URINALYSIS

By: Yani Triyani

Clinical Pathology Department
Faculty of Medicine UNISBA
2015
 URINE
is one of the most frequently performed procedures in
the medical laboratory

• Urine is easily to obtain

• Many information of the body’s metabolism can be
gained from the urinalysis result renal
extra renal
WHY STUDY URINE?
 COMPOSITION OF URINE

• 95% water
• 5% is solutes consists of:
- urea
- sodium
- potassium
- phosphate
- sulphate
- creatinine
- uric acid
- calcium
- magnesium and bicarbonate ions
 The purpose and function of
Clinical Pathology

1. Confirming or rejecting diagnosis

2. Providing guidelines in patient
management
3. Establishing a prognosis
4. Detecting disease through case finding
or screening
5. Monitoring follow up therapy
 URINALYSIS STEPS

Pre analytic Analytic

QUALITY
Post analytic CONTROL
(QC):
URINALYSIS STEPS

 PRE-ANALYTIC : patient preparation, samples collection, samples

handling, labelling, refrigeration, preservatives of urine specimens.

 ANALYTIC: principle of procedures, measurements, interpretation,

conventional & rapid and sophisticated

 POST-ANALYTIC: recording, reporting, use of units : conventional

unit and international unit

 QUALITY CONTROL (QC):calibration, control solution

to get good and reliable results
PRE-ANALYTIC
URINE SPECIMENS

• To diagnose and manage UTI

• To evaluate metabolic and systemic function

• The type of test that will be performed dictates

the manner in which the urine specimen is collected
• The time and manner of collecting and processing
specimens influence the accuracy of urine testing
 Pre-Analytic
1. Specimen collection
- Requisition form  must accompany with specimen delivered
to the lab; the form include : patient’s name, I.D number, date and
time of collection and additional information : age, location,
physician’s name, type of specimen/method, interfering medication
and clinical information
- Container  clean, dry, leak proof, disposable
- All specimens must be properly labeled  must be attach to
the container, not to the lid, should not become detached if the
container is refrigerated
- The information on form requisition  match with the
inform on the label
Specimen collection tool
Urine container
Labelling urine specimen
Name (min 2 initial, ex: Deni Darmawaty)

Sex : female

Date (day, month, year)

Time collection:

Adress and telp number :

Pre-Analytic
Two Type of Specimen
 Based on Time :
- Random specimen
- First morning/fasting specimen
- 2-hours post prandial specimen
- Timed urine (12-hours, 24-hours specimen)

 Based on method :
- Midstream Clean-Catch specimen
- Catheterized specimen
- Suprapubic aspiration
Type of Urine Specimens Purpose
Random Routine screening
First morning Routine screening
Pregnancy tests
Orthostatic protein
Fasting (second morning) Diabetic screening/monitoring
2-h postprandial Diabetic monitoring
Glucose tolerance test Accompaniment to blood samples in
glucose tolerance test
24-h (or timed) Quantitative chemical tests
Catheterized Bacterial culture
Midstream Clean-catch Routine screening
Bacterial culture
Suprapubic aspiration Bladder urine for bacterial culture
Cytology
• The first morning urine:
Collected upon rising, it represents the urine over
approximately an 8 hour period
• Ad random urine:
Collected any time
• The 2-hour postprandial urine:
Collected 2 hour following the meal ( for urine glucose)
• The 24-hour urine:
A pooling of all urine excreted by the patient over a 24 hour period
(for protein, uric acid, calsium quantitation, etc)
• Midstream urine:
The middle portion of a single urination
Pre-Analytic
3. Specimen Handling
Folowing collection  should be delivered
to the lab promptly and tested within 1-2
hours
If it can’t delivered  must be refrigerated
or add with chemical preservative
Analytic Stage
Method :
 Manual/ Conventional
 Automatic

 Classification :
 Screening Test
 Confirmatory test
Types of Clinical laboratory Examination

Screening Test
Confirmatory Test:
(urinalysis):

