indicates presence of Figure 9. Urines
bilirubin In cloudy urine, you should know the reason for its cloudiness. Not all
cloudy urine is pathologic. There might be cases that a patient will have
■ White foam - indicates withheld urine
cloudy urine due to normal causes.
(dehydrated)
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NORMAL CAUSES FOR TURBIDITY

● Precipitation of crystals or non-pathologic salts
○ Under the microscope, uric acid and phosphate will appear
the same.
○ Amorphous phosphates (and sometimes amorphous
carbonates) in alkaline urine redissolve when acetic acid is
added
★ Test for phosphate
■ Check the pH - if alkaline, it is phosphate
■ Then confirm with acetic acid - if it
redissolves, it is phosphate
○ Uric acid & urates in acid urine and redissolve on warming
to 60ºC
★ Test for uric acid & amorphous urates Figure 10. Clarity of Urine
■ Warm in 60ºC but do not boil
● Leukocytes (WBC) Now since in the physical examination we need to describe the color
○ Form a white cloud (similar to phosphate) but cloud remains and the transparency, at least we have a guide on how to describe the
after the addition of dilute acetic acid clarity.
■ Has to be confirmed microscopically
■ Occurs in patients with UTI We need to check the appearance of a sample by placing a print at the
● Bacterial growth back of your tube so that you can describe it as clear if you can not see
○ Causes a uniform opalescence that is not removed by visible particulates, its transparent if you can still see the print, you
acidification or by filtering describe it as hazy if you see few particulates and the print can still be
○ Ex. E. coli, Proteus, Enterococcus, yeast, Staph. (skin seen through the urine, cloudy if you have many particulates and the
contaminant) print is already blurred so you cannot read it, you can use the word
● Epithelial cells turbid to describe the urine when the print cannot be seen through the
○ Usually affects female patients urine. Milky if it may precipitate or be clotted.
○ When doctors see results positive for epithelial cells, the
patient is asked to submit another sample. This means that 3. Urine Odor
the urine collected is not a midstream sample. ● Chiefly important in the recognition of contaminated
● Red Blood Cells (hematuria) specimens and on standing are ammoniacal, fetid so
○ Does not clear on warming unsuitable for laboratory examination.
○ Has to be confirmed microscopically. ○ Urine odor is not really included in physical
○ If you warm it, the turbidity will not disappear and we have to examination
confirm it under the microscope ○ Urine is normally slightly aromatic in odor
● Spermatozoa & prostatic fluid
○ Contaminants that can cause a turbid urine sample ● Urine odors associated with amino acid disorders:
● Mucus from the urinary passages Isovaleric & glutaric - sweaty feet
○ Increases on inflammatory states of the lower urinary tract acidemia
○ Causes turbid sample Maple syrup urine disease - maple syrup
● Fecal material Methionine malabsorption - cabbage
○ Especially if the patient has also loose bowel movement Phenylketonuria - mousy
usually it will contaminate the urine sample. Trimethylaminuria - rotting fish
● Contamination with powders or antiseptics that became Tyrosinemia - rancid
opaque with water (ex. Phenol)
○ Concentrated phenol is clear but if diluted with water it 4. Urine Volume
becomes turbid and this is used in disinfection. When mixed
● Measured during urine urinalysis but also measured in time
with urine, it can cause it to become turbid.
specimens (e.g. 12-hr and 24-hr specimen) for their
● Chyluria
respective total volumes
○ maybe normal, opalescent, milky
○ Urine contains lymph associated with obstruction to lymph Average daily volume in normal adults 1200-1500 mL
flow and rupture of lymphatic vessels into the renal pelvis, Normal range 600 - 2000 mL
ureter, bladder or urethra
● Normal pregnancy - causes nocturia & the excretion of a
○ Soluble in ether
dilute urine
● Lipiduria
Nocturia - excretion by an adult of more than 500 mL urine
○ Fat globules appear in the urine with a specific gravity of less than 1.018 at night.
○ nephrotic syndrome and crush injury (major skeletal trauma
Polyuria - increase in urine volume of more that 2000 mL
with one or more fractures to major long bones or pelvis)
in 24 hours.
○ Also soluble in ether

HOW TO DESCRIBE URINE CLARITY

CLEAR No visible particulates, transparent
HAZY Few particulates, print easily seen through urine
CLOUDY Many particulates, print blurred through urine
TURBID Print cannot be seen through urine
MILKY May precipitate or be clotted

