CONTENTS

EXCRETORY SYSTEM : CYTOLOGY IN THE ABSENCE OF CANCER

URINE SPECIMEN COLLECTION

CYTOLOGY OF NORMAL VOIDED AND CATHETERIZED URINE

SCREENING OF URINARY SEDIMENTS

BLADDER IRRIGATION
Excretory system :

The excretory system is a biological system responsible for removing waste products and excess
substances from the body to maintain internal balance and homeostasis.

It comprises several organs and structures, including the kidneys, ureters, bladder, and urethra, as well
as accessory organs such as the liver, lungs, and skin.

The primary functions of the excretory system include filtering waste products from the blood,
regulating fluid and electrolyte balance, controlling blood pressure, and eliminating metabolic
byproducts, toxins, and excess substances through urine, sweat, feces, and exhalation.
Cytology in the absence of Cancer

Cytology plays a significant role in assessing the health of the excretory system, even in the
absence of cancer. Here are some examples:

1.Urinary Tract Infections (UTIs)

2. Kidney Diseases

3. Renal Tubular Disorders

4.Kidney Stones
Cytology of UTI

Cytology can provide valuable information in the diagnosis and management of urinary tract infections (UTIs) by
analyzing cellular changes in the urine sediment. Here's how cytology relates to UTIs:

1. White Blood Cells (WBCs):

- Increased numbers of white blood cells (leukocytes) in the urine, known as pyuria, are a hallmark of UTIs.

- Cytology can detect and quantify the presence of WBCs in the urine sediment, helping to confirm the
inflammatory response associated with UTIs.

2. Bacteria:
- While not as sensitive as bacterial culture, cytology may detect bacteria in the urine sediment, providing
preliminary evidence of bacterial infection.

- The presence of bacteria in cytology samples supports the diagnosis of a bacterial UTI and may guide initial
treatment decisions.
3. Epithelial Cells:

- Shedding of epithelial cells from the urinary tract lining may occur in response to inflammation or
infection.

- Cytology can identify epithelial cells in the urine sediment, which may provide additional supportive
evidence of UTIs, especially when observed alongside pyuria.

Overall, cytology provides valuable insights into the cellular changes associated with UTIs. However, it
is typically used in conjunction with other diagnostic tests, such as urine culture and urinalysis, to
ensure comprehensive evaluation of UTIs.
Cytology of kidney diseases

Cytology plays a limited role in the direct diagnosis of kidney diseases, as kidney tissues are not easily
accessible for cytological examination. However, cytology can sometimes provide valuable information
in certain contexts related to kidney diseases:

1. Urinary Sediment Analysis:

- Cytological examination of urinary sediment can reveal cellular abnormalities associated with kidney
diseases. For example, the presence of red blood cells (hematuria) or white blood cells (pyuria) may
indicate glomerular or tubulointerstitial inflammation.

- Casts, which are cylindrical structures formed from proteinaceous material in the kidney tubules,
may be observed in the urine sediment of individuals with various types of kidney diseases, including
acute kidney injury and glomerulonephritis.
2.Detection of Malignancy:
- In cases of kidney cancer (renal cell carcinoma), urinary cytology may detect malignant cells shed
from the tumor into the urine.

- However, urinary cytology has limited sensitivity and specificity for the diagnosis of kidney cancer
compared to other diagnostic modalities such as imaging studies and renal biopsy.

3.Identification of Infectious Agents:

- In cases of kidney infections (pyelonephritis), urinary cytology may detect the presence of
inflammatory cells and bacteria in the urine sediment.

- While urinary cytology is not as sensitive as urine culture for identifying bacterial pathogens, it can
provide supportive evidence of infection.

Overall, while cytology is not routinely used as a primary diagnostic tool for kidney diseases, it can
provide supplementary information in certain clinical contexts. However, other diagnostic modalities
such as imaging studies, laboratory tests, and renal biopsy are typically required for a comprehensive
evaluation and diagnosis of kidney diseases.
Cytology of Renal Tubular Disorders

Cytology can provide valuable insights into renal tubular disorders by examining cellular changes associated
with these conditions. Here's how cytology relates to the diagnosis and characterization of renal tubular
disorders:

1. Identification of Cellular Abnormalities:

- Cytological examination of renal tubular cells can reveal specific cellular changes indicative of renal tubular
disorders. These changes may include alterations in cell morphology, size, and abundance.