Physical exam Culture urine

chemical dipstick 24 h quantitative

urinalysis proteinuria

microscopic Oval fat bodies, etc

ANALYTIC

PHYSICAL ASSESSMENT OF URINE

COLOUR:
Normal: yellow ( primarily from the presence of urochrome)
Abnormal :
yellow brown ( bilirubin)
dark red (erythrocytes, hemoglobin, porphyrin product)
red brown ( myoglobin, erythrocytes, hemoglobin)
clear red ( hemoglobin, porphyrin product)
cloudy red ( erythrocytes)
Green (biliverdin)
Physical Examination
 Volume
 Color
 Clarity
 Odor
 Specific Grafity
 pH
Physical Examination
 Volume :
Interpretation :
 Normal : 1200 – 1500 ml/daily
(600 – 2000 ml/daily)
 Abnormal condition :
 Oliguria
 Polyuria
 Anuria
Physical Examination
 Color :
Variation of color  normal metabolic functions, physical
activity, ingested materials, pathologic conditions
Interpretation :
 Normal : light yellow  amber
 Abnormal : see next tabel
Variation color of urine
URINE COLOUR
ODOUR:
Normal : aromatic

Abnormal :
Sweet/ammonia
fruity
Putrid/fouled
clear red ( hemoglobin, porphyrin product)
cloudy red ( erythrocytes)
Green (biliverdin)
Analyte Change Cause
Color Modifed/Darken Oxidation or reduction of metabolites
Clarity Decreased Bacterial growth and presipitation of
amorphous material
Odor Increased Multiplication of bacteria or bacterial
breakdown of urea to ammonia
pH Increased Breakdown of urea to ammonia by urease
producing bacteria/loss of CO2
Glucose Decreased Glycolysis and bacterial use
Ketones Decreased Volatilization and bacterial metabolism
Bilirubin Decreased Exposure to light/photooxidation to
biliverdin
Urobilinogen Decreased Oxidation to urobilin
Nitrite Increased Multiplication of nitrate reducing bacteria
Red and White Decreased Disintegration in dilute alkaline urine
blood cell and Cast
Bacteria Increased Multiplication
Color Cause Clinical Laboratory Correlations

Colorless Recent fluid consumption Commonly observed with random

specimens
Pale Yellow Polyuria or diabetes insipidus Increased 24-hour volume
Diabetes mellitus Elevated spesific gravity and positive
glucose test result
Dark Yellow Concentrated specimen May be normal after sternuous
exercise or in first morning specimen
Amber - Dehydration from fever or burns
Orange Bilirubin Yellow foam when shaken and
positive test results for bilirubin
Acriflavine Negative bile test results and
possible green fluorescence
Phenazopyridine (Pyridium) Drug commonly administered for
urinary tract infections
May have orange foam and thick
orange pigment that can obscure or
interfere with reagent strip readings
Nitrofurantoin Antibiotic administered for UTI
Phenindione Anticoagulant, orange in alkaline
urine, colorless in acid urine
Color Cause Clinical Laboratory Correlations
Yellow-green Bilirubin oxidized to biliverdin Colored foam in acidic urine and false-
Yellow-brown 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
Methylene Blue Fistulas
Phenol When oxidized

Pink RBCs Cloudy urine with positive chemical test

Red results for blood and RBCs visible
microscopically.
Hemoglobin Clear urine with positive chemical test
result for blood; intravascular hemolysis
Myoglobin Clear urine with positive chemical test
results for blood; muscle damage
Porphyrins Negative chemical test results for blood
Detect with Watson-Schwartz screening
test or fluorescence under ultraviolet light
Beets Alkaline urine of genetically susceptible
persons
Rifampin Tuberculosis medication
Menstrual contamination Cloudy specimen with RBCs, mucus and
clots
Color Cause Clinical Laboratory Correlations
Brown RBCs oxidized to methmoglobin Seen in acidic urine after standing;
Black positive chemical test result for blood

Methemoglobin Denatured hemoglobin

Homogentisic acid (alkaptonuria) Seen in alkaline urine after standing;
spesific tests are available
Melanin or melanogen Urine darkens on standing and reacts
with nitroprusside and ferric chloride