Figure 11. Terminologies

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Polyuria If you consume large amounts of water CAUSES OF ALKALINE URINE

Normal output if you notice there are 2, 500 mL usually 1 Hyperventilation 4 Presence of Urease - producing
Oliguria there is a decrease in the urine output bacteria
Anuria If the patient can no longer void 2 Vomiting 5 Vegetatian Diet
3 Renal Tubular Acidosis 6 Old Specimens
5. Hydrogen Ion Concentration of Urine (pH)
Specific Gravity & Osmolality
● Reflection of the ability of the kidney to maintain normal H+
concentration in the plasma & ECF ● This is also being determined or included as a part of the
● 2 Basic Methods: physical examination. Although, this can still be a part of the
chemical examination because of another method, there are
Potentiometric Determination - unsuitable for routine urinary pH
several methods of determination of specific gravity.
(pH meter) measurement but should be used for
● A measure of the concentrating and diluting power of the
quality control
kidney
Indicator Paper Strips - rapid, inexpensive but still gain ● Inability to concentrate & dilute urine is an indication of renal
useful information disease or hormonal deficiency.
○ Ex. Multistix & Chemstrip ● Measurement of both tests should give an indication of the
brands - make use of a urinary total solute concentration.
double-indicator system of
methyl red and bromthymol ★ OSMOLALITY – depends on the number of solutes in a unit of
blue solution. It is considered a more exact measurement of urine
concentration than Sp.Gr.
★ SPECIFIC GRAVITY – depends on the number of particles
present in a solution & the density of these particles. It is
influenced by the size of the molecules such as urea, glucose, &
Figure 12. Formula protein that are not significant in renal concentration
From methyl red, it turns yellow then the pH of the urine is acidic. If it ★ Hyposthenuric urine – urines of low Sp.Gr. (less than 1.007)
changes from yellow to blue, it means that it is already alkaline. So the ★ Isosthenuric urine – if the patient constantly voids urine having
bromthymol blue will show color. urine of fixed Sp.Gr. (so dili mo gamay, mo dako)

Urine pH Color Chart ● The Sp.Gr. of the Protein-Free Glomerular filtrate is 1.010.
○ Example of osmolality:
■ Freezing Point Depression Method – commonly
employed method for Osmolality determination.
Figure 13. Reagent Strip
METHODS OF SP. GR. MEASUREMENT
This is a reagent strip, and in the laboratory you need to draw this, and In our urinalysis lab or in the clinical microscopy laboratory we have
identify which portion is for pH, which portion is for specific gravity several methods for determining or measuring the specific gravity:
determination, including the bleeding time, how many seconds each, A. Refractometer Method
and etc. B. Urinometer Method
C. Reagent Strip
Acid Indicator Alkaline Indicator D. Automated method
Methyl red Bromothymol blue
● For pH you read 60 seconds after dipping A REFRACTOMETER (TS Meter)
○ You need to dip it for a long period, because the ● Principle is based on the determination of the refractive index
reagent will be washed out. of a solution.
● pH ranges from 5.0 to 8.5 in half units ● Advantages:
○ temperature compensated between 60F to 100F.
More Information: ○ Requires a very small volume of urine sample for
● In healthy individuals: determination, even 1 drop of urine can be used
First morning specimen pH of 5 - pH of 6 ● Needs to be Calibrated prior to use
After meals (after lunch) A more alkaline pH (alkaline tide) ● Calibration:
Normal random samples pH 4.5 - 8.0 Distilled water 1.000
5% NaCl 1.022 ± .001
CLINICAL SIGNIFICANCE OF URINE pH 9% Sucrose 1.034 ± .001
1 Respiratory or Metabolic Acidosis/ketosis
2 Respiratory or Metabolic Alkalosis
3 Defects in renal tubular secretion & reabsorption of acids & bases
– renal tubular acidosis
4 Renal calculi formation
5 Treatment of urinary tract infection
6 Precipitation/ Identification of crystal
7 Determination of unsatisfactory specimens

CAUSES OF ACID URINE

1 emphysema 7 cranberry juice
2 diabetes mellitus 8 medications for UTI
3 starvation (ex: Mandelamine)
Figure 14. Refractometer
4 dehydration 9 presence of acid-producing
5 diarrhea bacteria (E.coli) This is the appearance of the refractometer. The one on the left will
6. high protein have a light source, an electric bulb inside. The right one is handheld.
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You face the light source so that you can read the calibration inside.
a. 0.001 to be added if the
B URINOMETER urine temperature is
above the calibration
temperature
b. 0.001 to be subtracted if
the urine temperature is
below the calibration
temperature

