CHAPTER ONE: INTRODUCTION TO URINALYSIS

Overview

 Urinalysis is defined as the testing of urine with procedures commonly performed in

reliable, accurate, safe, and cost-effective manner. Reasons for performing urinalysis
include:
- aiding in the diagnosis of disease,

- screening asymptomatic populations for undetected disorders,

- monitoring the progress of disease and

- the effectiveness of therapy

 Analyzing urine was actually the beginning of laboratory medicine.

 Previous physicians were able to obtain diagnostic information from such basic
observations as color, turbidity, odor, volume, viscosity, and even sweetness (by noting
that certain specimens attracted ants or tasted sweet).
 These same urine characteristics are still reported by laboratory personnel.
 Modern urinalysis has expanded beyond physical examination of urine to include
chemical analysis and microscopic examination of urinary sediment.
  Two unique characteristics of a urine specimen account for its popularity:
1. Urine is a readily available and easily collected specimen.
2. Urine contains information, which can be obtained by inexpensive laboratory tests,
about many of the body’s major metabolic functions.
I. URINE FORMATION, COMPOSITION AND VOLUME

Urine formation

 The kidneys continuously form urine as an ultrafiltrate of plasma.

 Reabsorption of water and filtered substances essential to body function converts
approximately 170,000 mL of filtered plasma to the average daily urine output of 1200
mL.
Urine Composition

 In general, urine consists of urea and other organic and inorganic chemicals dissolved
in water.
 Urine is normally 95% water and 5% solutes, although considerable variations in the
concentrations of these solutes can occur owing to the influence of factors such as dietary
intake, physical activity, body metabolism, and endocrine functions.
 Urea, a metabolic waste product produced in the liver from the breakdown of protein and
amino acids, accounts for nearly half of the total dissolved solids in urine.
 Other organic substances include primarily creatinine and uric acid.
 The major inorganic solid dissolved in urine is chloride, followed by sodium and
potassium. Small or trace amounts of many additional inorganic chemicals are also
present in urine.
 Although not a part of the original plasma filtrate, the urine also may contain formed
elements, such as cells, casts, crystals, mucus, and bacteria. Increased amounts of these
formed elements are often indicative of disease.
Urine Volume

 Urine volume depends on the amount of water that the kidneys excrete. Water is a major
body constituent; therefore, the amount excreted is usually determined by the body’s
state of hydration.
 Factors that influence urine volume include:
- Fluid intake,
- variations in the secretion of antidiuretic hormone, and
- Excretion of increased amounts of dissolved solids, such as glucose or salts.

 Taking these factors into consideration, although the normal daily urine output is usually
1200 to 1500 mL, a range of 600 to 2000 mL is considered normal.
1. Oliguria, a decrease in urine output is commonly seen when the body enters a state of
dehydration as a result of excessive water loss from vomiting, diarrhea, perspiration, or
severe burns.
2. Anuria, cessation of urine flow, may result from any serious damage to the kidneys or
from a decrease in the flow of blood to the kidneys.
3. The kidneys excrete two to three times more urine during the day than during the night.
An increase in the nocturnal excretion of urine is termed nocturia.
4. Polyuria, an increase in daily urine is often associated with diabetes mellitus and
diabetes insipidus; however, it may be artificially induced by diuretics, caffeine, or
alcohol, all of which suppress the secretion of antidiuretic hormone.
 Diabetes mellitus and diabetes insipidus produce polyuria for different reasons, and
analysis of the urine is an important step in the differential diagnosis.
 Diabetes mellitus is caused by a defect either in the pancreatic production of insulin or
in the function of insulin, which results in an increased body glucose concentration.
 The kidneys do not reabsorb excess glucose, necessitating excretion of increased amounts
of water to remove the dissolved glucose from the body.
 Diabetes insipidus results from a decrease in the production or function of antidiuretic
hormone (ADH); thus, the water necessary for adequate body hydration is not reabsorbed
from the plasma filtrate.
  Fluid loss in both diseases is compensated by increased ingestion of water (polydipsia),
producing an even greater urine volume.
 Polyuria accompanied by increased fluid intake (polydipsia)is often the first symptom of
either disease.

II. COLLECTION OF URINE SPECIMEN

 In order to make Urinalysis reliable the urine must be properly collected.

 Improper collection may invalidate the results of the laboratory.

Urine specimen Containers

 There are many types of containers used for collecting urine.

 Before specimens are collected, the containers must be clean, dry and leak-proof.

 Disposable containers should be used because they eliminate the chance of

contamination owing to improper washing.

 Containers for routine urinalysis should have a wide mouth to facilitate collections from
female patients and a wide, flat bottom to prevent overturning.

 They should be made of a clear material to allow for determination of color and clarity.

 The recommended capacity of the container is 50 mL, which allows 12 mL of specimen

needed for microscopic analysis and additional specimen for repeat analysis,

 Disposable plastic containers are available in many sizes and shapes are provided with
lids.

 When urine is to be cultured for bacterial content, the specimen must be obtained under
septic condition and collected in a sterile glass container or a sterile disposable plastic
container.
Methods of Obtaining Specimens

 A freshly voided urine specimen is adequate for most urinalysis except the
microbiological culture.