Phenol derivatives Interferes with copper reduction tests

Argyrol (antiseptic) Color disappears with ferric chloride
Methyldopa or levodopa Antihypertensive
Metronidazole (Flagyl) Darkens on standing
Physical Examination
 Clarity :
Interpretation :
Urine Clarity Term

Clear No visible aprticulates, transparent

Hazy Few particulates, print easily seen

through urine
Cloudy Many particulates, print blurred
through urine
Turbid Print can’t be seen through urine

Milky May precipitate or be clotted

Clarity
Physical Examination
Nonpathologic Causes of Urine Pathologic causes of Urine Turbidity
Turbidity

Squamous epthelial cells Red blood cells

Mucus White blood cells
Amorphous phosphates, carbonates, Bacteria
urates Yeast
Semen, spermatozoa Nonsquamous epithelial cells
Fecal contamination Abnormal crystals
Radiographic contrast media Lymph fluid
Talcum powder Lipids
Vaginal creams
Physical Examination
Laboratory Correlations in Urine Turbidity
Acidic Urine
Alkaline Urine
Soluble with heat
Soluble in Dilute Acetic Acid
Insoluble in Dilute Acetic Acid
Soluble in Ether
Amorphous urates
Radiographic contrast media
Amorphous phosphates, carbonates
Amorphous urates, uric acid crystals
Red blood cells
Amorphous phosphates, carbonates
White blood cells
Spermatozoa
Lipids
Lymphatic fluid, chyle
Physical Examination
 Odor

Odor Cause
Aromatic Normal
Foul, ammonia-like Bacterial decomposition, UTI
Fruity, sweet Ketones (DM, starvaion, vomiting)
Maple syrup Maple syrup urine disease
Mousy Phenylketonuria
Rancid Tyrosinemia
Sweaty feet Isovaleric acidemia
Cabbage Methionine malabsorption
Bleach Contamination
Physical Examination
 Spesific gravity :
 Method :
 Urinometer
 Refractometer
 Reagents Strip
 Interpretation :
 Normal : 1.003 – 1.035 (1.015 – 1.025)
 Abnormal :
 Hypostenuric
 Hyperstenuric
SPECIFIC GRAVITY:
The concentration of solutes in a urine sample

Normal: 1.015 – 1.025

Abnormal high:
-Glucosuria
-Proteinuria
-Hyperconcentrated urine (dehydration)

Abnormal low:
-Hypoconcentrated urine ( Diabetes insipidus)
-Overhydration
BERAT JENIS
- REFRACTOMETER

KEUNTUNGAN :
-BAHAN SEDIKIT
-MUDAH

KERUGIAN :
< AKURAT
1,000
1,020 KOREKSI

- URINOMETER 1,040

KEUNTUNGAN :
-> AKURAT HARUS DIKALIBRASI :
- SUHU
KERUGIAN : - GLUKOSA
-BAHAN BANYAK - PROTEIN
1.002-1.030 ; BJ URINE 24 JAM : 1.015-1,025
Physical Examination
 pH :
 Method :
 Reagent strip
 Lithmus paper
 Interpretation :
 Normal : 4.5 – 8.0 (5.0 – 6.0)
 Abnormal :
 Acid
 Alkaline
Physical Examination
Acid Urine Alkaline Urine

Emphysema Hyperventilation
Diabetes mellitus Vomiting
Starvation Renal tubular acidosis
Dehydration Presence of urease-produing bacteria
Diarrhea Vegetarian diet
Presence of acid-producing bacteria Old specimens
(Escherichia coli)
High protein diet
Cranberry juice
Medications
(methenamine mandelate
[mandelamine], fosfomycin
tromethamine)
SUPER NATANT