Example: calibrated at 200C; urine Example: If the temperature of

temperature is 300C, hence it is urine is 17°C so that it is below
above the proper temperature. the temperature of calibration. In
The difference of 200C and 300C this case, the difference is 3
is 100 C. Then divide it by 3 divided by 3 x.001, will give .001
because it is for every 3-degree which will then be subtracted to
difference and multiply it by 0.001. the specific gravity reading.
So that is about 0.003 to be
Figure 15. Urinometer added to the specific gravity
reading.
● The image shows a urinometer: the urine container is called
the urinometer cylinder while the instrument inside is called 2. Proteinuria
the urinometer float - increased amount of proteins in urine
● A hydrometer adapted to measure sp.gr. at room
- subtract 0.003 for every 1g/100ml protein
temperature: this is calibrated at a specific temperature
unlike your refractometer wherein it gives accurate result if the 3. Glycosuria
urine temperature is between 60-100°F. - subtract 0.004 for every 1g/100ml glucose
● Here, the urinometer is affected by temperature difference
● Consists of a weighted float with a calibrated stem 4. X-ray contrast media
● The float, the one inside, consists of a weighted float having a
calibrated stem where you will read the calibrations – Specific gravity may exceed 1.050
● The float displaces a volume of liquid equal to its weight & has There is a contrast media in the urine which is used in the
been designed to sink to a level of 1.000 using distilled water examination of patients to follow the course of a dye. A certain dye is
● It will displace an equal amount of liquid depending on the being injected and the course of the dye is being followed through
amount of solute in the urine sample: the additional mass X-ray. So, this dye is excreted later on through the urine. The urine
provided by the dissolved substance causes the float to passed out now will have a very high specific gravity that sometimes,
displace a volume of urine smaller than that of distilled water you cannot read it on the calibration. What you need to do is to simply
● Requires a larger volume of urine, unlike refractometer dilute the urine with distilled water and multiply your result for the
reading of the diluted sample by the dilution.
5. Urinary preservative

– preservatives increase the urinary Specific gravity

Example: the preservative tablet for urine

The use of this tablet can increase the specific gravity by .002. That's
why if this tablet has been added to the urine sample being examined,
you need to subtract .002 to your specific gravity reading. Let's say if
the reading is 1.015, subtract .002 so that what you will report is
1.013.

Example situation to determine the True Sp.Gr. of urine in the

Figure 16. Calibration
This is the calibration that you will see on the stem. The manufacturer
will put the temperature of calibration on the stem. The urinometer float
is also manufactured and calibrated.
The disadvantage of this method if compared to that of the
refractometer is that you will need a larger volume of urine because
you need to fill the urinometer cylinder about 3⁄4ths full, while in the
refractometer, you need only a drop. Also, the refractometer is not
affected by temperature changes because it gives an accurate reading
between 60-100°F whereas in urinometer, it is affected by
temperature. If it is calibrated at 20°C, it means that if the urine
temperature is 20°C, the reading you see on the stem is fairly accurate.
However, if the urine temperature is higher or lower, then you need to
compute for this temperature changes.
Sources of Error:
1. Temperature differences
– most urinometers are calibrated at 200 C. A difference of 30 C
between urine temperature & calibration temperature requires a
correction of 0.001 to be added if above & subtracted if below the
proper temperature:
urinometer method:
Name of Patient: Maria Cruz
Temp. of Urine 36.0 degrees Centigrade
Temp. of Calibration 21.0 degrees Centigrade
Urinometer reading 1.015
● Difference between the 2 temperatures=15, divided by 3
equals to 5. Then, multiply to 0.001 equals to 0.005.
● 0.005 is added to the Urinometer reading (1.015)
● So the True Sp.Gr. is 1.020
If the patient Maria Cruz has proteinuria, her urine contains 2
gm.protein/100ml. What is the final Specific Gravity to be reported?
★ 1.020 – (.003x2) = 1.014
● For urine samples with very high Specific Gravity which can’t
be read on both Urinometer & Refractometer, simply dilute the
urine with distilled water and multiply the Sp.Gr. Reading of
the diluted sample with the dilution.
○ You read the diluted sample, it is 1.020
● Ex: 5 ml urine was diluted with 10 ml.dist.water.
○ The dilution of 5ml urine added with 15ml (but in the lec
it’s 10ml) of distilled water is 1:3. You multiply the last 3
digits by 3. Don’t include the 1 because the specific gravity
always starts with 1. There is no specific gravity which
begins with 3. It only starts with 1. You only multiply the
last 3 digits that is why you have 1.060
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● Sp.Gr.reading= 1.020 x 3(dilution) = 1.060