- For example, in renal tubular acidosis (RTA), cytology may show abnormalities in the morphology or
distribution of renal tubule cells, reflecting impaired tubular function.
2. Detection of Cellular Casts:
- Cellular casts, which are formed from aggregates of renal tubular cells and cellular debris, may be
observed in the urine sediment of individuals with renal tubular disorders.

- The presence of cellular casts in cytology samples can provide diagnostic clues and help
differentiate renal tubular disorders from other kidney diseases.

3. Supportive Diagnostic Tool:

- While cytology alone may not provide a definitive diagnosis of renal tubular disorders, it serves as a
valuable adjunctive tool in conjunction with other diagnostic modalities such as imaging studies,
laboratory tests, and clinical evaluation.

- Cytological findings can provide supportive evidence and help corroborate the clinical suspicion of
renal tubular disorders.
Cytology of kidney stones

Cytology of kidney stones typically involves analyzing the cellular components present in the urine or
any material obtained during stone passage or removal.

However, it's important to note that kidney stones themselves are composed primarily of minerals and
salts, rather than cellular material.

Therefore, traditional cytological analysis may not directly identify kidney stones.

However, in cases where kidney stones cause irritation, inflammation, or damage to the urinary tract,
urine cytology may reveal secondary changes such as
1. Hematuria:
Kidney stones can cause bleeding in the urinary tract due to irritation or damage to the surrounding
tissues. Urine cytology may detect the presence of red blood cells, indicating hematuria associated with
kidney stones.

2. Inflammatory Cells:
In response to kidney stones or associated infections, the body may mount an inflammatory response.
Urine cytology may show an increased number of white blood cells, indicating inflammation in the
urinary tract.

3. Epithelial Cells:
Shedding of epithelial cells from the urinary tract lining may occur due to the passage of kidney stones
or associated irritation. These cells may be observed in urine cytology samples.
4. Crystalline Deposits:
While not cellular in nature, urine cytology may occasionally identify crystalline deposits that are
associated with kidney stones. These deposits may be visualized microscopically and can provide
indirect evidence of stone formation or dissolution.

In summary, while traditional cytological analysis may not directly identify kidney stones themselves,
urine cytology can provide valuable information about secondary changes and associated
complications, such as hematuria, inflammation, and epithelial cell shedding, which may be indicative of
kidney stone presence or related urinary tract issues. However, imaging studies remain the primary
diagnostic modality for identifying and characterizing kidney stones.
Urine Specimen Collection

PRINCIPLE:
Urine is one type of specimen that can be easily collected from a patient.

Urinalysis testing can give the doctor valuable information about many
body systems especially kidney function.

The physician uses the information from urine testing to diagnose and
treat many disease states.
TYPES With PROCEDURES

Random sample :

Sample which is collected anytime during the day. Usually used only for routine screening because the
composition of urine changes throughout the day.

Procedure :
The patient is given a collection container and instructed to collect a midstream specimen in the
container. This type of specimen is routinely used for urinalysis and may not be used for a culture and
sensitivity.

First voided specimen :

Sample also referred to as a first morning specimen. This sample is collected the first time the patient
urinates in the morning. A first voided specimen is the most concentrated and is the preferred
specimen for pregnancy testing, bacterial cultures and microscopic examinations.
Timed specimens :
These specimens are used when the physician requires urine samples to be taken at specific intervals
during the day.

Procedure:
The patient is given a large container (approximately 1 gallon) that is labeled with the patient’s
name and date. Space is provided to write the time the collection begins and ends.

The test usually begins in the morning. The patient is told to empty their bladder and discard the urine
in the toilet and record the time on the label of the urine container. For the next 24 hours, all urine
must be collected in the container. The next day at the same time the test began the patient empties
their bladder, collects the urine in the container, and records the time the test ended. The patient
should be instructed to avoid fecal contamination of the specimen.
Uses of Timed Specimen

Urea Creatinine

Proteinuria (Pre-Eclampsia and Nephrotic System)

Hormones, adrenocorticosteroids and glucose.