SEDIMENT
 ANALYTIC
CONVENTIONAL RAPID - SOPHISTICATED
pH : Lakmus
REAGENT STRIPS :
SG : Urinometry, Refractometry
Protein:Bang (sulfosalysilic acid) COMBUR, URISCAN, MULTISTIX
Glucose : Benedict (redox)
Urobilinogen : Schmidt READER :
Urobilin : Schlessinger visual or by using an automated ins-
trument (photometry)
Bilirubin : Foam test, Harrison,
Hawkinson
Ketones : Rothera, Gerhardt
Blood : Benzidine
CHEMICAL DIPSTICK URINALYSIS
PRINCIPLE OF THE METHODS
 IN GENERAL :
agent + reagent colour change (read visually or
photometrically by automated
instrument)

Except for SG that was based on pKa change in relation to ionic

concentration. SG is depend on solutes that disperse in solution
URINE TEST STRIP

CHARACTERISTIC OF THE TEST : RAPID, EASY, SPECIFIC AND CHEAP

MATERIALS : TEST STRIP

SPECIFIC GRAVITY
PROTEIN
NITRITE
KETOBODY
GLUCOSE
UROBILINOGEN
BLOOD

PLASTIK ROD

NYLON COVER

TEST FIELD
(PAPER CONTAIN REAGENT)

FILTER PAPER
COLOUR CHART STANDARD
PROCEDURE OF THE TEST :

1. IMMERSE THE TEST STRIP FOR APPROX 1 SECOND

2. REMOVE EXCESS URINE FROM THE STRIP BY WIPING
THE EDGE OF URINE ON THE CONTAINER (TUBE)

URINE

READ : COMPARE
THE COLOUR CHART

UROTRON
AUTOMATED READER (PHOTOMETRY)
Chemical Examination
Indicator Principles
Blood hemoglobin
H2O2 + chromogen    oxidized chromogen + H2O
peroxidase

Nitrite acid
Para-arsanilic acid or sulfanilamide + NO2  diazonium salt acid
(nitrite)

acid
Diazonium salt + tetrahydrobenzoquinolin  pink azodye
Leukocyte leukocyte esterase
Indoxycarbonic acid ester    indoxyl + acid indoxyl +
acid
diazonium salt  purple azodye
 Chemical Examination
Indicator Principles
pH Methyl red + H+  Bromthymol blue – H+
(Red  Yellow) (Yellow  Blue)

Protein pH 3.0
Indicator + Protein  Protein + H+
(Yellow) Indicator – H+ (Blue-Green)

Glucose glucose oxidase

• Glucose + O2 (air)    gluconic acid + H2O2
peroxidase
2. H2O2 + chromogen    oxidized colored
chromogen + H2O
Ketones (and acetone) alkaline
Acetoacetate + sodium nitroprusside + (glycine)   
purple color
MICROSCOPIC EXAMINATION OF URINE

NEW URINE < 6 HOURS

CENTRIFUGE AT 1500 RPM / 5 MINUTES

SEDIMENT
COVER WITH
COVER GLASS

SLIDE

MICROSCOPE OBJECTIVE 40 X
EYEPIECE 10 X
CONDENSOR
EXAMINATION ! !