C REAGENT STRIP METHOD

*based on the change in pKa (dissociation constant) of a polyelectrolyte
in an alkaline medium)
● The polyelectrolyte ionizes releasing Hydrogen ions in
proportion to the number of ions in the solution.
● The higher the concentration of urine, the more Hydrogen
ions are released, thereby lowering the pH.
● Indicator Bromthymol Blue measures the change in pH.

D HARMONIC OSCILLATION DENSITOMETRY: (Usually

used by Automated Instruments)
● Principle:
○ The frequency of a sound wave entering a solution will
change in proportion to the density of the solution
○ Used by the Yellow IRIS (International Remote Imaging
Systems)
○ A portion of urine enters a U-shaped tube. A sound
wave of specific frequency is generated at one end of
the tube, and as the sound wave passes thru the urine,
its frequency is altered by the density of the solution
(urine sample).

E FALLING DROP METHOD: (More Historical)

*A direct method for measuring Specific Gravity
*More accurate than the refractometer and more precise than the
urinometer

Falling Drop Method by Martha Winstead

● Utilizes a specially designed column filled with water
–immiscible oil. A measured drop of urine is introduced into
the column, and as the drop falls, it encounters two beams of
light; breaking the first beam starts a timer, while breaking the
second turns it off. The falling time is measured electronically
& expressed as a specific gravity.

References:
● Urinalysis and Body Fluids (Strasinger et al.)

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Table 4-1 Laboratory Correlation of Urine Color

Color Cause Clinical/Laboratory Correlations
Colorless Recent fluid consumption Commonly observed with random specimens
Pink yellow Polyuria or diabetes insipidus Increased 24-hour volume and low specific gravity
Diabetes mellitus Elevated specific gravity and positive glucose test result
Dilute random specimen Recent fluid consumption
Dark yellow Concentrated specimen May be normal after strenuous exercise or in first morning specimen
B complex vitamins
Dehydration Fever or burns
Bilirubin Yellow foam when shaken and positive chemical test results for bilirubin
Acriflavine Negative bile test results and possible green fluorescence
Nitrofurantoin Antibiotic administered for urinary tract infections
Orange-yellow Phenazopyridine (Pyridium) Drug commonly administered for urinary tract infections
Phenindione Anticoagulant, orange in alkaline urine, colorless in acid urine
Yellow-green Bilirubin oxidized to biliverdin Colored foam in acidic urine and false-negative chemical test results for bilirubin
Green Pseudomonas infection Positive urine culture
Blue-green Amitriptyline Antidepressant
Methocarbamol (Robaxin) Muscle relaxant, may be green-brown
Clorets None
Indican Bacterial infections, intestinal disorders
Methylene blue Fistulas
Phenol When oxidized
Pink RBCs Cloudy urine with positive chemical test results for blood and RBCs visible microscopically
Red Hemoglobin Clear urine with positive chemical test results for blood; intravascular hemolysis
Myoglobin Clear urine with positive chemical test results for blood; muscle damage
Beets Alkaline urine of genetically susceptible persons
Rifampin Tuberculosis medication
Menstrual contamination Cloudy specimen with RBCs, mucus, and clots
Port wine Porphyrins Negative test for blood, may require additional testing
Red-brown RBCs oxidized to methemoglobin Seen in acidic urine after standing; positive chemical test result for blood
Myoglobin
Brown Homogentisic acid (alkaptonuria) Seen in alkaline urine after standing; specific tests are available
Black Malignant melanoma Urine darkens on standing and reacts with nitroprusside and ferric chloride
Melanin or melanogen
Phenol derivatives Interfere with copper reduction tests
Argyrol (antiseptic) Color disappears with ferric chloride
Methyldops or levodopa Antihypertensive
Metronidazole (Flagyl) Darkens on standing, intestinal and vaginal infections
Urinalysis and Body Fluids (Strasinger et al.) pp. 60-61.

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