To check complete urine output per day

 Clean-catch midstream specimen

This sample type is collected if the urine is going to be cultured and examined for bacterial growth or
used for cytology.

Procedure for Male :-Hold penis, clean meatus with sterile or antiseptic towelette by using circular motion
(from center to outside 3 times).

During urination collect mid stream urine 190-120 ml) in a sterile container, (Discard first and last urine drops).

Procedure for Female :-Spread labia minora with fingers and clean urethral area with antiseptic swab, move
from front (urethral orifice) to back (towards anus).

Holding labia apart. During urination collect mid stream urine (90-120 ml) in a sterile container.
Dirty Specimen

This specimen will be used for DNA testing and the FIRST part of the voided stream is collected.

Procedure:
The patient is given a sterile urine cup and told to clean as stated above for a clean-catch specimen.
They are then instructed to collect the FIRST part of the voided stream. Fill the container one half to
two thirds full and finish voiding into the toilet. Apply the cap tightly and label the cup.
Catheterized Specimen

These specimens are obtained by inserting a catheter or sterile flexible tube into the bladder via the
urethra to withdraw urine. This procedure is done only by specially trained personnel.

To get a sterile urine sample in a person

who cannot urinate on their own.

 Normal Urine:

1. Cellular elements:

- Few transitional cells (rarely seen)

- Few squamous cells

- Rarely, renal tubular cells or casts

2. Epithelial cells:

- Normal urothelial cells (umbrella or dome-shaped)

- No atypical or malignant cells

3. Background:

- Clear or slightly cloudy

- No significant inflammation or hematuria

4. Microorganisms:

- No bacteria, yeast, or parasites

5. Casts:

- Rare or absent

6. Crystals:

- Few or no crystals (e.g., calcium oxalate, uric acid)

7. Other components:

- No mucin, pus, or blood clots

 Voided urine:

1. Cellular elements:

- Few transitional cells (from bladder and urethra)

- Few squamous cells (from urethra)

- Rare renal tubular cells or casts

2. Epithelial cells:

- Normal urothelial cells (umbrella or dome-shaped)

- No atypical or malignant cells

3. Background:

- Clear or slightly cloudy

- No significant inflammation or hematuria

4. Microorganisms:

- No bacteria, yeast, or parasites (or rare contamination)

5. Casts:

- Rare or absent

6. Crystals:

- Few or no crystals (e.g., calcium oxalate, uric acid)

7. Other components:

- No mucin, pus, or blood clots

catheterized urine:

1. Cellular elements:

- Increased transitional cells (from bladder and urethra)

- Squamous cells (from urethra and vaginal contamination)

- Renal tubular cells or casts (indicating kidney damage)

2. Epithelial cells:

- Atypical urothelial cells (due to instrumentation trauma)

- Possibly malignant cells (if cancer is present)

3. Background:

- Cloudy or turbid due to bacterial contamination

- Inflammation and hematuria common

4. Microorganisms:

- Bacteria (e.g., E. coli, Klebsiella)

- Yeast (e.g., Candida)

- Parasites (rare)

5. Casts:

- Hyaline or granular casts (indicating kidney damage)

6. Crystals:

- Calcium oxalate or uric acid crystals (due to instrumentation trauma)

7. Other components:

- Mucin, pus, or blood clots

Examination Of Urinary Sediments

Sample preparation

The quantity of formed elements (i.e., sediment volume) clearly

exceeds 0.2 mL in samples from subjects with conditions such as
advanced hematuria and pyuria. It is desirable to provide a
comment regarding such findings in the report.
Staining Techniques

In principle, the specimens without staining is used for microscopic examinations of urinary sediments.
Staining procedures may cause hemolysis and interfere with observations of the numbers and shapes of
RBCs in urine. The color characteristics of sediment elements may also be lost. Therefore, it is important
to use unstained specimens for observation.

However, the use of various suitable staining methods may be useful when urinary sediment elements
must be confirmed and identified or differentiated from analogous components.