ERITHROCYTE / LOW POWER

ORGANIC
SEDIMENT LEUKOCYTE / HIGH POWER

CAST / LOW POWER

EPHITEL CELL
ANORGANIC CRYSTAL
SEDIMENT
 MICROSCOPIC EXAMINATION OF URINE

ORGANIC ANORGANIC
• Erythrocyte
• Normally Crystal :
• Leucocyte
- Calsium oxalate
• Epithel
- Triple phosphate
• Cast: - Hyalin - Granular
- Leucocyte - Erythrocyte - Urate
- Epithel - Waxy • Pathological Crystal
- Fat
•Crystal due to Drugs
• Oval Fat Bodies
• Spermatozoa
• Microorganism: - Bacteria
- yeast
- parasite
 Microscopic Examination
 Organic sediments :
 Leukocyte
 Erytrocyte
 Cast (Hyalin, epithelial, granular, leukocyte, erytrocyte, fat, waxy, mix, fibrin)
 Epithelial
 Anorganic sediments :
 Crystal :
 Normal :
Acid :
o Uric acid, calsium oxalat
 Alkaline :
o Triple phosphates, calsium carbonate, calsium phosphate
 Abnormal :
 Cystin
 Thyrosine
 Amorph
Microscopic Examination
 Others :
 Egg (Helminthes)
 Parasite
 Bacteria
 Spermatozoa
 Mucus
Squamous epithelial cells
Squamous epithelial cells
Transitional epithelial cells
Casts are elements,
which form in the distal tubules and collecting ducts of the kidney.
They have a matrix, which is Tamm-Horsfall glycoprotein,
which is produced by the thick ascending segment of the loop of Henle.
There are different types of casts with different clinical meanings.
Even with glomerular injury causing increased glomerular permeability to
plasma proteins with resulting proteinuria, most matrix or "glue"
that cements urinary casts together is Tamm-Horsfall mucoprotein,
although albumin and some globulins are also incorporated.
An example of glomerular inflammation with leakage of RBC's
to produce a red blood cell cast is shown in the diagram below:
The factors which favor protein cast formation are low flow rate,
high salt concentration, and low pH, all of which favor protein denaturation
and precipitation, particularly that of the Tamm-Horsfall protein.
Protein casts with long, thin tails formed at the junction of Henle's loop
and the distal convoluted tubule are called cylindroids.
Hyaline casts can be seen even in healthy patients.
Hyalin cast
Red blood cell cast
White blood cell and granular cast
Stained white blood cell cast
Fatty cast
Uric acid crystals
Thus if we have an erythrocyte cast, we
must know, we must remember that this
means that the red cells come from the
kidneys.
Leukocyte casts. Again they tell us that the leukocytes come from
the kidney which may happen both in patients with glomerulonephritis
and in patients with for instance renal infection, pyelonephritis.
Epithelial casts, which contain tubular cells
these casts are typically seen in patients
with acute tubular necrosis but they are
also seen in patients with glomerular
nephritis
Bacterial casts, extremely rare but again
these tell us that the bacteria comes from
the kidney
We can even have yeast casts but in this case
this is a candial cast, again infection comes from the kidneys.
Common crystals first, uric acid crystals,
which we always find in acidic urine.
Calciumoxylate monohydrated and calcium oxalate dehydrated,
which is found in this range of urinary pH,
Calcium phosphate crystals and triple phosphate crystals, alkaline pH
 Cholesterol crystals

Cholesterol again as you can see it is a marker of heavy proteinuria.

 Cystine crystals

Cysteine crystals they are a typical marker of patients with cysteinuria.

The more the urine is acidic, the higher is the possibility
to find these crystals in the urine.
Miscellanous structures
Parasites

Enterobius vermicularis ova (400x)

Trichomonas vaginalis ova (400x)
Mucus
INTERPRETATION
Positive or abnormal results should be
confirmed according to clinical states and also
think about interfering factors from food or
drugs that were given to the patients.
Interfering Factor
Substance False + (FP)
Protein Prolonged periode of time
contact with urine
Contamination container with
detergent
Drugs : cephalosporine,
penisillin, sulfonamide
Keton
Blood Container contaminated with
strong detergent
Leukocyte Container contaminated with
strong detergent
Glucose Container contaminated with
strong detergent
Nitrite Not on fresh urine
False - (FN)
Highly alcaline urine
Levodopa high concentrate
High concentrate of ascorbic
acid
High level glucose and protein
Reductor : ascorbic
acid,aspirine,
levodopa
High concentration of ascorbic
acid
INTERFERING FACTORS

 Causing false positive/ high results :e.g

 glucose (stress, heavy meal, dextrose infusion,pregnancy, vit C);

 protein (strenuous exercise, penicillin G);

 ketone (high protein,carbohydrate-free, high fat diet, vit C, insulin);

 SG (refrigerated urine, radiogra- phic dyes); etc.

INTERFERING FACTORS (contd)
 Causing false negative/ low results : e.g
 Glucose : directions are not followed exactly, levodopa

 Leukocyte esterase : high level of protein

 WBC & RBC : delayed examination in room temperature and

stands for >2 hours, alkaline urine
 pH : strongly acid in highly concentrated urine; etc
REFERENCES