 The patient should be instructed to void directly into a clean, dry container, or a clean,
dry bedpan so that the specimen can be transferred to an appropriate container.

 Specimens from infants and young children can be collected in a disposable collection
apparatus.

 All specimens should be immediately covered and taken to the laboratory.

Specimen labels

 All specimens must be labeled properly with:

- the patient’s name and identification number,

- the date and time of collection, and

- additional information such as the patient’s age and location

 Labels must be attached to the container, not to the lid, and should not become detached
if the container is refrigerated or frozen.

Requisitions form

 A requisition form (manual or computerized) must accompany specimens delivered to

the laboratory.

 The information on the form must match the information on the specimen label.

 Additional information on the form can include method of collection or type of

specimen, and the patient’s clinical information.

 The time the specimen is received in the laboratory should be recorded on the form.

Specimen Rejection

 Improperly labeled and collected specimens should be rejected by the laboratory, and
appropriate personnel should be notified to collect a new specimen.

 Unacceptable situations include:

1. Specimens in unlabeled containers.

2. Nonmatching labels and requisition forms.
3. Specimens contaminated with feces or toilet paper.
4. Containers with contaminated exteriors.
5. Specimens of insufficient quantity.
6. Specimens that have been improperly transported.
 Laboratories should have a written policy detailing their conditions for specimen
rejection.
III. TYPES OF SPECIMEN

 First Morning Specimen - a specimen obtained during the first urination of the day.

- Most concentrated

 Best for:

- Nitrite

- Protein

- Microscopic examination

 Random Specimen - a specimen obtained at any time during examination.

- Most convenient

- Most common

- Good for chemical Screening and microscopic examination

 Second-voided Specimen - In this case first morning specimen is discarded and the
second specimen is collected and tested. Such type of specimen is good for:

- Reflection of blood glucose.

 Postprandial: a specimen obtained 2 hours after meal.

- Good for glucose.

 Mid- stream Specimen - a specimen obtained from the middle part of the first urine.

- It is commonly used for routine urinalysis.

- It is also important for bacteriological urine culture.

 24- Hours (Timed) specimen - a specimen obtained within 24 hours.

- Necessary for quantitative tests, especially for quantitative determination of protein.

Procedure for Collection of 24 hours Urine Specimen

1. Inform or Direct the patient to completely empty his bladder and discard his urine exactly
at the beginning of the 24 hours’ time collection (let say at 6:00 a.m.).
2. Collect all urine voided during the following 24 hours, including that voided exactly at
the end of the 24 hours period in a container (at 6:00 a.m.) of the following (second) day.
3. All the urine collected must be preserved.
4. The container should be labeled with:
- The test orders.
- The patient’s name
- Time of collection
- The preservative added

Clean Catch Urine Specimen

 Used for microbial culture and routine urinalysis.

 When specimens are collected for bacteriological examination they should be collected
by the ‘clean catch’ method or by catheterization into sterilized container.

 Catheterization is the process of passing a tube through the urethra to the bladder for the
withdrawal of urine.

 ‘clean catch’ urine specimen is collected as follows:

 - The genital area should be cleaned with soap and water and rinsed well. This is to keep
off bacteria on the skin from contaminating the urine specimen.
- The patient should urinate a small amount and this is discarded.

- The urine that comes next, the mid-stream specimen, should be collected into a sterile
container of 30 to 50 ml.

- After obtaining the specimen the patient continues to urinate and this is discarded.

Sources of Errors in the Collection of Urine

1. Bacteriologically or chemically contaminated specimen.

2. Wrong type/amount of preservative.

3. Partial loss of specimen or inclusion of two-morning specimen in the 24 hr collection.

4. Inadequate mixing of specimen before examination.

5. Careless measuring of the 24 hr volume.

Preservation of Urine Specimen

 Following collection, specimens should be delivered to the laboratory promptly and

tested within 2 hours.

 If urine specimen cannot be delivered and tested within 2 hours should be refrigerated or
have an appropriate chemical preservative added.

 Most of the changes of the urine specimen if it is not preserved are related to the
presence and growth of bacteria.

 The most routinely used method of preservation is refrigeration at 2°C to 8°C, which
decreases bacterial growth and metabolism.

 If the urine is to be cultured, it should be refrigerated during transit and kept refrigerated
until cultured up to 24 hours.

 The specimen must return to room temperature before chemical testing by reagent
strips.
  When a specimen must be transported over a long distance and refrigeration is
impossible, chemical preservatives may be added.

 Commercially prepared transport tubes are available.

 The ideal preservative should be bactericidal, inhibit urease, and preserve formed
elements in the sediment.

 Long standing of urine at room temperature can cause:

- Growth of bacteria

- break down of urea to ammonia by bacteria leading to an increase in the pH of the urine
and this may cause the precipitation of calcium and phosphates.

- Oxidation of urobilinogen to urobilin.

- Destruction of glucose by bacteria.

- Lysis of RBCs, WBCs and casts.

Method of Preservation of Urine Specimen

a. Physical Method
- Refrigeration
- Freezing

- b. Chemical Method

Use of chemical preservatives such as:

- Formaldehyde

- Thymol

- Toluene

- Hydrochloric acid (HCl)

- Chloroform
- Boric acid

- Sodium carbonate