Basic staining solutions include the Sternheimer staining (S staining) and Sternheimer–Malbin staining
(SM staining). When using these staining methods, an approximate 4:1 ratio of urinary sediment and
staining solution is recommended while considering possible dilution errors related to the staining
solution.
Sternheimer staining (S staining)

REAGENT

Solution I: 2% Alcian blue 8GS in water

Solution II: 1.5% Pyronin B in water

Solutions I and II are filtered and mixed in a 2:1 ratio. The staining performance of this
mixture remains stable for approximately 3 months if the mixture is stored in a cool and dark
place.

Staining procedure

At the time of the microscopic examination, add a drop of the staining mixture to
the sediment and mix.
Staining behavior

Red blood cells: unstained or pink/magenta

White blood cells: nucleus, blue; cytoplasm, pink/magenta

Epithelial cells: nucleus, blue; cytoplasm, pink/magenta (note: the stained cytoplasm of
mucus-containing cells such as columnar epithelial cells and adenocarcinoma cells is
bluish purple or dark magenta)

Macrophages: nucleus, blue; cytoplasm, bluish purple/dark magenta

Casts: hyaline casts, light blue/blue; granular casts and waxy casts, magenta.
Sudan III staining

Reagent

Dissolve 1.0–2.0 g of Sudan III in 100 mL of 70% ethanol with shaking, and allow this
solution to rest in an airtight container in a 56–60°C incubator for 12 h, followed by storage
at room temperature.

Staining procedure

Add 2–3 drops of the filtered solution to the sediment, allow the mixture to stand at
room temperature (15–30°C) for 15–60 min, and evaluate the sediment via a
microscopic examination. Sudan IV staining is also useful.
Staining behavior

Fat globules, fatty casts, oval fat bodies: yellowish red

Urine Mixing
Supernatant Removal
Preparing Specimen
Observation Methods

Morphology of RBCs in urine

In cases involving bleeding from the lower urinary tract (e.g., non-
glomerular hematuria), RBCs may exhibit morphological changes, including
disk-like (including confetti-like), spherical, swollen, and atrophic shapes, due
to urine properties, such as osmotic pressure.

In contrast, in cases of glomerular hematuria due to glomerulonephritis

and similar conditions, RBCs exhibit various, non-uniform shapes and
sizes, dehemoglobinized appearance, and frequent associations with
various casts including RBC casts or proteinuria
WBC’s

WBCs are important formed sediment elements; these cells are

suggestive of the presence of inflammatory lesions, such as renal
and UTIs. WBCs are usually spherical, with diameters of 10–15 μm;
however, their morphology can vary depending on cell viability
(viable cell or dead cell) and urine properties such as osmolality and
pH. In general, WBCs tend to be atrophic at high osmotic pressures
and become swollen at low osmotic pressures.
Bladder Irrigation

Bladder irrigation means to flush out the urinary bladder with a liquid.

To cleanse the bladder from decomposed urine, bacteria, excess of mucus, pus and blood
clots.

To maintain the patency of the urinary catheter.

To relieve congestion and pain in case of inflammatory conditions by the application of

heat.
Procedure

Pour normal saline or sterile irrigation solution into a bowl.

Draw the solution (usually 30 to 50 mL) into a Catheter tipped syringe. Disconnect the drainage bag
tubing urinary from drainage port.

Clean the drainage port with antiseptic swab and insert the Catheter tipped syringe.

Inject the solution slowly and aspirate it immediately.

Remove syringe and connect the drainage port with urinary drainage bag.
Continuous Irrigation

Explain the procedure to the patient.

Wash Hands & Arrange the articles.

Hang irrigation solution in the IV pole (24-36 inches above the bladder)

Insert (spike) tip of irrigation tubing into the port of the irrigation solution bag using aseptic technique.

Prime the irrigation tubing and close the roller clamp.

Clean the port & attach the irrigation tubing to the irrigation port of the catheter.

Open roller clamp, regulate drip as ordered.

Replace the articles.

Complication

Infection: urinary tract offer a favourable environment for the multiplication of bacteria
because it is dark, moist & warm.

Injury to the mucosa of the bladder leads to growth of the bacteria in bladder.

Changing the pH value of urine by medication force of the flow cause injury.

Tissue trauma
during the insertion of the catheter & procedures applied to the bladder, tissue trauma
may take place even the slight movement of the catheter can cause tissue trauma &
breakdown